Mandatory Health Insurance In Europe: Ensuring Access For All

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Mandatory Health Insurance In Europe: Ensuring Access For All

42% purchase supplemental nonprofit insurance to share costs for outpatient prescription drugs and dental care and expand covered benefits such as physical therapy. In addition, 30% receive additional commercial coverage, mostly through an employer, for extended access to private providers (eg, for minor elective surgeries).

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There is no overall limit, but co-pays decrease as out-of-pocket prescription drug costs increase. There is no sharing of drug costs above the annual limit of DKK 4,030 (USD 548).

Private providers who are mainly paid FFS rest on a per capita basis. Most people (98%) choose the gatekeeping model, where patient registration and referrals are required for most specialty care, but no gatekeeping is required for hospital care.

It is mainly paid for through public, mostly global budgets and work-based payments. Some bundled and value-based payment pilots at the local level.

In Denmark’s universal, decentralized healthcare system, the national government provides block grants from tax revenue to regions and municipalities that provide healthcare services. All residents are entitled to publicly funded care, including free primary, specialist, hospital, mental health, preventive and long-term care services. Residents can purchase optional supplemental insurance to cover co-pays for outpatient drugs, dental care and other services. Supplementary insurance, which is mainly provided by private employers, offers a wide range of opportunities to private providers. Cost-sharing limits for adults and children provide a safety net.

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All registered Danish residents automatically have access to publicly funded health care, which is largely free at the point of use. Registered immigrants and asylum seekers are also covered, while undocumented immigrants have access to acute care services through a voluntary, privately funded initiative supported by the Danish Medical Association, the Danish Red Cross and the Danish Refugee Council.

Danes can choose between two public insurance options. Practically all Danes (98%) choose Group 1 coverage, in which general practitioners (GPs) act as gatekeepers and patients must refer to specialists, except for a few specialties. The remaining 2 percent of Danes choose group 2 coverage, which allows them to apply without having to refer to a specialist, although additional fees apply. Under both insurance options, referrals are required to see hospitals.

Universal access to health care is the basis of the Danish Health Act, which sets out the government’s obligation to promote the health of the population, prevent and treat disease, suffering and functional limitations; ensure high quality care and easy and equal access; and promoting service integration, choice, transparency, access to information and short waiting times.

Universal coverage gradually evolved from the latter part of the 1800s through non-governmental insurance, known as sickness funds, which covered user costs for primary care and hospital care. In 1973, through legislative reforms, the current universal public coverage system was established.

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Role of government: The national government sets the regulatory framework for health services and is responsible for overall planning, monitoring the quality of care, and licensing health professionals. The national government also collects taxes and allocates funds to regions and municipalities based on socio-demographic criteria and performance.

The state has no direct role in the provision of health services. The five regions, governed by democratically elected councils, are responsible for the planning and delivery of specialized health services and play a role in specialized social care and coordination. Regions own, manage and finance hospitals. They also fund most services provided by private general practitioners (GPs), office-based specialists, physiotherapists, dentists and pharmacists, as well as specialist rehabilitation. 80 percent of financing of regions is done by the state and 20 percent by municipalities.

Municipalities are responsible for funding and delivering nursing home care, home nurses, health visitors, some dental services, school health services, home help, substance abuse treatment, public health and health promotion, and general rehabilitation.

General regulation, planning and control of health services, including general cost control mechanisms, are carried out at the National level through the Parliament, the Ministry of Health and four state institutions:

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National authorities also have important roles in planning the deployment of specialist services, approving regional hospital plans and approving binding health agreements between regions and municipalities to coordinate service delivery. In addition, the Health Information Agency provides online access to comparative data on service, quality and number of treatments provided, as well as data from clinical registries and information on drug prices and reimbursement levels.

Danish Regions and Local Government Denmark negotiates economic agreements on behalf of regions and municipalities and participates in monitoring agreed performance targets. They also play an important role in gathering and sharing knowledge to facilitate development and implementation.

Role of public health insurance: Public spending accounted for 84 percent of total health care spending in 2016, accounting for 8.7 percent of GDP. In general, healthcare costs made up 10.4 percent of GDP.

It should be noted that, unlike other countries of the Organization for Economic Co-operation and Development (OECD), Denmark includes long-term care services in the calculation of total health care costs.

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Health care is mainly financed by a progressive national income tax. The national government allocates health funding to regions and municipalities, mostly as block grants, with amounts adjusted for demographic and social differences. These grants finance 77 percent of regional health functions. A small proportion of public funding of regional and municipal services is usually tied to specific priority areas and targets defined in annual economic agreements between the national government and municipalities or regions. Current targets encourage a continued transition from hospital-based care to primary care and home care. The remainder of funding for regional services comes from municipal performance-based fees, funded by a combination of progressive municipal income taxes and state block grants.

The role of private health insurance: Supplementary voluntary health insurance purchased on an individual basis covers statutory co-payments – mainly for pharmaceutical and dental care – and services not fully covered by the government, such as physiotherapy. About 2.45 million Danes (42%) have such coverage, and it is provided almost exclusively by the non-profit organization Danmark.

In addition, approximately 1.69 million Danes (30%) have supplementary insurance to have wide access to private providers, mainly for physiotherapy and minor elective surgeries.

The seven for-profit insurers sell fringe benefits policies mainly through private employers, although some public sector workers are also covered. Students, pensioners, the unemployed and those outside the labor market are generally not covered by supplementary insurance.

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Home care is organized and financed by municipalities. Municipalities also fully fund maternity care, preventive home visits for babies and counseling for teenagers and preschoolers. It is also the responsibility of municipalities to provide durable medical equipment to citizens who are in constant need. Hospice care is funded and delivered by the regions.

There is no nationally defined benefit package for health care. Decisions about service levels and new medical treatments are made by regions within the framework of national laws, treaties, guidelines and standards. Municipalities decide the level of service for most other social services, including social care, within national regulation. Most evidence-based treatments are covered in practice. These include fertility treatments (with some limitations) and necessary cosmetic surgery.

Cost-sharing and out-of-pocket costs: Cost-sharing applies to dental care for adults (co-insurance 35%-60%), outpatient prescriptions, temporary home care, long-term care at home, corrective lenses, and travel vaccinations. There is no cost-sharing for hospital care, primary care services, dental care for children under 18, childhood immunizations, cancer screenings, maternity care, hospice care, or permanent home care. Only Danes who choose group 2 insurance owe an additional fee when visiting a specialist doctor.

Household out-of-pocket payments accounted for 13.7 percent of total health care spending in 2016, which mainly included outpatient drugs, corrective lenses, hearing aids, dental care, and payments to private specialists and clinics outside the public referral scheme.

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Safety nets: Because most care is covered by public health insurance, there is limited need for safety nets. Danes receive a subsidy for outpatient drugs and there is an annual out-of-pocket maximum for drugs (see table).

There are also subsidies for physiotherapy and dental care for adults. In addition, municipalities provide means-tested social assistance to older people for long-term care.

Medical education and workforce: The number of doctors is regulated at national level through limits on the number of medical education training posts and the number of practicing doctors per region eligible for public funding. There are four medical schools, all public, offering six years of medical education. None of them receive tuition fees.

In recent years, there has been a shortage of medical professionals willing to establish general practices in rural areas. This led to legislative changes allowing regions to invite proposals for experiments or to conduct experiments as regional units. Regions have also taken other initiatives to address the shortage, such as developing programs to attract foreign doctors, providing free clinic buildings and allowing doctors to own multiple clinics. The admission to the state medical faculties has also increased.

Health Insurance In Germany

Primary care: About 22 percent of physicians work in general practice. Almost all physicians are self-employed and are paid by the regions on a capitation basis (about 30% of revenue) and fee-for-service (70% of revenue). Prices are determined within the country

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