Public-Private Partnership in Healthcare · PDF filePublic-Private Partnership in Healthcare...

Public-Private Partnership in Healthcare Financing Survey of East Asian countries

SiaoWearn Leong Samuel Tan

Chi Cheng Hock Gideon Tan Joyce Poh

Joint IACA, IAAHS and PBSS Colloquium in Hong Kong www.actuaries.org/HongKong2012/

Session Number: TBR5

PPP in Healthcare Financing Survey of East Asian countries

Agenda


Goal of SAS project

Indicators of quality / level of health funding

Qualitative survey Public / private roles in healthcare financing

Public / private roles in healthcare provision

Actuaries' involvement in healthcare

Conclusion and inferences


Goal of SAS project


Establish repository of information on public-private healthcare

financing models around the world

Resource for actuaries and researchers Compare contribution to national healthcare expenditure (NHE)

by public sector / residents and correlate to economic and healthcare metrics

Identify trends over time e.g. - penetration of health insurance in the population - convergence of the design of private insurance plans - involvement of actuaries in the design of financing models


Indicators


Singapore

Malaysia Indonesia

Japan

Australia

South Korea

Philippines

Thailand

Taiwan

India

-10,000

0

10,000

20,000

30,000

40,000

50,000

60,000

0.00% 2.00% 4.00% 6.00% 8.00% 10.00% 12.00%

GD

P pe

r Ca

pita

l (U

S$)

NHE as % of GDP

Relationship between GDP per capita and NHE as % GDP

Singapore

Malaysia

Indonesia

Japan

Australia

South Korea

Philippines

Thailand

Taiwan

India

y = 5E+06x2 + 152820x - 6818.7


Indicators


4.2% 2.5% 3.6% 4.2%

4.6%

4.3%

6.9% 6.5%

5.1%

8.5% 8.7%

0

5,000

10,000

15,000

20,000

25,000

30,000

35,000

40,000

45,000

50,000

India Indonesia Philippines Thailand Malaysia Singapore South Korea

Taiwan Hong Kong Japan Australia

GD

P pe

r Ca

pita

l (U

S$)

GDP and NHE per capita

GDP per capita NHE per capita


Indicators


38%

56%

46%

81%

68%

58%

50%

35%

75%

66%

30%

53%

44%

54%

19%

32%

42%

50%

65%

25%

34%

70%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Singapore

Malaysia

Indonesia

Japan

Australia

South Korea

Hong Kong

Philippines

Thailand

Taiwan

India

GDP per Capital (US$)

Breakdown of NHE by source of funding

Govt Expenditure Private Expenditure


Indicators


6%

0%

7%

71%

0%

45%

0%

10%

8%

30%

5%

33%

55%

39%

10%

68%

13%

50%

25%

67%

36%

25%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Singapore

Malaysia

Indonesia

Japan

Australia

South Korea

Hong Kong

Philippines

Thailand

Taiwan

India

Breakdown of General Government Expenditure by source of funding (% Total NHE)

Social Security Expenditure Others


Indicators


53%

34%

41%

0%

20%

32%

54%

15%

60%

7%

7%

2%

0%

8%

5%

7%

7%

3%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Singapore

Malaysia

Indonesia

Japan

Australia

South Korea

Hong Kong

Philippines

Thailand

Taiwan

India

Breakdown of Private Expenditure on health by source of funding (% NHE)

Govt Out of Pocket Expenditure Private Prepaid Plans


Indicators


32

18

6.5

139

38.8

86

45

13

22

66.37

9

0 20 40 60 80 100 120 140 160

Singapore

Malaysia

Indonesia

Japan

Australia

South Korea

Hong Kong

Philippines

Thailand

Taiwan

India

Hospital Beds per 10,000 population

Beds per 10,000


Indicators


0.5

0.2

1.0

0.3

1.1

1.6

1.9

1.9

1.8

2.3

3.0

0 1 1 2 2 3 3 4

India

Indonesia

Philippines

Thailand

Malaysia

Singapore

South Korea

Taiwan

Hong Kong

Japan

Australia

Number of Doctors per 1,000 population

Number of Doctors per 1000


Indicators


Singapore

Malaysia

Indonesia

Japan

Australia

South Korea

Philippines Thailand

Taiwan

India 0

500

1,000

1,500

2,000

2,500

3,000

3,500

4,000

4,500

60 65 70 75 80 85

NH

E pe

r ca

pita

(US$

)

Life Expectancy at birth - Male (years)

Relationship between Life Expectancy and NHE per capita

Singapore

Malaysia

Indonesia

Japan

Australia

South Korea

Philippines

Thailand

Taiwan

India


Indicators


Singapore

Malaysia

Indonesia

Japan

Australia

South Korea


Taiwan

India 0

500

1,000

1,500

2,000

2,500

3,000

3,500

4,000

4,500

0 0.5 1 1.5 2 2.5 3 3.5

NH

E pe

r ca

pita

(US$

)

No of Doctors per 1000

Relationship between Life Expectancy and Doctors

Singapore

Malaysia

Indonesia

Japan

Australia

South Korea

Philippines

Thailand

Taiwan

India


Indicators


Singapore

Malaysia

Indonesia

Japan

Australia

South Korea


Taiwan

India 0

500

1,000

1,500

2,000

2,500

3,000

3,500

4,000

4,500

0 0.5 1 1.5 2 2.5 3 3.5

NH

E pe

r ca

pita

(US$

)

No of Doctors per 1000

Relationship between Doctors and NHE per Capita

Singapore

Malaysia

Indonesia

Japan

Australia

South Korea

Philippines

Thailand

Taiwan

India


Public / private roles in healthcare financing


Government role in healthcare financing

Limitations of publicly financed healthcare and

inference for private insurance role (to what extent

does private insurance succeed in "closing the gaps")

Coverage under public / private schemes


Government role in healthcare financing


Financing of providers

Compulsory savings

National health

insurance

Singapore

Hong Kong

Malaysia India (B/APL,

schemes by trade)

Australia Japan

Thailand Taiwan Korea

China (Urban SHI, rural co-op schemes)

social schemes


How is financing obtained?


General tax revenue Main form of financing for most countries

surveyed

Payroll levy on employers + employees

China (SHI), India

Notional income tax

Australia Medicare levy

Taiwan NHI levy


Limitations of government financing


Long waiting times (Australia:

"for certain conditions", Hong

Kong: "for electives")

Staff shortages (Hong Kong,

Malaysia: "public facilities

compete with private")

Uneven distribution of quality

and facilities (China, Korea,

India, Thailand and others)

Corruption (China, India)

Reform of system

Opportunity for private sector

to fill gaps

Hong Kong Taiwan China

Everywhere


Coverage under public / private schemes


to insert




Provider ownership: Primary / tertiary

Provider payment structure: Primary / tertiary

Role of primary care




Primary Care

Provider Ownership

(Private or Public?)

• Mainly private

Dominant Method of payment

• Fee for Service (FFS)




Hospital : Provider Ownership

Public Private

Australia 67% 33%

Hong Kong 88% 12%

Japan 45% 55%

Malaysia 75% 25%

Singapore 72% 28%

Taiwan 34% 66%

Thailand 75% 21%

India 60% 40%

Indonesia 71% 29%

Philippines 38% 62%

South Korea 10% 90%

China 92% 8%




Hospital : Dominant Method of Payment

Global Budget

Fee for Service

Diagnostic Related Group

Case Based

Australia X ∆ X ∆

Hong Kong X ∆

Japan X ∆ X ∆

Malaysia X X∆

Singapore X X∆

Taiwan X∆ X∆

Thailand

India

Indonesia

Philippines X∆

South Korea X∆

China X∆ ∆

X - Public ∆ - Private


Role of primary care


Is registration with GP required?

GP performs gatekeeping

UK Yes Yes

Australia No Yes

Hong Kong No No *

Japan No No

Malaysia No No *

Singapore No No *

Taiwan No No

Thailand No No

India No No

Indonesia No No

Philippines No No

South Korea No No

China No No

*Often a claim

condition for PMI


Actuaries' involvement in healthcare


Actuaries in public / private sector

Roles of actuaries in different markets


No. of practising actuaries in health


Actuaries Public Private Comment

Australia 3 36 in health Hong Kong 1 No statistics

Japan 0 No statistics Malaysia 0 No statistics

Singapore 3 40 in health Taiwan 0 No statistics

Thailand 0 350 300-400 in total

India 6 238

total no of Fellows in 2011

Indonesia 0 No statistics Philippines 0 No statistics

Korea 4 773 practising actuaries

China 0 37


Role of health actuary in Asia


Australia Hong Kong Japan Malaysia Singapore Taiwan Thailand India Korea China Product development / pricing / marketing Advice on product design Y Y Y Y Y Y Y Y Calculation of premium rates Y Y Y Y Y Y Y Y Advice on underwriting Y Y Y Y Y N Y Y Work on reinsurance arrangements N Y Y Y Y N Y Y IT-Development / Datasets Support of IT development and implementation Y Y Y N N N N N Establish or managing data sets Y Y Y Y N N N N Product management Revision and review of premium rates at least yearly Y Y Y Y Y Y Y Y

Approval of rates is required by a qualified actuary Y Y Y Y Y Y Y N

Reserving

Calculation of aging provisions N N N Y Y Y Y N Calculation of active reserves (i.e. DAC) Y Y N Y Y Y Y Y Calculation of technical provisions (Unearned premium, reported but not paid claims, IBNR, claims handling reserve):

Y Y Y Y Y Y Y Y

Accounting / Statistics and reporting Statutory accounting Y Y N Y N N N Y Statistics, reporting and consulting Provide reports to management Y Y Y Y Y N Y Y Provide information or reports to supervisory authorities Y Y Y Y Y Y Y Y Compile statistics or publications Y Y Y Y Y N Y Y Financial modelling Business planning Y Y Y Y Y N Y Y Valuation Y Y Y Y Y Y Y Y Forecasting/Profit testing/Stress tests Y Y Y Y Y Y Y Y Medical management and operational reviews N Y Y (for a few) Y N N Y N Benchmarking Y Y N N N Y Y Other activities

Analysis for mergers

Y Y Y (if working for consultancy)

Y Y N N N

Companies appraisal analysis Y Y Y Y Y N N N Involvement in risk management Y Y Y Y Y N N N

PPP in Healthcare Financing Survey of East Asian countries Conclusion and inferences


Public / private contributions to health care financing in Asia

ranges across wide spectrum

As GDP/capita increases, NHE increases exponentially

Public role must extend even more beyond direct financing of

providers to providing framework for national health insurance,

compulsory savings and incentivisation of private sector

There is room for primary caregiver to have stronger role in

directing utilization of health services

Actuaries' role in public and private health financing is evolving

and expanding

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