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The Portuguese health system and its regulation. Jorge Simões President of the Board Porto, 8 May 2014. The Portuguese health system Challenges for the health system The Health Regulation Authority (ERS). Outline. I. The Portuguese health system. General characterization - PowerPoint PPT Presentation
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Jorge Simões
President of the Board
Porto, 8 May 2014
The Portuguese health system and its regulation
2
I. The Portuguese health system
II. Challenges for the health system
III. The Health Regulation Authority (ERS)
Outline
3
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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Public and private mix in funding
Source: INE (2013), Health Care Satellite Account (2012)
Current expenditure in healthcare, Portugal 2012
I. The Portuguese health system
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%
Private funding 5,839 37.4%
- Private subsystems 288 1.8%
- Voluntary health insurance 503 3.2%
- Out-of-pocket payments 4,947 31.7%
- Social funding 100 0.6%
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Public and private mix in provision
Proportion of total consultations in private providers, Portugal, 2005
Source: Simões, Barros and Pereira (2008)
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%
I. The Portuguese health system
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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
I. The Portuguese health system
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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
I. The Portuguese health system
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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)
I. The Portuguese health system
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Expenditure on health
Source: OECD, Health Data 2012
Exp
end
itu
re o
n h
ealt
h a
s %
of
GD
PI. The Portuguese health system
0,0
2,0
4,0
6,0
8,0
10,0
12,0
1970
1972
1974
1976
1978
1980
1982
1984
1986
1988
1990
1992
1994
1996
1998
2000
2002
2004
2006
2008
2010
Portugal Média OCDE
Portugal – 10,2%OCDE average – 9,3%
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I. The Portuguese health system
II. Challenges for the health system
III. The Health Regulation Authority (ERS)
Outline
11
II. Challenges for the health system
1) Demographic context
2) Economic context
3) Financial sustainability
4) Europe
5) Regulation
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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).
II. Challenges for the health system
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2) Economic context
II. Challenges for the health system
100.000
110.000
120.000
130.000
140.000
150.000
160.000
170.000 1
99
5
19
96
19
97
19
98
19
99
20
00
20
01
20
02
20
03
20
04
20
05
20
06
20
07
20
08
20
09
20
10
20
11
20
12
-4%
-3%
-2%
-1%
0%
1%
2%
3%
4%
5%
6%PIB a preços de 2006 Taxa de crescimento
GD
P i
n m
illi
on
of
EU
RR
eal gro
wth
rate of G
DP
Source: INE, 2013
Gross Domestic Product, Portugal
GDP (prices of 2006) Growth rate
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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 2012.
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4) Europe
EU Directive on cross-border healthcare:
facilitate access to cross-border healthcare in the EU
II. Challenges for the health system
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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 targetsPerformance targets may collide with patients rights and
interestsContainment of global investment on health
Health regulator is essential to balance sustainability measures and ensuring patients rights and interests
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I. The Portuguese health system
II. Challenges for the health system
III. The Health Regulation Authority (ERS)
Outline
18
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
III. The Health Regulation Authority
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Who we regulate
All health care providers, public, private for-profit and private not-for-profit ownership
All types of providers
Hospitals
Individual physician's offices
Outpatient care clinics
Diagnostic tests providers
Dentist offices and clinics
(…)
III. The Health Regulation Authority
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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.
III. The Health Regulation Authority
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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)
III. The Health Regulation Authority
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Providers registered with the ERS
III. The Health Regulation Authority
6.1907.518 8.147 8.481
9.19810.151 10.808 11.385
8.778
10.65911.752 12.496
13.68215.085
16.25217.160
2006 2007 2008 2009 2010 2011 2012 2013
Ent. Registadas Estab. Registados
23
Complaints handled in 2013
III. The Health Regulation Authority
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%
Total 8.160 100%
24
Investigations initiated in 2013
III. The Health Regulation Authority
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%
25
Inspections carried in 2013
Inspections focus Number %
Legal requirements of health care establishments 984 79%
Thematic reviews 169 14%
Audits related to SINAS 61 5%
Quality of health care 33 3%
Total 1.247 100%
III. The Health Regulation Authority
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Administrative offence procedures initiated in 2013
III. The Health Regulation Authority
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%
Total 556 100%
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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)
III. The Health Regulation Authority
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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)
III. The Health Regulation Authority
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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
III. The Health Regulation Authority
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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)
III. The Health Regulation Authority
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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.
III. The Health Regulation Authority