The Impact of the Economic Crisis on Health and the Health System in Ireland Anne Nolan (TCD, ESRI)...
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Transcript of The Impact of the Economic Crisis on Health and the Health System in Ireland Anne Nolan (TCD, ESRI)...
The Impact of the Economic Crisis on Health and the Health System in
Ireland
Anne Nolan (TCD, ESRI)Charles Normand (TCD)
Irish Economic Policy ConferenceDublin, 31st January 2014
2
Context
Substantial health system pressures in Ireland
Large, real declines in public expenditure
Total public health expenditure2000-2013
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 20130.0
2.0
4.0
6.0
8.0
10.0
12.0
14.0
16.0
18.0
nominal real (2000=1)
€bn
(cap
ital +
cur
rent
)
Sources: Department of Public Expenditure and Reform; CSO
4
Context
Substantial health system pressures in Ireland
Large, real declines in public expenditure
External pressures: Demographic change (population growth; fertility)
Internal pressures: Limited capacity in some sectors Weak primary and community care Demand-led schemes High costs (salaries; pharmaceuticals) Programme for Government commitments
5
Approach
Review responses and policy levers in three key areas: Level and mix of statutory resources for health Health cover Health service efficiency
Examine impact of crisis, and health system responses, on population health Mortality Self-assessed health Health behaviours
Conclusions
6
1 Level and mix of statutory resources for health
Statutory resources, i.e., payments that are pre-paid and mandatory General taxation (direct/indirect) Payroll taxes/social health insurance Mandatory health insurance (e.g., Netherlands)
Principles: Adequate level Stability and predictability Fairness/equity Transparency Other (e.g., impact on labour costs)
7
Current situation in Ireland
Public health expenditure as % of total health expenditure has been falling Trend in contrast to OECD average Increasing reliance on out-of-pocket payments and PHI
Public health expenditure as % of total public expenditure has been relatively stable Initial pace of cuts could not be sustained
8
Public health expenditure as% total health expenditure, 2000-2011
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 201150.0
55.0
60.0
65.0
70.0
75.0
80.0
Ireland OECD
% o
f tot
al h
ealth
exp
endi
ture
Source: OECD
9
Public health expenditure as % of total public expenditure, 2008-2012
2008 2009 2010 2011 201220.0
22.0
24.0
26.0
28.0
30.0
24.7 24.6 24.4 24.725.1
% o
f tot
al p
ublic
exp
endi
ture
Source: Department of Public Expenditure and Reform
10
Policy options
Continue with budget reductions
‘Earmark’ resources for health (within existing funds)
Introduce a new source of statutory revenue, e.g., payroll tax But, off-setting reductions in general taxation Adequacy and stability (pro-cyclical fluctuations)
Introduce a new source of statutory revenue, e.g., tax on sugar-sweetened drinks (SSD) Primary objective is behavioural change HIA report on SSD tax published in May 2013
11
2 Health cover
Three aspects of public health cover: Breadth: who is covered? Scope: what is covered? Depth: how much is covered? Are there user fees?
Principles, i.e., role of coverage in: Alleviating/exacerbating fiscal pressure Strengthening health system performance Enhancing efficiency in allocation and use of statutory resources
12
Current situation in Ireland
Complex system of public healthcare entitlements Category I (full medical card) Category II
Also GP visit card (since 2005) Other entitlements: LTI, HTD, etc.
Role of private health insurance (PHI) Recent declines in cover
13
Population cover (%)
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
% Category I % GP Visit card % Category II
% o
f pop
ulati
on
Source: Thomson et al. (2012), Figure 4.2
14
Changes to statutory coverage
Breadth e.g., re-introduction of means test for over 70s in 2009, proposed
extension of GP visit cards to all those 5 and under
Scope Reductions in dental, optical and aural entitlements
Depth Increases in user fees (e.g., public hospital charges; prescription
deductible for Category II) Introduction of new user fees (e.g., prescription fee-per-item for
Category I)
15
Policy options
Breadth International trend is towards increasing coverage Removing coverage increases role for PHI (fiscal pressure via tax relief)
Scope Role of HTA Streamlining the benefit package is often technically and politically
difficult to achieve
Depth Usual arguments for user fees do not hold in health care May conflict with Programme for Government objectives
16
3 Health system efficiency
Concerned with purchasing arrangements What to purchase? Who should purchase? From whom? At what price? Under what conditions?
Principles: Matching resources to need Reducing waste Ensuring quality Setting priorities
17
Current situation in Ireland
Purchasing largely co-ordinated by HSE Sometimes also plays a provider role
Paying for primary care
Paying for acute hospital care
Reforming delivery structures Primary care teams Hospital trusts/groups Working practices
18
Policy options Payment of providers
GPs: increasing capitation component Acute hospitals: increased use of DRGs, MFTP Specialists: salary levels
Reform of delivery structures Primary care teams Integration across primary, community and acute sectors Hospital autonomy
Input prices In particular, pharmaceuticals
Impact of economic crisis on health?
Caveats Availability of timely data Time lags in effects Establishing causality (crisis, response to crisis, something else?)
Large international literature on the impact of the macroeconomic cycle on population heath In general, mortality found to be procyclical (with exception of suicide) In general, poor physical health status found to be procyclical, while
poor mental health status found to be countercyclical In general, negative health behaviours found to be procyclical
Complex relationships (income, unemployment, leisure-time, stress, access to health care, etc.)
20
All- and cause-specific mortality2007-2010 (age standardised)
Note: Causes of death with rates below 10 are excludedSource: OECD
2007(per 100,000
pop)
2010(per 100,000
pop)
change
Cancer 246.8 227.3
Endocrine 22.8 19.5
Mental & behavioural 15.9 20.1
Nervous 28.9 29.4
Circulatory 322.6 272.0
Respiratory 110.1 95.6
Digestive 35.6 30.0
Genitourinary 22.3 19.6
External injury & poisoning
43.8 38.6
All causes 877.6 775.4
Mortality from ‘external causes of death’2007-2010
2007 2008 2009 20100
2
4
6
8
10
12
14
Transport Accidents Intentional Self-Harm
Deat
hs p
er 1
00,0
00 p
opul
ation
(sta
ndar
d-ise
d)
Source: OECD
Self-assessed health &subjective well-being, 2007-2012
% >= ‘good’ self assessed health
% ‘very’ satisfied with life
2007 84.2 33
2008 84.4 29
2009 83.4 29
2010 83.3 31
2011 83.4 29
2012 n/a 25
Sources: OECD; Eurobarometer
Alcohol and tobacco consumption2000-2011
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 20110
2
4
6
8
10
12
14
16
0.0
0.5
1.0
1.5
2.0
2.5
3.0
Alcohol consumption (litres per capita) Tobacco consumption (kgs per capita)
Litr
es p
er c
apita
Kilo
s per
cap
ita
Source: OECD
24
Summary
Irish health system experiencing unprecedented cuts in expenditure
Backdrop of external and internal pressures
So far, cuts achieved by cutting staff numbers and pay; increased activity; increased user fees
Ongoing concerns over ability to absorb further cuts (in context of rising demand and Programme for Government commitments)
Difficult to ascertain impact on health at this stage
25
Further Challenges
Questions over feasibility of future cuts in required timeframe
Programme for Government commitments are welcome, but will require extra resources and strong governance
Recognise the difficulty of improving efficiency in times of structural/organisational change
Important to maintain a focus on policy goals
Contact
Dr Anne NolanResearch Director, [email protected]
Professor Charles NormandEdward Kennedy Professor of Health Policy and Management, [email protected]