Patient Cost-Sharing for Health Care in Europe

Patient cost-sharing for health care in Europe Citation for published version (APA): Tambor, M. (2015). Patient cost-sharing for health care in Europe. Maastricht University. https://doi.org/10.26481/dis.20150615mt Document status and date: Published: 01/01/2015 DOI: 10.26481/dis.20150615mt Document Version: Publisher's PDF, also known as Version of record Please check the document version of this publication: • A submitted manuscript is the version of the article upon submission and before peer-review. There can be important differences between the submitted version and the official published version of record. People interested in the research are advised to contact the author for the final version of the publication, or visit the DOI to the publisher's website. • The final author version and the galley proof are versions of the publication after peer review. • The final published version features the final layout of the paper including the volume, issue and page numbers. 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ISBN: 978-94-6259-717-4 Printed by: Ipskamp Drukkers, Enschede Patient cost-sharing for health care in Europe Dissertation to obtain the degree of Doctor at the Maastricht University, on the authority of the Rector Magnificus, Prof. dr. L.L.G. Soete in accordance with the decision of the Board of the Deans, to be defended in public on Monday 15 June 2015, at 12 hours by Marzena Tambor Supervisors: Prof. dr. Wim Groot Prof. dr. hab. Stanisława Golinowska (Jagiellonian University Collegium Medicum) Co-supervisor: Dr. Milena Pavlova Assessment Committee: Prof. dr. Hans Maarse (chair) Prof. dr. Helmut Brand Prof dr. Peter Groenewegen (Utrecht University) Prof dr. Jacques Scheres Prof. dr. hab. Maciej Żukowski (Poznań University of Economics) Acknowledgement of funding: The study is financed by the European Commission under the 7th Framework Program, Theme 8 Socio-economic Sciences and Humanities, Project ASSPRO CEE 2007 (Grant Agreement no. 217431). The content of the publication is the sole responsibility of the authors and it in no way represents the views of the Commission or its services. Contents Chapter 1 General introduction 7 Chapter 2 Diversity and dynamics of patient cost-sharing for physicians’ and hospital services in the in 27 European Union countries 31 Chapter 3 The formal-informal patient payment mix in European countries. Governance, economics, culture or all of these? 47 Chapter 4 Towards a stakeholders’ consensus on patient payment policy: the views of health care consumers, providers, insurers and policy makers in six Central and Eastern European countries 69 Chapter 5 The inability to pay for health care services in Central and Eastern Europe: evidence from six countries 87 Chapter 6 Willingness to pay for publicly financed health care services in Central and Eastern Europe: evidence from six countries based on a contingent valuation method 101 Chapter 7 General discussion 117 References 137 Appendices 149 Summary 161 Acknowledgments 179 Curriculum Vitae 182 Chapter 1 General introduction Chapter 1 1.1. Motivation of the study The great achievement of the last century - the extension of people’s life expectancy - brings with it challenges for the health care systems. As people live longer, the need for long-term treatment due to chronic diseases becomes greater. New technologies have been developed to respond to the growing population’s health needs and expectations. Although they give more treatment opportunities, they also inflate the cost of health care (Lloyd-Sherlock, 2000; Martins et al., 2006; Przywara, 2010). The increase in health care cost becomes a relevant problem when confronted with resource constraints. As a result of demographic changes, the share of the economically active population, which in most developed countries bears a vast majority of health care cost, is shrinking. To generate more resources for health care through taxes or social insurance contributions, people need to share more of their wealth. However, imposing a higher tax burden has its impact on a countries’ economy and might be politically difficult. There is also a question whether countries which already devote a high share of their wealth on health care, should further increase their health care spending or rather allocate resources to other goods and services which can bring greater welfare gains for society (Thomson et al., 2009). In face of the increasing health care cost and the limited capacity to spend on health, enabling the financial sustainability of the health care systems without jeopardizing the main health system objectives has been recognized as one of the biggest challenges facing governments (Thomson et al., 2009). During the past few decades, various strategies have been worked out to address this challenge (Rechel et al., 2009). In order to reduce the cost of health care, much emphasis is placed on health prevention, i.e. eliminating risk factors and improving control of chronic diseases. The attention of policy makers is also attracted by strategies to increase consumers’ individual responsibility for financing health care (Mossialos & Le Grand, 1999; Thomson et al., 2009). It can be done by excluding some services and commodities from the statutory benefit package (usually those without significant contribution to the health of the population), or by limiting their number (waiting lists). In both instances, it can result in consumers being shifted to the private sector where they pay out-of-pocket the full price of goods and services (unless private insurance is available). Patients might be also asked to share the cost of services and commodities in the statutory benefit package 1. 1 Cost-sharing might take different forms. Patient might be asked to pay a flat-rate fee (co-payment), percentage of the cost (co-insurance) or a given amount of money before the public coverage begins (deductibles). There is 8 Introduction The potential of patient cost-sharing to contribute to the sustainability of the health care system relies on two elements. First, cost-sharing is an additional source of funds. Hence, some of the health care cost might be shifted from public budgets to patients. Second, cost- sharing promises to improve efficiency in publicly financed health care, as it is expected that patients when faced with a price would reduce the utilization of unnecessary and low-value health care (Robinson, 2002; Zweifel & Manning, 2000). It is also assumed that this could slow the growth of health care costs. However, opponents of cost-sharing question the potential of cost-sharing to improve efficiency and instead point to its potentially negative effects on equity in health care, documented by various evidence, among them the best known is the RAND health insurance experiment (Manning et al., 1987; Newhouse, 1993). Due to the ambiguity of the effects, the implementation of patient charges for publicly financed health care raises concerns. Patient cost-sharing is often the subject of public and political discourse, particularly in Europe where values like solidarity and equity are considered to be fundamental for the design of the health care systems (Maarse & Paulus, 2003; Meulen et al., 2001). Despite the ongoing debates, the continuous growth of public health expenditure during the past few decades compelled many Western European countries’ governments to apply patient cost-sharing for commodities and services, as a cost- containment measure (Abel-Smith & Mossialos, 1994; De Gooijer, 2007; Saltman & Figueras, 1998). In Central and Eastern European (CEE) countries, following the collapse of communism, the reliance on out-of pocket payments has substantially increased compensating for the low public resources for health care (Björkman & Nemec, 2013; Kutzin et al., 2010). Patient cost-sharing in these countries broadly applies to pharmaceuticals. However, the implementation of obligatory patient payments for publicly financed health care services encounters public opposition and proved to be politically difficult in many CEE countries. Nevertheless, consumers in CEE countries frequently pay informally or quasi-formally

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