Feasibility of a Regional Health Insurance Mechanism for Caricom. 6 th Caribbean Conference. Presentation to the. November 23, 2011, Bermuda

Transcription

1 Feasibility of a Regional Health Insurance Mechanism for Caricom Presentation to the 6 th Caribbean Conference on Health Financing Initiatives November 23, 2011, Bermuda Presenter: Raphael D. Barrett RDB_DAHCON_6 th CCHFI_BERMUDA_NOV2011

2 OVERVIEW Study was commissioned by the Caricom Secretariat funded by the Caribbean Development Bank and conducted by DAH Consultants Inc. RDB_DAHCON_6 th CCHFI_BERMUDA_NOV2011

3 Study Objectives Analyze the intra-regional movements of patients Assess the implications of the free movement of people (CSME) on the demand for health services in Caricom Assess the feasibility of a RHIM Recommend options for meeting the healthcare needs of CARICOM nationals travelling or working in member states

4 RHIM Evaluation Phases I II III

5 Health Needs of Patients Intra-Regionally and for CSME Essential Services: Infectious diseases, cardiology & cardiovascular services, dialysis, neurology & neurosurgery, oncology, ophthalmology, urology Diagnostic services: laboratories and diagnostic imaging (eg. MRI and CT) Many of these services require the same facility support structure so measures taken to improve one specialty will undoubtedly improve others

6 Health Insurance Options Universal Coverage is the goal with defined services financed through contributions/taxes National Insurance: government and individuals contribute, state funds the poor and indigent through taxes; defined services, barriers could be financial or due to economic performance. Special purpose plans: funded by special taxes and/or contributions, e.g. CDAP (Trinidad & Tobago), MBS (Antigua), NHF (Jamaica), NPDP (Bahamas) Private: Private Health Insurance, Out-Of-Pocket payments, Grants, External Aid

7 Financing Arrangements Role of Private Health Insurance Industry dominated by a few large firms Administrative costs for large companies between 10% and 20%; smaller companies average around 30% Non price competition and medical underwriting Industry has network of providers across the region

8 Financing Arrangements Role of Social Security Organisations SSOs collect revenues, pool resources, purchase and administer services Analysis of 2008 performance for SSOs in Caricom countries showed Administrative Costs varied from a low of 4% to a high of 34% Health Claims varied from a low of 1% to a high of 210%

9 Cost of Care Private Health Insurance sets limits on costs with cost-sharing Per referral costs are greater for government entities Cost per referral varies across Caricom Some countries report medical capacity as Centres of Excellence

10 Methodology A risk-based approach to National Health Financing The policymaker must determine: Healthcare Benefits: the range of Individual and Institutional benefits to be provided Healthcare Coverage: the population to be provided with the benefits and the nature of the coverage Financial Resources: the extent of financing available to provide benefits

11 Policy Questions Capacity and Equity in accessing healthcare Does Caricom have the capacity and resources to handle a shift in referrals from extra-regional to intra-regional facilities? Which organisations can provide access to medical care with a network of providers at competitive rates Social Security Organisations: Can their capacity to plan, collect revenues, develop risk pools, purchase services, distribute benefits and support inter-country transfers be applied to a RHIM? Do they enjoy or share economies of scale from running their programmes throughout Caricom

12 FINDINGS and RECOMMENDATIONS RDB_DAHCON_6 th CCHFI_BERMUDA_NOV2011

13 RHIM Analysis Three scenarios considered CARICOM Population - residents CSME Population persons with skills certificate PATIENT Population - persons referred outside their country for treatment Medical areas for priority attention Epidemiologic analysis was used to identify Specific Medical Conditions for treatment Prevalence Rates were determined for each condition Typical Annual Treatment Costs were estimated for each condition

14 Fiscal Space & Insurance Considerations Direct taxes VAT/sales/property/Cin taxes Import duties (tariffs) Social security/payroll taxes Private insurance limited scope some scope limited scope some scope limited scope

15 Analysis of Options TAX based SSO Social Ins Private Ins Value = [score] x [weight] score value score value score value score value Revenue Collection What is the most efficient and equitable way to collect revenues? (High) What is the most sustainable source of funding? (High) What is the best system to ensure equity? (High) Pooling Contributions What system is planned to share costs and equalize risks? (Medium) What mechanism is used to increase solidarity in the system and equalization of risk? (Medium) Purchasing Services What method is used to purchase appropriate and effective health interventions? (Medium) What provider payment mechanism is adopted? (Medium) What provider network systems are in place to provide services? (Medium) Governance, Admin & Distributional Effects What policy objectives are most achievable by the financing method? (High) What organization, system and cultural sympathies are in place to support the proposed system? (Medium) What revenue, pooling, payment system has a tradition with the population that can be built upon? (High) What fiscal space for collecting contributions? (High) What is the proposed timing of implementation? (High) TOTAL

16 Results of Analysis

17 RHIM data references/sources RHIM coverage Prevalence rate Cardiology 3.3% Prostate cancer Reference NHF-JA Study (Barrett ) World Bank Study (Armstrong ) NHF-JA member 4.1% data (Barrett ) Typical Cost (Est) Reference US$35,000 RHIM Study (2010) US$12,000 Crawford et al. (European countries) Fourcade et al. (USA) (2010) Breast cancer 1.9% NHF-JA member data (Barrett ) US$21,000 Wendy Max (California, USA), University of California San Francisco (2003) Diabetes 6.3% NHF-JA Study (Barrett ) World Bank Study (Armstrong ) US$5,000 RHIM Study (2010)

18 RHIM Preliminary Results (US$M) LIABILITY ESTIMATES: CARICOM POPULATION UTILISATION 1% 10% 10% 10% CARICOM State 2K9 Pop(000) Cardio Prostate Breast Diabetes ToTal Antigua & Barbuda 86 $1.00 $4.23 $3.40 $2.73 $11.36 Bahamas 342 $3.98 $16.82 $13.52 $10.85 $45.18 Barbados 256 $2.98 $12.59 $10.12 $8.12 $33.82 Belize 307 $3.58 $15.10 $12.14 $9.74 $40.55 Dominica 73 $0.85 $3.59 $2.89 $2.32 $9.64 Grenada 104 $1.21 $5.12 $4.11 $3.30 $13.74 Guyana 762 $8.87 $37.48 $30.13 $24.17 $ Jamaica 2,719 $31.67 $ $ $86.24 $ Montserrat 5 $0.06 $0.25 $0.20 $0.16 $0.66 St. Kitts & Nevis 40 $0.47 $1.97 $1.58 $1.27 $5.28 St. Lucia 172 $2.00 $8.46 $6.80 $5.46 $22.72 St. Vincent & Grenadines 109 $1.27 $5.36 $4.31 $3.46 $14.40 Suriname 520 $6.06 $25.58 $20.56 $16.49 $68.69 Trinidad & Tobago 1,339 $15.60 $65.87 $52.95 $42.47 $ Sub-ToTal 6,834 $80 $336 $270 $217 $903 Anguilla 14 $0.16 $0.69 $0.55 $0.44 $1.85 Bermuda 68 $0.79 $3.34 $2.69 $2.16 $8.98 British Virgin Islands 24 $0.28 $1.18 $0.95 $0.76 $3.17 Cayman Islands 49 $0.57 $2.41 $1.94 $1.55 $6.47 Turks & Caicos Islands 23 $0.27 $1.13 $0.91 $0.73 $3.04 Sub-ToTal 178 $2 $9 $7 $6 $24 ToTal 7,012 $82 $345 $277 $222 $926

19 RHIM Preliminary Results (US$000) LIABILITY ESTIMATES: CSME POPULATION UTILISATION 1% 10% 10% 10% COUNTRY OF ORIGIN (est) Cardio Prostate Breast Diab ToTal Antigua & Barbuda % $7.34 $30.99 $24.91 $19.98 $83.22 Bahamas Barbados 694 2, % $30.91 $ $ $84.18 $ Belize % $1.54 $6.49 $5.22 $4.19 $17.44 Dominica % $6.09 $25.73 $20.68 $16.59 $69.09 Grenada % $9.38 $39.60 $31.83 $25.53 $ Guyana 2,785 6, % $80.27 $ $ $ $ Jamaica 1,913 5, % $67.88 $ $ $ $ Montserrat St. Kitts & Nevis % $6.89 $29.12 $23.41 $18.78 $78.20 Saint Lucia 650 2, % $26.45 $ $89.80 $72.03 $ St. Vincent& Grenadines 266 1, % $16.17 $68.28 $54.89 $44.03 $ Suriname % $1.28 $5.41 $4.35 $3.49 $14.53 Trinidad & Tobago 2,039 4, % $57.17 $ $ $ $ ToTal 9,208 26, % $311 $1,315 $1,057 $848 $3,532

20 RHIM Preliminary Results (US$000) LIABILITY ESTIMATES PATIENT POPULATION (MOH/NIS) Referrals UTILISATION 1% 10% 10% 10% COUNTRIES # Referrals Cardio Prostate Breast Diabetes ToTal Anguilla 112 $1.304 $5.509 $4.429 $3.553 $ Bahamas 466 $5.427 $ $ $ $ Barbados 117 $1.363 $5.755 $4.627 $3.711 $ British Virgin Islands 169 $1.968 $8.313 $6.683 $5.361 $ Cayman Islands 1,795 $ $ $ $ $ Guyana 706 $8.223 $ $ $ $ Montserrat 287 $3.343 $ $ $9.103 $ St. Lucia 80 $0.932 $3.935 $3.164 $2.538 $ St. Vincent & Grenadines 150 $1.747 $7.379 $5.932 $4.758 $ Suriname 242 $2.819 $ $9.570 $7.676 $ Trinidad & Tobago 79 $0.920 $3.886 $3.124 $2.506 $ Turks & Caicos 3,154 $ $ $ $ $ Total 7,357 $86 $362 $291 $233 $972 No data available for Antigua & Barbuda, Belize, Dominica, Grenada, Jamaica, St. Kitts & Nevis

21 RHIM Preliminary Conclusions The per capita cost for coverage considered is US$ annually US$2.50 weekly The estimated liability for the conditions considered were distributed as follows cancers 67% diabetes 24% cardiovascular 9%

22 Policy Options for RHIM For a sustainable health financing mechanism Decision guided by fiscal space and capacity to perform three insurance functions Advantage of institutions with experience, cultural acceptability and reach Good governance is a major requirement Health infrastructure to provide quality services in keeping with an Essential package of care Incentives to use cost saving precision technology focused around outcomes telemedicine, clinics

23 Administration of RHIM OPTION A The RHIM would be an insurance organisation collecting revenues, pooling resources, and purchasing services with the ability to administer and manage the operation. OPTION B The RHIM would be a Supervisory agency and contract the insurance function to a private or public entity with the operational tasks carried out by the Social Security organisation in each country.

24 RHIM Preferred Option Social Security Organisations because they have the administrative capacity to collect revenues and pool resources lowest administrative/transaction costs structure for timely implementation of a RHIM policies, contingent rights and agreements Network and reach throughout Caricom

25 RHIM STAKEHOLDERS CONSULTATION RDB_DAHCON_6 th CCHFI_BERMUDA_NOV2011

26 COHSOD 21 Guyana, 2011 The Caricom Council for Human and Social Development (COHSOD) at its April 2011 meeting received a presentation on the RHIM Study. COHSOD agreed that the Caricom Secretariat should have a policy document on a RHIM reflecting, a consensus of the stakeholders, presented for its consideration and agreement. This would then be submitted to the Heads Of Government for approval.

27 RHIM Workshop - Barbados, 2011 A RHIM workshop bringing together the Chief Medical Officers and the Head of the SSO in each Caricom country was held in Barbados in January The workshop reviewed the findings and recommendations of the RHIM Study and agreed on the following issues.

28 RHIM Workshop - Participants Feedback: STRUCTURE Major role for SSOs in the RHIM An Essential package of health services should be provided including primary care The essential package should consider each country s current health service for nationals The Caricom essential healthcare package should be basic to each country s healthcare system Target Beneficiaries - CARICOM nationals

29 RHIM Workshop - Participants Feedback: Administration OPTION #1 OPTION #2 Financing Fee for Service Global Budget Operations SSOs finance and manage RHIM (incl. claims processing) SSOs finance but do not manage RHIM Control, Monitoring & Evaluation Case Management System - full-time case managers on staff Case Management System use of Health Review Nurses Administrative Cost Delivery of Health Care Peer Reviews Use of Approval Codes for authorizing and monitoring health care treatment Higher administrative costs (tied to full time case managers) Long-term savings through better management of cases by medical professionals Preferred providers across the region Peer Reviews Strong MIS for recording and tracking health care treatment and costs Lower costs over the short and medium term Preferred providers across the region

30 NEXT STEPS Based on the feedback from Caricom and the major stakeholders, to advance the process we recommend Technical Working Groups to A. develop the details of a Benefits Package standard for Caricom residents (Universal Coverage) B. develop procedures for Administration of the system funding, transferring benefits, paying providers etc. C. develop a Referral Policy regarding the use of medical facilities in-country/ in-caricom/ extra-regionally support for Caricom centres of excellence We suggest membership of the TWG be from the major stakeholders with administrative support from the Caricom Secretariat and technical support from the Study Consultant