Health Insurance Risk Mgmt

1.5 Credits · Level: Graduate

The health financing scheme adopted by a country to fund its health system is key to its performance. It will not only impact its accessibility, affordability and equity, it will also impact its quality, cost-effectiveness and sustainability. For example, it is now widely acknowledged that there is no other way to reach universal health coverage than to establish a risk pooling scheme that includes all the members of a society (Universal Health Coverage being defined by WHO as ensuring that all people can use the promotive, preventive, curative, rehabilitative and palliative health services they need, of sufficient quality to be effective, while also ensuring that the use of these services does not expose the user to financial hardship). It is clear that some schemes are more successful than others. And if there are still many debates about which risk pooling scheme is the most effective, cost-effectiveness or cost-benefit analyses clearly demonstrate that some schemes cost more (in GDP percent term) than others, for lesser results (health indicators of life expectancy, mortality and morbidity). However, in this course, the measure of success for a health financing system will not be limited to its degree of cost effectiveness/cost benefit. Success will essentially be measured by the degree of achievement of universal health coverage. This course will present a detailed analysis of the three main risk pooling schemes that are implemented in the world: • The first model is general tax-based, managed by a National Health Service (NHS) or a Ministry of Health (about 100 countries in the world) such as in United Kingdom, Canada and most African countries; • The second is payroll tax-based, managed by a quasi-public entity (about 60 countries in the world) such as in Germany and France; • The third is private sector-based health insurance financed by voluntary contributions, managed by private insurers (less than 10 countries in the world) such as in the USA. From their generic principles to the versions that are currently implemented in countries all over the world, both developed and developing, the course will study: (i) their history and especially the enabling conditions that made possible the launching of these schemes; (ii) the numerous changes that were made for the schemes to survive and/or become more efficient, and especially the measures that aims at alleviating the population fast aging as in Asia; (iii) the controls and regulations, so essential for a scheme’s sustainability, which were developed and implemented to compensate the scheme’s flaws and ultimately contain costs; (iv) the logistics (such as patients’ reimbursement modalities, health providers’ payment modalities, documents processing and information system) because they are key in the level of administrative costs spent for a scheme’s functioning; and (v) the scheme’s performance, which will be assessed through different sets of indicators (such as: accessibility, coverage, quality, affordability, equity, cost-effectiveness, sustainability and population health status) and through its universal coverage achievement.