Alternative designs of benefits packages and their implications for coverage and financial

risk The Case of breast cancer in Colombia

Ramiro GuerreroAna María Amarís

Héctor Castro

Acknowledgments• This presentation is based on a case study on

cancer in Colombia prepared by PROESA as a background paper for the Global Task Force on Cancer Care and Control in Developing Countries, with funding from the Harvard Global Equity Intiative.

The Colombian Health System Reform

• Before 1993: Services for catastrophic illnesses were mostly directly paid out of pocket.– WHO: out of pocket expenditure in Colombia was

44% of private spending in 1993. • In 1993: Universal social health insurance is

adopted, with a basic mandatory benefits package.– Two modalities: contributory and subsidized

insurance

The Colombian Health System today

• Universal Coverage is almost achieved.• The basic package covers surgery,

chemotherapy, radiotherapy and drugs, such as tamoxifen, doxorubicin and paclitaxel.

• Increasing amount of “tutelas” for claiming oncologic services in the courts.

- 2009: Almost US$120 million were spent in oncologic excluded drugs.

Enrollment

1995 2000 2005 20100

10

20

30

40

50

60

70

80

90

100

Contributory Subsidized

% o

f p

op

ula

tio

n

Little package and Big package

Extra-Package Benefits Explosion

• In 2010, 25% of capitation payments

• Fee for service• Concentrated in

contributory• Curative bias2002 2003 2004 2005 2006 2007 2008 2009 2010

-

0.20

0.40

0.60

0.80

1.00

1.20

1.40

Non POS Claims(in US$ billion)

Non POS Claims

Source: Melo et al. 2010

The package as a cubeH

eigt

h

Depth

Breadth

Breadth: Fraction of the population covered

Depth: Specific procedures, services and technologies covered

Height: Fraction of cost covered ( 1 – copayment)

Source: Schreyogg 2005

Breast Cancer in Colombia• The most frequent type among Colombian women.• In 2008 = 6.655 new cases (Globocan).• 21.5% of all types of cancer among women.• Increasing mortality:

-2000 = 7.5 of each 100.000.-2007 = 9.6 of each 100.000.

• Low coverage of mammography (16% of women over 40)• 77.8% of breast cancer patients first consult in advanced

stages.

Mammography among Colombian women during the last 3 years

40-49 years 50-69 years 40-69 years0

102030405060708090

100Percentage of Mammography

Percentage of Mam-mography

Stage Distribution at Diagnosis

Stage Contributory % Subsidized % Non affiliated % Total %

In Situ 11 3.3 4 1.6 0 0 15 2.3

Early 88 26.6 31 12.8 9 13.4 128 20

Advanced 206 62.2 177 72.8 47 70.1 430 67.1

Metastatic 26 7.9 31 12.8 11 16.4 68 10.6

n 331 100 243 100 67 100 641 100

Source: Velásquez-De Charry LC, Carrasquilla G, Roca-Garavito S. Equity in access to treatment for breast cancer in Colombia. Salud Publica Mex 2009;51 suppl 2:S246-S253

Cancer in the basic package (POS)• Important services excluded:– Mammography not included in subsidized regime.- Trastuzumab, rituximab, leuprolide acetate,

imatinib excluded from both packages.• Increasing amount of “tutelas” for claiming

oncologic services in the courts.

The trade offs of benefit packages design

Stage 0: Universal coverage and POS equalizationStage 1: Horizontal vs. Vertical Approach

- Early diagnosis vs. full coverage of treatment?Stage 2: Scope and Depth of coverage

- Reimbursement of all new costly medicines vs increasing out of pocket spending?

Some numbers to depict the opportunity costs

POS equalization

Just to equalize POS C and POS S for breast cancer screening will cost: 114,465,278 USD.

Age group Population subsidized Price (USD) Total (USD)

30-50 years old 2,666,510 19.96 53,223,539

Over 50 years 1,751,766 34.96 61,241,739

114,465,278

Screening to all women in need

Service Population Price (USD) Total (USD)

Ultrasound 5,673,426 19.96 56,620,791

Mammography 3,727,162 34.96 65,150,791

Medical Consultation 9,400,588 8.88 83,477,221

205,248,803

Screening done in one year for women over 30 years old costs 205,248,803 USD.

Diagnosis

Service Population Price (USD) Total (USD)

Biopsy 6,655 93,75 623,906

RMN 6,655 256,55 1,707,340

2,331,246

Each year at least 2,331,246 USD are allocated for diagnosis

Basic Treatment to all women in need

Service Population Price (USD) Total (USD)

Mastectomia 6655 1,584 3,162,456

Radioterapia 6655 9,106 42,420,301

Quimioterapia 6655 549 1,826,797

47,409,554

To treat each case per year 47,409,554 USD are allocated, for basic treatment

Advanced tratment to all women in need

Service Population Price (USD) Total (USD)

Trastuzumab 6655 57,058 75,944,198

Paclitaxel 6655 1729 2,301,299

Costs of advanced treatment in one year.

Discussion

• The political imperative of unifying the packages• High nominal coverage with low effective coverge– Infrastructure and training– The mix of services (insufficient detection)

• The redesign of the package (an opportunity)• New institutions for priority setting• The rationing model, the infinite plan and

sustainability

The breast cancer cube

Contribu-tory Subsidized

01234

Early detection

Basic treatment

Last generation treatment

Breadth

Hei

ght

Dep

th

The cube redefinedH

eigt

h

Depth

Breadth

Breadth: Fraction of the population covered

Depth: Effective coverage of integral treatment

Height: Degree of financial protection

Effective Coverage of Integral Treatment

The maximum possible health gain an individual with a given health care need can expect to receive from the health system.

For intervention j and individual i

1 ijijijij NUQEC

Conclusions

• Costs of universal:– Screening: US$205M– Diagnosis: US$2,3M– Basic tratment: US$47M– Advanced treament: US$78M

• Coverage by component:– Screeing (16% of the challenge)– Basic treatment (most of the challenge)– Advanced treatment (nearly half)

• Impact of this mix? – Allocative efficiency seems to dominate the results