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Modelling in Health Care Finance a Compendium of Quantitative Techniques for Health Care Financing

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Modelling in Health Care Finance a Compendium of Quantitative Techniques for Health Care Financing QUANTITATIVE METHODS IN SOCIAL PROTECTION SERIES Modelling in health care finance A compendium of quantitative techniques for health care financing Michael Cichon • William Newbrander Hiroshi Yamabana • Axel Weber Charles Normand • David Dror • Alexander Preker A joint technical publication of the International Labour Office (ILO) and the International Social Security Association (ISSA) , . ^ International Labour Office • Geneva Copyright © International Labour Organization 1999 First published 1999 Publications of the International Labour Oifice enjoy copyright under Protocol 2 of the Universal Copyright Convention. Nevertheless, short excerpts from them may be reproduced without authorization, on condition that the source is indicated. For rights of reproduction or translation, application should be made to the Publications Bureau (Rights and Permissions), International Labour Office, CH-1211 Geneva 22, Switzerland. The International Labour Office welcomes such applications. Libraries, institutions and other users registered in the United Kingdom with the Copyright Licensing Agency, 90 Tottenham Court Road, London WIP OLP (Fax: +44 171 631 5500), in the United States with the Copyright Clearance Center, 222 Rosewood Drive, Danvers, MA 01923 (Fax: +1 978 750 4470), or in other countries with associated Reproduction Rights Organizations, may make photocopies in accordance with the licences issued to them for this purpose. Michael Cichon, William Newbrander, Hiroshi Yamabana, Axel Weber, Charles Normand, David Dror, Alexander Preker Modelling in health care finance: A compendium of quantitative techniques for health care financing Geneva, International Labour Office, 1999 /Medical care/, /health insurance/, /fmancing/, /social security financing/,/ model/,/simulation/, /developed country/,/developmg country/. 02.07.6 ISBN 92-2-110862-7 ILO Cataloguing-in-Publication data The designations employed in ILO publications, which are in conformity with United Nations practice, and the presentation of material therein do not imply the expression of any opinion whatsoever on the part of the International Labour Office concerning the legal status of any country, area or territory or of its authorities, or concerning the delimitation of its frontiers. The responsibility for opinions expressed in signed articles, studies and other contributions rests solely with their authors, and publication does not constitute an endorsement by the International Labour Office of the opinions expressed in them. Reference to names of firms and commercial products and processes does not imply their endorsement by the International Labour Office, and any failure to mention a particular firm, commercial product or process is not a sign of disapproval. ILO publications can be obtained through major booksellers or ILO local offices in many countries, or direct from ILO Publications, International Labour Office, CH-1211 Geneva 22, Switzerland. Catalogues or lists of new publications are available free of charge from the above address. Printed in the United Kingdom ALD To all our friends and colleagues who work to keep national health systems affordable for all in need The authors July 1999 FOREWORD Quantitative health care analysts around the world must constantly respond to the queries of health policy makers. These days, their main question is 'how much?'. They may ask for information that is relatively simple and straightfor- ward - the financing provisions of existing schemes, for example. At the other end of the spectrum, they may ask for complex analyses - for example, regard- ing possible future scenarios. Some typical questions from policy makers include: • What would be the aggregate cost of an increase in doctors' fees by amount x? • What would we save if we were to increase co-payments by amount y? • How much does the existing system cost? • Can we afford to introduce a national health insurance scheme? If so, how would it affect the health care financing liabilities of the government, employers and employees? • Who bears the cost at present, and how can the financial burden be reallocated? This book will help analysts to answer these questions. Answers can only be derived from simpler images of complex reahties - i.e. from financial models of national health care systems. The book offers instruction on how to build such models. In order to do so, analysts need to have at least a grounding in macro- economics, health economics, health policy, financial planning and management, as well as actuarial techniques. This is a tall order for any one person. Without such knowledge, analysts run the risk of using ad hoc methodologies, which often breed uneasiness about the capacity to deal with the problems at hand. Lessons from the field experience of the ILO and other organizations are brought together in this book. Quantitative work in many countries is often done in an uncertain policy environment, with deficient data, and usually under a variety of other constraints. -. The approach to the subject of this book is pragmatic and output-oriented, offering a guideline for the busy professional. The book attempts to create vii Foreword synergies and bridge gaps between quantitative health economics, health financing and actuarial science. Field practice will put the techniques mentioned here to the test. It is intended for planners and managers in charge of national health care financing systems, as well as specialists in international technical cooperation. Theoretical, actuarial and health-related economic concepts are translated into pragmatic tools for short- to medium-term financial planning, management and monitoring. This book also follows up on a previous guidebook on health insurance published by the WHO and the ILO.1 We hope that it will prove to be a practical guide to financial modelling for the specialist, as well as a reference for modelling methodology. This volume is part of a series on quantitative techniques in social protection being published by the Financial, Actuarial and Statistical Branch of the Social Security Department of the ILO, together with the International Social Security Association. Other volumes in this series are: Actuarial mathematics of social security pensions Actuarial theory of social security pension schemes Actuarial practice in social security pension schemes Social budgeting These monographs are all scheduled to be published over the next two years. The objective of this series is to provide a full set of compendiums on the quantitative analysis of national social protection schemes. It is also hoped that they will find their way into university and professional training courses, where training materials on these issues are notoriously scarce. Future ILO and ISSA training courses on quantitative techniques in social security issues will also use these manuals as required reading. The Financial, Statistical and Actuarial Department welcomes your com- ments and feedback on the book in general, on your experience with the use of the modelling techniques described here, and on their adaptation to the specific situations found in your country or scheme. Colin Gillion Dalmer D. Hoskins Director Secretary General Social Security Department International Social Security Association International Labour Office Geneva, Switzerland Geneva, Switzerland 1 WHO and ILO, Social health insurance: A guidebook for planning, Geneva: WHO, 1994. CONTENTS Foreword vii Acknowledgements XV About the authors xvii Part I The context of modelling 1 1 Introduction 3 1.1 Background 3 1.2 Modelling 5 1.3 Objectives and audience 6 1.4 The structure of this book 7 2 Scope and focus 10 2.1 Modelling in health care financing: Focus, context and process 10 2.2 The dual processes of health policy design and modelling 22 2.3 Model limitations and the learning process 31 2.4 Summary 32 3 The modelling object 34 3.1 The economics and economic environment of the health sector 35 3.2 National health care financing systems 37 3.3 Public health care financing systems 41 3.4 Summary 68 Part II Model building 71 4 Databases 73 4.1 Health accounting 74 4.2 Health statistics 83 4.3 Core statistical data and data sources for financial modelling 87 4.4 Data handling for modellers 89 4.5 Summary 94 ix Contents 5 The modelling process 97 5.1 The six steps of the modelling process 97 5.2 Methodological philosophy and principles: Six ground rules 109 5.3 A typical model design 114 5.4 Summary 129 6 Calculation techniques 132 6.1 A standard population projection method 132 6.2 Key projection factors 134 6.3 Income projections 134 6.4 Projecting expenditure 141 6.5 Plausibihty controls 157 6.6 Calculation of a medium-term contribution rate 158 6.7 A pragmatic, stochastic extension of the modelling approach 160 6.8 Summary 162 7 Model examples 165 7.1 The actuarial model of Management Sciences for Health (MSH) 165 7.2 The WHO model for local governments 170 7.3 The WHO budget model for ministries of health (SimFin) 174 7.4 The model of the Australian Health Insurance Commission 176 7.5 The Japanese Ministry of Health social health insurance model 179 7.6 The stochastic model of the German Ministry of Labour 182 7.7 Some ILO models 184 7.8 Summary 207 Part III Using models in policy decisions 209 8 Policy decisions 211 8.1 What are the most critical health needs? 211 8.2 How can a health system provide effective and efficient services? 214 8.3 How can countries finance their health systems? 215 8.4 What is the appropriate mix of the public and private sectors in
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