Otros conceptos relacionados con la Inteligencia Emocional

• Creation of independent technical agencies to regulate and govern the new mandatory private health insurance market:

o Health Quality Board (HQB)

o Health Information and Market Transparency Board (HIMTB) o Health Insurance Regulator (HIR)

• Government(s) should define the:

o Safety net – the basic basket of services to be publicly subsidised o Tasks the HQB and the HIMTB must perform (below).

Year 2

• Establishment responsibilities for the boards: o HQB responsibility:

• Setting standards of care quality provision, safety and efficacy • Setting maximum waiting times

• Setting guidelines for quality in provision of healthcare, with special focus on chronic and social care, prevention strategies

• Its relationship with Health Technology Assessment

• Publicising the indicators used for measuring performance and quality.

o HIMTB responsibility for defining the way in which insurers, providers, individuals and the HIMTM itself will use, collect and make public information on the health insurance market:

• From insurers to regulator or to the HIMTB, in respect of public subsidies: • Individuals insured

• Risk profile

• Performance (past years starting in year 1) • Cost of provision (past years starting in year 1)

• All the information to be provided from insurers to individuals • From providers to insurers in respect of reimbursement • Individuals attended, full episodes

• Performance, especially for prevention and disease management programs • Co-payments to be paid by individuals for service use

• Out-of-pocket payments obtained from individuals

• From insurers to individuals in respect of encouragement to enrol: • Menu of contract, at least covering the basic package

• The network of providers from which individuals can obtain care

• From the HIMTB to individuals:

• Publicise all the relevant information from insurers and providers so that there is transparency in the market and individuals can freely choose

• From the HIMTB to insurers:

• Indicators of quality and performance to be used (quality of life, waiting times, vaccinations, screening, o HIR responsibility for provisions relating to:

• The length of duration of health insurance contract (1 year)

• Open enrolment every year from December 1st to December 31st to be effective on January 1st next year • Mandatory acceptance

• Automatic renewal – unless he or she opts out, the individual is directly renewed with the previous insurer • Opt-out procedures for public and private insurers

• Terms and conditions for insurers in the market including that:

• An insurer who decides to enter the market must trade for at least 7 years

• insurers can freely contract with different providers to form their network of providers and at the same time, a private provider (GP, specialist, or hospital) can belong to the network of providers of different insurers under private contracts

• Risk adjustment formula for subsidy arrangements for individuals

• Progressive implementation towards comprehensive health, chronic, and social care by year 10 (below) • The management of the medical savings account per individual.

Year 2, June (and each year if there are changes)

• Both boards should be functional, and have collected and publicised the abovementioned information. The terms published in Year 2 would be applicable in year 3. Any change in contracts, coverage (basic by the Australian Department of Health or supplementary for the insurers), premiums or co-payments should be published before the end of June to oblige in January.

Year 2, December

• Individuals choose their initial carrier and a GP of reference, effective in January year 3. Year 3 – 1st quarter

• Medical Savings Accounts established • Operation of the health insurance market • Insurers payments implemented.

• Creation and mandatory enrolment for all insurers into a risk-sharing group or reinsurance. Premium equals 5% of all public subsidies.

Progressive reimbursement and coverage of primary care

In year 3, coverage by public and private health insurers in the market is complete in terms of primary care, specialist care and hospital care. (Therefore, by June of Year 2, insurers have published their network of providers, including primary care.) However, reimbursement remains unchanged.

• Rebates for the use of primary care doctors are delivered by private health insurers directly to primary care doctors (not through patients), but the amount of the rebate remains unchanged. Patients only have to pay the co-payment per visit established in the contract (with the rebate taken into account).

• Flexible provisions could apply in the establishment of networks of providers. If appropriate, all medical practitioners could be deemed to be members of all insurers’ networks for an initial period.

Social care, nursing care, institutional and home care

From year 3, an additional one per cent income tax levy would apply to finance social, nursing, home, institutional and residential care. Although ideally this care will be also included in private insurance, that should be implemented progressively.

Years 3 to 5

Social, home, nursing and residential care, based on assessed need, is publicly financed through the additional 1% of income tax. The federal government determines organisation and provision of care. High co-payments (40% of cost) apply for the first years of application to reduce the intergenerational problem. Public subsidies could reduce co-payments for low-income individuals in need.

Years 4 to 6

Reimbursement from health insurers to the primary care practitioners changes to the model shown in Table 2, with a progressive implementation of capitation, taking into account the number of individuals that have chosen a GP of reference belonging to the insurer’s network of providers.

TABLE 2: Progressive blended payment for primary care doctors

FFS Capitation Supplementary wage per remote location programs, vaccination, screening, preventionEconomic incentives: disease management

year 3 100 0

✗

✗

year 4 75 25

✓

✓

year 5 50 50

✓

✓

year 6 25 75

✓

✓

During years 4 to 6, vertical integration of primary care networks or primary care units for insurers would be expected to become common, as was the case with the UK’s Primary Care Trusts. A supplementary wage compensates doctors for working at a remote location, using the Consumer Price Index (CPI) and the cost of living in different geographical areas. The economic incentives taking into account performance would be similar to those implemented in Canada.

Reimbursement for specialist care and hospital care, and pharmaceutical expenditure

As this type of service is already being reimbursed in the current system by private insurers, no transition applies. Hospital and specialist care units are reimbursed under a private contract that based on a blended payment of fee for service and capitation with weights of diagnosis, or any other type of private contract,

from year 3 on. Including pharmaceutical coverage in the same contract will provide incentives for efficiency in the use of pharmaceutical products.

Years 6 to 8

By year 6, private health insurers would be providing full integrated health insurance to the general population. Individuals and markets will be familiar with social, residential and home care related to long-term care and chronic conditions. In years 6 to 8, the States, Territories or cities will begin to organise the provision of these services, with progressive decentralisation of these services. Co-payments could be lowered simultaneously. Years 9 to 10

Once social and residential care has been decentralised to States, Territories or cities, full responsibility ill transfer subsequently to private insurers and organisations. By year 9 or 10 the system transition would be complete. The outcome will be a financially sustainable mandatory and integrated health insurance market designed for chronic health and social care, publicly funded through income taxes with some co-payments to diminish the problem of moral hazard. This model would provide more choice for consumers, and freedom for insurers and providers in contracting as well as competition on quality and price.