Transcript Exploring - World Health Organization

Exploring the role of insurance-based financing
reforms to improve universal coverage of TB
services
December 11, 2014
Manila, Philippines
Alisha Smith-Arthur
URC/ USAID TB CARE II Project
Outline
I.
Why examine the role of health insurance in the
context of TB service delivery?
II. Meeting on TB and insurance based financing
reforms, Bangkok, Thailand, Sept 2014
III. Discussion of outcomes, main points, and
implications going forward
Current context for examining TB in insurance-based systems
• Continued adoption of the principles of Universal Health
Coverage, including emphasis on increasing access to
care and reduction of financial burden, with health
insurance as a key component
• Introduction of health insurance programs and push for
decentralization leading countries to explore integration of
TB services within insurance coverage packages
• Unclear impact of state-supported health insurance
programs on use of TB services and outcomes
• More information needed to understand the processes
and mechanisms to optimize TB service delivery in the
context of health insurance introduction
Starting point 1: What is the benefit of health
insurance (through a TB lens)?
Insurance aims to:
• Protect households from impoverishment due to high out-of pocket
spending for TB services.
– Requires a system to catch patients early and avoid other
spending; needs to minimize costs for more expansive, in-patient
curative care
• Increase access to and use of TB services where payment is normally
required at the time of need.
• Influence provider and consumer behavior to improve quality,
efficiency, and effectiveness.
• Harness private providers to provide TB services within a framework of
quality and accountability
– Requires high level of oversight, adequate compensation levels,
and timely payments.
Landscape of health insurance options
Types of insurance Financing source
Management
National health
insurance
General taxes
Public sector
Social health
insurance
Payroll taxes from
employers and
employees
Social security agency,
health/sickness fund
Community-based
health insurance
Premium payments
from individuals and/or
community
Community or
insurance association
Private voluntary
health insurance
Premium payments
from individuals or
employers / employees
Commercial insurance
company
Adapted from Health Insurance Handbook, World Bank
Starting Point 2. What are the implications of
introducing a health insurance program (through a
TB lens)?
• Defining the degree of integration of TB services
• Establishing roles and responsibilities of NTP and
insurance authority
• Developing coordination mechanisms for decisions
around policy, coverage, oversight, targets
• Affect of insurance programs on TB objectives:
outcomes, case finding, reduced financial burden
(i.e., social support and patient-centered care)
I.
Policy: TB and UHC policy • Defining landscape of insurance programs and
objectives
relationship to TB
• Incorporating strategic TB objectives within UHC
reforms
II.
Administration and
organization
• Outlining coordinated responsibilities for insurance
and TB authorities
• Defining mechanisms for routine engagement and
coordination
III.
Service delivery
• Defining a benefits package for TB services
• Ensuring all patient needs are covered
IV.
Facilitating access and
utilization
• Continuum of care between service providers
(referrals and follow up)
• Informing and educating TB patients around access
to services, required costs
V.
Engaging more care
providers
• Accreditation and role of other professional
associations
• Reimbursement and incentivizes
VI.
Ensuring quality of care
• Monitoring patient outcomes
• Promoting patient-centered care
Current approach to health insurance in WPR
representative countries
• Among representative countries: 3 with existing or
planned national health insurance programs
• Health insurance funding used for clinical services,
diagnostics, enablers (wide variation between
program models)
• Universal perception among respondents that
introduction of health insurance will positively impact
TB case notification and quality of care, and
decrease patient OOP expenditures
Meeting on TB and insurance-based UHC financing
“Exploring the promise of improving access and delivery
of TB services through insurance-based financing
reforms,” Bangkok, Thailand, Sept 2014
• Participation from 9 countries in WPR and SEAR
• Participation from NTP, Finance, Insurance
authorities, others
 Diverse models, experiences and goals for UHC
financing
Meeting Objective and Purpose
• Provide a forum for information sharing and review of
current systems for ensuring access to, and provision
of, essential TB services and core public health
functions in the context of UHC financing reforms in
Asian countries
• Discuss and develop common principles, best
practices, and policy options around essential public
health functions and core services for TB control and
care in insurance-based systems
• Create a foundation for further investigation and
development on framework guidance
Topic areas for presentation and discussion
• TB and Universal Health Coverage
• Overview of regional models of insurance-based
financing and TB service delivery
• Defining a benefits package for TB services
• Planning and administering TB services effectively in
an insurance-based system
• Engaging more providers effectively through
insurance-based financing
I. Programmatic and policy roles
The role and functions of the NTP in an insurancebased financing system and the impact of
decentralization:
• Necessity of defining the essential public health
functions of a national TB program
– Policy and supervision functions
– Oversight and support for supply and TB commodity
management
– Division of responsibilities for TB and MDR TB diagnostic
and clinical services
I. Programmatic and policy roles
Coordination vs. fragmentation:
• Importance of step-based, coordinated planning for
phased introduction of health insurance between
Finance, insurance authority and NTP
– Avoid disruptions in free access to services
– Rational decentralization
– Two-tiered delivery networks (NTP and insurance based
providers)
II. Provider engagement, payment, and quality of care
Effectiveness of payment mechanisms and provider
engagement function:
• Address the complexity in the development of
effective purchasing and reimbursement mechanisms
for TB providers
– Potential models (i.e., case-based payments, capitation, feefor-service) with relative (dis)advantages depending on the
type of service, service site, and administrative requirements
– Strong oversight functions needed
– Development of additional organizational layers
II. Provider engagement, payment, and quality of care
Provider follow up, monitoring and quality of care:
• Mechanisms for ensuring in-network providers deliver
services according to TB standards
– Effectively matching payments to incentives or incorporate
targets for service delivery outcomes or outputs
– Linked payment mechanisms to structured accreditation and
certification systems
• Facilitates oversight by NTP and/ or insurance authority for
compliance to standards and quality of care
• Requires robust organizational management, in the context of
decentralization
III. Patient needs and patient-centered care
Impact on reducing patient costs:
• More evidence needed to demonstrate impact on
reducing OOP costs for TB patients. Common
challenges:
–
–
–
–
Access to an accredited provider vs. shopping around
Utilization of insurance benefits
Gaps in coverage for needed clinical services
Lack of coverage for social support benefits
Conclusion
• Stronger engagement and continued consultations
between National TB Programs and other planning
authorities around UHC financing and the role of
health insurance
• Develop further evidence on the impact of the impact
of health insurance on the TB outcomes and
economic wellbeing of beneficiaries
• Introduce guidance on development of financing
and/or insurance-based reforms in the context of
national TB and UHC objectives
Change has a considerable psychological impact on the
human mind. To the fearful it is threatening because it
means that things may get worse. To the hopeful it is
encouraging because things may get better. To the
confident it is inspiring because the challenge exists to
make things better.
-King Whitney Jr.
Thank you!