This presentation was made by Eva Zver, Slovenia, at the 6th meeting of the joint OECD DELSA-GOV network on fiscal sustainability of health systems held in Paris, on 18-19 September 2017

1. KEY BUDGETARY CHALLENGES FOR LTC IN SLOVENIA
E VA Z V E R , I N S T I T U T E O F M A C R O E C O N O M I C A N A LY S I S A N D D E V E L O P M E N T
D AV O R D O M I N K U Š , M I N I S T R Y O F L A B O U R , FA M I LY, S O C I A L A F FA I R S A N D E Q U A L
O P P O R T U N I T I E S
TATJ A N A B U Z E T I , M I N I S T R Y O F H E A LT H
O E C D , 6 T H M E E T I N G O F T H E J O I N T N E T W O R K O N F I S C A L S U S T A I N A B I L I T Y O F
H E A L T H S Y S T E M S
REPUBLIC OF SLOVENIA
MINISTRY OF LABOUR, FAMILY,
SOCIAL AFFAIRS AND EQUAL OPPORTUNITIES
REPUBLIC OF SLOVENIA
MINISTRY OF HEALTH

2. Overview of presentation
1. Current state of LTC provision and financing in Slovenia
2. Reasons behind the need for a LTC reform
3. Information on the envisaged LTC reform
REPUBLIC OF SLOVENIA
MINISTRY OF HEALTH
REPUBLIC OF SLOVENIA
MINISTRY OF LABOUR, FAMILY,
SOCIAL AFFAIRS AND EQUAL OPPORTUNITIES

3. 1. Current LTC financing and provision:
Imbalances, fragmentation, no uniform system
LTC is provided within different social protection systems:
– health care system
– pension and disability system
– social and parental protection systems
Benefits in kind:
– Institutional care is prevailing
– Lack of community based services
– Home based services are not integrated (health/social)
Benefits in cash:
- not related to comparable needs
- different levels of benefits related to specific legislation
- not means tested
- No unified entry point
- No unified needs
assessment
REPUBLIC OF SLOVENIA
MINISTRY OF HEALTH
REPUBLIC OF SLOVENIA
MINISTRY OF LABOUR, FAMILY,
SOCIAL AFFAIRS AND EQUAL OPPORTUNITIES

4. Total LTC expenditure as % of GDP are lower then
on average in OECD
S O U R C E : O E C D S T A T
0.0
0.5
1.0
1.5
2.0
2.5
3.0
3.5
4.0
4.5
Netherlands
Finland
Sweden
Norway
Denmark
Belgium
Switzerland
UnitedKingdom
Germany
Ireland
Iceland
France
OECD(28)
Luxembourg
Austria
Canada
CzechRepublic
Slovenia
Korea
Portugal
Italy
Spain
UnitedStates
Hungary
Latvia
Poland
Estonia
Australia
Greece
ShareinGDP.%
Health part Social part
1,6%
1,3%
REPUBLIC OF SLOVENIA
MINISTRY OF HEALTH
REPUBLIC OF SLOVENIA
MINISTRY OF LABOUR, FAMILY,
SOCIAL AFFAIRS AND EQUAL OPPORTUNITIES

5. 2. Reasons behind the need for a reform:
High share of funding from compulsory health insurance…
Structure of total LTC expenditure by financing source, 2015
Source : OECD and SURS, calculations by IMAD
74
26
Public Private
33
16
9
15
0.4
24
0.4
Health Insurance Fund
Pension Fund
Central budget (Minitry of
Labor and Social Affaires)
Local governments
Complementary health
insurance
Out-of-pocket
Non profit
REPUBLIC OF SLOVENIA
MINISTRY OF HEALTH
REPUBLIC OF SLOVENIA
MINISTRY OF LABOUR, FAMILY,
SOCIAL AFFAIRS AND EQUAL OPPORTUNITIES

6. Very fast growth of private LTC expenditure…
Real growth of expenditure for long-term care per capita, 2005-2015
Source : SORS, calculations by IMAD
128
119
161
111
90
100
110
120
130
140
150
160
170
2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015
Indexofrealgrowth,2005=100
Total Public Private GDP
REPUBLIC OF SLOVENIA
MINISTRY OF HEALTH
REPUBLIC OF SLOVENIA
MINISTRY OF LABOUR, FAMILY,
SOCIAL AFFAIRS AND EQUAL OPPORTUNITIES

7. The growth of out-of-pocket LTC expenditure
exceeds the growth of private HC expenditure…
Real growth of private HC and LTC expenditure per capita, 2005-2015
Source : SORS, calculations by IMAD
90
100
110
120
130
140
150
160
170
2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015
Indexofrealgrowth,
2005=100
Health (voluntary health insurance) Health (Out-of-pocket) LTC (Out-of-pocket)
REPUBLIC OF SLOVENIA
MINISTRY OF HEALTH
REPUBLIC OF SLOVENIA
MINISTRY OF LABOUR, FAMILY,
SOCIAL AFFAIRS AND EQUAL OPPORTUNITIES

8. High share of LTC health component and low public financing of
social LTC care…
LTC expenditure by function - health and social care, 2015
67
33
Total LTC
expenditure
LTC (health)
LTC (social)
87.2
12.2
Public LTC expenditure
LTC (health) LTC (social)
Source : OECD, calculations by IMAD
REPUBLIC OF SLOVENIA
MINISTRY OF HEALTH
REPUBLIC OF SLOVENIA
MINISTRY OF LABOUR, FAMILY,
SOCIAL AFFAIRS AND EQUAL OPPORTUNITIES

9. The structure of health expenditure by
functions, 2003 and 2015
8 10
0%
20%
40%
60%
80%
100%
2003 2012
Governance and health administration (HC.7)
Preventive care (HC.6)
Medicines and therapeutic appliances (HC.5)
Anciliary services (HC.4)
Long-term care - health (HC.3)
Rehabilitative care (HC.2)
Curative care (HC.1)
Average annual real growth rate,
2005-2015
In the structure of HC expenditure the share for LTC
(health) is growing very fast
Source : SORS, calculations by IMAD
1.4
2.5
0
0.5
1
1.5
2
2.5
3
Health expenditure LTC expenditure
In%
REPUBLIC OF SLOVENIA
MINISTRY OF HEALTH
REPUBLIC OF SLOVENIA
MINISTRY OF LABOUR, FAMILY,
SOCIAL AFFAIRS AND EQUAL OPPORTUNITIES

10. High share of spending for institutional care
LTC expenditure by settings – institutional and home, 2015
75
25
In institutions At home
REPUBLIC OF SLOVENIA
MINISTRY OF HEALTH
REPUBLIC OF SLOVENIA
MINISTRY OF LABOUR, FAMILY,
SOCIAL AFFAIRS AND EQUAL OPPORTUNITIES

11. Low financing of home care
O E C D : H E A L T H A T A G L A N C E 2 0 1 5
-5.0
0.0
5.0
10.0
15.0
20.0
Estonia
Japan
France
Finland
Norway
Spain
Belgium
OECD18
Switzerland
Germany
Canada
CzechRepublic
Austria
Hungary
Denmark
Netherlands
Slovenia
Luxembourg
Poland
Averageannualgrowthrate,in%
Annull growth rate in public expenditure on LTC care (health), by
setting, in real terms, 2005-2013
Institution LTC Home LTC
REPUBLIC OF SLOVENIA
MINISTRY OF HEALTH
REPUBLIC OF SLOVENIA
MINISTRY OF LABOUR, FAMILY,
SOCIAL AFFAIRS AND EQUAL OPPORTUNITIES

12. Information on the envisaged LTC reform
 Preparation of the LTC reform started 15 years ago!
 Since than several drafts of legislative act were prepared
 Since 2013 recommendations from EC and OECD
 In 2014: developed official statistics on LTC with detailed information on LTC
expenditure and recipients
 Since 2014 better collaboration of the Ministry of Health with the Ministry of
Labor, Familiy, Social Affaires and Equal Opportunities
 In 2017: The Ministry of Health took the responsibility for preparation of
LTC reform and established new Department for LTC
REPUBLIC OF SLOVENIA
MINISTRY OF HEALTH
REPUBLIC OF SLOVENIA
MINISTRY OF LABOUR, FAMILY,
SOCIAL AFFAIRS AND EQUAL OPPORTUNITIES

13. LTC REFORM - PARDIGM SHIFT
REPUBLIC OF SLOVENIA
MINISTRY OF HEALTH
REPUBLIC OF SLOVENIA
MINISTRY OF LABOUR, FAMILY,
SOCIAL AFFAIRS AND EQUAL OPPORTUNITIES
PLANNED LTC SYSTEMPRESENT SYSTEM OF LTC
SOCIAL CARE SYSTEM
PARENTAL CARE
SYSTEM
PENSION SYSTEM
EDUCATIONAL SYSTEM
DISABILITY CARE
SYSTEM
HEALTH CARE SYSTEM
- unifiedgovernance,
definitions,assessment,
single entry point
-integrated delivey of
community based
services, active role of
user
- prevention,ICT,
rehabilitation
- integrated financing
- introduction of
mandatory and
volontary LTC
insurance
- differentgovernance
- differentassessment
procedures
- uneven delivery of
services
- lack of coordination,
prevention, ICT,
comunity based services
- unequal financing
of the same needs
- unsustainable
financingsources
INTEGRATED
LONG TERM
CARE
SYSTEM

14. Planned LTC system - Key changes
 Unification of mandatory insurance rights
 Standardized assessment of needs (eligibility), single entry point
(one stop shop), active involvement of user in planning
 Integrated (coordinated) provision of LTC services, emphasis on
community based services
 Greater support for informal caregivers
 Prevention, rehabilitation and use of ICT
 Integrated quality control
 Integrated financing of LTC
REPUBLIC OF SLOVENIA
MINISTRY OF HEALTH
REPUBLIC OF SLOVENIA
MINISTRY OF LABOUR, FAMILY,
SOCIAL AFFAIRS AND EQUAL OPPORTUNITIES

15. Integrated financing of LTC – LTC as a new social risk
 The starting point of financing reform: a need for LTC as a (new) social risk
 Ensuring a sustainable financing system that needs to be adaptable and
predictable in times
To keep three pillars of funding:
1. A compulsory public LTC insurance, based on the merged parts of the
existing health and disability/pension insurance currently intended for LTC
2. Tax based financing (including the introduction of new special levy for LTC
– (approx. 0,2 % of GDP)
3. Out of pocket co-payments
 and optional voluntary private insurance
REPUBLIC OF SLOVENIA
MINISTRY OF HEALTH
REPUBLIC OF SLOVENIA
MINISTRY OF LABOUR, FAMILY,
SOCIAL AFFAIRS AND EQUAL OPPORTUNITIES

16. Piloting and verification of the planned solutions
 Piloting of the new LTC system (2018/19)
 Monitoring and evaluating the financial effects of the reform,
before actual start of new system
 Preparation of micro simulation model
REPUBLIC OF SLOVENIA
MINISTRY OF HEALTH
REPUBLIC OF SLOVENIA
MINISTRY OF LABOUR, FAMILY,
SOCIAL AFFAIRS AND EQUAL OPPORTUNITIES

17. Conclusions - structural reform of LTC system
Structural reform of LTC system focused on:
 Ensuring a sustainable financing of LTC system that needs to be adaptable
and predictable in times
 Higher investment at the beginning (prevention, early rehabilitation, ICT) to
get lower growth of LTC and HC expenditure in the long run
 A shift towards more developed social component of LTC
 Improved needs assessment procedures
 Strengthening of community based services
 Changed provision and payment of providers (money following user)
 Quality assurance
REPUBLIC OF SLOVENIA
MINISTRY OF HEALTH
REPUBLIC OF SLOVENIA
MINISTRY OF LABOUR, FAMILY,
SOCIAL AFFAIRS AND EQUAL OPPORTUNITIES

18. Thank you!
eva.zver@gov.si
davor.dominkus@gov.si
tatjana.buzeti@gov.si
REPUBLIC OF SLOVENIA
MINISTRY OF HEALTH
REPUBLIC OF SLOVENIA
MINISTRY OF LABOUR, FAMILY,
SOCIAL AFFAIRS AND EQUAL OPPORTUNITIES