The role of sickness funds in strategic purchasing: an international comparison.

Background: Health systems need to address the needs of populations, rather than simply groups of individuals. For third-party payers this implies active purchasing of care, determining the health needs of those for whom they are responsible and defining models of care that meet these needs. This paper explores the role of social sickness funds in this process. Aim: Research questions are: To what extent does strategic purchasing of care take place in different social insurance systems? What models are most effective in supporting strategic purchasing? Method: Data were collected via: -The published literature, particularly the Health System in Transition series. -A structured survey (conducted in March-April 2002) of key informants in Austria, Belgium, France, Germany, the Netherlands, and Switzerland. Results: Strategic purchasing involves: -Assessment of health care needs: Innovative ways of presenting information on population health needs have been developed in many countries. -Specifying models of care to meet those needs: Many countries have seen a growth in health technology assessment. But this has often focused on individual technologies instead of the overall framework of care within which they are used. -Purchasing health care that conforms to these models: This is problematic, e.g. because of the many actors involved, the lack of coherence in the populations covered by the relevant organisations, or the lack of freedom to contract selectively. -Monitoring the outcomes achieved: These challenges are greatest for population based interventions. Examples of how governments (national/regional), sickness funds, and providers can co-operate to enhance the effectiveness and equity of care include consultative mechanisms (e.g. Germany) and more formal structures (e.g. France). Conclusion: Social insurance countries differ markedly in the degree to which sickness funds engage in strategic purchasing. Although it is premature to draw firm conclusions, the 1996 reforms in Switzerland, giving insurance funds a greater role in population interventions, have faced problems. In contrast, France provides an example of 'best practice', although the introduction of regional hospital agencies has required the state to play a leading role in a range of activities previously undertaken by sickness funds, so creating a model that is quite distinct from that seen in other social insurance systems. (aut. ref.)