1. Tuzla, september 2007. godine Review of Financing Methods in Health Care Salihbašić Šehzada, dipl.ecc. Technical Training for Rehabilitation Center Managers Economy and Funding of Health Care Systems Health System Economies and Financing

2.  Key participants in health care system are: - citizens, insurees, patients - health service providers - budgets, funds - payer of the service Financing and providing health care can be viewed as circular movement of the participants involved in health care system An Overview of Methods of Funding of Health Care

3. Basic functional relations between participants in health care system  fund raising  merging of funds  purchase or payment for health care and  providing health care

4. Efficiency and fairness as the basic criteria for evaluating and financing health care Efficiency principle Efficiency is an economic term which can be defined as the relation of the output (effect, income, profit) to the inputs, resources, investment, costs or in other words as the efficiency of utilization of resources.

5. Fairness in financing health care means that heath care should financed in accordance with the solvency of the user. That is the principle of vertical fairness. Fairness in financing health care means that heath care should financed in accordance with the solvency of the user. That is the principle of vertical fairness. Fairness principle in providing health care or the principle of horizontal fairness means that every individual receives appropriate health care. (solidarity) Fairness principle

6. Financing of health care as an integral connection fund raising fund raising merging risk and resources merging risk and resources allocation of resources including methods of purchasing services and paying staff and institutions allocation of resources including methods of purchasing services and paying staff and institutions

7. Financing Establishing financially viable health care in order to make efficient and fair financing of health services possible should be in accordance with the standard approach and clinically proven procedures (primary and secondary risks) and also with the reform of health care financing and finally with the funds at disposal.

8. Characteristics of good models of financing

9. Contractual method Develop mechanisms of contracting Conditions for contracting set of laws, basic and additional conditions for contracting health care program for registered citizens, taking into consideration special distance solve the problem of citizens without health care, municipalities

10. Contractual relations Key participants in contractual relations in health care are: Ministry of Health Care Public Health Care Fund Health Center TOM Services for consultancy, diagnosis, specialist treatment and community centers Nongovernmental sector (chambers, associations)

11. The ways of payment of doctors and health care services Health care services can be paid in different ways: budget (estimation of all costs) capitation payment specific cases ( diagnostic groups) per day; patients should pay health care treatments for every day spent in hospital specific treatment; different prices for different medical treatments

12. Capitation payment represents a fixed amount of money per patient for certain period time (one year) made to medical service provider by a health maintenance organization. Capitation payment is calculated on the basis of age, sex, spatial distance and doctor’s education.

13. Payment of health care services Combined payment Capitation Payment per service ( only for certain services defined in advance) Special bonus payment ( promotion of health, prescriber service)

14. Formula: absolute value of capitation payment RN=(DS1 x 2X) + (DS2 x X) + (DS3 x 1,5X) + (DS4 x 2,5X) RN – an amount of money at disposal for family medical care DS – number of people in particular are group X – capitation payment in particular age group

15. Monitoring Monitoring and evaluation of the health care program which is subject matter of the agreement Presentation of data to the public and government health care results financial viability quality efficiency

16. Reform of the health care Reform of the health care should be based on solidarity, which should protect citizens from enormous expenditure. Fairness and equal access to health care Introduction of the new ways of payment Contracting at all levels Protection of patients Development of prevention program in order to minimize primary and secondary risks

17. Tuzla, september 2007. godine Principles of financing health care reform required health insurance Experience of Bosnia-Herzegovina Federation Tuzla Canton Salihbašić Šehzada, economist

18. MISSION, VISION AND STRATEGIC GOALS Mission  Insure universal, financially viable approach to the basic package of services, which should be efficient and of high quality. Vision  Establish an institution oriented towards users, which is dedicated to quality, efficiency and solidarity in health care. Strategic goals  Aim to establishing effective approach in fund rising;  Lobbing for ‘the equal share’ of funds from government budget for the support citizens without health insurance;  Aim to establishing an union with the Federal Health Institute and Ministry of Health to rationalize service providers;  Analyze the basic package of services and make certain adjustments that may become necessary;  Merge the responsibility and resources for financing secondary and tertiary health care with the Federal Health Institute;  Incorporate monitoring of quality and special bonus payment for medical service providers;  Demand information about basic costs of the institution involved in negotiating  agreements based on the success.

19. GENERAL GOALS  Ensure universal, universal, qualitative, qualitative, continual health care based on family health and continual health care based on family health and oriented toward promotion of health and prevention of diseases; oriented toward promotion of health and prevention of diseases;  Equal health care for everyone;  Achieving efficiency through providing health care of standard quality and price;  Contracts with health care institutions at all levels of health care

20. GOALS OF THE IMPLEMENTATION OF THE PROGRAM  Equal rights and conditions for all citizens with health care insurance at the territory of Tuzla Canton for using health care services they need;  Efficiency in handling funds raised from the required health insurance, taking into consideration proportions, quality and type of health service and also relations with patients;  Reports on all the indicators of management, costs, providing health care set by the agreement, achieved quality and the proportions of the health care and improvement in partner relations that are supposed to improve the health of the citizens should be sent in due time;  Quality and proportions of the health care services provided;  Dealing with open questions that may arises should be done with suitable objective argumentation an in accordance with the rules. However, good will for fining an adequate solution for both parties should be shown.

21. Principles of funding Incomes Number of people with health insurance, taxpayers and tax payments, taking into account the average growth rate of macroeconomic factors of growth for 2007 represent the basis for planning of incomes. growth rate of tax payments at the level of canton, 7,8% nominal GDP 8,2% employment growth and payment growth 12%Expenditure Basic criteria for providing health care from required health insurance in 2007 are: number of people with health care insurance region staff and equipment of the service provider type of service quality of service price (tariff)

22. Price of the service Develop and test new ways of payment for all types of health care services in service providing agencies (health centers, hospitals) in which payment is obtained via service acquisition agency (heath insurance board); In health centers: primary health care (capitation payment) specialist-consultative health care per patient- service In hospitals: specialist-consultative health care per patient- service hospital care - DRG system

23. Capitation payment is a periodic payment (one year) – per head- made to medical service providers for medical services in specific categories: RN=(DS1 x 2X) + (DS2 x X) + (DS3 x 1,5X) + (DS4 x 2,5X) RN – funds at disposal DS –number of persons in specific age group X – capitation payment for age group that involves 7-19 years old persons DRG (Diagnosis Related Groups) is a classification system which groups together patients into clinically meaningful categories of similar levels of complexity that consume similar amounts of resources. Price of the service

24. Additional criteria for obtaining health care from required health insurance in 2007 are:  The effects of the present program of health care on medical institutions in surrounding municipalities  Distance medical institution and the University Clinical Centre Tuzla as a criterion for travel expenses for the ambulances  Number of employed with health care insurance in the municipalities in Tuzla Canton as a criterion for working hours in medical institutions  Number of pupils and full-time students who live in other municipalities of Tuzla Canton as a criterion for coordination of program for funding health care  Number of people with health insurance represents a criteria for adjustment of capitation payment on the basis of number of people who use out patient clinics and number of people estimated in the agreement  Number of pupils from Tuzla Canton who play sport as a criterion for health care service at the sports health center

25. Population and number of people with health care insurance in Tuzla Canton NumberMunicipality Number % People with health insurance involved Population People with helath insurance 01234 1Banovići25.51924.99097,93 2Čelić14.4009.61666,78 3Doboj Istok10.09610.592104,91 4Gračanica51.45044.99187,45 5Gradačac46.17937.48881,18 6Kalesija34.91131.78091,03 7Kladanj15.25212.39681,27 8Lukavac51.55146.34489,90 9Sapna13.9349.53768,44 10Srebrenik40.92937.82992,43 11Teočak7.3946.78891,80 12Tuzla 131.374124.36094,66 13Živinice 53.89653.33798,96 UKUPNO496.885450.04890,57

26. Area of Tuzla Canton Izvor: "Kanton Tuzla u brojkama" Jul 2000. godine - Federalni zavod za statistiku Sarajevo area in km² Tuzla Canton 2.649 km²

27. Funds - total 2007. 71.544.199 € Social structure of the people with health care

28. Health care is set by law and it involves:  ambulance service,  treatment of infectious diseases,  treatment of acute, chronic diseases if the patient’s life is endangered,  health care of children under 15  health care of full-time students and pupils,  diagnosis and treatment of endemic nephropathy,  treatment of cancer and insulin-dependent diabetes,  health care in pregnancy and maternity,  health care of mentally infirm who can endanger their life and life of other people or damage certain goods,  health care for those suffering from progressive neuromuscular diseases, paraplegia, quadriplegia, cerebral paralysis and multiple sclerosis.  routine inoculation of children infectious diseses,  treatment of work injury, professional disease,  health care for citizens over 65 under the condition that the incomes of the family members is not higher than the average salary in Bosnia- Herzegovina Federation,  treatment of drug addicts  blood-collecting service,

29. Health care, set by law implements as:  primary health care  specialist and diagnostic health care,  hospital health care,  right to use medicines from the list proposed by Public Health Care,  right to dental prothetics care and aid,  right to use orthopedic aid and other aid in accordance with by-laws  right to obtain medical care abroad in accordance with by-laws  right to receive reimbursement involves:  right to receive salary during sick leave  right to receive travel expenses; this right is ensured in the basic health insurance

30. EXPENDITURE AND COSTS In order to maintain achieved level of funding rights from health insurance it is estimated that expenditure and costs of health insurance board should be 71.544.199 €, which is for 9,37% or 6.130.547 € more than in 2006.

31. Required funding and income and expenditure from health insurance Nedostajuća sredstva 33,256 39,715 23,438 16,974 18,942 14,455 - 6,650 U mil.

32. In order to successfully implement health care program in Tuzla Canton 845 team are required:  589,83 teams at the primary level:  501,67 teams at the primary level of health care out of which 125 teams are registered by public health institutions in Canton. There are 228.745 people who use family medical care.  63,58 teams of specialist and diagnostic health care in outpatient clinics  24,58 teams of diagnostic health care in outpatient clinics;  255,13 teams at the hospital level which implies :  1.504 hospital beds and  496.830 days of medical treatment in hospital.

33. Expenditure of the first- contact care in 2007

34. Conclusion  Develop team work and continuous education  Human resources management  Planned allocation of resources  Set ‘basic package of rights’ and networks of medical care at hospital level and primary health care in order to establish contractual relations between health insurance board and public as well as private medical institutions and medical professionals who work in private medical institutions.  Monitor and evaluate programs of health care that are subject matter of the contract in order to present data that concerns with health results, financial viability, quality, efficiency to the public.  Raise certain funds from the budget of the establisher for people without health care insurance.  Open dialogue between the participants in health care sector (providers and users of the services)  Development of prevention programs