Funding universal health and social care in ireland
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Transcript of Funding universal health and social care in ireland
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Funding Universal Health and Social Care in Ireland:
Charles Normand Edward Kennedy Professor of Health Policy and Management 11 February 2015
Ageing, dying and affordability
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Trinity College Dublin, The University of Dublin
Outline of Presentation
• Why is health different?
• Stated objectives in Irish health policy (and what happened)
• What do we mean by universal health care?
• Nothing comes from nothing
• Funding what?
• Ageing and dying
• System capacity and plausibility of UHC
• Dealing with legacy issues
• Towards affordable universal coverage
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Trinity College Dublin, The University of Dublin
Why is health different?
• Information issues, monopolies and other market failures
• Fees discourage both useful and less useful use
• The perfect storm – we can pay when we do not need and we need when we cannot pay
• As a society we are not willing to allow access to be determined only by ability to pay.
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Trinity College Dublin, The University of Dublin
Stated objectives in Irish health policy (and what happened)
• Access to good quality services
• On basis of need and not ability to pay
• Efficient provision, with access at lowest feasible level of complexity
• No significant changes in entitlements
• Retention of fees despite evidence
• Poorly thought out organisational changes (with new ones under way now)
• Continued support for private insurance and provision.
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Trinity College Dublin, The University of Dublin
What do we mean by universal health care?
• Everything that is good value
• Good value generally in terms of being effective and cost-effective
• As a rough guide, everything with cost/QALY below €45,000?
• We should cover all of some things and NOT some of all things
• None of this implies a callous approach or a refusal to support innovation and development.
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Trinity College Dublin, The University of Dublin
Nothing comes from nothing
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Trinity College Dublin, The University of Dublin
Funding what?
• All cost-effective services
• Efficient provision of care – evidence suggests we could still get 10-15% more from system and an extra 2-3% per year
• Explicitly rationed (or explicit priorities set)
• Carefully considered approach to rare conditions and very high cost (price) services.
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Trinity College Dublin, The University of Dublin
Ageing and dying
• Ageing will increase health care costs (but only very slowly and slightly)
• Balance of needs will change substantially
• Dying is much more important than ageing
• Some of recent growth has been giving more to existing older people and not more older people – the weakening of implicit rationing
• Changing demographics bring some gains from more care of older people by older people
• Some interesting new challenges from multi-morbidity and need for more team work and skill mix changes.
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Trinity College Dublin, The University of Dublin
System capacity and plausibility of UHC
• People are generally willing to pay more to get more, but not more for the same
• Even those in Ireland with higher levels of entitlement tend to face constraints in access
• UHC as conceived in this paper needs increased capacity and co-ordination of care, especially around primary care and areas of chronic disease management and continuing care.
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Trinity College Dublin, The University of Dublin
Dealing with legacy issues
• Private medical insurance – enshrines unequal access but contributes relatively little to funding (around 10% cash but less value)
• Supported and subsidised despite conflict with policy objectives and effects on wider system
• Current model clear evidence of path dependency!
• Difficult to see how community rating can survive as a genuine feature of PHI in Ireland
• It is not useful to have full fee access to GPs, and it makes integrated care hard to develop.
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Trinity College Dublin, The University of Dublin
Towards affordable universal coverage
• How universal is a choice, but what kind of universal is a given
• We could have a pretty good universal service for what is currently paid in tax, PHI and out of pocket
• There would be some losers – who currently get better access from PHI
• The often criticised USC provides a possible framework for a single contribution to UHC
• Long term care will be an areas of growing need – some mechanism like Fair Deal is probably best, but covering all aspects of care
• Two tier systems tend to advantage the rich and the very poor and disadvantage the low paid working population.
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Thank You for Your Attention