I MPROVING ESTIMATES OF INTERNATIONAL TRADE IN HEALTH SERVICES UNDER A S YSTEM OF H EALTH A CCOUNTS Working Party on International Trade in Goods and Trade.

IMPROVING ESTIMATES OF INTERNATIONAL TRADE IN HEALTH SERVICES UNDER A SYSTEM OF HEALTH ACCOUNTS

Working Party on International Trade in Goods and Trade in Services Statistics

November 7-9, 2011, PARIS

BACKGROUND

Key definition of health expenditure in SHA:– Includes health care goods and services provided to

residents by non-resident providers– Excludes goods and services provided to non-

residents by resident providers

• Past experience – poorly reported, no explicit reporting of services provided to non-residents, insufficient guidelines, data sources

• Growing importance in recent years• Significant for some countries Need to better define, measure and

monitor2

CROSS-BORDER HEALTH CARE IN THE EU

EU Directive• Respect patients’ rights to seek healthcare

abroad while preserving rights for states to manage healthcare systems

• Reimbursed for treatment if entitled to in own country

• Prior authorisation only for ‘hospital’ care • Covers prescription and medical goods (excl. LTC

and organ transplants)• Information on safety, quality and tariffs• Monitoring (flows and financing) - EC

Regulation 1338/20083

OECD TRADE IN HEALTH PROJECT

• 2 year project supported by EU• First phase 2009/2010

– review of concepts and boundaries– links to existing frameworks (BPM6, MSITS, TSA)– country case studies (regulations, sources,

recommendations) – DEU, GRC, HUN, KOR, SVN, USA

• Second phase 2010/2011– Draft framework, definitions, guidelines.– Workshop and feasibility testing– Final report

• Parallel with SHA Revision (Chapter 12 on Int. Trade)

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BASIC CONCEPTS AND DEFINITIONS

Balance of Payments (BPM6/SNA08) as basis:

• Economic territory – national, supra-national, sub-national

• Residence and non-residence – households and providers - Residence vs. covered population

• Valuation– Consistent with SHA basic concepts (Follow SNA)– Exporting vs. importing countries valuation (in kind)

• Timing– Accrual basis– Reporting delays

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EXISTING CLASSIFICATIONS AND LINKS

• Mode of supply of trade in services (WTO/GATS)– (1) Cross-border supply , (2) consumption abroad, (3)

commercial presence (outside SHA), (4) foreign persons (partial SHA)

• MSITS/EBOPs classification:– International statistics responding to BoP and GATS– ‘Health-related travel’ and ‘Health services’ close to

SHA definitions

• Tourist Statistics/TSA– Consumption of visitors with ‘health/medical’ purpose– Provides some common concepts and definitions/

sources

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HEALTH SERVICES UNDER EBOPS 2010

4 Travel• 4.2 Personal• 4.2.1 Health-related• 4.2.2 Education-related• 4.2.3 Other•  11 Personal, cultural and recreational services• 11.2 Other personal, cultural and recreational

services• 11.2.1 Health servicesAlternative EBOPS groupings8 Health services = health services in travel + health services in

personal, cultural and recreational services

Plus: Other direct insuranceBusiness servicesOther personal, cultural and recreational services n.i.e.

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SHA CONCEPT OF TRADE

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Health careprovider in Country A

Resident in Country A

Health care provider in Country B

Import for ‘final use’ b y resident

Import for ‘ intermediate use’ by

resident provider

IMPORTS AND EXPORTS UNDER SHA

Health care goods and services classified according to health care functions

• Personal health care :– Medical goods

• internet pharmacies, mail order

– Tele-medicine, e-health, etc– Patient mobility : planned, unplanned care

(tourists, students, workers, etc)– Health professionals abroad

• Collective care :– Health care insurance– Outsourcing of governance, administration, etc

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BORDERLINE ISSUES

• Cosmetic surgery – for aesthetic purposes

• Well-being/Spas – health-related item• Illegal / unethical treatments• Transport and travel costs –

accompanying persons/agency costs• ‘Health-y’ goods• Health professionals (temporary)

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GUIDELINES FOR ESTIMATING TRADE

• Current reporting limited but improving• Common sources with BoP/SNA/TSA –

detail/ adjustments needed• Improvement of measurement of mutual

benefit• Inventory of current/potential sources• Weigh up investment in resources / new

sources with perceived value of trade in health

• Review in light of national and international obligations

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DATA SOURCES

• Business surveys - administrative/ad hoc• Government administrative data –

budgetary, social security funds, liaison offices

• Private insurance records• Household and tourist surveys• Associations and other bodies – insurance,

NGOs• Other sources - mirror statistics, non-

financial data, modelling.• Other BoP data sources – ITS, ITRS, etc

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REPORTING AND SUPPLEMENTARY TABLES

• Imports included - cross-classified by Function and Financing– non-resident providers of health goods and services

(HP.9)

• Supplementary tables– ‘Imports’ (HC.I.1-7) broken down by Financing scheme

(HF)– ‘Exports’ (HC.E.1-7) broken down by resident provider

• Memorandum items– TCAM, Spa/well-being (non-health), Non-health, etc

• Other country specific breakdowns– Mode of supply, trading partners, population groups,

patient numbers, etc

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SHA 2011: CHAPTER 12

• Background and Policy Relevance

• Basic concepts and definitions

• Classifications of trade (in health) and links to other statistical systems

• Imports and exports under SHA

• Data sources and Guidelines

• Reporting and Supplementary tables

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CURRENT REPORTING: IMPORTS

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1. Refers to balance-of-payments concept of health-related travel.

Source: OECD Health Data 2011 and OECD-Eurostat Trade in Services Database.

DenmarkIreland ¹Poland

Greece ¹

Sw eden

United Kingdom ¹United States ¹

Norw ayEstoniaFrance ¹

SloveniaMexico ¹

Canada ¹Czech RepublicSlovak Republic

AustriaKorea

Turkey ¹Hungary

LuxembourgIcelandPortugal

NetherlandsBelgium ¹Germany

Italy ¹

0.04

0.05

0.06

0.06

0.07

0.08

0.10

0.13

0.14

0.14

0.14

0.14

0.16

0.18

0.20

0.20

0.21

0.24

0.30

0.44

0.47

0.59

0.89

1.02

1.11

0.00.51.01.52.0% of total health expenditure

9.49

13.0

8.4

-14.0

-4.0

3.0

-5.4

-10.0

-4.4

23.6

2.0

58.1

-6.4

19.7

4.6

13.2

6.2

48.6

1.0

40.0

23.5

7.3

-3.9

1.7

5.5

12.2

-6.8

-20 0 20 40 60 80Annual grow th rate (%)

2009 2004-2009

CURRENT REPORTING: EXPORTS

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Source: OECD-Eurostat Trade in Services Database.

United KingdomNew Zealand

AustriaIceland

FranceKoreaIsrael

United StatesItaly

Canada

TurkeyBelgiumEstoniaMexico

SloveniaGreece

Luxembourg

Czech RepublicHungaryPoland

Note: Health-related travel exports occur w hen domestic providers supply medical services to non-residents travelling for medical reasons.

0.02

0.03

0.06

0.06

0.08

0.08

0.11

0.13

0.15

0.15

0.19

0.20

0.48

0.67

0.84

0.98

1.15

1.62

2.08

3.58

01234% of total health expenditure

-6.0

5.7

-1.7

2.4

5.2

0.7

6.9

-5.2

8.9

0.6

-7.7

-13.5

-1.3

9.9

-2.0

3.5

35.7

41.9

-3.6

27.8

-20 0 20 40 60Annual growth rate (%)

2009 2004-2009

For further information:

www.oecd.org/health/sha

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