1. Alternative designs of benefits packages and their implications for coverage and financial risk The Case of breast cancer in Colombia Ramiro Guerrero Ana María Amarís Héctor Castro

2. 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.

3. 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

4. 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.

5. Enrollment

6. Little package and Big package

7. Extra-Package Benefits Explosion In 2010, 25% of capitation payments Fee for service Concentrated in contributory Curative bias Source: Melo et al. 2010

8. The package as a cube Heigth 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

9. 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.

10. Mammography among Colombian women during the last 3 years

11. Stage Distribution at Diagnosis StageContributory%Subsidized%Non affiliated%Total% In Situ113.341.600152.3 Early8826.63112.8913.412820 Advanced20662.217772.84770.143067.1 Metastatic267.93112.81116.46810.6 n33110024310067100641100 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

12. 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.

13. The trade offs of benefit packages design Stage 0: Universal coverage and POS equalization Stage 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

14. POS equalization Just to equalize POS C and POS S for breast cancer screening will cost: 114,465,278 USD. Age groupPopulation subsidizedPrice (USD)Total (USD) 30-50 years old2,666,51019.9653,223,539 Over 50 years1,751,76634.9661,241,739 114,465,278

15. Screening to all women in need ServicePopulationPrice (USD)Total (USD) Ultrasound5,673,42619.9656,620,791 Mammography3,727,16234.9665,150,791 Medical Consultation9,400,5888.8883,477,221 205,248,803 Screening done in one year for women over 30 years old costs 205,248,803 USD.

16. Diagnosis ServicePopulationPrice (USD)Total (USD) Biopsy6,65593,75623,906 RMN6,655256,551,707,340 2,331,246 Each year at least 2,331,246 USD are allocated for diagnosis

17. Basic Treatment to all women in need ServicePopulationPrice (USD)Total (USD) Mastectomia66551,5843,162,456 Radioterapia66559,10642,420,301 Quimioterapia66555491,826,797 47,409,554 To treat each case per year 47,409,554 USD are allocated, for basic treatment

18. Advanced tratment to all women in need ServicePopulationPrice (USD)Total (USD) Trastuzumab665557,05875,944,198 Paclitaxel665517292,301,299 Costs of advanced treatment in one year.

19. 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

20. The breast cancer cube

21. The cube redefined Heigth Depth Breadth Breadth: Fraction of the population covered Depth: Effective coverage of integral treatment Height: Degree of financial protection

22. 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

23. 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