Health care financing and the sustainability of health systems.

The economic crisis brought an unprecedented attention to the issue of health system sustainability in the developed world. The discussion, however, has been mainly limited to "traditional" issues of cost-effectiveness, quality of care, and, lately, patient involvement. Not enough attention has yet been paid to the issue of who pays and, more importantly, to the sustainability of financing. This fundamental concept in the economics of health policy needs to be reconsidered carefully. In a globalized economy, as the share of labor decreases relative to that of capital, wage income is increasingly insufficient to cover the rising cost of care. At the same time, as the cost of Social Health Insurance through employment contributions rises with medical costs, it imperils the competitiveness of the economy. These reasons explain why spreading health care cost to all factors of production through comprehensive National Health Insurance financed by progressive taxation of income from all sources, instead of employer-employee contributions, protects health system objectives, especially during economic recessions, and ensures health system sustainability.

Private health expenditure in the Greek health care system: where truth ends and the myth begins.

UNLABELLED: Greece today has the most "privatized" health care system among EU countries. Given the country's universal coverage by a public system this may be called "the Greek paradox". The objective of this paper is to analyze private health payments by provider and type of service in order to bring to light the reasons for and the nature of the extraordinary private expenditure in Greece. METHODS: We used a randomized countrywide sample of 1616 households. Regression analysis was used to determine the extent to which social and economic household characteristics influence the frequency of use of certain health services and the size of household payments for such services. In all statistical analyses we used the p<0.05 level of significance. RESULTS: Out of the total private household health expenditure (euro6141 million), 66% is for outpatient services, with the largest share for dental services, absorbing 31.1% (euro1912 million or 1.5% of GDP) of the total out-of-pocket health expenditure. Rural dwellers seek private outpatient care more often, because of the understaffed public primary facilities. The hospital sector absorbs less than 15% (or euro884 million) of household private health expenditure. A significant part (20%) of hospital care financed privately concerns informal payments within public hospitals, an amount almost equal with formal payments in the form of cost sharing. Admissions to private hospitals are only 16% of total admissions. Our results indicate that this is a result of the political emphasis in public hospitals and of the considerably high cost of private hospital care. CONCLUSIONS: The rise in private health expenditure and the development of the private sector during the last 20 years in Greece is associated with public under financing. The gap was filled by the private sector through increased investment, mostly in upgraded amenities and new technology. Today, the complementary nature of private care in Greece is no longer disputed, but is a matter of serious concern, as it undermines the constitutionally guaranteed free access and equitable distribution of health resources.

Informal payments in public hospitals in Greece.

UNLABELLED: Informal payments are an ingrained social institution in Greece. In some cases, they are also part of corruption in the health area, which includes a variety of other forms. OBJECTIVE: The objective of this paper is to measure and analyze the size and nature of informal payments in the Greek public hospitals, concentrating on payments made to health personnel to facilitate access to services and preferred providers. METHODS: We used a randomized countrywide sample of 1616 households, amounting to 4738 individuals. The survey methodology was telephone interviews with a questionnaire supported by the software of Computer Assisted Telephone Interviewing. RESULTS: Out of the total number of those reporting treatment in public hospitals (N=336), 36% reported at least one informal payment to a doctor. Of these, 42% reported it was given because of the fear of receiving sub-standard care (if they did not pay) and another 20% claimed that the doctor demanded such a payment. None of the socio-economic characteristics of the family were related to the size of extra (informal) payments. The probability of extra payments is 72% higher for patients aiming to "jump the queue", compared to those admitted through normal procedures. Also, surgical cases had a 137% higher probability for extra payments compared to non-surgical patients. CONCLUSIONS: A very high percentage of informal payments are made in order to gain access to public hospitals and to receive a higher quality of services. Despite near universal coverage of the population by public health insurance, informal payments are widespread and a major source of inequity and inefficiency in the Greek health care system.

Informal payments in the Greek health sector amid the financial crisis: old habits die last...

BACKGROUND: Under-the-table informal payments are commonplace as reimbursements for health care services in Greece. As the country faces a severe financial crisis, the need to investigate the extent of such payments, their incidence and their impact on household income is pressing. METHODS: A survey of 2,741 persons from across the country was conducted between December 2011 and February 2012. The sample was defined via a multistage selection process using a quota for municipality of residence, sex and age. The maximum error margin was 2.41% with a confidence interval of 95%. RESULTS: The survey reports under-the-table payments for approximately 32.4% of public hospital admissions. Private clinics, which display the bulk of out-of-pocket payments, naturally display the lowest under-the-table payments. The highest percentage of under-the-table payments in the private sector appears at visits to private practitioners and dentists (36%). Informal payments are most frequently made upon request, prior to service provision, to facilitate access to care and to reduce waiting times, and at a much lower percentage, to post-service provision, and out of gratitude. CONCLUSIONS: This survey reveals that, due to severe financial pressure, there is a growing unwillingness of citizens to pay informally and an increasing demand for these payments as a prerequisite for access to services or to redeem services provided. This "hidden" financial burden of at least 27% impacts negatively on the living conditions of households and is not reported as purchasing ability or cost of living.

Health policy making under information constraints: an evaluation of the policy responses to the economic crisis in Greece.

INTRODUCTION: Cost consolidation in the highly fragmented and inefficient Greek health care system was necessary. However, policies introduced were partly formed in a context of insufficient information. Expenditure data from a consumption point of view were lacking and the depth of the political and structural problems was of unknown magnitude to the supervisory authorities. METHODS: Drawing upon relevant literature and evidence from the newly implemented OECD System of Health Accounts, the paper evaluates the health policy responses to the economic crisis in Greece. The discussion and recommendations are also of interest to other countries where data sources are not reliable or decisions are based on preliminary data and projections. RESULTS: Between 2009 and 2012, across-the-board cuts have resulted in a decline in public health expenditure for inpatient care by 8.6%, for pharmaceuticals by 42.3% and for outpatient care by 34.6%. Further cuts are expected from the ongoing reforms but more structural changes are needed. CONCLUSION: Cost-containment was not well targeted and expenditure cuts were not always addressed to the real reasons of the pre-crisis cost explosion. Policy responses were restricted to quick and easy fiscal adjustment, ignoring the need for substantial structural reforms or individuals' right to access health care irrespective of their financial capacity. Developing appropriate information infrastructure, restructuring and consolidating the hospital sector and moving toward a tax-based national health insurance could offer valuable benefits to the system.

Can cost sharing measures improve the function of outpatient departments of public hospitals: the opinions of administrative directors.

This paper describes a study aiming to investigate the opinions of administrative personnel concerning the effectiveness of a cost sharing mechanism (of euro 5/visit) at public hospitals' outpatient departments. Data was derived through a structured questionnaire (developed by the researchers) which appealed to 112 administrative directors of public hospitals. Results highlighted a positive attitude concerning the function of the cost - sharing mechanism at public hospitals, a rather fair measure for the users (vulnerable groups are excluded) which probably is enhancing the monetary flow in public hospitals.

Private expenditure and the role of private health insurance in Greece: status quo and future trends.

The health care system in Greece is financed in almost equal proportions by public and private sources. Private expenditure, consists mostly of out-of-pocket and under-the-table payments. Such payments strongly suggest dissatisfaction with the public system, due to under financing during the last 25 years. This gap has been filled rapidly by the private sector. From this point of view, one might suggest that the flourishing development of private provision may lead in turn to a corresponding growth in private health insurance (PHI). This paper aims to examine the role of PHI in Greece, to identify the factors influencing its development, and to make some suggestions about future policies and trends. In the decade of 1985-1995 PHI show increasing activity, reflecting the intention of some citizens to seek health insurance solutions in the form of supplementary cover in order to ensure faster access, better quality of services, and increased consumer choice. The benefits include programs covering hospital expenses, cash benefits, outpatient care expenses, disability income insurance, as well as limited managed care programs. However, despite recent interest, PHI coverage remains low in Greece compared to other EU countries. Economic, social and cultural factors such as low average household income, high unemployment, obligatory and full coverage by social insurance, lead to reluctance to pay for second-tier insurance. Instead, there is a preference to pay a doctor or hospital directly even in the form of under-the-table payments (which are remarkably high in Greece), when the need arises. There are also factors endogenous to the PHI industry, related to market policies, low organisational capacity, cream skimming, and the absence of insurance products meeting consumer requirements, which explain the relatively low state of development of PHI in Greece.

Extracapsular hip fracture management: cost-consequences analysis of two alternative operative methods.

OBJECTIVES: The aim of this prospective study was to perform a cost and outcome comparison between two alternative operative techniques (osteosynthesis and hemiarthroplasty) used in the treatment of elderly patients with unstable trochanteric hip fracture. MATERIALS AND METHODS: One hundred seventy-three trochanteric hip fracture patients were followed-up for 1 year after surgery. For each operative technique, hospital treatment's cost per patient was computed. Mortality and complication rate in-hospital and at specific time points after surgery were used as outcome measures. Patients' functional level before and after hip fracture was estimated according to their mobility and ability to perform basic and instrumental activities of daily living. RESULTS: The cost for patients undergoing osteosynthesis reached euro 1,931 per case, whereas for those treated with hemiarthroplasty reached euro 3,719 per case (2001 rates). There was no statistically significant difference regarding in-hospital mortality and complication rate, as well as mortality and complication rate 1 year after surgery, between the two patient groups. CONCLUSIONS: The quite similar performance of the two operative techniques suggests that cost could be the key factor for choosing between them. However, it is critical that many more randomized studies, with larger sample sizes and wider follow-up time periods should be conducted.

Economic evaluation of treatment strategies for patients suffering acute myocardial infarction in Greece.

INTRODUCTION: Acute myocardial infarction (AMI) is one of the leading causes of death in Greece and elsewhere. The objective of this paper was to conduct an economic evaluation of three alternative treatment options, alteplase, reteplase, and tenecteplase, in different groups of patients. METHODS: A systematic review of the literature was undertaken to identify studies evaluating the three treatments considered. Data from selected trials were extracted and applied to a decision analytic model, which has a time horizon extending to the end of a patient's life. The health outcomes included in the analysis contain all major health events that may occur after an AMI. Total treatment cost comprises the cost of initial treatment, the cost associated with hospitalisations due to AMI and events such as stroke, reinfarction, etc., and the lifetime costs of patients surviving. The model allows for different patient sub-groups. Simulation was used to test the robustness of the findings. RESULTS: For the baseline group, there was no major difference between the three treatments, in terms of treatment cost and survival. Specifically, lifetime cost per patient was around Euro 18,950 (range Euro 18,947 - Euro 18,990) and overall survival was around 8.4 years (range 8.359 - 8.472). Nonetheless, for patients above the age of 75 and for patients starting treatment 4 hours after symptom onset, tenecteplase was more cost-effective compared to the other two treatments. Its incremental cost effectiveness ratio was Euro 2,205 in the former group and Euro 868 in the latter and these results reached high levels of significance. CONCLUSION: Despite its higher price, in the setting of the Greek National Health Service tenecteplase is a cost-effective treatment for AMI patients, comparable to alteplase and reteplase, and it should also be included in the positive drug list along with the other two drugs. Simple price comparison of alternative treatments is not the best option for supporting decisions on pricing and reimbursement of new therapies.