Dr Josep Figueras

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Dr Josep Figueras

• European Observatory on Health Systems and
  Policies.

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The European context
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Re-examining financial sustainability in
Europe

• Helsinki, 8th February 2007
• Josep Figueras
• European Observatory on Health Systems

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Solidarity at the core of European systems

• WHO, EU, Council of Europe
• Health as a human right
• Solidarity and Equity

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Addressing financial sustainability

• Reforming sources of funding
• Statutory insurance competition
• Shift costs to the patient privatisation of
  funding
• Reforming the supply (payment provision)
• Empowering the consumer (increasing choice)
• Strengthening public health
• Rethinking financial sustainability
• Health systems, Health and Wealth

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In the longer term, America, like this adamantly
pro-market newspaper, may have no choice other
than to accept a more overtly European-style
system. In such a scheme, the government would
pay for a mandate insurance system, but leave the
provision of care to a mix of public and private
providers. The Economist, January 28th 2006
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Rather than copying Europes distorting payroll
taxes, the basic insurance package would be paid
for directly by government, though that cash
might be raised by a hypothecated tax which
would make the cost of health care more
evident The Economist, January 28th 2006
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Concentration of total health expenditures,
France 2001
Source CNAMTS/EPAS
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Insurance competitionIn Theory it ought to work

• Consumer freedom of choice
• Market competition incentives efficiency
  quality
• Insurers as prudent buyers
• Cost-effective purchasing
• Selective contracting
• Without negative impact on equity quality
• Risk adjustment formula, open enrolment,
  monitoring, regulation,

Preconditions???
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Insurance competitionIn Practice the evidence

• Equity risk selection
• Marketing / tailoring benefits / barriers to
  enrolment
• Limited scope of most risk adjustment formulae
• Efficiency regardless of whether (or not)
  efficiency savings there is an increase in
  transaction costs
• Efficiency increases linked to active (strategic)
  purchasing capacity and selective contracting.
• Purchasing success not associated to multiple
  insurers

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Addressing financial sustainability

• Reforming sources of funding
• Statutory insurance competition
• Shift costs to the patient privatisation of
  funding
• Reforming the supply (payment provision)
• Empowering the consumer (increasing choice)
• Strengthening public health
• Rethinking financial sustainability
• Health systems, Health and Wealth

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Reforming the supply

• Purchasing / performance based payment
• Selective contracting / provider competition
• Integration between levels of care / substitution
• Management decentralization / self government
• Primary care at the driving seat
• Evidence base medicine / HTA
• Translating research evidence evidence
  brokering
• Changing clinical practice

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Addressing financial sustainability

• Reforming sources of funding
• Statutory insurance competition
• Shift costs to the patient privatisation of
  funding
• Reforming the supply (payment provision)
• Empowering the consumer (increasing choice)
• Strengthening public health
• Rethinking financial sustainability
• Health systems, Health and Wealth

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Responsiveness
Efficiency
Access
EuroObserver 2004 Thomson S et al
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Patient empowermentIncreasing choice
(responsiveness)

• Sufficient information / benchmarking?
• Trade offs with efficiency?
• Trade offs with equity?
• Inverse participation law

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Addressing financial sustainability

• Reforming sources of funding
• Statutory insurance competition
• Shift costs to the patient privatisation of
  funding
• Reforming the supply (payment provision)
• Empowering the consumer (increasing choice)
• Strengthening public health
• Rethinking financial sustainability
• Health systems, Health and Wealth

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Investing in public health The ultimate demand
reduction strategy

• Prevention is (often) better than cure
• Cost effectiveness of public health interventions
• Stepping up public health interventions in the EU
• Health in All Policies Finland presidency (2006)
• Wanless reports (2002, 2004) in the UK
• Public health bills France (2003), Sweden (2002)
• Reducing inequalities the Netherlands (2001)
• Smoking ban Ireland, Spain, UK, Belgium

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Re-examine financial sustainability Health is
Wealth
Source The Contribution of Health to the Economy
Surke, Mckee et al 2005
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Re-examine financial sustainability Health
Systems, Health and Wealth
Health Systems
Performance
Impact on economic growth
Wealth
Health
WHO EURO Ministerial Conference 2008
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Re-examine financial sustainability Health
Systems, Health and Wealth

• Sustainability as willingness to pay (for
  solidarity)
• Private spending also exercises pressure on the
  economy

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Re-examine financial sustainability Health
Systems, Health and Wealth

• Consider Social Sustainability
• Health and social cohesion
• Economic impact of reduced solidarity
• Health inequities and economic growth

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Re-examine financial sustainability Health
Systems, Health and Wealth

• Its the economy stupid
• Health expenditure as percentage of GDP
• Addressing sluggish economic (GDP) growth
• The Lisbon agenda global competitiveness
• Health system expenditure as investment
• Addressing the demographic crisis
• Compression of morbidity and late retirement?

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