funding and reimbursement – planning healthcare pp

Funding and Reimbursement – Planning healthcare

Abu Dhabi Healthcare system

History

• The restructuring of Abu Dhabi healthcare system started with the formation of HAAD and SEHA

• Prior to 2007, government owned healthcare facilities in the Emirate of Abu Dhabi were managed by the General Authority for Health Services (GAHS)

• In 2007, the Government of Abu Dhabi issued specific laws (Emirati Decrees) concerning the restructuring of healthcare provision in the Emirate. This resulted in the creation of SEHA and Health Authority-Abu Dhabi (HAAD)

Process• HAAD is the regulator, Daman the

leading insurer/payer and SEHA the leading service provider

Abu Dhabi health Insurance market

Universal healthcare coverage is mandatory, serviced by different insurance plans

Health Insurance is mandatory In 2011, Daman has 28.6% market

share of insured members in Abu Dhabi

Insurance levels

o Thiqa Insurance Plan for nationals – exclusive to Daman, paid by government, Daman does not underwrite risk

o Basic Insurance Plan for lower income expats – exclusive to Daman, subsidized by government, Daman takes limited risk

o Enhanced Insurance Plan for higher income expats – no exclusivity to Daman and insurance companies take complete underwriting risk, premiums paid mostly by employers

Coverage

Increasing demand • Compulsory health insurance law

mandated universal coverage by 2007 and expanded coverage for Nationals to include private sector providers

• Health insurance makes healthcare more affordable for over 800,000 blue collar expats

• Supply constraint was eased by allowing Nationals free access to private providers

Increasing supply

• Healthcare consumption is typically supply constrained; new private sector players may have induced demand

• Number of private hospital beds has strongly increased

Issues for Nationals

• Limited patient contribution by nationals

• Unlike non-GCC countries, Abu Dhabi nationals are responsible for only minor co-payments at selected facilities (private sector pharmacies and dentists) leading to moral hazard

• Free healthcare system leads to overtreatment – unnecessary procedures

Increased demand

• High per capita income coupled with sedentary lifestyle and dietary pattern has increased the incidence of obesity

No. 1 for Diabetes in GCC

Bed capacity

• SEHA is dominant player although the private sector is actively growing

Inpatient care

• The public sector (SEHA) is the leading provider for inpatient care and this is expected to continue in the near to mid-term

Outpatient care

• The private sector has focused on providing high margin outpatient care

SEHA• Abu Dhabi Health Services Company,

Public Joint Stock Company was established in 2007

• SEHA became the vehicle to own and operate all of the public health facilities

• SEHA’s strategy must align with HAAD and Abu Dhabi Government

• Over 16,500 employees 12 hospitals, 2,369 beds

• 57 ambulatory and primary care centres • Comprehensive, integrated health system

SEHA aims to:-

• Customers and Community Stakeholders- Manage Patients and Stakeholders Expectations effectively

• Financial- Manage financial performance to achieve efficiency and competitiveness

• Service, Quality and Operational Efficiency- Provide Integrated high quality and Patient Centered Services

- Deliver superior operational execution

• Learning , Growth and Infrastructure- Establish SEHA among the UAE employers of choice

- Develop National Leadership and support Emiratization

- Develop infrastructure to achieve world class standards

- Promote Research & Education

Funding

• Insurance payments and government subsidy are the main sources of funding

• 40% - Daman and other insurance plus direct payments from patients

• 20% - Government mandates such as medical education

• 40% - Government subsidy • The goal is to have ZERO government

subsidy by 2015 / 2016

SEHA output 2011

• Performed 5.2 million1 outpatient visits and admissions

• Delivered 18,298 babies • Performed over 39,000 surgeries • Patient satisfaction of 88.2% • Improved clinical outcomes • Reduced waiting times; improved access • JCI Accreditations and ISO Re-Certifications • Improved financial sustainability (increase net

patient revenue, 5.9%3 ahead of budget)

Plans

• Total construction project cost in excess of AED 20 billion (USD 5.4 billion)

Plans cont.

Amalgimation

Role of Healthcare in 2030 Economic

SEHA

• …. and Abu Dhabi healthcare system vision states the need for a “predominantly private” provision …

Task

• In twos or threes look growth in healthcare in respect of:-

1. Supply of health services?

2. Why demand is increasing?

3. Where is growth?

4. How will services be funded?

5. What is the role of SEHA?