Macedonia's Healthcare Committee

7/30/2019 Macedonia's Healthcare Committee

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POINTS FOR THE AGENDA OF THESTEERING COMMITTEEFOR THEADVANCEMENT of HEALTHCARE in the REPUBLIC OF MACEDONIA

Presented to the Plenum of the Committee on J une 15, 2009

By:Sam Vaknin, Ph.D., economist

GENERAL

Healthcare legislation in countries in transition, emerging economic, and developing

countries should permit - and use economic incentives to encourage - a structural reformof the sector, including its partial privatization.

KEY ISSUES

Universal healthcare vs. selective provision, coverage, and delivery (forinstance, means-tested, or demographically-adjusted)

Health Insurance Fund: Internal, streamlined market vs. external marketcompetition

Centralized systemor devolved? The role oflocal government in healthcare.

Ministry of Health: Stewardship or Micromanagement?

Customer (Patient) as Stakeholder

Imbalances: overstaffing (MDs), understaffing (nurses), geographicaldistribution (rural vs. urban), service type (overuse of secondary and tertiaryhealthcare vs. primary healthcare)

AIMS

To amend existing laws and introduce new legislation to allow for changes totake place.

To effect a transition from individualized medicine to population medicine, withan emphasis on the overall welfare and needs of the community

Hopefully, the new legal environment will:

Fosterentrepreneurship;

Alterpatterns of purchasing, provision, and contracting;

Introduce constructive competition into the marketplace; Prevent market failures;

Transform healthcare from an under-financed and under-invested public goodinto a thriving sector with (more) satisfied customers and (more) profitableproviders.

Transition to Patient-centred care: respect for patients values, preferences, andexpressed needs in regard to coordination and integration of care, information,
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communication and education, physical comfort, emotional support and

alleviation of fear and anxiety, involvement of family and friends, transition and

continuity.

The Law and regulatory frameworkshould explicitlyallow for the following:

I. PURCHASING and PURCHASERS

(I1) Private health insurance plans (Germany, Czech Republic, Netherlands), includingfranchises of overseas insurance plans, subject to rigorous procedures of inspection and

to satisfying financial and governance requirements. Insured/beneficiaries will have theright to apply contributions to chosen purchaser and to switch insurers annually.

Private healthcare plans can be established by large firms; guilds(chambers ofcommerce and other professional or sectoral associations); and regions (see thesubchapter on devolution underVI.Stewardship).

Private insurers: must provide universal coverage; offer similarcare packages; applythe same rate of premium, unrelated to the risk of the subscriber; cannot turn applicantsdown; must adhere to national-level rulesabout packages and co-payments; compete onequality and efficiencystandards.

(I11)Breakup of statutory Health Insurance Fund to 2-3 competing insurance plans(possibly on a regional basis, as is the case in France) on equal footing with private

entrants.

Regional fundswill be responsible for purchasing health services (including from

hospitals) and making payments to providers. They will be not-for-profit organizationswith their own boards and managerial autonomy.

(I12)Board of directors and supervisory boardsof health insurance funds to include:

- Two non-executive, lay (not from the medical professions and notpoliticians) members of the public. These will represent the patients and

will be elected by a Council of the Insured, (as is the practice in theNetherlands)

- Municipal representatives;- Representatives of stakeholders (doctors, nurses, employees of the funds,

etc.).

(I13) The funds will be granted autonomyregarding matters of human resources(personnel hiring and firing); budgeting; financial incentives (bonuses and penalties); andcontracting.

The funds will be bound by rules ofpublic disclosureabout what services werepurchased from which providers and at what cost.


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Citizen juriesand citizen panelswill be used to assist with rationing and priority-settingdecisions (United Kingdom).

(I2)Procurement of medicines to be done by an autonomous central purchasingagency, supervised by a public committee (drug regulatory authority) aided by outside

auditors.

All procurement of drugs and medications will be done via international tenders.

The agency will submit its reimbursement rates for drugs on the PLD to external audit inorder to accurately reflect pharmacists overhead costs. At the same time, the profitmargins on all drugs, whether on the PLD or not, will be regulated.

This agency should be separate from the Health Insurance Fund and the Ministry ofHealth. This agency will also maintain national drug registries. It will secure volumediscounts for bulk purchasing and transparent, arms-length pricing.

(I21) Use ofreference prices for medicines. If the actual price exceeds the referenceprice, the price difference has to be met by the patient.

(I3) The Approved (Positive) List of Medicineswill be recomposed to include genericdrugs whenever possible and to exclude expensive brands where generics exist. This

should be a requirement in the law. Separately, an Essential Drug List will be drawn up.

(I31) Encourage rational drug prescribing by instituting a mixture ofGP and PHCincentives and penalties, or a fundholding system: budgets will be allocated to each GPfor the purchase of drugs and medications. If the GP exceeds his/her budget, s/he is

penalized. The GP gets to keep a percentage of budget savings. Prescription decisionswill be medically reviewed to avoid under-provision.

(I4) Payments and Contracting

Payment to providers should combine, in a mixed formula:

BLOCK CONTRACTS

Capitation - A fixed fee for a list of services to be provided to a single patient in a givenperiod, payable even if the services were not consumed, adjusted for the patients'

demographic data and reimbursement for fee-for-service items.

Inflation-adjusted Global budgeting (hospitals) and block (lump sum) grants(municipalities)


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COST and VOLUME CONTRACTS

Provide incentives and reward marketing efforts which result in an increase indemand/referral beyond the limit set in a block contract.

COST PER CASE CONTRACTS

Apply Diagnosis Related Group (DRG)/ Resource-based Relative Value (RBRV) /Patient Management Categories (PMCs) / Disease Staging/Clinical Pathways

Levels ofreimbursement, case-mix adjusted to be decided by external auditors.

Contracts with providers should include:

Waiting Times Guarantee Single Contact Person(Case Officer) for the duration of a stay at the hospital

Hospital benchmarking (individual-level data on costs, diagnoses, andprocedures during entire case episodes: inpatient admissions and outpatient visits;

cost-effectiveness of services.

Performance targets in performance agreements with all healthcare facilities,both public and private.

All payments - wages included - will be tied to these targets and their attainmentas well as to healthcare qualityas determined by objective measures(internal,external, and functional benchmarking), clinical audits (sampling), as well ascustomer satisfaction surveysand interviews and discussions with patients.

Provider and Staff Bonuses and penalties tied to exceeding/under-performingtargets and contract variance

Patients rights, including their rights to litigate

Selective contractingwill be allowed on all levels (including specialist ambulatory careand hospitals), although all providers, private and public, will be permitted to apply forcontracts with health funds and insurers. The funds will choose from among private

providers either following a process of deliberation, or via an auction, orpublic tender(United Kingdom).

(I5) Commissioning preference will be given to the purchase of Primary Healthcare

over secondary, or tertiary Healthcare.


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II. PROVIDERS


(II1) Hospital Management

(See separate document)

The law should allow:

I. Co-locationof a private wing within or beside a public hospital

II. Outsourcing ofnon-clinical support services

III. Outsourcing ofclinical support services

IV. Outsourcing ofspecialized clinical services

V. Private managementof public hospitals

VI. Private financing, construction, and leaseback of new public hospitals

VII. Private financing, construction, and operation of new public hospitals

VIII. Sale of public hospitals as going concerns

IX. Sale of public hospitals foralternative use

X. Consolidation of redundant public healthcare facilities by merging them or closingdown some of them

XI. Privatization ofPrimary Healthcare (PHC) clinics within medical centers

XII. Healthcare institutions will be granted autonomyregarding matters of humanresources (personnel hiring and firing); administering financial incentives or penalties,

budgeting; and contracting.

XIII. Privatization pharmacies inside medical centers and hospitals.

(II2) Primary, Ambulatory, and Secondary Care and General Practitioners (GP)

(II21) Limit the number of patientsper GP
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(II22) Stimulate and financially incentivize the following activities, which should be

declared national prioritieswithin a National Needs Assessment:

Group practices and networks (for continued, around-the-clock services)

Day and minimally invasive surgery

Dispensaries Home and day care services

Long-term care (nursing homes, visiting nurses, home I.V. and other servicesprovided to chronically ill or disabled persons)

Patient hotels

Rehabilitation facilities and programs

Provision ofmerit goods (also through mass campaigns)

Conversion of hospital units to outpatient services,and day-care centers

Example of such financial incentives:

Physicians will be entitled to see patients who receive services free-of-costin the public sector in the morning, and private patientswho pay the fullcost of the medical consultation in the afternoon.

Allow private beds in public hospitals and private financingof hospital stays(NHS, UK)

Subsidize or fully covertransaction costs (legal fees of contracting, compliance,accounting, etc.)

(II23) Allow hospitals to administerpackages of outpatient services and be reimbursedby the Health Insurance Fund (or funds).

(II24) Impose an admission quotaon medical schools; reduce the obligatory number ofdoctors per 1000 population; and make GP a medical specialty.

(II25) Strengthen the gatekeeper function of GPs and healthcare provision in outpatientsettings.

Encourage gatekeeping by instituting a mixture ofGP and PHC incentives andpenalties, or a fundholding system (United Kingdom, Estonia, Spain):

Budgets will be allocated to each GP for the purchase of secondary and tertiaryhealthcare (as well as to cover salaries, premises, diagnostic tests). If the GP exceeds

his/her budget, s/he is penalized. The GP gets to keep a percentage of budget savings.

Referrals will be medically reviewed to avoid under-provision.

(II26) Introduce GP target incomeand adjust services and fees to reach it (perhaps byusing tax credits).


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(II27) Provide GPs and other types of primary and secondary healthcare providers withfinancial incentives to relocate to remote and rural areas

(II28) Renderclinical and best practice guidelines mandatory (not merelyrecommended)

(II29) Encourage managed care(peer review panels, pre-approval procedures forsurgery, case management for the chronically ill, formularies limiting pharmacy

reimbursement to an approved list, and other contractual provisions).

III. PRIVATE SECTOR

Risks of privatization and private non-managed, imperfect competition: market

failure, as patients received too many unnecessary services, due to fee-for-servicereimbursement and information asymmetry.


(III0) Allow private primary healthcare physicians to offer preventive care, treatmentsand interventions after office hours, emergency dental and medical care, emergencyhome treatment, preventive checkups for preschool and school children, patronage and

polyvalent patronage services, and all other elements of comprehensive healthcare.

(III1) Arrangements with the private sector and Private-Public Partnerships (PPP) forthe provision of healthcare:

(III11) Service Contract (Dominican Republic), or Contracting-out

The government pays private entities - including doctors - to perform specific healthcaretasks, or to provide specific healthcare services under a contract. The private service

providers can make use of state-owned facilities, if they wish, or operate from their own

premises.

Payments by the government are usually based on capitation (a fixed fee for a list of

services to be provided to a single patient in a given period, payable even if the serviceswere not consumed) adjusted for the patients' demographic data and reimbursement for

fee-for-service items.

(III12)Management Contract Outsourcing (Cambodia)

The government pays private entities to manage and operate public health care facilities,

like clinics, or hospitals.


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(III13)Lease (Romania since 1994)

Private entities - including doctors - pay the government a lump sum or monthly fees touse specific state-owned equipment, state-employed manpower, clinics, or complete

public health care facilities.

The private entity is entitled to all revenues from its operations but also bears all

commercial risks, is responsible for management and operations and liable for

malpractice and accidents.

The state is still responsible to make capital investments in the leased facility or

equipment, but maintenance costs are borne by the private entity.

(III14)Concession and Build-Operate-Transfer (BOT) (Costa Rica)

Concession is exactly like a lease arrangement (see above) with one exception: the

private entity is responsible for capital investment. In return, the contract period isextended and can be voided only with a considerable pre-advice.

In BOT (Build-Operate-Transfer) and ROT (Rehabilitate-Operate-Transfer) the capital

investment involves the construction or renovation/upgrade of new healthcare facilities.

The private entity uses the constructed facility to provide services. After a prescribedperiod of time has elapsed, ownership is transferred to the government.

(III15)Divestiture and Build-Own-Operate (BOO) (Texas, USA)

The law should permit the outright sale of state- owned health care facilities to a qualified

private entity, including physician groups who band together to purchase previouslystate-run facilities.

Another possibility is a BOO scheme, in which the private entity contractually undertakes

to add facilities, improve services, purchase equipment, or all three.

(III16)Free entry

The law should allow qualified private providers to operate freely. Though regulated,

these private firms will have no other relationship with the state.

Such entities would have to be licensed, certified, overseen, and accredited for expertise,

safety, hygiene, maintenance, track record, liability insurance, and so on.

The state may choose to encourage such providers to locate in specific regions, to cater to

poor clients, or to provide specific healthcare tasks or services by offering tax incentives,

free training, access to public facilities, etc.


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(III17) Franchising (Kenya, Pakistan, Philippines)

A private firm (franchisee) acquires a license from and shares profits with the franchisor(a domestic, or, more often, foreign firm). The franchisee uses the brand name,

trademarks, marketing materials, management techniques, designs, media access, access

to approved suppliers at bulk (discounted) prices, and training offered by the franchisor.The franchisor monitors the performance and quality of service of the franchisee.

This model works mainly in preventive care, family planning, and reproductive health.

The World Bank ("Public Policy for the Private Sector", Note number 263, dated June2003):

"Franchisers in the health sector, often supported by international donors andnongovernmental organizations (NGOs), establish protocols, provide training forhealth workers, certify those who qualify, monitor the performance of franchisees, and

provide bulk procurement and brand marketing."

(III18)Allow Charitiesand Not-for-profit organizations to run health insurance fundsand a variety of providers (including full-scale secondary and tertiary healthcare

institutions).

(III9)Voluntary Health Insurance(substitutive; complementary; and complementary),subject to open enrollment periods and mandatory coverage of dependants (to preventcream-skimmingand adverse selection).

IV. FINANCING


(IV0) Institute co-payments for examination by a GP, emergency medical care, andcertain preventive programs.

(IV01) Introduce negative co-payments: rebates or credits (to be deducted from futurecontributions) to insured persons who, in the preceding year, did not use services and didnot consume interventions or drugs from the positive list above a level determined by the

Ministry of Health.

(IV02) Introduce provider co-payments for hospital stays above the European Unionaverage. Whenever the length of stayexceeds the EU average, the provider (hospital)will make a co-payment to the Health Insurance Fund or to the insurer.


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(IV1) Voucher System (Nicaragua)

The law should allow for experimenting with novel payment and resource allocationtechniques, such as vouchers or prepaid health cards distributed to needy populations

and guaranteeing free basic service packages provided by a limited list of clinics or other

healthcare facilities. Such schemes can also be managed by the private sector.

(IV2) Medical Savings Accounts (Singapore)

Allows or mandates people to place money in (tax-free) savings accounts to be used only

for medical expenses, usually in conjunction with the purchase of a catastrophic stop-losshealth insurance plan.

Contributions by employers and employees accumulate over time and are used, tax-free,

to pay for hospital expenses in public and private hospitals, national supplementaryhealth insurance premiums, special procedures (including abroad), and expensive

outpatient treatment and drugs for the saver and his immediate family.

(IV3) Consumer Organizations and Community Healthcare Financing

Consumer organizations in the healthcare field (such as buyers' clubs orHealthMaintenance Organizations-HMOsowned by cooperatives, NGOs, municipalities).

These groups will shop and tender for the best, most reasonably priced, and most efficient

healthcare services for their members (Switzerland).

Example: HMO in USAIntegrated Model of Healthcare

(Source: WHO)

Health maintenance organization (HMO) is US health care sector term. It is anorganization that contracts to provide comprehensive medical services (not patient

reimbursement) for a specified fee each month.

The term health maintenance organization arose because doctors under this arrangementhave a financial incentive to keep their patience healthy, since they are not paid more for

providing more services.

Health maintenance organizations, which focus on providing patients comprehensivemedical care and pay doctors a specified monthly fee, have become increasingly popular

in the United States, prompted by high costs from the previous fee-for-service, traditionalindemnity health insurance plans.

In this model, doctors are typically paid by salary and hospitals are typically funded byglobal budgets. Benefits are supplied to patients in-kind, often free of charge. The public

version of this model involves government financing and provision of health care and is


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often funded mainly out of general taxation. In the US, the voluntary form of this model

is better known as the staff model of the health maintenance organisation. Integration

as such is not only used for integrated model, but also for types of care provisions inwhich providers offering differing services (e.g., ambulatory care, inpatient care,

rehabilitative care) provide them in an integrated way.

(IV4)Voluntary Health Insurance(substitutive; complementary; and complementary)with the right to apply ones contributions to pay the premium and the right to switch

insurers annually.

(IV51)Earmark a percentage ofvice (sin) taxes, customs duties, VAT, and excise (onalcohol and tobacco; drugs and medications) for healthcare purposes.

(IV52)Reform healthcare budgeting. All healthcare budgets (including the budgets ofthe Ministry of Health; of hospitals, clinics, and primary healthcare facilities) will includeamortization (and capital investments), goodwill and intellectual property, and

intangibles (such as environmental externalities).

(IV6) Allow providers to retain a percentage of the user-fees they collect.

(IV7)Means-tested system: affluent and certain constituencies will be excluded fromcoverage (Netherlands, Germany) or pay much higherco-payments, co-insurance, ordeductible (cost-sharing).

In such a system, private insurersadministercompulsory insurance for the excludedgroups (e.g., civil servants in Netherlands).

(IV8) Introduce VAT on hospitals to encourage investment, the purchase ofmedications, the retention of external services (e.g. training, skilling, continued

education, management consultancy, auditing, etc.), where the hospitals can deduct VATand retain it as an addition to their own budget.

(IV9)Community rating systemvs. Demographically-adjusted or experience-ratedpremiums(e.g., the old and sick pay more than the young and healthy or vice versa;people with dependants pay more than insured or subscribers without dependants, etc.)

(IV10)Blind Fundholding:Financial resources for health care are allocated on a percapita basis; financial resources are held in a fund; and the general practitioner is usually

the decision-maker for allocating the funds to purchase hospital and community services(with the patient choosing the providers, not the GP as was the case in the United

Kingdom).


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V. E-HEALTH


(V1) Citizen-centered and Mobile Healthcare

(V12) Provide a legal framework forhealth data transfer

(V13) Harmonize confidentiality and privacy laws

(V14) Establish legal liability or waiver thereof fore-treatment

(V15) Settle issues ofentitlement and reimbursement

(V16) Encourage Medical e-Tourism (inbound telemedicine)

(V17) Provide forinfrastructure and interoperability

(V18) Permit and licence Web Health and (outbound) Telemedicine (laws, regulations,

forms)

(V19) Establish early warning systems

(V110) Fosterpatient-driven comparative indicators (e.g., online rating ofprofessionals and providers) and empowerpatient organizations

(V111) Electronic European Health Insurance Card

(V112) Each citizen (or his/her custodian) will have full access to a personal Health

Home Page with his EMR (Electronic Medical Records)/EPR (Electronic PatientRecord)/EHR (Electronic Health Record)


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VI. STEWARDSHIP


(VI0) The Benefits Packages (basic and supplementary) to be decided by a conference

of all stakeholders: Ministry of Health, patient groups and advocacy groups, and medicaldoctors associations, assisted by healthcare economists and experts.

(VI01) Consider the introduction of a Negative Benefits Package, listing only theinterventions and services that are excluded from coverage. The interventions andservices not on the Negative List are automatically covered.

(VI02) Consider exclusion ofdental and oral carefrom the Benefits Package.

(VI03) Make preventive occupational health and safetymeasures, equipment, andtraining in the workplace mandatory. Re-establish occupational dispensaries in all

workplaces with more than 100 workers.

(VI04) Generate annual National Needs Assessment reports (including technologicalneeds assessment), including prioritized allocation of funding and foreign aid.

(VI05) Transform teaching hospitals into publicly-owned independent trusts (Italy,United Kingdom): the corporatetype of hospital (hard budget; autonomous managersaccountable to board; board accountable to government).

(VI1) Licencing and accreditation (including periodical renewal and relicencing by thedoctors, dentists, and pharmacists chambers) will depend on continuing medical

education (CME) and on education in management and financefor certain jobs (such asward, clinic, and hospital directors).

All positions from ward doctor upwards will be subject to periodic review and open,public tenders.

(VI2) Private Sector Healthcare Monitoring and Regulatory Agency

The law should provide for the establishment of an agency to monitor and regulate

private sector healthcare provision: compliance with contracts, servicing the indigent and

the uninsured, imposing sanctions or "step-in" rights, and dispute resolution.

This agency will also maintain and supervise the operation of internal open-markets inthe public sector; the outsourcing of primary care functions; and the purchase of primary

care packages from private providers.


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(VI3) Devolution (Finland)

Responsibility for the provision of some types of healthcare services (health promotion;preventive care; occupational health; mental health) and the allocation of inputs should be

devolved to local authorities (municipalities), which will be required to produce budgets

of needs vs. costs.

Consider possibility ofturning municipalities to purchasers of secondary and tertiaryhealthcare from providers of their choice.

Local government will coverprimary healthcare capital expendituresout of municipaltaxes and fees and weighted capitation-based transfers from the central budget

The MoH will maintain a Fiscal Equalization Fund to ensure consistent quality and

availability of healthcare provision across regions and localities.

(VI4) Health Academy

The Ministry should establish an Academy to train healthcare administrators with

emphasis on systems administration and reform. The Academy will invite foreignexperts as guest lecturers and teachers.

In conjunction with the Republic Institute for Health Protection, the Academy will co-maintain databases of case studies and evidence-based practices (feeding into theCochrane Network) and the Medical Map of Macedonia.

(VI5)Campaign to encourage the public to consume generic drugs will be launched.

(VI6)External audit and cartel (antitrust) investigation regarding tertiary healthcarefacilities.

(VI7) Wait Time Reduction Fund (Canada, 2004)

(VI8) National Waiting Times Guarantee

(VI9)Minister of Health Award of Excellence, presented annually to individuals andinstitutions of outstanding merit and excellence among healthcare professionals,

purchasers, and providers of all types.

(VI10) Appoint aHealth Ombudsman and consumer advocates in each major healthcarefacility. Strengthenpatients rights and thePatients Charter. Provide all patients (Or

their custodians) with full access to their medical records; compensation foriatrogenicdiseases; a statutory role forpatients associations; and the establishments ofcommissions with patient representatives in all hospitals (France).


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(VI11)SPECIFIC PROJECTS

Uniform Emergency Number

Neonatal Emergency Ambulance

Health cabinets in schools

Health Tourism(VI12) National Inventory of Medical Assets

Extend the current central registry of all medical equipment in publicly-owned healthcare

facilities to include private healthcare facilities.

The Inventory should also profile medical personnel, real estate, fixtures,

infrastructure, and other capital assets.

(VI13) Coordinative Council for Social and Health Services: to plan and guaranteeinter-sectoral action (together with the ministry of Social Welfare and Labor).

(VI14) Publish standardized contracts, forms, and performance criteria (includingqualitative clinical pathways and benchmarks) to reduce transaction costs.

Example: the National Health Service Frameworks in the United Kingdom provide ahealth strategy; list priority interventions, treatment guidelines and performance targets;

and proffer model contracts.

(VI15) Medical and Health Technology Assessment Board(examples: NICE in UnitedKingdom or SBU is Sweden)to decide all purchases of technology in secondary andtertiary facilities; to publish Positive Lists of technology for GPs and PHC facilities;and to obtain discounts on bulk purchases.

The WHO defines Health Technology Assessment as:

Comprehensive evaluation and assessment of existing and emerging medical

technologies including pharmaceuticals, procedures, services, devices and equipmentin regard to their medical, economic, social and ethical effects.

The systematic evaluation of properties, effects and/or impacts of health caretechnology. Health Technology Assessment defines a multidisciplinary activity thatsystematically examines technical performance, safety, clinical efficacy andeffectiveness, cost, cost-effectiveness, organisational impact, social consequences, legaland ethical aspects of the application of a health technology (European Commission,1999, from EUR-ASSESS 1997).


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(VI16) National Health AccountsInstitute

(Sources: WHO, OECD, USAID)

Will publish the Healthcare PPP (Purchasing Power Parity), taking into account prices

of imported healthcare inputs. Indicators may include total health expenditure, publicexpenditure, private expenditure, out-of-pocket expenditure, tax-funded and other public

expenditure, social security expenditure, public expenditure on health.

The National Health Accounts will also provide the following annual data, analyses,and indicators:

Sectoral opportunity costs, the value of benefits foregone by failure to apply theresources to the most productive alternative cost;

Sectoral marginal costs, the extra cost of increasing output by one unit;

Sectoral variable costs: costs that vary with changes in output volume, such as thematerial required to provide a service versus

Sectoral fixed costs: costs which do not vary with quantity or volume of output provided,at least in the short run (e.g. rent for space).

Sectoral direct costs: all the goods, services and other resources that are consumed in theprovision of a particular service or area (e.g. hospital supplies), including medical costs

(e.g. payments to providers, material) and non-medical costs (e.g. transportation tohospital);

Sectoral indirect costs: total sum ofmorbidity costs (goods and services not produced bythe patient because of the illness), mortality costs (goods and services the person couldhave produced had the illness not been incurred and the person not died prematurely),

and productivity cost (related to lost productivity incurred by an employee who leaveswork to provide care for the patient);

Sectoral intangible costs: usually used in economic evaluation, to indicate features likepain, anxiety or grief, which cannot be directly quantified in monetary terms.

Sectoral resource costsare the resources used in the production of goods and services;

user cost: cost to the user of purchasing or making use of a product.

Sectoral cost-effectiveness analysis (CEA), a type of analysis that comparesinterventions or programmes having a common measurement of health outcome in a

situation where, for a given level of resources, the decision maker wishes to maximise the

health benefits conferred to the population of concern;


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Sectoral cost-utility analysis (CUA), a type of analysis that measures benefits in utility-weighted life-years (QALYs) and which computes a cost per utility-measure ratio for

comparison between programmes;

Sectoral cost-benefit analysis (CBA), a type of analysis that measures costs and benefits

in monetary units and computes a net monetary gain/loss or a cost-benefit ratio.

Outcomes research: the Institute will evaluate the impact of health care on the healthoutcomes of patients and populations, including an evaluation of economic impactslinked to health outcomes, such as cost effectiveness and cost utility. Outcomes research

emphasises health problem- (or disease-) oriented evaluations of care delivered in

general, real world settings; multidisciplinary teams; and a wide range of outcomes,including mortality, morbidity, functional status, mental well-being, and other aspects of

health related quality of life.

Total expenditure on health: Total (or national) expenditure on health based on: Personal

health care services + Medical goods dispensed to outpatients = Total personalexpenditure on health + Services of prevention and public health + Health administration

and health insurance = Total current expenditure on health + Investment into medicalfacilities = Total expenditure on health.

Another formula is: total expenditure on health = * private health care expenditure + *public health care expenditure.

(VI17)Hospital League Table and star ranking (like with hotels and restaurants) toinclude information made publicly-available in various media: number of patientstreated; complication rates; waiting times; data about procedures; food and amenities;

other quality measures.

(VI18)Annual National Health Survey: will measure attitudes; customer satisfaction;emerging trends among purchasers and providers; and the increase or decrease in quality

and performance standards as well as in capital investments.


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Sam Vaknin

(,//e-mail) [email protected]

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Health academy within Public Health Institute: training, research, medical map

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No such Academy exists, although some of its functions are carried by the Public Health institute


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Health Systems in Transition: Macedonia (2006)

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The Ministry should establish a Health Academy with the following functions:

1. To train healthcare administrators with emphasis on systems administration and reform.The Academy will invite foreign experts as guest lecturers and teachers.

2. In conjunction with the Republic Institute for Health Protection, to co-maintain databasesof case studies and evidence-based practices (feeding into the Cochrane Network)

3. To update and maintain the Medical Map of Macedonia.

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http://asr.regione.emilia-

romagna.it/wcm/asr/aree_di_programma/cdf/gr_ist/pr_whole/whole_ingl/WHOLE_ing.pdf
http://sc-healthreform.org.mk/http://sc-healthreform.org.mk/http://asr.regione.emilia-romagna.it/wcm/asr/aree_di_programma/cdf/gr_ist/pr_whole/whole_ingl/WHOLE_ing.pdfhttp://asr.regione.emilia-romagna.it/wcm/asr/aree_di_programma/cdf/gr_ist/pr_whole/whole_ingl/WHOLE_ing.pdfhttp://asr.regione.emilia-romagna.it/wcm/asr/aree_di_programma/cdf/gr_ist/pr_whole/whole_ingl/WHOLE_ing.pdfhttp://asr.regione.emilia-romagna.it/wcm/asr/aree_di_programma/cdf/gr_ist/pr_whole/whole_ingl/WHOLE_ing.pdfhttp://asr.regione.emilia-romagna.it/wcm/asr/aree_di_programma/cdf/gr_ist/pr_whole/whole_ingl/WHOLE_ing.pdfhttp://sc-healthreform.org.mk/


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http://www.nationalacademies.org/opportunities

http://www.who.int/healthacademy/countries/pilot_jordan/en/index.html

http://www1.aston.ac.uk/about/news/releases/2008/march/080314-1/

::

National health academies exist in many countries, including the United States and the

United Kingdom.

The European Union is establishing a Virtual Health Academy.

The WHO is running pilot projects for the establishment of health academies (for instance,

in Jordan).

, July 24, 2009()

..( ) Sam Vaknin

(,
http://www.nationalacademies.org/opportunitieshttp://www.nationalacademies.org/opportunitieshttp://www.who.int/healthacademy/countries/pilot_jordan/en/index.htmlhttp://www.who.int/healthacademy/countries/pilot_jordan/en/index.htmlhttp://www1.aston.ac.uk/about/news/releases/2008/march/080314-1/http://www1.aston.ac.uk/about/news/releases/2008/march/080314-1/http://www1.aston.ac.uk/about/news/releases/2008/march/080314-1/http://www.who.int/healthacademy/countries/pilot_jordan/en/index.htmlhttp://www.nationalacademies.org/opportunities


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11 ( ):

Ministerial inter-sectoral council for healthcare

22 ( , , , ,

( .), .)

The Ministry of Health provides the stewardship function of the entire health system of Macedonia. Butthe sector is very fragmented. Various healthcare functions are performed by the Health Insurance Fund

(nominally under the Ministry, but, actually, a semi-independent institution); Ministry of Social Welfareand Labor; the ministry of Defense; the Ministry of Education; and the Ministry of Local Self-government.


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(())--

Conversations with office-holders in the Ministries of Health and Social Welfare and Labor as well asthe management of the Health Insurance Fund and the Prime Minister.

Health Systems in transition: The Former Yugoslav Republic of Macedonia (2006), available inthe eLibrary:http://sc-healthreform.org.mk

33 ( ) , , , , ( .),

.

To establish an Inter-Ministerial Council for Health with the following members:

Minister of Health - ChairmanMinister of FinanceMinister of Defense

Minister of EducationMinister of Local Self-government

Director of the Health Insurance FundConsultative Role

The Council will meet periodically. Its functions will be:

- To coordinate health-related activities that require the input or collaboration of more than one

Ministry- To exchange information regarding health issues- To share data and coordinate activities in times of health emergencies- To resolve inter-Ministerial disputes- To secure financing, manpower and resources

The Council will have a standing Secretariat.
http://sc-healthreform.org.mk/http://sc-healthreform.org.mk/http://sc-healthreform.org.mk/http://sc-healthreform.org.mk/


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(())--

Forexamples from other countries, see the next section.

::

Most countries (as well as supranational bodies, such as the EU and the Commonwealth) have

such councils in place.

Examples:

http://www.phac-aspc.gc.ca/aids-sida/publication/ministerreport/interministerial/app3-eng.php

http://www.arr.ro/cisr/cisr_eng.ppt

http://www.ambafrance-uk.org/Joint-press-conference-after.html

http://gateway.nlm.nih.gov/MeetingAbstracts/102280351.html

http://www.lsblog.org/blog/?tag=guardian-newspapers

http://www.emro.who.int/lebanon/reports/IntroductionforAnnualReport2001.pdf

, 01.09.2009

()

..

( )

Sam Vaknin

(,
http://www.phac-aspc.gc.ca/aids-sida/publication/ministerreport/interministerial/app3-eng.phphttp://www.phac-aspc.gc.ca/aids-sida/publication/ministerreport/interministerial/app3-eng.phphttp://www.arr.ro/cisr/cisr_eng.ppthttp://www.arr.ro/cisr/cisr_eng.ppthttp://www.ambafrance-uk.org/Joint-press-conference-after.htmlhttp://www.ambafrance-uk.org/Joint-press-conference-after.htmlhttp://gateway.nlm.nih.gov/MeetingAbstracts/102280351.htmlhttp://gateway.nlm.nih.gov/MeetingAbstracts/102280351.htmlhttp://www.lsblog.org/blog/?tag=guardian-newspapershttp://www.lsblog.org/blog/?tag=guardian-newspapershttp://www.emro.who.int/lebanon/reports/IntroductionforAnnualReport2001.pdfhttp://www.emro.who.int/lebanon/reports/IntroductionforAnnualReport2001.pdfhttp://www.emro.who.int/lebanon/reports/IntroductionforAnnualReport2001.pdfhttp://www.lsblog.org/blog/?tag=guardian-newspapershttp://gateway.nlm.nih.gov/MeetingAbstracts/102280351.htmlhttp://www.ambafrance-uk.org/Joint-press-conference-after.htmlhttp://www.arr.ro/cisr/cisr_eng.ppthttp://www.phac-aspc.gc.ca/aids-sida/publication/ministerreport/interministerial/app3-eng.php


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11 ( ):

National health legal forms and contracts

22 ( , , , ,

( .), .)

Currently, in Macedonia, there are no published standard contracts, forms, or performance criteria in

the health sector.


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33 ( ) - , , , , ( .),

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The Ministry of Health should publish online and in print form:

1. Sstandardized contractsbetween all those involved in the health system: providers,

purchasers, patients, unions, etc.

2. Standardizedforms to be used by providers, patients, purchasers, government, etc.

3. Benchmarks and performance criteria (including qualitative clinical pathways and

benchmarks) to be incorporated into contracts between purchasers and providers and

in processes of accreditation and re-licensing.

(())--

http://www.nhs.uk/chq/Pages/1080.aspx
http://sc-healthreform.org.mk/http://sc-healthreform.org.mk/http://www.nhs.uk/chq/Pages/1080.aspxhttp://www.nhs.uk/chq/Pages/1080.aspxhttp://www.nhs.uk/chq/Pages/1080.aspxhttp://sc-healthreform.org.mk/


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http://www.dh.gov.uk/en/Aboutus/OrganisationsthatworkwithDH/Workingwithstakeho

lders/FAQ/DH_091943

http://www.dh.gov.uk/en/Managingyourorganisation/Commissioning/Systemmanagem

ent/DH_085048

::

The more complex the healthcare system, the more is it rendered competitive, the more

patient choice it offers the higher the transaction costs involved (for example: the costs of

preparing contracts and monitoring compliance).

Experience throughout the world and especially in the United Kingdom demonstrates that

the publication of standardized documents (forms, contracts, performance criteria) saves alot money and makes the system far more efficient.

Example: the National Health Service Frameworks in the United Kingdom provide ahealth strategy; list priority interventions, treatment guidelines and performance targets;and proffer model contracts.

, July 24, 2009()

..( ) Sam Vaknin

(,
http://www.dh.gov.uk/en/Aboutus/OrganisationsthatworkwithDH/Workingwithstakeholders/FAQ/DH_091943http://www.dh.gov.uk/en/Aboutus/OrganisationsthatworkwithDH/Workingwithstakeholders/FAQ/DH_091943http://www.dh.gov.uk/en/Aboutus/OrganisationsthatworkwithDH/Workingwithstakeholders/FAQ/DH_091943http://www.dh.gov.uk/en/Managingyourorganisation/Commissioning/Systemmanagement/DH_085048http://www.dh.gov.uk/en/Managingyourorganisation/Commissioning/Systemmanagement/DH_085048http://www.dh.gov.uk/en/Managingyourorganisation/Commissioning/Systemmanagement/DH_085048http://www.dh.gov.uk/en/Managingyourorganisation/Commissioning/Systemmanagement/DH_085048http://www.dh.gov.uk/en/Managingyourorganisation/Commissioning/Systemmanagement/DH_085048http://www.dh.gov.uk/en/Aboutus/OrganisationsthatworkwithDH/Workingwithstakeholders/FAQ/DH_091943http://www.dh.gov.uk/en/Aboutus/OrganisationsthatworkwithDH/Workingwithstakeholders/FAQ/DH_091943


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Sam Vaknin


11 ( ):

National inventory of healthcare resources

22 (

, , , ,

( .), .)

There is a current central registry of all medical equipment in publicly-owned healthcare facilities


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33 ( ) - , , , , ( .),

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Extend the current central registry to include:1. All medical equipment in publicly-owned healthcare facilities and in private

healthcare facilities (in both secondary and tertiary healthcare.)

2. To maintain a register of all medical personnel.

3. To maintain a register of healthcare-related real estate.

4. To maintain a register of healthcare-related fixture, infrastructure, and capital assets.

5. To interface and collaborate with other state organs (UJP, Customs, municipalities)

in order to verify the accuracy and up to date status of the registers.

6. To feed information into the Medical Map of Macedonia (in conjunction with the

Public Health institute or the Health Academy).

(())--
http://sc-healthreform.org.mk/http://sc-healthreform.org.mk/http://sc-healthreform.org.mk/


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Sam Vaknin


11 ( ):

Defining the basic benefits package via consultations with all stakeholders

22 ( , , , ,

( .), .)

The Basic Benefits Package is largely determined by the Health Insurance Fund (HIF) and the Ministry

of Health.


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Discussions with Minister of Health and Ministry of Health officials.


Can be found in the eLibrary:


33 ( ) - , , , , ( .),

.

Recommend to establish a public, permanent Committee to recommend what should be

the composition of the Basic Benefits Package and to review it on an annual basis.

The Committee should include all stakeholders as well various experts in law, economics,

medical ethics, and finance.

The Ministers of Health and Finance should send representatives to the Committee.


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(())--

Israeli experience with such a Committee since 2007:

http://www.health.gov.il/pages/default.asp?maincat=1&catid=6&pageid=4549




::

Israel has established such a public Committee to recommend to the Ministry of Health and

the Ministry of Finance the composition of the Basic (or Uniform) Benefits Package.

Israel has developed detailed procedures regarding this Committee which can be adapted to

fit Macedonias needs and particular circumstances.
http://www.health.gov.il/pages/default.asp?maincat=1&catid=6&pageid=4549http://www.health.gov.il/pages/default.asp?maincat=1&catid=6&pageid=4549http://www.health.gov.il/pages/default.asp?maincat=1&catid=6&pageid=4538http://www.health.gov.il/pages/default.asp?maincat=1&catid=6&pageid=4538http://www.health.gov.il/pages/default.asp?maincat=1&catid=6&pageid=4431http://www.health.gov.il/pages/default.asp?maincat=1&catid=6&pageid=4431http://www.health.gov.il/pages/default.asp?maincat=1&catid=6&pageid=4320http://www.health.gov.il/pages/default.asp?maincat=1&catid=6&pageid=4320http://www.health.gov.il/pages/default.asp?maincat=1&catid=6&pageid=4320http://www.health.gov.il/pages/default.asp?maincat=1&catid=6&pageid=4431http://www.health.gov.il/pages/default.asp?maincat=1&catid=6&pageid=4538http://www.health.gov.il/pages/default.asp?maincat=1&catid=6&pageid=4549


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, July 29, 2009()

..( ) SAM VAKNIN

(,


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Sam Vaknin


11 ( ):

-

E-health

22

(

, , , ,

( .), .)

Macedonia has signed a contract with a Croatian company to install a comprehensive Information

Technology software in Macedonia, including basic forms of EMR/EPR (Electronic Medical

Records/Electronic Patients Records), inventory and cost control, and HMS (Hospital Management

System).


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Review of ISIS documents (ISIS is the country-wide software mentioned in Step 2 above).

33 ( ) - , , , , ( .),

.

A special Law should be authored.


(V1) Citizen-centered and Mobile Healthcare

(V12) Provide a legal framework forhealth data transfer

(V13) Harmonize confidentiality and privacy laws

(V14) Establish legal liability or waiver thereof fore-treatment

(V15) Settle issues ofentitlement and reimbursement


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(V16) Encourage Medical e-Tourism (inbound telemedicine)

(V17) Provide forinfrastructure and interoperability

(V18) Permit and licence Web Health and (outbound) Telemedicine (laws, regulations,

forms)

(V19) Establish early warning systems

(V110) Fosterpatient-driven comparative indicators (e.g., online rating of professionals

and providers) and empowerpatient organizations

(V111) Electronic European Health Insurance Card

(V112) Each citizen (or his/her custodian) will have full access to a personal Health Home

Page with his EMR (Electronic Medical Records)/EPR (Electronic Patient Record)/EHR

(Electronic Health Record)

(())--

Towards Interoperable eHealth for Europe (Telemedicine Alliance/European

Commission)

::

The Ministry should set up an eHealth Committee to review experience in other countries.

The EU has funds available for the implementation of telemedicine and eHealth projects. So

do many other countries (Norway, Finland) and even private companies such as Google, Inc.

, IBM, etc.


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, July 29, 2009()

..( ) SAM VAKNIN

(,


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Sam Vaknin


11 ( ):

Measures fr reducing waiting times

22

(

, , , ,

( .), .)Currently there are no national measures, or plans in place to reduce waiting times.


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(())--


33 ( ) - , , , , ( .),

.

To introduce Waiting Times Guaranteesas part of contracts with hospitals and other

providers in both secondary and tertiary healthcare. Providers to be penalized and rewardedaccording to their success or failure in curbing waiting times for specified interventions.

Hospital League Table and star ranking (like with hotels and restaurants) to includeinformation made publicly-availablein various media: number of patients treated;complication rates; waiting times; data about procedures; food and amenities; other qualitymeasures.

National Waiting Times GuaranteeThe state will guarantee specified maximum waitingtimes for specific interventions. It will compensate patients who had had to wait longer than

the national waiting times guaranteed. To this effect, the state will establish a Wait Time

Reduction Fund,managed by the HIF or MoH. Hospital and other secondary and tertiaryhealthcare providers will pay monthly premiums to the Fund and will be rewarded or

penalized according to their success or failure in reducing waiting times.


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Various publications by WHO, available in the eLibrary:


Canadian experience:

http://www.parl.gc.ca/information/library/PRBpubs/prb0582-e.htm

::

Canada has the most extensive experience regarding this issue with its Patient Wait TimesGuarantee Trust and other steps adopted since 2004.

, July 29, 2009

()

..

( ) SAM VAKNIN

(,
http://sc-healthreform.org.mk/http://sc-healthreform.org.mk/http://www.parl.gc.ca/information/library/PRBpubs/prb0582-e.htmhttp://www.parl.gc.ca/information/library/PRBpubs/prb0582-e.htmhttp://www.parl.gc.ca/information/library/PRBpubs/prb0582-e.htmhttp://sc-healthreform.org.mk/


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11 ( ):

Hospital ranking system

22 ( , , , ,

( .), .)

Currently, Macedonia has no publicly available or public-driven system of ranking and rating hospitals.


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Conversation with relevant hospital administrators and heads of clinics in the Clinical Center in Skopje.

33 ( ) - , , , , ( .),

.

OPTION 1

Government-administered PlanHospital League Table and star ranking(like with hotels and restaurants) to include information madepublicly-available in various media: number of patients treated; complication rates; waiting times; dataabout procedures; food and amenities; other quality measures.OPTION 2Public-driven PlanAnnual National Health Survey: will measure attitudes; customer satisfaction; emerging trends amongpurchasers and providers; and the increase or decrease in quality and performance standards as well asin capital investments.Will foster and include patient-driven comparative indicators (e.g., online rating of professionals andproviders, similar to eBay) and empower patient organizations.

OPTION 3Peer-driven PlanDoctors, nurses, and administrators will rank their colleagues and institutions in anonymous surveys.These will be compiled to yield to an index and rate and rank the hospitals and clinics.

All three options can be implemented by the Ministry of Health or by an independent, commercial pollingfirm, chosen in a public tender (recommended).


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Purchasing to improve health systems performance(Open University Press)(available in the eLibrary here:http://sc-healthreform.org.mk)

http://www.telegraph.co.uk/health/3354787/Hospital-league-tables-Overall-experience.html

http://www.guardian.co.uk/society/2001/sep/25/hospitals.nhs1

http://www.usnews.com/besthospitals

http://www.netdoc.com/hospital-rankings/

http://www.huliq.com/25361/new-hospital-rankings-by-government

http://www.consumerreports.org/health/doctors-hospitals/hospital-ratings.htm

::

The United Kingdom has had a Hospitals League Table. It was run by the NHS (National Health Service).

In the United States, a variety of organizations offer hospital rankings and ratings: state governments,consumer associations, the media, insurance companies, HMOs (health Maintenance Organizations), andpatients organizations.

, 01.09.2009()

..( )

Sam Vaknin

(,
http://sc-healthreform.org.mk/http://sc-healthreform.org.mk/http://sc-healthreform.org.mk/http://www.telegraph.co.uk/health/3354787/Hospital-league-tables-Overall-experience.htmlhttp://www.telegraph.co.uk/health/3354787/Hospital-league-tables-Overall-experience.htmlhttp://www.guardian.co.uk/society/2001/sep/25/hospitals.nhs1http://www.guardian.co.uk/society/2001/sep/25/hospitals.nhs1http://www.usnews.com/besthospitalshttp://www.usnews.com/besthospitalshttp://www.netdoc.com/hospital-rankings/http://www.netdoc.com/hospital-rankings/http://www.huliq.com/25361/new-hospital-rankings-by-governmenthttp://www.huliq.com/25361/new-hospital-rankings-by-governmenthttp://www.consumerreports.org/health/doctors-hospitals/hospital-ratings.htmhttp://www.consumerreports.org/health/doctors-hospitals/hospital-ratings.htmhttp://www.consumerreports.org/health/doctors-hospitals/hospital-ratings.htmhttp://www.huliq.com/25361/new-hospital-rankings-by-governmenthttp://www.netdoc.com/hospital-rankings/http://www.usnews.com/besthospitalshttp://www.guardian.co.uk/society/2001/sep/25/hospitals.nhs1http://www.telegraph.co.uk/health/3354787/Hospital-league-tables-Overall-experience.htmlhttp://sc-healthreform.org.mk/


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Sam Vaknin

(,//e-mail) 070-565488

[email protected]

11 ( ):

Funding sources

22 ( , , , ,

( .), .)

Macedonia has a social insurance system with a single, statutory Health Insurance Fund (HIF).

Deficits are periodically covered by transfers from the central budget, but these transfers areunpredictable, minimal, and politically-motivated.


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Available in the eLibrary:


Discussions with officials of the Health Insurance Fund and Ministry of Health.

33 ( ) - , , , , ( .),

.

(See the Notes zabeleski - section for reasons)

Macedonia should maintain its social insurance model, but with a clear commitment

by the state to cover the deficits of the Health Insurance Fund.

This commitment should be embedded in the law. The central budget should make an

annual transfer to the HIF to cover its operational deficit in a transparent manner.Many workers go undeclared, or are self-employed, or have no permanent jobs, or are

foreigners and illegal immigrants. It is only logical and just for tax money to fund the

HIF which pays for healthcare for these individuals, too.

Another option is for the central budget to transfer matching funds to the HIF equal to

a fixed or escalating percentage of the HIFs revenues with a cap-guarantee equal to a

fixed percentage of GDP.

All transfers from the central budget to the HIF should be linked to the cost inflation

in the healthcare sector.

Investments in maintenance and capital goods should come from the central budget

and be based on a multi-annual needs and technology assessment.


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See: Funding Healthcare: Options for Europe

See: Purchasing to Improve Health Systems Performance

Available in the eLibrary:


::

Both tax-funded and social insurance health systems are less regressive and more equitablethan private, market-based alternatives and more progressive than systems heavilydependent on user-charges. But tax-based systems are more progressive that social insurance

based ones.

Both tax-funded and social insurance health systems are better at cost containment thanmarket-based alternatives.

Tax-funded systems are vulnerable to political pressures and shifts in political priorities.

Expertise in purchasing and contracting accumulates in social health insurance funds (buttransaction costs tend to increase).

Social insurance adversely affectsjob mobility and economic competitiveness. Tax-basedsystems adversely affect the costs of doing business and, therefore, competitiveness.

, July 19, 2009()

..( )

Sam Vaknin

(,


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Sam Vaknin


11 ( ):

Health care provider

22 ( , , , ,

( .), .)

Hospitals and clinics in Macedonia are allowed to charge clients for certain goods andservices and even keep some of the proceeds. They are not allowed, however, to offerinsurance plans and to tie these plans into their services.

(())--

BOOK: Health Systems in Transition: Macedonia (2006)


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Conversations with hospital and clinic administrators and with members of the SteeringCommittee for the Advancement of the Health System in Macedonia.

33 ( ) - , , , , ( .),

.

To allow the formation of managed care organizations:

- HMOs (Health Maintenance Organizations);

- Health co-ops

- Other group healthcare management organizations

(For details, see articles below)

(())--

http://en.wikipedia.org/wiki/Hmo

http://en.wikipedia.org/wiki/Managed_care

http://en.wikipedia.org/wiki/Health_insurance_cooperative

::

, 30.09.2009

()

..

( )

Sam Vaknin
http://en.wikipedia.org/wiki/Hmohttp://en.wikipedia.org/wiki/Hmohttp://en.wikipedia.org/wiki/Managed_carehttp://en.wikipedia.org/wiki/Managed_carehttp://en.wikipedia.org/wiki/Health_insurance_cooperativehttp://en.wikipedia.org/wiki/Health_insurance_cooperativehttp://en.wikipedia.org/wiki/Health_insurance_cooperativehttp://en.wikipedia.org/wiki/Managed_carehttp://en.wikipedia.org/wiki/Hmo


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Sam Vaknin

(,//e-mail) 070-565488

[email protected]

11 ( ):

Indirect taxes ("Sin taxes" earmarks, and taxes on medications)

( , )

22 ( , , , ,

( .), .)

5 MKD per box of cigarettes collected and transferred to the general budget of the MoH.


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33 ( ) - , , , , ( .),

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OPTION 1

To levy a special tax or surcharge on:

(i) All tobacco products(ii) All alcoholic drinks (including beer and wine)(iii) All prescription and over-the-counter (OTC) medication

The revenues from this surcharge or tax will go to a special fund and used to finance dedicated programs andactivities (e.g.: public health; drug and alcohol rehabilitation centers; anti-drug and anti-drinking campaigns;encouraging rational prescription and usage of medication; medical map and national medical inventory, etc.)

OPTION 2

The central budget will transfer a fixed percentage of all incomes (customs duties and taxes) on:

(iv) All tobacco products(v) All alcoholic drinks (including beer and wine)(vi) All prescription and over-the-counter (OTC) medication

The funds will be transferred directly from the central budget to a special fund and used to finance dedicatedprograms and activities (e.g.: public health; drug and alcohol rehabilitation centers; anti-drug and anti-drinkingcampaigns; encouraging rational prescription and usage of medication; medical map and national medicalinventory, etc.)


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Sin taxes and earmarked income from taxes (also known as hypothecated revenues

or hypothecated taxes) are very common in many countries.

See: Funding Healthcare: Options for Europe in the eLibrary:


::

Sin taxes and earmarked income from taxes (also known as hypothecated revenues

or hypothecated taxes) are very common in many countries.

Hypothecated or earmarked taxes/revenues are unstable and not conducive to long-term

planning, policies, and objectives. They have to be supplemented from the MoHs generalbudget.

I, therefore, recommend the establishment of a countercyclical Equalization Fund.

In years where income from earmarked taxes exceeds the outlays on the dedicated programs,the surplus will go into the Equalization Fund. In years where income from earmarked taxesfalls short of the outlays on the dedicated programs, money will be withdrawn from the

Equalization Fund.

Earmarked or hypothecated revenues should not go to the general budget. They should beused exclusively to finance dedicated program: specific programs which carry specificfunctions and have specific objectives.

, July 19, 2009

()

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Sam Vaknin


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Sam Vaknin

(,//e-mail) 070-565488

[email protected]

11 ( ):

Other insurance funds (medical savings account)

( )

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Does not exist.

No legal framework exists. Legislation required.


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(())--

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.

Medical Savings Accounts (MSAs)

Citizens are required to save a proportion of their income every month in an earmarked

account, specifically for meeting health care costs, especially catastrophic costs (major

operations; medical treatment abroad; expensive medical devices).

The accounts will be tax-free (contributions will be deductible from taxable income and when

withdrawn, free of tax).

MSAs are available in several countries, most notably in Singapore and the United States.

(())--

Funding Healthcare: Options for Europe (chapter 5) in the eLibrary:


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::

Medical Savings Accounts encourage cost inflation and are inequitable (poor people cannoteffectively save). To prevent these outcomes, MSAs must be coupled with publicly-managed

cost control mechanisms and equity-restoring measures (see Singapores supplementaryinstitutional solutions below).

The most famous example of a successful implementation of a Medical Savings Account isSingapore where it is called Medisave.

Note the following features:

1. At death, any account balance can be bequeathed to relatives. The account holders

have free choice of provider.

2. Medishield is catastrophic illness insurance created in 1990. Premiums are deducted

from medical savings accounts and there are high deductibles, co-insurance and lifetime

limits to reduce moral hazard.

3. Medifund is an endowment fund created in 1993. Interest can be used to fund care for

poor people based on means tests. Care is only available in open wards, and only 3 per

cent of patients used this in 1993. Governmentsubsidizes public hospital beds and outpatient facilities on a scale that diminishes in

relation to luxury.

, July 19, 2009()

..( )

Sam Vaknin

(,


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Sam Vaknin


11 ( ):

National health accounts unit

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Macedonia has no dedicated unit for national health accounts. The Bureau of Statistics and somedepartments of the Ministry of Health and the Health Insurance Fund issue their own statistics.

Statistics in Macedonia are not regularly updated. Many data are withheld or even kept secret owing to

issues of privacy and national interest.

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Conversations with the WHO, World Bank, Ministry of Health officials and former workers of theBureau of Statistics.

Review of the data incorporated in the medical map.

33 ( ) - , , , , ( .),

.

To establish a National Health Accounts Institute.

The Institute will be in charge of all health statistics and will supervise the work of the Bureauof Statistics in this field.

To amend the relevant laws to mandate the disclosure of anonymous and aggregated data on a

periodical basis.

The National Health Accounts Institute will publish the Healthcare PPP (Purchasing PowerParity), taking into account prices of imported healthcare inputs. Indicators may include totalhealth expenditure, public expenditure, private expenditure, out-of-pocket expenditure, tax-

funded and other public expenditure, social security expenditure, public expenditure on health.

The National Health Accounts will also provide the following annual data, analyses, andindicators:

Sectoral opportunity costs, the value of benefits foregone by failure to apply theresources to the most productive alternative cost;

Sectoral marginal costs, the extra cost of increasing output by one unit;

Sectoral variable costs: costs that vary with changes in output volume, such as the materialrequired to provide a service versus

Sectoral fixed costs: costs which do not vary with quantity or volume of output provided, atleast in the short run (e.g. rent for space).

Sectoral direct costs: all the goods, services and other resources that are consumed in theprovision of a particular service or area (e.g. hospital supplies), including medical costs (e.g.

payments to providers, material) and non-medical costs (e.g. transportation to hospital);

Sectoral indirect costs: total sum ofmorbidity costs (goods and services not produced by thepatient because of the illness), mortality costs (goods and services the person could haveproduced had the illness not been incurred and the person not died prematurely), and


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productivity cost (related to lost productivity incurred by an employee who leaves work toprovide care for the patient);

Sectoral intangible costs: usually used in economic evaluation, to indicate features like pain,anxiety or grief, which cannot be directly quantified in monetary terms.

Sectoral resource costsare the resources used in the production of goods and services; usercost: cost to the user of purchasing or making use of a product.

Sectoral cost-effectiveness analysis (CEA), a type of analysis that compares interventions orprogrammes having a common measurement of health outcome in a situation where, for a given

level of resources, the decision maker wishes to maximise the health benefits conferred to the

population of concern;

Sectoral cost-utility analysis (CUA), a type of analysis that measures benefits in utility-weighted life-years (QALYs) and which computes a cost per utility-measure ratio for

comparison between programmes;

Sectoral cost-benefit analysis (CBA), a type of analysis that measures costs and benefits inmonetary units and computes a net monetary gain/loss or a cost-benefit ratio.

Outcomes research: the Institute will evaluate the impact of health care on the healthoutcomes of patients and populations, including an evaluation of economic impacts linked to

health outcomes, such as cost effectiveness and cost utility. Outcomes research emphasises

health problem- (or disease-) oriented evaluations of care delivered in general, real world

settings; multidisciplinary teams; and a wide range of outcomes, including mortality, morbidity,functional status, mental well-being, and other aspects of health related quality of life.

(())--

Various publications by the WHO, OECD, USAID, including:

http://www.who.int/nha/

http://www.who.int/nha/docs/English_PG.pdf

http://www.oecd.org/dataoecd/10/53/33661480.pdf

http://nha.healtheconomics.org/2009/

http://www.healthsystems2020.org/section/topics/finance/nha

http://www.hsph.harvard.edu/ihsg/publications/pdf/No-2.pdf

Examples from other countries:
http://www.who.int/nha/http://www.who.int/nha/http://www.who.int/nha/docs/English_PG.pdfhttp://www.who.int/nha/docs/English_PG.pdfhttp://www.oecd.org/dataoecd/10/53/33661480.pdfhttp://www.oecd.org/dataoecd/10/53/33661480.pdfhttp://nha.healtheconomics.org/2009/http://nha.healtheconomics.org/2009/http://www.healthsystems2020.org/section/topics/finance/nhahttp://www.healthsystems2020.org/section/topics/finance/nhahttp://www.hsph.harvard.edu/ihsg/publications/pdf/No-2.pdfhttp://www.hsph.harvard.edu/ihsg/publications/pdf/No-2.pdfhttp://www.hsph.harvard.edu/ihsg/publications/pdf/No-2.pdfhttp://www.healthsystems2020.org/section/topics/finance/nhahttp://nha.healtheconomics.org/2009/http://www.oecd.org/dataoecd/10/53/33661480.pdfhttp://www.who.int/nha/docs/English_PG.pdfhttp://www.who.int/nha/


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http://www.nscb.gov.ph/stats/pnha/default.asp

http://www.mohfw.nic.in/

http://www.unescap.org/aphen/asia_pacific_nha.htm

http://gateway.nlm.nih.gov/MeetingAbstracts/102280576.html

http://ideas.repec.org/p/wpa/wuwppe/0509006.html

::

Total expenditure on health: Total (or national) expenditure on health based on: Personalhealth care services + Medical goods dispensed to outpatients = Total personal expenditure

on health + Services of prevention and public health + Health administration and healthinsurance = Total current expenditure on health + Investment into medical facilities = Total

expenditure on health.Another formula is: total expenditure on health = * private health care expenditure + * publichealth care expenditure.

, 01.09.2009

()

..

( )

Sam Vaknin

(,
http://www.nscb.gov.ph/stats/pnha/default.asphttp://www.nscb.gov.ph/stats/pnha/default.asphttp://www.mohfw.nic.in/http://www.mohfw.nic.in/http://www.unescap.org/aphen/asia_pacific_nha.htmhttp://www.unescap.org/aphen/asia_pacific_nha.htmhttp://gateway.nlm.nih.gov/MeetingAbstracts/102280576.htmlhttp://gateway.nlm.nih.gov/MeetingAbstracts/102280576.htmlhttp://ideas.repec.org/p/wpa/wuwppe/0509006.htmlhttp://ideas.repec.org/p/wpa/wuwppe/0509006.htmlhttp://ideas.repec.org/p/wpa/wuwppe/0509006.htmlhttp://gateway.nlm.nih.gov/MeetingAbstracts/102280576.htmlhttp://www.unescap.org/aphen/asia_pacific_nha.htmhttp://www.mohfw.nic.in/http://www.nscb.gov.ph/stats/pnha/default.asp


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Sam Vaknin


11 ( ):

Negative co-payment

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Macedonia has no system of stimulating non-consumption of health products and services which areinsured by the Health Insurance Fund.


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Interviews of relevant functionaries in the Health insurance Fund.

33 ( ) - , , , , ( .),

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OPTION 1

Insured who do not use any health products and services in a given fiscal year (January 1

December 31) will get a refund representing a percentage of their annual contributions to the

Health insurance Fund.

OPTION 2

Insured who use less than a specifiedlist or level of health products and services in a given

fiscal year (January 1 December 31) will get a refund representing a percentage of their

annual contributions to the Health insurance Fund.

OPTION 3

The future contributions of insured who use less than a specifiedlist or level of health products

and services in a given fiscal year (January 1 December 31) will be adjusted downward

(reduced) in the following fiscal year.

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http://www.ahrq.gov/QUAL/value/incentives6.htm

http://ideas.repec.org/h/eee/heachp/1-08.html

http://www.taxpolicycenter.org/taxtopics/healthinsurance.cfm

http://samvak.tripod.com/pp150.html

::

Negative com-payments and other forms of rewarding insured who consume fewer

insurance resources are common throughout the insurance industry.

Thus, insured who made no claims on their car insurance in a given year, pay a lower

premium the next year.

Financial incentives not to consume health products and services are very common in

countries withprivate health insurance. There is no reason not to implement them in a

publicsystem, too.

Negative co-payments (negative participation) has proven effective at preventingmoral

hazardand supply-side over-prescription of interventions, drugs, and services.

, 01.09.2009()

..( ) Sam vaknin

(,
http://www.ahrq.gov/QUAL/value/incentives6.htmhttp://www.ahrq.gov/QUAL/value/incentives6.htmhttp://ideas.repec.org/h/eee/heachp/1-08.htmlhttp://ideas.repec.org/h/eee/heachp/1-08.htmlhttp://www.taxpolicycenter.org/taxtopics/healthinsurance.cfmhttp://www.taxpolicycenter.org/taxtopics/healthinsurance.cfmhttp://samvak.tripod.com/pp150.htmlhttp://samvak.tripod.com/pp150.htmlhttp://samvak.tripod.com/pp150.htmlhttp://samvak.tripod.com/pp150.htmlhttp://samvak.tripod.com/pp150.htmlhttp://samvak.tripod.com/pp150.htmlhttp://samvak.tripod.com/pp150.htmlhttp://samvak.tripod.com/pp150.htmlhttp://samvak.tripod.com/pp150.htmlhttp://www.taxpolicycenter.org/taxtopics/healthinsurance.cfmhttp://ideas.repec.org/h/eee/heachp/1-08.htmlhttp://www.ahrq.gov/QUAL/value/incentives6.htm


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Sam Vaknin

(,//e-mail) 070-565488

[email protected]

11 ( ):

Commercial insurance fund

22 ( , , , ,

( .), .)

No private commercial health insurance funds exist or allowed by law (only voluntary private healthinsurance legally allowedsee separate template).


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Various legislation

33 ( ) - , , , , ( .),

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Macedonia should go on having a single, statutory Health Insurance Fund.

Macedonia should not introduce private, commercial health insurance funds.

For my reasons, see the Notes (zabeleski) section.

(())--

See: Funding Healthcare: Options for Europe

See: Purchasing to Improve Health Systems Performance

in the eLibrary:



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Macedonia is a poor country with limited management resources; inadequate regulatory capacity;poor information technology; and deficient statistical data gathering capabilities. The healthsectors main problem is lack of sufficient financial resources coupled with cost inflation and

rampant illegal private, out of pocket, payments.

This lamentable situation leads to under-investment in infrastructure, technology, andcontinuing education; interminable waiting times owing to lack of capacity; and a relatively

poor quality of healthcare and customer experience.

With 2 million impoverished citizens, Macedonia lacks the critical mass to support privatefunds. If such funds are introduced, income disparities may lead to inequity and regressivity.

Macedonias regulatory deficit and the lack of sophistication of its consumers will likely

result in confusion (on the part of the consumers); adverse selection (cream-skimming);cartelization; risk selection; increased transaction costs; and overuse of services.

Researchers in the United States identified these problems:

Cost-unconscious demand: with the third party (insurer) paying passively for benefits,neither providers nor consumers have an incentive to economize.

Biased ri

Macedonia's Healthcare Committee

Documents

Transcript of Macedonia's Healthcare Committee