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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) 2 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 3 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) 4 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) 5 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 6 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 7 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) 8 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) 10 II. Challenges for the health system 1) Demographic context 2) Economic context 3) Financial sustainability 4) Europe 5) Regulation 11 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). 12 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% 13 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 14 2012. II. Challenges for the health system 4) Europe EU Directive on cross-border healthcare: facilitate access to cross-border healthcare in the EU 15 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 16 Outline I. The Portuguese health system II. Challenges for the health system III. The Health Regulation Authority (ERS) 17 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 18 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 (…) 19 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. 20 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) 21 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 22 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 23 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% 24 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 25 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 26 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) 27 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) 28 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 29 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) 30 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. 31 32