（卫生经济学ppt课件）

1Health care FinancingHengjin Dong,MA,MD,PhD1Health care Financing1Outline of SessionsConceptual framework for health care financingOptions for mobilizing resources for the health sectorOptions for health sector resource allocationHealth purchaser and provider payment2Outline of SessionsConceptual 2Topic 1Conceptual framework for health financing.3Topic 1Conceptual framework fo3（卫生经济学ppt课件）4（卫生经济学ppt课件）5Allocation of Resources to the Health SectorWhat are the main expenditure allocation patterns and sources of finance for health sector?-Health expenditures as%of GNP-Government expenditure as%of total-Per capita health expenditures6Allocation of Resources to the6Health Expenditures and GDP(2005)Health Expenditures and GDP(2005)CountryGNI p.c.($)P.C.Health exp.($)Health exp.(%of GDP)Gov.h.Exp.as%of total h.exp.(90-98)Low income584244.731.0Middle income2,6361385.954.4High income34,9623,68711.163.3OECD36,5063,84311.374.272000 and 2007 world development indicatorsLow income(2005):$10,725Health Expenditures and GDP(27The Role of Health InsuranceInsurance:Prepayment for services that will be paid for by a(public or private)third party(the insurer)if a pre-defined event occurs.A(full or partial)substitute for direct payment for services by the consumer of the services.8The Role of Health InsuranceIn8The Rationale for InsuranceReduce risk to individuals by pooling risk across a group.Increase the predictability of unexpected losses.Redistribute the costs of unexpected losses(improve equity).9The Rationale for InsuranceRed910Individual Health Care CostsHealthySickThe Healthy Pay More than they UseThe Sick Pay Less than they UseSick individuals can become healthy and healthy individuals can become sickHealth Insurance ContributionPooling Health Care Risks10Individual Health Care Costs10Topic 2Options for mobilizing resources for the health sector.11Topic 2Options for mobilizing 1112Options for Financing Health CareCentralized public funding-general tax financing-social insuranceVoluntary insurance-Community-based insurance-Private insuranceOut-of-pocket payments(User Fees)12Options for Financing Health12Evaluation CriteriaEfficiencyEquitySustainabilityAccessQuality13Evaluation CriteriaEfficiency113Why public funding for health care?Public goods(efficiency)Financing care for the poor(equity)Risk pooling(private insurance market failure)14Why public funding for health 14Improved Equity with Public FinancingImproved Equity with Public Financing15Distribution of Health Spending by Income level%of Total Health SpendingSource:Gottschalk,Wolfe,and Haveman 1989Improved Equity with Public Fi15General Tax Financing16General Tax Financing1616Social Insurance17Social Insurance1717Issues with General TaxSensitive to political priorities.-More of a problem in U.K.-national budget-Less of a problem in Canada-local province budgetsAchieving equity in resource allocation to geographic areas.-U.K.population-based formulaAchieving purchaser-provider split.18Issues with General TaxSensiti18Issues with Social InsuranceHow to achieve universal coverage.Appropriate structure of insurers(single insurer or competition).19Issues with Social InsuranceHo1920Comparison of General Taxation and Social InsuranceAdvantages of general taxation:-More progressive(equitable)-Non-distortionary-Lower administrative costsAdvantages of social insurance:-Earmarked tax for health;-Not viewed as social welfareIn practice,success depends on implementation20Comparison of General Taxati20Disadvantages of a Mixed System of Public FinanceDifficult to control the total flow of resources when there are multiple payers.Difficult to coordinate(mixed signals to providers;cost-shifting).21Disadvantages of a Mixed Syste21Combinations of financing and service deliveryFinancingProvidersPublicPrivate MixedGeneral tax(G)Canada,UKSocial insurance(S)JapanBulgaria,Israel,Czech Republic,France,GermanyMixed(G+S)MexicoRussiaKoreaPrivate I(P)Mixed(S+P)HungaryUSChina,Chile22Combinations of financing and 2223Voluntary InsuranceDifferent from mandatory insurance-actuarially fare premiums.Market imperfections:-Adverse selection-Moral hazardRelationship to public funding:-Supplementary rather than competitive23Voluntary InsuranceDifferent23Community-based InsuranceRisk-sharing scheme for health care expenditures that is owned and managed at the community level.Usually focuses on primary care,but may include referral services.Often has a broader community development focus.Other types of voluntary risk-sharing schemes:health facility,cooperative,NGO.24Community-based InsuranceRisk-24Types of Risk-Sharing SchemesType 1High-cost,low frequency eventsTend to be hospital-ownedTend to cover whole districtUse actuarial basis or variable costs to calculate premiumCommitted to meeting certain designated costs.Type 2Low-cost,high frequency eventsTend to be community ownedTend to be based at the village levelPremium set mainly according to ability to payCommitted only to raising extra revenue for services.25Source:Creese and Bennett 1997Types of Risk-Sharing SchemesT2526Out-of-Pocket Payments(User Fees)May provide supplemental resources and utilization incentivesNot adequate as main source of financing because:-Does not generate sufficient resources-Does not pool risks-Inequitable26Out-of-Pocket Payments(Use26User Fees in Public FacilitiesGoals:Revenue generationStrengthen the role of markets-quality-based competition-introduce price signals-greater efficiency-incentives to increase supply of services(access)Reduce excess utilization(moral hazard)Improve sustainability(affordable)Reinforce decentralizationPrivate sector development27User Fees in Public Facilities27Possible Negative Affects of User FeesMay reduce utilization of necessary services.May reduce utilization disproportionately among the poor.Administrative costs are high.May add to“under-the-table”payments.28Possible Negative Affects of U28Performance of User FeesPeople are willing to pay for some quality improvement,particularly drugs(Cameroon,Ghana,Nigeria,Kenya,the Philippines).Utilization may decrease(Zaire),increase if quality (pre-natal care in Niger),or shift to private sector(Indonesia,Lesotho)Impact on health outcomes(Indonesia-in duration of illness,infectious disease symptoms,physical function age 50)29Performance of User FeesPeople29Performance of User Fees,cont.Cost of collecting fees may be higher than revenue generated.Evidence that quality or access to services has improved?Interpretation of performance often ideologically based.30Performance of User Fees,cont30Issues with User FeesHow to set prices:-relate to costs(cross-subsidization of services)-relate to demand(willingness vs.ability to pay;elasticity;role of quality)Exemption policies(protect the poor).Efficient administration and fee collection.Do revenues stay in the facility,the health sector?31Issues with User FeesHow to se3132Topic 3Options for allocating resources in the health sector.32Topic 3Options for allocati3233Resource Allocation within the Health SectorService activities(preventive vs.curative;primary vs.secondary/tertiary)Population groups(rural/urban,regions,income levels,etc.)Input combinations(personnel,medical/nonmedical supplies)Disease patterns and categories(infectious vs.chronic)33Resource Allocation within t33More Cost-Effective Resource Allocation3475%of Resources to Inpatient Care25%of Resources to PHC50%of Resources to Inpatient Care50%of Resources to PHCMore Cost-Effective Resource A34Topic 4Health purchasers and Provider payment35Topic 4Health purchasers and P3536Examples of Possible Health PurchasersMinistry of HealthLocal government health authorityArea health boardsSocial health insurance fundsPrivate insurance funds/companiesEmployersMember-owned/community-based insurance funds36Examples of Possible Health 3637Market Structure of PurchasersSingle purchaser(Canada,U.K.)Multiple purchasers:-competitive(Germany,Korea)or-non-competitive(Mexico,Kyrgyzstan)-unified payment systems(Germany,Japan)or different payment systems37Market Structure of Purchase3738Role of Health PurchasersAn agent on behalf of the enrolled population promoting improved quality and efficiency in the delivery of services.Example:traditional indemnity insurance vs.HMOs in the U.S.38Role of Health PurchasersAn 3839Active Purchasing StrategiesFinancial incentives through provider payment methods;Primary care“gatekeeper”conditions;Management of patient choice;Selective contracting;Provider profilingStandard treatment protocols/prior authorization39Active Purchasing Strategies3940Provider Payment MechanismsProvider payment mechanisms create incentives that influence the behavior of providers.May be prospective or retrospective.Relationship to quality and patient choice(“the money follows the patient”).40Provider Payment MechanismsP4041Examples of Provider Payment MethodsBudget(line item and global budgets)SalariesCapitation(with full or partial fundholding)Case-based paymentFee-for-serviceDRGMixed41Examples of Provider Payment4142Issues for Provider Payment SystemsBalancing efficiency incentives with quality incentives.Supporting information systems.Provider autonomy.42Issues for Provider Payment 42