Health System
Reform in Chile
Guillermo Paraje, PhD
Escuela de Negocios
Universidad Adolfo Ibáñez
Chile
Some health outcomes for
Chile
Preston curve
Infant mortality
Total health expenditure, per capita (USD PPP)
Organization of the Chilean
health system
OECD Classification of health
systems
1. National Health System (“Beveridgian”)
2. National Health Insurance (“Bismarckian”)
3. Statist social insurance system
4. Private insurance
OECD Classification of health
systems
1. Unclasiffied
MINISTRY OF HEALTH: Regulation and Sanitary Supervision
FINANCING
WORKERS
CONTRIBUTIONS
GOVERNMENT
FIRMS
7% del swages
INSURANCE
ARMED
FORCES
FONASA
80%
PROVISION
Armed forces
Hospitals
Public
Hospitals
ISAPRE
16%
MUTUALS
Clinics and
Hospitals
Hospitls for
lsbout related
conditions
Primary Care Centres
PUBLIC SECTOR
PRIVATE SECTOR
FONASA, ISAPRE and others (1990 - 2012)
100%
90%
80%
70%
60%
Otros
50%
Seguros Privados
Seguro Público
40%
30%
20%
10%
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
0%
Dual systems for health insurance
1. Strong income segmentation
Distribution of beneficiaries by income quintile
FONASA 2011
ISAPRE 2011
Quintile 1
Quintile 1
Quintile 2
Quintile 2
Quintile 3
Quintile 3
Quintile 4
Quintile 4
Quintile 5
Quintile 5
Per capita expenditure by health system (thousands of
current pesos)
450
400
350
300
250
Gasto Per Capita Público
Gasto Per Capita Privado
200
150
100
50
0
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
Dual systems for health insurance
1. Strong income segmentation
2. Strong cream-skimming and “captivity”
Beneficiaries distribution by sex and age
Average coverage by type of service and sex, by age
group, 2013
90.0%
80.0%
70.0%
60.0%
50.0%
40.0%
30.0%
20.0%
10.0%
0.0%
Cobertura Ambulatoria Femenino
Cobertura Hosptalaria Femenino
Cobertura Ambulatoria Masculino
Cobertura Hosptalaria Masculino
Average portfolio risks
Beneficiaries “captivity”
Cautividad GES en Isapres
(n = 3.206.312)
1.245.182 personas
Nota
Dual systems for health insurance
1. Strong income segmentation
2. Strong cream-skimming and “captivity”
3. Impossibility of comparing health plans
Stock and effectively sold plans by January
2014 de 2014
Planes Vigentes en Enero
Isapre
Isapres Abiertas
Isapres Cerradas
Sistema
Planes de Salud a Enero de 2014
Comercializados
Vigentes
55.123
11.413
707
191
55.830
11.604
20,8% de los planes se encuentran en comercialización
Dual systems for health insurance
1. Strong income segmentation
2. Strong cream-skimming and “captivity”
3. Impossibility of comparing health plans
4. Differential use (and misuse) of the system
Use of medical services by income quintiles
(2009)
20%
18%
17%
17%
16%
16%
14%
14%
12%
13%
13%
13%
13%
14%
14%
13%
12%
12%
10%
9%
10%
9%
9%
8%
8%
6%
6%
4%
6%
5%
6%
4%
7%
6%
10%
8%
8%
Exámenes de laboratorio
Rayos y ecografías
6%
Decil de ingreso autónomo
2%
0%
I
II
III
IV
V
VI
VII
VIII
IX
Consultas especialidades
Consultas dentales
5%
5%
Consultas generales
11%
10%
10%
7%
6%
4%
4%
9%
15%
X
Human Resources in Health (circa 2013)
Dual systems for health insurance
1. Strong income segmentation
2. Strong cream-skimming and “captivity”
3. Impossibility of comparing health plans
4. Differential use (and misuse) of the system
5. Ineffective insurance in the long run
Out-of-pocket expenditure (as share
of total household consumption)
Out-of-pocket expenditure (as share of
total household consumption)
Dual systems for health insurance
1. Strong income segmentation
2. Strong cream-skimming and “captivity”
3. Impossibility of comparing health plans
4. Differential use (and misuse) of the system
5. Ineffective insurance in the long run
6. Unilateral premium increase and vertical
integration
Unilateral premium increase and
vertical integration
• Mandatory health insurance companies can, once
per year, unilaterally increase premiums (in real
terms)
• Insurance companies mostly pay fee-for-service
• There are some insurance companies vertically
integrated with providers
Average increase in premiums
Lawsuits against premium increases
Reform proposals
Health Plan
1. Health Plan mandatorily offered by all insurance
companies (no rejection)
• A wide catalogue of procedures /illnesses
• Catastrophic expenditures insurance
• Emergency coverage
Alternative 1: keeping the ISAPRES
1. Health Plan mandatorily offered by all insurance
companies (no rejection)
2. Unique compensatory fund for all the system
Health Fund
1. Unique compensatory fund for all the system
• Allows income solidarity
• Decreases cream-skimming: ISAPRES get a risk
adjusted premium (eg, sex, age, region,
occupation, DRG, etc.)
• Free movement across insurance companies
• Long run insurance (inter-generational
solidarity)
MINISTERIO DE SALUD: Autoridad Sanitaria Reguladora
FINANCIACION
SEGUROS:
COTIZACION
TRABAJADORES
7% del salario
ESTADO
FUERZAS
ARMADAS
EMPRESAS
UNIQUE HEALTH
FUND
PRIMAS AJUSTADAS
POR RIESGO
FONASA
ISAPRE
MUTUALES
Alternative 1: keeping the ISAPRES
1. Health Plan mandatorily offered by all insurance
companies (no rejection)
2. Unique compensatory fund for all the system
3. Better integration between public and private health
system (cost containment by accessing the primary
health care centres)
MINISTERIO DE SALUD: Autoridad Sanitaria Reguladora
FINANCIACION
SEGUROS:
COTIZACION
TRABAJADORES
7% del salario
ESTADO
FUERZAS
ARMADAS
EMPRESAS
FONDO UNICO
SALUD
MUTUALES
PRIMAS AJUSTADAS
POR RIESGO
FONASA
PROVISION
SERVICIOS:
Hospitales
FF.AA.
Hospitales
SNSS
ISAPRE
Ambulatorio
Hospitalario
Hospitales
Atención de
Enfermedades
Profesionales
Consultorios
SECTOR PÚBLICO
SECTOR PRIVADO
Alternative 2: National Health
Insurance
1.Health Plan
2.National health insurance
3.Private complementary insurance
4.Centralized negotiation with providers
MINISTERIO DE SALUD: Autoridad Sanitaria Reguladora
FINANCIACION
SEGUROS:
COTIZACION
TRABAJADORES
7% del salario
ESTADO
FUERZAS
ARMADAS
EMPRESAS
NATIONAL
HEALTH
INSURANCE
MUTUALES
Seguros
Complementarios
PROVISION
SERVICIOS:
Hospitales
FF.AA.
Hospitales
SNSS
Ambulatorio
Hospitalario
Hospitales
Atención de
Enfermedades
Profesionales
Consultorios
SECTOR PÚBLICO
SECTOR PRIVADO
Conclusions
There are no perfect health systems. All of
them need constant regulation and
supervision
Challenges are enormous. The lobby of
different groups is huge
Cost increase generates an extra challenge,
as it is hard to disentangle “natural”
increases from artificial ones.
¡Muchas gracias!
[email protected]
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Economía de la Salud y Políticas Públicas: El caso chileno