Patient paymentsin Europe

Wim GrootWim GrootMaastricht UniversityMaastricht University

National University of Kyiv - Mohyla AcademyNational University of Kyiv - Mohyla AcademyKyiv, March 3, 2011Kyiv, March 3, 2011

Project funded under the Socio-economic Sciences and Humanities theme

European Commission

ASSPRO CEE 2007Collaborative Focused Research Project FP7-SSH-2007 Grant Agreement No.: 217431

Assessment of patient payment policies and projection of their efficiency, equity and quality effects:

The case of Central and Eastern Europe

ASSPRO CEE 2007http://assprocee2007.com

Project funded under the Socio-economic Sciences and Humanities theme

European Commission

ASSPRO CEE 2007Collaborative Focused Research Project FP7-SSH-2007 Grant Agreement No.: 217431

Consortium

Number Beneficiary name Short name Country

1 Universiteit Maastricht (coordinator)

UMThe Netherlands

2 Medical University of Varna MU-Varna Bulgaria

3 Public Enterprise “MTVC” MTVC Lithuania

4Scoala Nationala de Sanatate Publica si Management Sanitar

SNSPMS Romania

5 Shkola Ohorony Zdorovia SOZ Ukraine

6Uniwersytet Jagiellonski Collegium Medicum

UJ CM Poland

7Center for Public Affairs Studies Foundation

CPASF Hungary

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Research Team

• Project coordinator: Milena Pavlova

• Scientific coordinators: Wim Groot, Frits van Merode

• Researchers: Jelena Arsenijevic, Elka Atanasova, Petra Baji, Andriy Danyliv, Vladimir Gordeev, Tetiana Stepurko, Marzena Tamor, Sonila Tomini

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For further reference:

• Tambor, M., Pavlova, M., Woch, P. & Groot, W. (2010). Diversity and dynamics of patient cost-sharing for physicians’ and hospital services in the 27 European Union countries. European Journal of Public Health. Forthcoming. http://eurpub.oxfordjournals.org/content/early/2010/09/29/eurpub.ckq139.abstract

• T. Stepurko, M. Pavlova, I. Gryga & W. Groot (2010), Empirical studies on informal patient payments for health care services: A systematic and critical review of research methods and instruments, BMC Health Services Research 10:273

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Patient payments

• Formal cost-sharing arrangements

• Informal payments

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Formal-informal patient payments mix in Europe

Form

al o

blig

ator

y/un

avoi

dabl

e se

rvic

e fe

es

Informal patient payments

2Belgium, Cyprus, Finland, Germany, Iceland, Ireland, Netherlands, Norway, Portugal, Slovenia, Sweden,

3Austria, Croatia, Czech Republic, Estonia, France, Italy, Luxembourg

5Albania, Bulgaria, Latvia, Lithuania

1Denmark, Malta, Spain, UK

6Greece, Hungary, Poland, Romania, Russia, Slovakia, Turkey, Ukraine,

no some cases widely spread

noye

s

4

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• Formal cost-sharing arrangements and informal payments seem independent from eachother

• Formal cost-sharing does not seem an option to eradicate informal payments

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Source: Stepurko et al.: Empirical studies on informal patient payments for health care services: a systematic and critical review of research methods and instruments. BMC Health Services Research 2010, 10:273.

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Cost-sharing policies

• To improve efficiency and quality of health care

• To contain (public) health care expenditures• To generate revenues for health care• To improve sustainability of health care

system

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Types of cost-sharing

Cost-sharing = official arrangement aimed to partially involve the user in the payment for public health care services

Four types of cost-sharing– Co-payments– Co-insurance– Deductibles– Reference pricing (extra billing)

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Basic characteristics of the EU health care systems(2007-2008)

Source: Tambor, M., Pavlova, M., Woch, P. & Groot, W. (2010). Diversity and dynamics of patient cost-sharing for physicians’ and hospital services in the 27 European Union countries. European Journal of Public Health. Forthcoming.

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Co-payments as percentage of total health care expenditures, 2000-2004

2000 2001 2002 2003 2004

Canada 15.9 15.2 15.2 14.5 14.9

Denmark 16.0 15.9 15.8 13.9 13.9

Germany 10.6 10.7 10.3 10.4

France 10.5 10.4 7.9 7.7 7.6

Greece 44.9 42.4 43.3 43.7 45.2

Italy 22.8 20.3 20.4 20.7 19.6

Japan 16.9 16.5 17.3 17.3

Luxemburg 7.0 6.5 6.9 6.7 6.7

Netherlands 9.0 8.7 8.0 7.9 7.8

Norway 16.7 15.7 15.8 15.5 15.7

Austria 16.7 15.7 15.0 15.0 14.7

Poland 30.0 28.1 25.4 26.4 28.1

Portugal 22.2 23.2 22.3 21.2 21.6

Spain 23.6 23.9 23.7 24.1 23.6

Tsjech rep. 9.5 10.1 9.7 10.0 10.4

United States

14.9 14.2 13.7 13.5 13.2

Switzerland 32.9 31.7 31.5 31.6 31.9

Source:OECD Health Data 2006

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Characteristics health care systems 27 EU countries

• Insurance based systems prevail over tax based systems

• Three methods of paying for GP’s: capitation, salary and fee-for-service

• Medical specialists: fee-for-service and salary• GP gate keeping is rather common• Only in 7 member states patients do not need

a referral from a GP

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Patient cost-sharing arrangements in the EU for three types of services(2007-2008)

Source: Tambor, M., Pavlova, M., Woch, P. & Groot, W. (2010). Diversity and dynamics of patient cost-sharing for physicians’ and hospital services in the 27 European Union countries. European Journal of Public Health. Forthcoming.

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Characteristics cost-sharing arrangements• In nearly half the member states there are

no formal patient cost-sharing arrangements for GP, medical specialists or hospital care

• The most common type of cost-sharing for GP is co-payment followed by coinsurance and mixed patient cost-sharing

• The same forms of cost-sharing are applied to medical specialists and hospital care

• Cost-sharing for pharmaceuticals in EU is more diverse

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Exemption mechanisms

• The majority of EU countries has exemptions in case of low income, age (children, pensioners) or poor medical status

• Only 2 countries have no exemptions

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Patient cost-sharing arrangements in the EU have been changing considerably (mostly being extended) during the last decades and they are quite diverse at present.

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The dynamics of patient cost-sharing in the EU

Source: Tambor, M., Pavlova, M., Woch, P. & Groot, W. (2010). Diversity and dynamics of patient cost-sharing for physicians’ and hospital services in the 27 European Union countries. European Journal of Public Health. Forthcoming.

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Relation cost-sharing and financial characteristics health care systems• GP gate keeping does not preclude the

application of cost-sharing for physician services and vice versa: without gate-keeping not always cost-sharing for medical specialists

• Coinsurance is most common in case of fee-for-service to providers, co-payment goes together with salaries and capitation payment

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Relation cost-sharing and financial characteristics health care systems• Absence of cost-sharing is most frequent in

countries where GP’s are paid capitation and medical specialists are paid fee-for-service

• Cost-sharing is slightly more common in countries with insurance systems

• In tax based systems co-payments are most frequent for physician and hospital services

• In insurance based systems cost-sharing arrangements are more pluralistic

• For pharmaceuticals cost-sharing arrangements are diverse in both systems

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Relation cost-sharing and financial characteristics health care systems

No significant relation between exemptions and financial characteristics of health care systems in EU countries

Thank youfor your attention

Wim GrootProfessor of Health Economics