The Cross-Border Health Care Directive (CBHD) has the potential to herald a revolution in the ability of EU citizens to access healthcare across European boundaries. The author argues that the CBHD, while activating rights, does too little to operationalize them. The CBHD could function as a major corrective to government failure in the healthcare setting, but critically, its implementation means that information asymmetry and related problems are not tackled systematically. In addition, the calculation of reimbursement tariffs by the Member States is largely un-policed, leading to potential gaming. Nevertheless, very dysfunctional public delivery systems may begin to face material patient out-flows. Although the CBHD makes provision for the Member States to curb reimbursement rights in response, this requires developing a detailed framework for that purpose. The relative priority this framework gives to patient as opposed to provider interests is likely to determine its strictness.
Jos Boertjens and Mary Guy
In this chapter the authors compare the health care systems of England and the Netherlands with respect to contracting, accountability frameworks and the duty to provide care and access to health care. The objectives of contracting are different in these two countries. While in the Netherlands contracting is envisaged to promote efficiency and quality, contracting in England appears to set a minimum requirement. Under the Dutch system, the insurer must fulfill its duty to provide care. In England it is difficult to hold any party accountable for ensuring that patients receive necessary care. Various types of co-payments and out-of-pocket charges occur in both England and the Netherlands. In both countries personal care budgets exist to put patients in charge of their own budgets.
Ana Rodríguez-Álvarez and Maria J. Perez-Villadoniga
In health care systems such as Spain where patients do not pay the full price for health care services, waiting lists may be used as a rationing mechanism. The authors describe a theoretical model of the demand for and the supply of health care. They derive a waiting list function from the theoretical model that implies that waiting lists will increase as a result of increases in demand or reductions in supply. Then the authors estimate the obtained waiting list function. The results of the empirical estimation confirm the predictions of the theoretical model. Notably the recent recession has led to significant reductions in public expenditure of health care and caused longer waiting lists.
This chapter is a case study of a payment reform in New York State by Medicaid. The payment was organized as a Delivery System Reform Incentive Payment (DSRIP) programme with the ultimate goal of reducing avoidable hospital care by 25 per cent, while making sure that no more providers would require financial state-aid to survive. The programme aimed to incentivize providers to coordinate care, increase transparency of services and payments based on outcome. The programme runs from 2015 until 2020. The first results look promising, but it is too early to draw definite conclusions. Although the programme is still unfolding, some lessons can already be drawn: rewarding voluntary participation ensures motivated participants, the programme must be flexible and the programme should maintain pace.
Peter Bogetoft, Misja Mikkers and Victoria Shestalova
In this chapter the authors describe an integrated contract (population based financing) between health care payers, such as governments and/or health insurers) and different health care providers. The chapter considers a simple and stylized theoretical model involving a health care payer and two different health care providers (e.g., general practitioners and hospitals) and compares different contracting options. Based on the theoretical model, the authors argue that population bases financing offers better incentives for the coordination in the provision of health care services. Contracts should be augmented with quality outcome measures to provide incentives to prevent undertreatment. The chapter gives examples of integrated contracting in the US, Germany and a proposed experiment in the Netherlands.
Julia Bobek, Lena Lepuschütz and Florian Bachner
Austria has a long history of social protection through the social health insurance (SHI) system. Insurance coverage is mandatory and the assignment to a particular insurance fund is determined by law, depending on the place of occupation, type of occupation and occupational status (unemployed, retired person, and so on). This means that there is no regulated competition between SHI funds in Austria and the level of SHI coverage is very high. Around 99.9 per cent (8.8 million residents in 2017) of Austrians are covered by SHI. The Austrian healthcare system in general and the hospital sector in particular are characterized by a high degree of fragmentation. Competencies in the field of inpatient care lie with the nine federal states; financing is split between the federal level, the federal states and SHI.
Filip Dewallens and Julie Vermeulen
The Belgian healthcare system has a system of compulsory insurance with almost universal coverage of the population (99 per cent), administered by healthcare sickness funds (mutualité’s). Citizens can choose a mutualité freely, and can switch between mutualités at any time. Mutualités do not negotiate directly with individual hospitals, negotiations take place at the national level. Hospitals need to meet a limited set of national criteria in order to obtain recognition and must fit within standards for national programming. Most physicians in Belgium work within the Belgian state health insurance scheme, while some combine this with private work or work entirely in the private sector. Future developments involve proposals for strengthening value based financing of healthcare and clustering of hospitals, the latter creating a network of neighbouring hospitals, a development aimed at sharing of the financial risks between hospital and insurance.
The Bismarck type health care system relies on mandatory health insurance. Contributions to health insurance are paid by the employer as well as the employee. Self-employed persons pay their fees directly. For the economically inactive population, contributions are covered by the state. Contributions are collected directly by the health insurance funds and are pooled and redistributed through a risk adjusted scheme based on age, sex, high costs during the reference period and pharmacy-based costs. All policyholders are covered under the same benefits package, which is defined by law. There are seven health insurance funds. There is no competition since premiums are identical and reimbursements are not dependent on the quality of care. The publicly managed General Health Insurance Fund holds approximately 60 per cent of the market and guarantees the functioning of the whole system. The other six health insurance funds are ‘occupational’ funds.
Catalina Góngora Torres
Dating back to 1992, healthcare in Colombia is characterized by a managed competition model, where citizens may choose between one of the health insurance companies. Insurers are financed by premiums and tax revenues. Healthcare services are largely provided by private care providers, but there are also public hospitals. Access to secondary care is dependent on a GP referral and the insurer’s authorization. Remuneration of services (emergency care excepted) depends on a contract between provider and insurer. Services are usually contracted on a fee-for-services basis, in some areas a fee per capita is used. The Colombian healthcare system recently has made significant advances, for example regarding universal coverage (covering more than 95.6 per cent of the population). Some serious challenges remain, notably regarding a clearer delineation of the coverage, an increase of insurer’s financial sustainability and actual or potential anticompetitive behaviour.
The English National Health Service (NHS) is a taxpayer funded healthcare system established in 1948 and provides healthcare services to everyone who lives in the UK and remains free of charge at the point of use. Funding is largely allocated to 195 local Clinical Commissioning Groups (CCGs), clinically led statutory NHS bodies. At the time of referral, patients have a legal right to choose the provider. NHS-funded hospital care is provided by (135) acute trusts that are responsible for ensuring that high-quality care is provided. The private healthcare sector (with private healthcare insurance held by around 11 per cent of the population) is increasingly offering an equivalent range of services, including primary care. The NHS continues to perform well in international comparisons. However, recent developments – such as the increase of waiting lists, staff shortages and loss of efficiency – put the system’s original principles seriously to the test.