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HEALTH BENEFIT PLANS
IN OECD COUNTRIES
Valérie Paris (OECD)LAC webinar, May 15, 2014
Health benefit package/basket/plan = all services, activities, and goods covered by publicly funded statutory/mandatory insurance schemes (social health insurance) or by National Health Services (NHS)
(definition proposed by Busse et al, 20005, in a European context)Covered = “at least partially covered” (there might be cost-sharing)Publicly funded refers to the agent who finances health care. It needs to be government or mandatory health insurance (could be private).
In OECD countries, in 2012
What is this webinar about?
Benefit package is one of the three dimensions of health coverage
Source : Adapted from Busse, Schreyögg and Gericke, 2007
OECD countries have organised coverage for health care in many ways
Main source of basic health care coverage
Countries
Tax-funded health system
Australia, Canada, Denmark, Finland, Iceland, Ireland, Italy, New Zealand, Norway, Portugal, Spain, Sweden, United Kingdom
Health insurance system
Single payer Greece, Korea, Luxembourg, Poland, Slovenia, Turkey, Hungary
Multiple insurers, with automatic affiliation
Austria, Belgium, France, Japan, Mexico
Multiple insurers, with choice of insurer
Chile, Czech Republic, Germany, Israel, the Netherlands, Slovak Republic, Switzerland, United States
Source: OECD Health Systems characteristics survey, 2012
The range of benefits covered can be defined:
•Explicitly, i.e. by itemised list of activities and good,
– e.g. « positive list » of reimbursed medicines; catalogs of procedures and activities;
•Or implicitly, i.e. in very broad terms, e.g. « all medically necessary services » (Germany)
•Positively, by stating which services and goods are covered
•Negatively, by stating which services and goods not covered
•Often, by a mix of those methods (depending on categories of goods and services)
How do patients and doctors know what is covered?
The OECD collected information on health systems characteristics in 2012
Question 1. How are the services or benefits covered by basic health coverage defined (check all that apply)?
a) For medical/surgical procedures:
A positive list is established at the central level A negative list (of non-covered procedures) is established at the central level Individual health insurance funds establish their own positive lists (e.g., services that are required
to be covered) Individual health insurance funds establish their own negative lists (e.g., services that are excluded
from coverage) Providers under budget constraints establish their own positive lists at the local level The benefit basket is not defined, every procedure performed by a clinician is considered by basic
primary coverage schemes
Comments/clarifications: b) For pharmaceuticals
A positive list is established at the central level A negative list (of non-covered procedures) is established at the central level Individual health insurance funds establish their own positive lists (e.g., services that are required
to be covered) Individual health insurance funds establish their own negative lists (e.g., services that are excluded
from coverage) Providers under budget constraints establish their own positive lists at the local level The benefit basket is not defined; prescription drugs that are approved for marketing are
systematically covered by basic primary coverage schemes Comments/clarifications:
NHS countries
Source: OECD Health Systems characteristics survey, 2012
Positi
ve li
st,
cent
ral l
evel
Neg
ative
list
, ce
ntra
l lev
el
Indi
vidu
al p
ayer
s po
sitive
list
s
Indi
vidu
al p
ayer
s ne
gativ
e lis
ts
Prov
ider
s' po
sitive
list
s
Bene
fit b
aske
t no
t defi
ned
Positi
ve li
st,
cent
ral l
evel
Neg
ative
list
, ce
ntra
l lev
el
Indi
vidu
al p
ayer
s po
sitive
list
s
Indi
vidu
al p
ayer
s ne
gativ
e lis
ts
Prov
ider
s' po
sitive
list
s
Bene
fit b
aske
t no
t defi
ned
AustraliaCanadaDenmarkFinlandIcelandIrelandItalyNew ZealandNorwayPortugalSpainSwedenUK (England)
Medical procedures Pharmaceuticals
Health insurance systems
Posi
tive
list
, ce
ntra
l lev
el
Neg
ative
list
, ce
ntra
l lev
el
Indi
vidu
al
paye
rs p
ositi
ve
lists
Indi
vidu
al
paye
rs
nega
tive
list
s
Prov
ider
s'
posi
tive
list
s
Bene
fit b
aske
t no
t de
fined
Posi
tive
list
, ce
ntra
l lev
el
Neg
ative
list
, ce
ntra
l lev
el
Indi
vidu
al
paye
rs p
ositi
ve
lists
Indi
vidu
al
paye
rs
nega
tive
list
s
Prov
ider
s'
posi
tive
list
s
Bene
fit b
aske
t no
t de
fined
AustriaBelgiumChile (public)Chile (private)Czech Rep.EstoniaFranceGermanyGreeceHungaryIsraelJapanKoreaLuxembourgMexicoNetherlandsPolandSlovak RepublicSloveniaSwitzerlandTurkey
Medical procedures Pharmaceuticals
Do OECD countries use HTA to make coverage decisions?
Source: OECD Health Systems characteristics survey, 2012
Nombre of countries using HTA systematically or occasionnally to make coverage decisions or to set reimbursment price
CountryHTA includes
economic evaluation
Public payer perspective
included
Health system perspective
included
Societal perspective
included
Affordability or budget
impact considered
Australia ● ● ● ● ●Austria ● ● ● ○Belgium ● ● ○ ● ●Canada ● ● ● ○ ●Chile ○ ○Czech RepublicDenmark ● ● ● ○ ○Estonia ● ●Finland ● ● ● ● ●France ● ● ● ● ●GermanyGreece ● ○ ● ○ ●Hungary ● ● ● ● ●Iceland ● ● ●Ireland ● ● ● ● ●Israel ● ● ● ○ ●Italy ● ● ● ● ●Japan ○ ○Korea ● ● ● ● ●LuxembourgMexico ● ○ ● ○ ●Netherlands ● ○ ○ ● ●New Zealand ● ○ ● ○ ●Norway ● ● ● ● ●Poland ● ○ ● ○ ○Portugal ● ○ ○ ●Slovak RepublicSlovenia ● ● ○ ○ ●Spain ● ○ ● ○ ○Sweden ● ○ ● ○ ○Switzerland ● ● ● ○ ○Turkey ●United Kingdom ● ○ ● ○ ○United States
HTA methods differ across OECD countries
CountryIndependent
body at central level
Purshasers at central
level
Purshasers at local levels
Independent body on request
Not performed
Australia ● ● ● ○ ○Austria ○ ○ ○ ● ○Belgium ● ● ○ ○ ○Canada ● ○ ● ● ○Chile ○ ○ ○ ○ ●Czech Republic ○ ○ ○ ○ ●Denmark ○ ● ● ○ ○Estonia ○ ○ ○ ● ○Finland ● ○ ○ ○ ○France ● ○ ○ ○ ○Germany ○ ○ ○ ○ ○Greece ○ ○ ○ ● ○Hungary ○ ● ○ ○ ○Iceland ○ ○ ○ ○ ●Ireland ● ● ○ ○ ○Israel ○ ● ○ ○ ○Italy ○ ● ● ○ ○Japan ● ○ ○ ○ ○Korea ○ ● ○ ○ ○Luxembourg ○ ○ ○ ○ ●Mexico ○ ● ● ○ ○Netherlands ● ○ ○ ○ ○New Zealand ● ● ○ ● ○Norway ● ○ ○ ○ ○Poland ● ○ ○ ○ ○Portugal ● ○ ○ ○ ○Slovak Republic ○ ○ ○ ○ ○Slovenia ● ○ ○ ○ ○Spain ○ ● ● ○ ○Sweden ○ ● ○ ○ ○Switzerland ○ ○ ○ ○ ○Turkey ● ○ ○ ○ ○United Kingdom ● ○ ○ ○ ○United States ○ ○ ○ ○ ●
HTA is performed by different stakeholders
DECISIONS ON COVERAGE AND PRICES FOR
PHARMACEUTICALS
Context: « Value-based pricing » envisaged in UK, recent changes in Germany, and changes announced in France
Objectives were to explore:
• How a sample of OECD Member Countries refer to “value” when making decisions on reimbursement and prices of new medicines;
• How this value is assessed;
• Whether countries are willing to pay a price premium for innovation
• Which kind of innovations receives an extra premium;
• Whether specific rules apply for some medicines (orphan drugs, end of life drugs, etc.)
The 2013 OECD study on Value in pharmaceutical pricing
13
14
METHOD: Analyse of reimbursement and pricing process in 14 countries
METHOD : Sample of 12 Products, marketed in 2004-2011
Bevacizumab: cancer, several indications (breast, colorectal, lung, kidney) with different therapeutic valueCetuximab: cancer, 2 indications (colorectal, head and neck)Sunitinib: cancer, oral, several indications (GIST, renal cell, pancreas)Cabazitaxel: prostate cancer
Dabigatran: oral anticoagulant and prevention of stroke
Fingolimod: Multiple sclerosis
Eculizumab: orphan drug
Boceprevir and Telaprevir: hepatitis C
Ranibizumab: age-related macular degeneration
Sitagliptin, Sitagliptin-metformin, Type 2 diabetes
Illustrative of different situations (severity, efficacy, cost-effectiveness, social impact, size of population target, etc.), not representative of the whole market
15
• Clinical outcomes: guidelines prefer final endpoints (i.e. survival) but accept intermediate and surrogate outcomes (i.e. reduced cholesterol) if final not available. Assessment bodies use what is available (quite similar across countries)
Countries do not always agree on the level of “innovativeness” of new products
• Utility weights used to estimate QALYs gained: Countries’ guidelines for economic evaluation often indicate a preference for multi–attribute utility (MAU ) “generic” instruments used in Randomised Clinical Trials;
• In practice: assessment reports use data provided by companies, who use both generic MAU instruments and disease-specific instruments which are more sensitive to specific outcomes
Utility weights can has an impact and can potentially change the decision
How is « value » assessed
16
• The perspective adopted is potentially influential on the price paid
• Several possible perspectives:
• Public payer only: considers costs (and savings) for public payers for health system + social services where relevant : Australia, UK, Canada’s public plans
• All health care payers: including patients, families or private complementary coverage (e.g. France)
• Societal perspective: considers and monetizes all costs and benefits for the society (cost-benefit analysis): preferred in Nordic countries and the Netherlands
• In our sample: most often public payers and direct costs only
What are the perspectives and methods adopted for economic evaluation?
17
Observed for the sample of products studied:
•Comfort of use valued when it is likely to reduce costs
E.g.: The oral anticoagulant got a price premium over competitors in some countries for its 1st indication but its price was reduced when the second indication was approved (market size x 4)
•No evidence that « innovation per se » is rewarded
•No evidence that recognition of wider societal benefits are valued (even for the drug for multiple sclerosis)… but sample of products is not representative
Not much consideration of « wider benefits » (beyond clinical improvement) in our sample of products
18
• Most countries seem reluctant to set and publish an explicit incremental cost-per-QALY threshold (or range) beyond which they refuse to pay for any drug (England, Netherlands are exceptions)
• “Implicit thresholds” can be revealed by past decisions
• The threshold (or threshold range) varies across therapeutic areas
• Countries pay more for life-threatening disease, end-of-life and orphan dugs, well beyond explicit or implicit thresholds. Rules are more or less explicit.
• Other limits? Several countries consider budget impact as an integral part of the evaluation process (with an impact on decision-level) and high BI sometimes led to delayed entry or referral to a higher level of decision-making.
Setting limits?
19
International price benchmarking is still being used by many OECD countries
20
• In our sample, more than 20 agreements used to address:
– Uncertainties about clinical efficacy or effectiveness:
– Uncertainties about cost-effectiveness (ICER): performance-based agreements, linking price to actual performance (for individuals or for a group of patients treated)
– Uncertainties about budget impact : financial agreements aiming to control budget impact and ensure value-based pricing
• Most product-specific agreements in our sample address uncertainty on ICER or too-high ICER (= price negotiation).
• Used for cancer medicines with variable ICER / by indication (price discrimination across indications) – value-based pricing
– But indications subject to agreements are not always similar across countries...
• Italy and the UK are big users (of non-confidential agreements)
The use of product-specific agreements in our sample of countries/products
21
• Obviously: price premium over competitors... and non inclusion in reference price clusters (Germany) or lower price than competitors (France)
• In some countries, most innovative products get “international price” while others are priced relative to competitors’ price in internal market (France, Canada Federal, Germany, etc)
• There seems to be a link between the price premium granted and added therapeutic value but it is impossible to say “how much does a QALY worth” – even within a given country because the price of a QALY (or ICER accepted) varies across therapeutic areas: does it reflect value of market conditions?
• International benchmarking and volumes are important determinants of prices
What do products get for added therapeutic value?
22
WHAT ABOUT COST-SHARING REQUIREMENTS FOR COVERED SERVICES?
Section 4. Comprehensiveness of basic health care coverage Section 4 aims to assess the level of basic health care coverage to which “typical” working-age adults are entitled to. Responses should not consider children, seniors and other categories of population which may be entitled to higher levels of benefits (e.g. people with serious illnesses). In countries with multiple insurers allowed to offer different levels of benefits, responses should refer to the most frequent or most typical situation.
Question 13. Is there a general deductible* that must be met before basic health coverage pays a share of the cost or the full cost of covered services?
□ Yes If so, what is the amount of the deductible that must be met before basic primary health coverage pays/reimburses? (national currency units) ______What is the period in which the deductible applies (e.g. year, lifetime, episode of illness, etc.)? □ No
Information collected in the Health Systems Characteristics survey on cost-sharing
Information collected in the Health Systems Characteristics survey on cost-sharing
Outpatient primary care physician* contacts
Examples: - Free at the point of care; - Copayment of €2 per visit; - Copayment of €10 for the first of each semester; - Co-insurance of 20%; - Not reimbursed if not referred
Pharmaceuticals Examples: - Copayment per prescription item ($5 for generics and $20-25 for brandname drugs); - Cost-sharing: 10% of cost with a min of €5 and a max of 10€ per item; - Cost-sharing of 0%, 35%, 65% or 85% depending on drug category + €0.50 per item - Deductible of SEK 900 beyond which cost-sharing diminishes by step as spending increases (from 50%, 25%, 10% and 0%). - Any difference between actual price and reference price for medicines subject to reference price
Question 14. Are patients required to share the costs of health care for the services and goods listed below? Please indicate the type and level of cost-sharing left at the charge of users by basic primary health coverage, in the case of an adult with no specific exemption of user charge. If there is no cost-sharing, please indicate "no cost-sharing".
Different types of cost-sharing
Co-insurance: cost-sharing requirement whereby the insured person pays a share of the cost of the medical service (e.g. 10%).
Copayment: fixed sum (e.g. USD 15) paid by an insured individual for the consumption of itemized health care services (e.g. per hospital day, per prescription item). User fee, prescription fee sometimes used as synonymous.
Deductible: lump sum threshold below which an insured person must pay out-of-pocket for health care before insurance coverage begins. It is defined for a specific period of time: one year, one quarter or one month. Deductibles can apply to a specific category of care (e.g. physicians’ visits, pharmaceutical spending) or to all health expenditures (general deductible).
Extra-billing: refers to any difference between the price charged and the price used as a basis for reimbursement purpose. In the pharmaceutical sector, where “reference prices” are often used, a fixed reimbursement amount is determined for a cluster of products, while sellers remain free to set a higher price. The patient pays out-of-pocket any difference between the price of a medicine and the reference price.
User charges for outpatient medical services
Cost-sharing on outpatient medical care Primary care Specialised careFree of charge for all Canada, Denmark, Hungary, Italy,
Poland, Spain, United KingdomCanada, Denmark, Hungary, New Zealand, Poland, Spain, United Kingdom
Australia (≈80% of GP services) Australia,Chile (public-public) Germany (SHI)Germany (SHI-85% pop) Greece (public providers),Greece (public provider) Ireland (public-public)Ireland (40% of pop), Israel (3 out of 4 HIFs)
Mexico (public-public)
Mexico (public-public)Austria (specific) Austria, Israel (specific)Netherlands (general) Netherlands (general)Czech Republic, Finland, Czech Republic, Finland, Italy,Iceland, Norway, Portugal, Sweden
Iceland, Norway, Portugal, Sweden
Chile (provider choice) Chile, Japan, Korea, Luxembourg,
Japan, Korea, Luxembourg, New Zealand, Slovenia
Slovenia
Copayment+co-insurance Belgium, France Belgium, France, IcelandDeductible + co-insurance Switzerland SwitzerlandFull price Ireland (60% of pop)
Free of charge for some
Deductible
Copayment
Co-insurance
• Inpatient care is more often free of charge or only subject to small daily copayments, except in a few countries with co-insurance rates (France, Japan, Korea, etc)
• In a few countries, inpatient care is free for patients admitted as public patients in public hospital but subject to copayments for patients admitted as private patients (Australia, Italy)
• User charges are the common rule for pharmaceuticals, with a few exceptions. They most often take the form of co-insurance (with differentiated rates) or fixed prescription charges. Several countries also have deductibles
User charges: for other benefits
Exemption/reduction of cost-sharing
Chronically ill and/or disabled
Low-income
Entitled to social
benefits Seniors Children
Pregnant women
Beyond an absolute
cap on cost-sharing
Beyond a cap
related to income
Australia
Austria
Belgium
Canada
Chile Czech Republic
Denmark
Finland
France
Germany
Greece
Hungary
Iceland
Ireland
Israel
Italy
Japan
Korea
Luxembourg
Mexico
Netherlands
New Zealand
Norway
Poland
Portugal
Slovak Republic
Slovenia
Spain
Sweden
Switzerland
United Kingdom
United States
WHAT DO HEALTH ACCOUNTS TELL US ABOUT
HEALTH COVERAGE AND BENEFIT BASKET?
From « entitlements » to actual coverage
Entitlements: benefit basket and cost-sharing
Health spending level and financing structure
Availability of health care supply
Affordability of health care services and goods
Cost-sharing exemptions and caps
Population not covered, services not covered, informal payments
• Canada and Hungary indicated that patients can access primary care services for free.
• Japan indicated a 30% co-insurance rate for these services.
• The share of PHI and OOP payments in spending for basic medical and diagnostic care is:
Examples
Share of spending in inpatient care by financing agent, 2011
Share of pharmaceutical spending by financing agent, 2011
Note: This indicator relates to current health spending excluding long-term care (health) expenditure.1. Including rehabilitative and ancillary services.2. Including eye care products, hearing aids, wheelchairs, etc.Source: OECD Health Statistics 2013
What do patients pay for?Shares of out-of-pocket medical spending by services and goods, 2011 (or nearest year)
• What is the decision-making process to update/revise the benefit basket in OECD countries? – Stakeholders involved– Criteria used– Assessment in terms of transparency,
acceptability– Case studies on decisions made for a
set of « borderline activities »
Future OECD work on benefit basket
• Thank you for your attention• Contact: valerie.paris@oecd.org
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