International Health Systems: The Western

International Health Systems: The Asian

Borwornsom Leerapan, MD PhD

MGMG 548: Health Service Systems and Health Systems

CMMU, Mahidol University Aug 3, 2014

Pix source: ra.mahidol.ac.th

Format

Pix source: online.wsj.com

F/U

Mini-lecture

Presentation Discussion

Q&A

Wrapup

To-do list


Housekeeping Issues

1)  [Confirmed] Guest lecturer on Aug 10th (week 13): –  Thaworn Sakunphanit. MD, MSc (Social Policy Financing),

Director of Health Insurance System Research Office (HISRO)

2)  [Canceled/Postponed] Scheduling a site visit to Ramathibodi Hospital & Somdech Phra Debaratana Medical Center (SDMC) –  To settle down on your preferred dates

–  To prepare a scope of your interviews with the executives

•  How do the advanced Asian countries (e.g. Japan, Taiwan, Singapore) finance and organize health services?

•  How such health systems have performed? •  What would be the lessons learned for

healthcare managers currently working in Thai healthcare system?

•  Discussions/Q&A

Outline for Today


Reviewing what we have learned: Organizing & Financing Healthcare


Major Mechanisms of Healthcare Financing

Healthcare Regulator(s)

2) Taxes Payers

4) Employer-based private

health insurance

3) Individual private health

insurance

Hospitals

Medical Specialists

Generalists & PCPs

1) Out-of-pocket

Payments

Ambulatory Facilities

Payment Mechanisms: Salary, Fee-for-Service,

Global Budget, Capitation, etc.

CGD (CSMBS),

NHSO (UCS)

Taxes Payers

Employer-based private health

insurance

Individual & Employer’s

private health insurance

(Voluntary)

Hospitals

Medical Specialists

Generalists & PCPs

Patients paying out-of-pocket



Global Budget, Capitation, DRGs, etc.

Thai Healthcare Systems

Providers in Public & Private Sector

Commercial Insurance

Companies

Social Security

Office (SSS)

Motor vehicle’s owners (Mandatory by the Motor

Vehicle Victim Protection Law)

Federal Government

(e.g. Medicare, VA, Indian)

Taxes Payers

Employer-based private

health insurance

Individual private health

insurance

Hospitals

Medical Specialists

Generalists & PCPs

Uninsured Patients paying out-of-pocket



Global Budget, Capitation, DRGs, etc.

US Healthcare System

Most Providers in the Private Sector

Commercial Health Plans/

HMOs (private health

insurance companies)

State Government (Medicaid,

CHIP)

German National Health Insurance System

Source: Bodenheimer TS, Grumbach K (2009). Understand health policy: a clinical approach

Employer-based private

health insurance

Most Providers in the Private Sector

British National Health Service System (the traditional model)


Taxes Payers

Most Providers in the Public Sector

British National Health Service System (the model after recent reforms)



Taxes Payers

Comparing Asian Healthcare Systems: Organizing & Financing Healthcare


Japanese Healthcare System


Most providers are in the private sector, most small

facilities are private, but large facilities are in the public sector.

Taxes Payers

Negotiated standardized payment rates

(e.g. FFS, per diem)

Corporates

Central govt.

Local govt.

Employers &

Employees

Retirees & (ex-employers) Self-employed, Farmers,

Fishermen, etc.

Japanese Healthcare Systems Ø  “Social Health Insurance” with standard comprehensive benefits, including

payment for hospital and physician services, prescription drugs, maternity care, and dental care, disable adults with long term insurance and earmarked income tax.

Healthcare financing mix

Figure source: Wagstaff (2005). World Bank Policy Research Working Paper 3790.

Compulsory Savings Scheme

(Employees &

Employers)

Individual Insurers

Taxes payers

“Corporatized” public hospitals

& Private hospitals

Medical Specialists

Generalists & PCPs

Patients paying out-of-pocket


Singaporean Healthcare Systems

Providers in Public & Private Sector

Medical Saving Accounts

(Medisave)

Catastrophic insurance program

(Medishield)

Central Provident Fund(CPF)

Public assistant program

(Medifund)

Severe disability insurance program

(Eldershield)

“3M”, “Means-testing”

Source: Hsiao (1995); Singapore's Ministry of Health (2003)

Ø Govt. subsidies aim to provide all Singaporeans basic health care defined as “good and affordable medical services”, but not provide “the latest and best of everything”

Ø Emphasize on greater transparency about costs and prices, more regulation of insurance company’s prices and policies.

Singaporean Healthcare Systems

Taiwanese Healthcare System


Taxes Payers

Govt-run, Single fund,

National Health

Insurance

Ø “Consolidated System”: providing everyone equal access to health care, free choice of doctors, with no waiting time, and a system that encouraged a lot of competition among medical providers.

Ø Efficient administrative system: utilization of information technology, including smart cards, online medical information systems, and online billing systems.

Taiwanese Healthcare Systems

Figure source: Wagstaff (2005). World Bank Policy Research Working Paper 3790.

How have health systems performed?


Health System’s Building Blocks

Pix source: WHO (2007).

Source: WHO (2000). The World Health Report 2000. Pix source: buelahman.files.wordpress.com

Health System’s Performance

Pix source: WHO (2000). World Health Report 2000.

What would be your lessons learned from these comparative health systems?


What Level of Our Learning?

•  Why Wisdom

•  How Knowledge

•  What, Who, When, Where Information

•  Number, Text, Picture, Sound, etc. Data

Four Major Types of Healthcare Systems

Source: Adapted from Roemer (1993).

US Singapore Germany Japan Canada Taiwan UK Cuba

The least !market interventions"

-Private financing "-Private providers "

Socialist !Health Systems"

Entrepreneurial Health Systems"

Comprehensive !Health Systems"

Welfare-oriented !Health Systems"

The most !market interventions"

-Public financing "-Public providers "

Control Knobs Framework for Health Reform

Source: Adapted from Roberts et al. (2003).

Source: Mills A. Health Care Systems in Low- and Middle- Income Countries. N Engl J Med. 2014;370:552-7.


Financing of Healthcare Systems

Financing of Thai Healthcare System CSMBS SSS UCS Motor Vehicle

Victim Protection Law

Private Health Insurance

Feature State/Employer welfare

Compulsory heath insurance with state subsidies

State welfare Compulsory heath insurance for vehicle owners

Voluntary health insurance

Targeted groups of beneficiaries

Civil servants, state enterprise employees and dependents

Employees in private sector and temporary employees in public sector

Thai citizens without the coverage of CSMBS & SSS

Victims of vehicle accidents

General public

Source of financing

Govt. budget

Tri-party (Employee, employer and govt. budget)

Govt. budget

Vehicle owners Household

Method of payment to health facilities

Fee-for-service Capitation and Fee-for-service

Capitation and Fee-for-service

Fee-for-service Fee-for-service

Major problems Rapidly and constantly rising costs

Covering while being employed only

Inadequate budget

Redundant eligibility and slow disbursement

Redundant eligibility and slow disbursement

Source: Adapted from Wibulpolprasert et al. (2011). Thailand Health Profile 2008-2010.


Desirable Healthcare Systems

•  Systems Thinking •  Focus on quality,

efficiency & equity •  Responsive (esp. to

health needs of certain disease and certain populations)

•  Good governance in all level of health system


Towards a Better Healthcare System





Food-for-Thought


Pix source: en.wikipedia.org/

“The track of the previous cart is the teacher of the following cart.”

--A Chinese proverb

Q& A Discussions
