14.30 – 16.30 Section 6
Section partner – MHS Slovakia

Modern concept of health insurance
Tomáš Macháček
(Health Reform CZ, member of CEE HPN,Czech Republic)

 Presentation (password needed)

Tomáš Macháček M.D. graduated from Charles University in Prague and since 1992 he has been a practicing primary care physician. He is one of the three founders of the think tank Health Reform.cz and Chairman of the Board since 1st September 2006. He was responsible for agenda of four International Health Summits held by Health Reform.cz in 2004-2008. Tomáš is an expert in the field of health insurance and systems of health care financing; these issues he studied in the United States as well as South Africa. He is a pioneer of managed care tools in the Czech Republic: He has designed and implemented the first capitation contracts between IPAs (Individual Practices Associations) and health insurance company. Furthermore, he has been the driving force behind first Czech experiments with integrated managed care health plans based on a capitation contract. Being founded in 2000, his company Klient PRO Ltd. operates as a third party administrator of managed care projects for health insurers and IPAs. The MEDIPARTNER system run by Klient PRO for Hutnicka zamestnanecka pojistovna is the first Czech system integrating public health insurance, organizing of health care providing in the preferred providers network and motivation scheme for clients based on the principles of a reward based health care. Tomáš is co-author of the Czech health care reform proposal. Within the reform, he designed and tested a model combining health insurance and health savings subsidized with risk adjusted public contribution. He is an advocate of introducing nominal premium system into the Czech health insurance scheme. As a member of Minister Tomáš Julínek's reform team he has elaborated a legislative framework for public health insurance administration through competitive standardized products (health plans) offered by health insurance companies at a regulated market, including the concept of high deductible health plans in combination with health savings accounts. During years 1996-1998 and 2006-2008 he worked as an advisor to the Minister of Health.

In comparison to the past, currently we are living in the age of chronic diseases, which cause higher financial risks for the provision of health insurance. The old relational model between physicians, patients and pharmacists is obsolete and a new model based on integration is required. The reason is that one of the main determiners of patients’ health condition is their behavior (40%), followed by genetic factors (30%). Therefore a change of the patients’ role may be cheaper than changing the healthcare micro-system. Consumer centrism should replace the current physician centered system. However, a stronger customer role is not achievable without their cost sharing.
This cost sharing may create an alliance between health plans and the consumer, where health insurance is combined with health savings accounts. A reward based healthcare concept is needed in order to distribute benefits to clients thanks to their “desirable” behavior.
Health insurance products need to be integrated, e.g. through motivation programs rewarding clients for his/her pro-active approach regarding health. In this respect, a vibrant health insurance market is also one of the key elements of modern and successful healthcare system.

Case study from USA – Card-based Incentive Programs
Wesley P. Berkovsky
(Centene Corporation, USA)

Wesley, known more as Chip, is a corporate development professional at Centene Corporation, a leading healthcare services company providing innovative delivery solutions to public health insurance programs that are proven to improve quality and reduce costs. He is responsible for the company’s evaluation of strategic business opportunities in Central and Eastern Europe and works closely with local leaders in the private and public sectors to find ways to improve the efficiency of public health insurance programs. Prior to his current role, Chip was responsible for developing the company’s portfolio of managed care services for Medicaid, long-term care and other public health insurance programs administered by state governments in the U.S. In 2009, he led the firm’s expansion into Massachusetts, unique to other states with its near-universal health insurance model, through a startup health insurer formed as a joint venture with a local community hospital system. After securing the contract awards for both the subsidized and non-subsidized programs offered through the Massachusetts insurance exchange, he designed the proposal for what later became known as Commonwealth Care Bridge which allowed over 30,000 low-income legal immigrants to maintain state-funded health insurance after losing their previous public insurance due to state budget cuts. Chip joined the firm’s Mergers & Acquisitions (M&A) group in early 2006 and spent two years working on dozens of transactions covering acute & LTC Medicaid managed care organizations (MCO), reinsurers, mental health MCOs, pharmacy benefit managers, vision benefit managers, disease management and other specialty healthcare companies. In early 2011, Chip was appointed to Missouri’s Health Insurance Advisory Committee and was an active participant in multiple work groups in other states focusing on the implementation of President Obama’s Patient Protection And Affordable Care Act (PPACA). Chip earned his undergraduate (Economics and Finance) and MBA degrees from the Trulaske College of Business at the University of Missouri.

It is ultimately patients themselves who have the greatest influence over health outcomes but how can we expect patients to consistently make rational decisions with so much information asymmetry in healthcare? Public healthcare systems are arguably the best equipped to help overcome these information asymmetries but ironically there is rarely much incentive for them to do so. The more diverse the medical needs and resource-limitations of the underlying population, the more difficult it is to predict (and underwrite) how patients may react to new information or interventions. Additionally, most public insurance schemes offer a broad scope of benefits with a material portion of the insured population having minimal or no out-of-pocket costs and have little economic incentive to become more efficient consumers if more treatment information were made available. This presentation highlights how a private managed care organization is partnering with governments to promote consumerism in public insurance settings using incentive-card programs to target specific patient segments.  These award-winning programs encourage patients to make healthier decisions that improve health outcomes and demonstrate how public-private partnerships at the payor-level can achieve higher quality care for patients and guaranteed savings for governments.             

Integrated care in Slovakia - case study Klient Pro
Angelika Szalayová
(Klient Pro SK, Slovakia)

Angelika Szalayová is one of the co-founders of Health Policy Institute (2005) During 2002-2004 healthcare reform she was responsible for pharmaceutical policy. She is also an expert on quality of health care and pioneers managed
health care in Slovakia. Graduate of the Faculty of Medicine, Comenius University, Bratislava (2000). Specialization: General Medicine. Studied also Psychology at the Faculty of Arts of Comenius University (1993 – 1995). Postgradual study in
Clinical Pharmacology at the Faculty of Medicine of Comenius University (2000 – 2005). Angelika Szalayová participated in many courses and training programmes (e.g. 2002 – 2003 Health Outcomes Research, Moduls I., II . and III . – EBM and its applications to Drug Utilization, Pharmacoeconomics, Pharmaceutical pricing and reimbursement, Vienna School of Clinical
Research, Austria). During 2000 - 2005 she was assistant professor of the Farmacology Department Faculty of Medicine, Comenius University. She worked in 2003 – 2005 at the Ministry of Health in the Drug Policy Department; she has been head/deputy of the Drug Reimbursement Committee. Angelika Szalayová is author and co-author of many publications and scientific reports on pharmacotherapy quality evaluation, especially in the area of cardiovascular diseases, neurology, psychiatry, endocrinology and antimicrobial therapy. In 2005 and 2006 she was a member of the Board of Directors of the General Health Insurance Company, Inc.She was a member of the Drug Reimbursement Committee at the Czech Ministry of Health 2006 – 2007.

The health care in Slovakia and many other countries today is fragmented. Different physicians treat isolated episodes of problems as they occur, but coordinated care for chronic diseases that are representing the majority of today’s health problems is scarce. This situation is aggravated by lack of communication among providers and lack of active involvement of patients in caring for and maintaining their health. As a result, lot of provided health care is unnecessary and lot of necessary care is never provided, because there’s not enough resources left. Systems of integrated health care based on managed are principles and rewarding patients for taking care for their health might help with these problems. To implement such a system, based on our experiences in Czech Republic and Slovakia, you not only need know-how, a group of people, who believe it is possible and more money and time than you originally planned, but also favorable regulation with plurality in insurance market, fair risk adjustment, implemented motivation for effectiveness, plurality in providers market with free choice of providers. Very important and often lacking is also stability and predictability of health care regulations. Key elements are partners among insurance companies and providers. They must be enthusiastic, courageous, and willing to change. The biggest unknown is still the reaction of insurees, who are the ultimate recipients.

Panel Discussion with Speakers led by Jim A. Rice
(Management Sciences for Health, USA)

16.30 – 17.00 Coffee break
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