Price and Quality Transparency: Focused on Payers and Consumers
Health Reform.cz
Lucie Bryndová International Health Summit 6.4.2008
Overview ...focused on payers:
Contract, price and payment regulations and restraints Quality and price transparency
...focused on consumers:
Quality and price transparency Transparency of consumer entitlement
Reforma zdravotnictví-forum.cz
... focused on payers
Main payment mechanisms - overview Historically developed and set payment mechanisms:
GPs – capitation, fee-for-service for selected services (prevention) Out-patient care – fee-for-service, caps and regulation in place Hospitals (acute) – prospective budgets (loosely conditioned upon performance) Hospitals (long-term care) – per diem payment
Reforma zdravotnictví-forum.cz
... focused on payers
Payment methods and price regulation Until recently, binding by-law (ministerial decree) on payment methods and the increase in level of reimbursement per segments => Persistence of unjustified, historically given, inequalities between remuneration of different providers => Impossibility for a payer to give a better price for higher quality care
Existence of not very well proportionate list of medical services/procedures => some medical specializations more "lucrative" while others "less lucrative"
Reforma zdravotnictví-forum.cz
... focused on payers
Payment methods and price regulation – recent development Starting 2008, ministerial decree is only a guideline => not binding for payers and providers, who are free to agree on a different payment method and to set price accordingly => decree would be used in case of no price/payment method agreement can be reached between a payer and a provider
Trend towards developing package contracts => the decree defines procedures to be withhold from hospitals' prospective budgets (total hip replacements, knee replacements, cataracts) and to be paid on a per case basis => care package (per case) price experiments at some insurers => outcome-based payments not yet explored Reforma zdravotnictví-forum.cz
... focused on payers
Contracts regulation Regulations on conditions of contracts between providers and payers still apply => existence of by-law: ministerial decree => can be considered a barrier to market flexibily, an obstacle for innovative approaches to provider-payer relationship
Reforma zdravotnictví-forum.cz
... focused on payers
Summary Formerly many obstacles for insurers and providers to take on innovative approach to payment methods and contracts. Recent withdrawal of legislative barriers opens the way, but active participation and willingness from both sides is needed. Development of per case or package payments has a potential, yet performance payments should be also explored. Proper motivation to take on active approach is needed on both sides. Current lack of it in some cases may signal a too much of "comfort space“ in finance. Reforma zdravotnictví-forum.cz
Overview ...focused on payers:
Contract, price and payment regulations and restraints Quality and price transparency
...focused on consumers:
Quality and price transparency Transparency of consumer entitlement
Reforma zdravotnictví-forum.cz
... focused on consumers
Price transparency Currently, general public knowledge of the price of health care is very low
Health care is free of charge at the point of use with the exception of newly introduced user fees Possibility for consumers to ask insurer for an Overview of his/her health care costs
However, not very commonly used Starting 2008, insurers can distribute the Overview to their clients together with the statement on user fees
With the introduction of stop-loss limit, side effect occurs – more people may be interested in the user fees statements and overview on what the insurer has paid to providers on behalf of them
Target groups for rising interest in health care consumption overviews are people with high heath care needs, hence those that are likely to reach the stop-loss limit Reforma zdravotnictví-forum.cz
... focused on consumers
Quality transparency Information on quality of health care is limited in its complexity
Individual projects:
Any ranking should respect the diversity of provided health care
www.jaksekdeleci.cz, www.doktorka.cz. Patient satisfaction surveys Ranking of whole hospitals is not the appropriate approach, rather comparisons of medical departments
Important role of medical associations
Reforma zdravotnictví-forum.cz
... focused on consumers
Transparency of consumer entitlement Currently, very vague definition of consumer entitlement
Does not provide for clear enforcement Important differences in accessibility of health services exist
New definition of insurance package in preparation
General definition of entitlement + negative list + positive list Standards of access to care
Maximum limits on accessibility of health services + responsibility of insurers to ensure their fulfillment Geographical accessibility - measured in necessary travel time Time accessibility - on selected procedures (mainly elective care)
