Download Diapositivo 1

The Portuguese health system and its
regulation
Jorge Simões
President of the Board
Porto, 8 May 2014
Outline
I.
The Portuguese health system
II. Challenges for the health system
III. The Health Regulation Authority (ERS)
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I. The Portuguese health system
General characterization
 The Portuguese health system is characterized by three layers:
The National Health Service
Public insurance schemes for certain professions (health
subsystems)
Voluntary private health insurance
 The Portuguese health system is a mixed system, with a combination of
public and private funding, and also public and private provision
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I. The Portuguese health system
Public and private mix in funding
Current expenditure in healthcare, Portugal 2012
EUR million
Percentage
Public funding
9,790
62.6%
- National Health Service
8,439
54.0%
- Public professional subsystems
585
3.7%
- Other public funding
765
4.9%
5,839
37.4%
- Private subsystems
288
1.8%
- Voluntary health insurance
503
3.2%
4,947
31.7%
100
0.6%
Private funding
- Out-of-pocket payments
- Social funding
Source: INE (2013), Health Care Satellite Account (2012)
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I. The Portuguese health system
Public and private mix in provision
Proportion of total consultations in private providers, Portugal, 2005
Specialty
% private consultations
Dental Care
92.1%
Gynecology
67.6%
Ophthalmology
66.9%
Cardiology
54.2%
Orthopedics
45.5%
Pediatrics
31.1%
Primary care
17.1%
Source: Simões, Barros and Pereira (2008)
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I. The Portuguese health system
Access and equity
 Primary health care:
only 0.03% of the population lives more than 30 minutes away from a
NHS primary care facility (ERS, 2009)
85.2% are assigned to a family doctor (ACSS, 2010)
 Hospital care:
88% of the population lives less than 30 minutes away and only 1%
of the population lives more than 60 minutes away from a hospital
asymmetries in the concentration of medical specialists, which is
higher in the region of LVT and lower in Alentejo and Algarve
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I. The Portuguese health system
Access and equity
 Vaccination:
immunization rates above 90% and inclusion of new vaccines
in the National Plan of Vaccination
 Dental Care Programme
Set up in 2005 within the NHS, covers basic dental care for
children, aged people with economic difficulties, pregnant
women and HIV positive individuals
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I. The Portuguese health system
Health gains
 From 2000 to 2012:
life expectancy at birth increased from 76.4 to 79.9 years;
under 1 year mortality rate decreased from 5.5 to 3.4‰.
Source: INE (2013)
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I. The Portuguese health system
Expenditure on health
Portugal – 10,2%
OCDE average – 9,3%
Média OCDE
12,0
10,0
8,0
6,0
4,0
2,0
9
2010
2008
2006
2004
2002
2000
1998
1996
1994
1992
1990
1988
1986
1984
1982
1980
1978
1976
1974
1972
0,0
1970
Expenditure on health as % of GDP
Portugal
Source: OECD, Health Data 2012
Outline
I.
The Portuguese health system
II. Challenges for the health system
III. The Health Regulation Authority (ERS)
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II. Challenges for the health system
1) Demographic context
2) Economic context
3) Financial sustainability
4) Europe
5) Regulation
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II. Challenges for the health system
1) Demographic context
 15% of residents in Portugal are aged under 15 years and 19%
are over 65 years (INE, 2012)
 In the last decade (2001-2011):
 old-age dependency ratio increased (24.5 to 29.0)
 natural growth rate became negative (0.07 to -0.06)
 total fertility rate decreased (from 1.46 to 1.37) (INE, 2012)
 life expectancy at birth increased from 76.4 to 79.7 years
 Forecast for 2020: a 2% decrease in population, a 13.8%
decrease in youth (0-14 years) and a 20.6% increase in elderly (≥
65 years).
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II. Challenges for the health system
2) Economic context
Gross Domestic Product, Portugal
PIB
preços of
de2006)
2006
GDPa (prices
Taxa derate
crescimento
Growth
170.000
6%
5%
4%
150.000
3%
2%
140.000
1%
130.000
0%
-1%
120.000
Real growth rate of GDP
-2%
110.000
-3%
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2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
-4%
1996
100.000
1995
GDP in million of EUR
160.000
Source: INE, 2013
II. Challenges for the health system
3) Financial sustainability
“Memorandum of Understanding” signed with IMF and EU,
for the health sector, sets:
 revision of existing user fee exemption categories (more
150 M€ in 2012 e 50 M€ in 2013)
 reduction in public expenditure on drugs (1.25% of GDP in
2012, 1% of GDP in 2013)
 hospitals costs: reduction in operational expenditures of 200
million euros (in 2012)
 reduction in budgetary costs of public subsystems (ADSE,
ADM and SAD) by 30% in 2012 and 20% in 2013, achieved
by reducing the benefits to users
 reduction in expenditure of the NHS with the acquisition of
private diagnostic and therapeutical services in 10% in
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2012.
II. Challenges for the health system
4) Europe
 EU Directive on cross-border healthcare:
facilitate access to cross-border healthcare in the EU
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II. Challenges for the health system
5) Regulation
 Financial pressure in health care generates risks to
patients:
Management of health care units increasingly oriented by
financial targets
Performance targets may collide with patients rights and
interests
Containment of global investment on health
 Health regulator is essential to balance sustainability
measures and ensuring patients rights and interests
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Outline
I.
The Portuguese health system
II. Challenges for the health system
III. The Health Regulation Authority (ERS)
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III. The Health Regulation Authority
Who we are
Mission of the Health Regulation Authority (ERS)
 Regulating the activity of health care providers in Portugal (drugs
and medical devices are excluded)
Nature
 ERS is an independent public body
Juridical regime
 Decree-Law no. 309/2003 – creation of ERS
 Decree-Law no. 127/2009 – restructuring
 Decree-Law no. 66/2014 – restructuring under the new framework law
for independent regulation in Portugal
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III. The Health Regulation Authority
Who we regulate
 All health care providers, public, private for-profit and private notfor-profit ownership
 All types of providers
 Hospitals
 Individual physician's offices
 Outpatient care clinics
 Diagnostic tests providers
 Dentist offices and clinics
(…)
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III. The Health Regulation Authority
What we do
The ERS aims at delivering independent assurance about:
 the compliance with the legal requirements for health care
services and establishments,
 the protection of health care service users rights, including access
and freedom of choice,
 the legality and transparency in the economic relations between
providers, funders and users,
 fair competition in health care markets.
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III. The Health Regulation Authority
How we do it
ERS carries out several regulation and supervision activities:
 registering and licensing health care providers,
 handling complaints from service users, providers and institutions,
 carrying out inspections and audits to heath care provider facilities,
 carrying out investigations of situations with significant adverse impact
on the rights of patients or on the quality and safety of care,
 conducting administrative offence procedures involving health care
providers and applying the resulting sanctions,
 producing studies, advice papers and recommendations,
 assessing the quality of health care (SINAS)
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III. The Health Regulation Authority
Providers registered with the ERS
Ent. Registadas
Estab. Registados
15.085
16.252
17.160
13.682
10.659
8.778
7.518
11.752
8.147
12.496
9.198
8.481
10.151
10.808
11.385
2012
2013
6.190
2006
2007
2008
2010
2009
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2011
III. The Health Regulation Authority
Complaints handled in 2013
Subject of complaint
number
%
Administrative service quality
2.019
24,7%
Health care quality
1.765
21,6%
Waiting times
1.762
21,6%
Financial issues
794
9,7%
Invalid complaint
596
7,3%
Access
396
4,9%
Human assiance
340
4,2%
Facilities
228
2,8%
Legal issues
143
1,8%
Other
102
1,3%
Discrimination
15
0,2%
8.160
100%
Total
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III. The Health Regulation Authority
Investigations initiated in 2013
Subject
number
%
Quality
26
27%
Legal issues
26
27%
Access
20
21%
Transparency
12
13%
Contracting with NHS
4
4%
Service billing
4
4%
Discrimination
1
1%
Supplier induced demand
1
1%
Other
1
1%
Total
95
100%
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III. The Health Regulation Authority
Inspections carried in 2013
Inspections focus
Legal requirements of health care establishments
Number
%
984
79%
Thematic reviews
169
14%
Audits related to SINAS
61
5%
Quality of health care
33
3%
1.247
100%
Total
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III. The Health Regulation Authority
Administrative offence procedures initiated in 2013
Offence
Number
%
Non compliance with licensing rules
223
40%
Not registered with the ERS
203
37%
Not owning a Complaints Book
87
16%
Irregular handling of Complaints Book
19
3%
Refusal to collaborate with the ERS
10
2%
False declarations or information
7
1%
Other legal issues
7
1%
556
100%
Total
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III. The Health Regulation Authority
Studies, advice papers and recommendations (2012/2013)
Topics of analysis:
 Quality of health care (4)
 Inequalities in access to health care (5)
 Competition in health care markets (4)
 Regulation of economic relations (2)
 Patient rights safeguarding (4)
 Organization and performance of the NHS (4)
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III. The Health Regulation Authority
Our people
The Board
 ERS is managed by a Board of three members (one of which is
the president)
 Appointed by the Government for a period of 5 years
Staff
 51 permanent employees
 external experts (doctors, nurses, dentists)
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III. The Health Regulation Authority
Independence
 Independence of Board members
 Cannot be dismissed (except in cases of serious failure)
 Cannot be involved in regulated activities
 100% funded from registration fee income
 Public accountability
 Reporting activities to the Parliament and the Government
 Advisory board
 Activity is overseen by Court
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III. The Health Regulation Authority
With whom we network
 Professional associations
 Patient associations
 Health care providers
 Government health related institutions
 Regulators of other sectors
 Academic institutions and experts
 European health care regulators (EPSO)
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III. The Health Regulation Authority
Impact of ERS activity
 Better knowledge of the health system – registration, sectoral
studies;
 Greater empowerment of citizens – complaints and information;
 Better assurance of user rights – control of access rights;
 Better knowledge of health care markets – competition studies;
 More safety – licensing, supervision and sanctioning;
 More quality – quality assessments and studies.
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