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Social health insurance systems

In social health insurance system, private healthcare providers are usually included in the
health care delivery system. Therefore, their strategic purchasing methods usually evolve with
the reform of their whole health financing system.

Japan: Tokutei-Kenshin, annual health check-up & management system

The healthcare financing system in Japan is based on the social health insurance model
which consists of three major insurance systems: a health insurance scheme for government
and company employees; a scheme for self-employed workers, farmers, retirees, and the
unemployed; and a scheme for elderly adults aged 75 years or over. The majority of
healthcare services in Japan are delivered by private clinics and hospitals. Nevertheless, the
government has one of the most successful stories in purchasing healthcare services from
the private sector. The government has not only exerted tight control over the price of
medical services, but has also been promoting the delivery of certain cost-effective and
preventive services by manipulating their prices. For instance, primary care is promoted
through higher reimbursements, and some costlier services are reduced through lower
reimbursements.

In Japan, however, because the medical institutions and patients have not been adequately
motivated, there have been gaps in chronic disease management. To trigger national action
in disease management, in April 2008, the Japanese government launched an annual health
check-up programme (Tokutei-Kenshin) targeting metabolic syndrome; insurers are obliged
to provide a check-up to all beneficiaries aged 40–74 years. Based on the evaluation results,
participants are assigned to one of three risk groups, including “information provided group”,
“motivation support group”, or the “aggressive support group”. Insurers need to provide
different levels of health care instruction for individuals assigned to different groups. Initially,
insurers will engage a health care provider company for outsourcing. After registration of the
covered citizens, the health care provider will begin service. If providers do not produce
adequate outcomes, insurers must pay a penalty as they must take overall responsibility.

China: Increasing health insurance benefits for chronic disease management in
outpatient care
The basic public health insurance scheme in China covers over 95% of the population, but it
has historically provided insurance mainly against catastrophic inpatient expenses. For
outpatient expenses, including drugs, monthly reimbursements are capped at a relatively low
rate. However, cost concerns among patients with chronic diseases can contribute to
patients’ low adherence to treatment plans or lack of routine follow-up care, especially
among patients with multiple chronic health problems. Reduced access to drugs is of
particular concern if those drugs are cost-effective. Accordingly, the Chinese central
government with its latest healthcare reform effort mandated an increase in health insurance
benefits specifically for patients with chronic diseases at the outpatient level, seeking to
encourage regular clinical visits and adherence to treatment plans and eventually to reduce
catastrophic costs associated hospitalisations. Moreover, patients are encouraged to
manage chronic diseases at primary care facilities. In urban China, community health centres
(CHCs) are the main primary care facilities, of which a quarter are non-profit private providers.
Unlike public CHCs which are subject to direct government control over staffing and
budgets, private CHCs earn most of their revenues from service provision. Medicines and
services provided by CHCs are mainly reimbursed by the social health insurance scheme
under a fee-for-service payment model.

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