Recommended
More Related Content
Viewers also liked
Viewers also liked (14)
Similar to Iadnam ooc presentation 3 oct
Similar to Iadnam ooc presentation 3 oct (20)
More from Oliver O'Connor
More from Oliver O'Connor (14)
Recently uploaded
Recently uploaded (20)
Iadnam ooc presentation 3 oct
- 2. A way of thinking about it • This presentation will distinguish between • UNIVERSALITY • and • INSURANCE • To help untangle the many complex issues involved • And perhaps give a pointer to likely developments www.oliveroconnor.co 2
- 3. Universal Health means… • A set of health beneJits for EVERYONE • With Equity: no faster access to these beneJits for ANYONE • Compulsory funding by ALL • graduated contributions according to means • ALL (essential) areas of healthcare covered • And all providers (hospitals) available to all patients www.oliveroconnor.co 3
- 4. And Insurance implies… • BeneJits speciJied by rules • not just HSE/hospitals funded to do their best • A personal contract‐based entitlement to a service • not limited by resources of a hospital or insurer • radical difference in law and budgeting • A requirement to maintain solvency and reserves • Usually, payor and provider are different organisations • Choice: social insurance (like unemployment beneJit) or • Run through commercial insurance companies • With choice of insurers ✔ www.oliveroconnor.co 4
- 5. To distinguish… • We could have Universal Healthcare (NHS, Sweden, Spain) • without • Universal Health Insurance (NL, Germany, France) • but decision made: it will be insurance • it will be multi‐insurers, not just one • Still, helpful to identify which elements of the Government plan involve ‘universality’ and which ‘insurance’ www.oliveroconnor.co 5
- 6. Two essential problems • Primary Care: fees prevent some people getting care www.oliveroconnor.co 6 Address with • Universality: medical card/GP card expansion • Insure annually? • Hospital care: two‐tier hospital access • Universality: enforce equity, access private hospitals • Same insurance for all • EfJiciency, cost and quality • Universality? indirect role • Insurance? small role now, but should grow Other issues….
- 7. Common issues for both • People: create new public law entitlements and obligations • You all get the same beneJits • But some people pay more than others, and more than now • Money: merge two funding streams • Public capitation and private fees • Exchequer funding and private health insurance • Insurers as intermediaries • Customer facing: administer all beneJits and claims • Innovation: scope to design new policies, beneJits • Money: receive funding and pay providers www.oliveroconnor.co 7
- 9. Primary care ‐ free GP care www.oliveroconnor.co 9 • Cost of extension of GP care: €40m for under‐5s • GP fee: €70 per year per child capita8on • Avg 3 visits per year per child under 5* • Will GPs agree? Difficult to implement without agreement • Free GP care for whole popula8on: • €445m paid now to cover c.43% of popula8on • Cost for rest depends on GP payment • Anywhere from €400m up: more usage • What will 2,800 GPs agree? Fee, capita8on or salary? How much? A replacement of all private fees? • Health policy balance: cost as barrier to access vs over‐use of ‘free’ service • Hiring of new primary care staff for full service: slow *Source: ESRI, Resource Alloca8on Group Report, 2010, old data back to 1987
- 11. Primary care – insurance issues www.oliveroconnor.co 11 • Will free GP care first be paid by Exchequer? • Increase taxa8on, increase public spending • Later insurance policies will incorporate this benefit. Will this then reduce Exchequer spending? • One way or another, a compulsory annual payment by some people to eliminate GP fees at point of use • More logical to require people to buy GP insurance now as “free GP care”, saving the Exchequer cost • What else will be covered by the insurance policy? • All primary care • No fees (deduc8bles) at the point of use for any service? • Insurers not ready for some years to fund primary care services • Apart from limited cash‐plans => fees, not capita8on, for doctors
- 12. Hospital UHI – all about Equity • Whole population can already use public hospital care • 1970 Act Jirst, then extended to all in 1993/4 • Universality in place but… • Equity test: • What about faster access to private care in public hospitals? • Access to private care in private hospitals? • Policy op8ons • Implement single appointments system in public hospitals • Underpin with legal obliga8on to give certainty of equity • Allow private hospitals par8cipate in public benefits provision • On condi8on they offer first‐come, first‐serve appointments • Actual policy: equity will be achieved the same insurance contracts for all, using both public and private hospitals www.oliveroconnor.co 12
- 15. UHI issues for hospital care • Why do you need insurance to address the equity issue? • Would people voluntarily con8nue to buy private health insurance if equity of access were built in before insurance is made compulsory? • How to sustain the insurance money flow while merging with taxa8on? • Must any merging of the two money flows await a Big Bang? • Even with UHI, do you allow people buy private hospital care outside the State system, as in UK? • Will private hospitals fully join the State system or will some stay out? www.oliveroconnor.co 15
- 16. Hospital access ‐ present www.oliveroconnor.co 16 People with Benefit Direct Payment* No insurance Public hospitals only Slowest access, least choice None Low to Mid level insurance Public hospitals, public and private beds; some private hospitals Faster access, more choice €500‐€1000 per adult High insurance All hospitals, public and private Fastest access, most choice €2,500 ‐ €4,000 * Excluding statutory bed night charges, ED charges, applicable to all except medical card holders
- 17. UHI Hospital care – who wins? www.oliveroconnor.co 17 People now with Popula>on Win Lose No insurance 2.6m 56% Most get faster access, free Some neutral or lose – have to pay Low to mid‐ level insurance 1.8m 39% Some may get subsidy Most lose faster access, s8ll pay High level insurance 220k 5% est. at most None Some neutral – may keep faster access • Who will no8ce they win or lose, and when? • Perhaps everyone happy that all have equal access and everyone pays according to means
- 18. UHI ‐ Hospital Care ‐ Progress? • Universality/equity: no change yet • implementation of 2008 consultant contract • Insurance: VHI authorisation near, risk equalisation needing revision, market under price/cost pressure • Governance: creation of 7 hospital groups: good, but not directly relevant to universality, equity and insurance • Access: private hospitals still limited to private insurance • Charging all private patients in public hospitals: • aimed at increasing income for public hospitals • payment remains bed night charge, not per procedure • increases incentive for public hospitals for more private patients • Awaiting UHI White Paper at end this year www.oliveroconnor.co 18
- 19. Clarity – on key issues • Decide if key goals on universality and equity must wait for payments and beneJits to be routed through insurance companies • Recognise that the transition to insurance is most complex: Payments systems and pricing Reserves requirements BeneJits deJinition Supplementary insurance scope Relationships with providers Competition law Risk equalisation Private contracts replacing public law provision • And put in place sufJicient expertise to deal with these • Grasp the nettle early: budget‐cap and spending control www.oliveroconnor.co 19
- 20. Clarity for providers, insurers • GPs and primary care staff: payments, contracts, services • Consultants: salary/fee mix, employee/contractor • Seven public hospital groups and 21 private hospitals • Anticipate future funding sources, sustainability • Pricing, competition, standards, commercial freedoms • Scope for services outside the State beneJits package • Who will survive, doing what? • Insurers: complex issues only starting to be talked about www.oliveroconnor.co 20
- 21. Clarity for the public • Free GP care: 3 options • Pay by Exchequer – raise taxes, increase public spending • Compulsory private cash‐plan contracts, part subsidised • Modify: include graduated private fee payments (as per Resource Allocation Group Report 2010); rest paid by taxes • UHI in hospitals: make clear it has beneJits and costs • Who will pay, and how much • Means‐tested contributions: what are the limits • What choice will there be of doctor, hospital, beneJits www.oliveroconnor.co 21
- 22. What is needed, when • White Paper with serious policy detail, 2013‐14 • Including an estimate of cost of UHI and how it is borne • Decisions on free GP care or variations: 2013‐15 • Negotiations with GPs: 2013‐14 • Huge amount of technical work with insurance experts: 2013‐20 • Stabilisation of insurance market and risk equalisation: 2014 ‐> • New consultant contract: 2018? • Strategic agreement with public and private hospitals to allow planning: 2014‐15 • Post‐White Paper implementation plan: 2014‐15 www.oliveroconnor.co 22