The bene fits package

EU health systems gener ally provide a compre hens ive range of bene fits, includ-ing public health services. Among coun tries that do not offer compre hens ive cover age, there is most often signi fic ant vari ation in cover age of prescribed medi cines and medical devices (Richardson 2014). In the past, health systems financed through alloc a tions from the govern ment budget did not define bene-fits expli citly. Analysis suggests this is chan ging; in the last two decades many Table 4.2 Reported changes to popu la tion enti tle ment, 2008–13

Basis for

enti tle ment Expanded enti tle ment for Restricted enti tle ment for Residence Residents: Russian Federation Foreign resid ents: Czech Republic

Undocumented migrants: Russian Insurance Greece: intro duced enti tle ment to

limited outpa tient services to unin sured people

Plan to change from resid ence to contri bu tion: Latvia

Spain: clari fied the basis for enti tle ment for adults and intro duced a policy allow ing the unin sured to buy cover for a

care), Bosnia Lower means- test threshold for older people: Ireland

coun tries have intro duced more trans par ent criteria for the inclu sion of new bene fits and make greater use of health tech no logy assess ment (HTA) in cover-age decisions (Sorenson et al. 2008), partic u larly in EU coun tries, where cost- effect ive ness plays a growing role.

Countries rarely find it easy to restrict the scope of the publicly financed bene fits package (Ettelt et al. 2010). One of the keys to policy success lies in being select ive and system atic – for example, prior it iz ing the de- listing of low- value (inef fect ive or non- cost- effect ive) health services. In contrast to ad hoc reduc tions, HTA- based with drawal of low- value services from cover age offers the dual advant age of enhan cing effi ciency in public spend ing and minim iz ing concerns about negat ive effects on popu la tion health.⁶

A draw back is that HTA poses a range of tech nical, finan cial and polit ical chal lenges. In addi tion to polit ical will, it requires invest ment and capa city, which may be lacking in a severe economic crisis, and its bene fits are often felt at the margin (Stabile et al. 2013), which explains why it is not as widely or optim ally used as it might be, even in normal circum stances. In fact, very few coun tries use HTA for disin vest ment; most assess ments focus on new tech no lo-gies (Ettelt et al. 2007). Even though system atic de- listing does not usually gener ate substan tial savings in the short- term, it offers poli cy makers the chance to enhance effi ciency and may make cover age reduc tions more polit ic-ally feas ible, espe ciic-ally when accom pan ied by public consulta tion and commu nic a tion.

Changes to the bene fits package

Twenty- five coun tries repor ted trying to restrict or redefine the publicly financed bene fits package (Table 4.3). Of these, about half repor ted doing so in a system atic way, using expli cit criteria.⁷ Systematic changes were often repor-ted as having been planned before the crisis.

Several coun tries heavily affected by the crisis repor ted the intro duc tion of a new minimum bene fits package (Greece, Portugal) or plans to intro duce minimum bene fits (Cyprus, Spain). Other notable devel op ments include the intro duc tion of rules making cost- effect ive ness a mandat ory criterion in HTA in France from 2013, and making all new drugs in Germany subject to eval u-ation of their addi tional thera peutic benefit.⁸

Drugs were the most common target for ad hoc exclu sions and system atic disin vest ment, followed by tempor ary sick ness leave. Bulgaria and Romania repor ted limit ing access to primary care, in Romania by capping the number of covered visits to a GP for the same condi tion (five a year, later reduced to three a year) and in Bulgaria by moving respons ib il ity for immun iz a tion, ambu lat ory mental health care, derma to logy and treat ment of sexu ally trans mit ted infec-tions from the Ministry of Health to stat utory health insur ance. As a result, these services are now only avail able to the insured in Bulgaria.

Some coun tries repor ted intro du cing and revers ing cover age reduc tions follow ing oppos i tion from the public. Switzerland removed eyeglasses for the whole popu la tion but rein tro duced them for chil dren, while the Netherlands dropped plans to reduce cover age of mental health services.

86 Economic Crisis, Health Systems and Health in Europe

Thirteen coun tries repor ted expand ing the bene fits package, but not usually in direct response to the crisis. Many of these addi tions appeared to be part of efforts to strengthen finan cial protec tion for specific groups of people. For example, Belgium intro duced reim burse ment of travel costs for chron ic ally ill chil dren being treated in rehab il it a tion centres and new cash bene fits to cover the cost of incon tin ence mater i als; Bulgaria abol ished the cap on refer rals to special ists for chil dren; the Republic of Moldova exten ded the enti tle ment of the unin sured to include emer gency care and outpa tient prescrip tion drugs;⁹ and Austria and France increased sick leave bene fits for self- employed people and agri cul tural workers respect ively. Other coun tries expan ded cover age of prevent ive services: free check- ups for people living in remote areas of the former Yugoslav Republic of Macedonia, and a new bowel cancer screen ing programme for older people in the United Kingdom (Northern Ireland). In Croatia and Serbia, policies to improve drug pricing and cover age enabled new drugs to be added to posit ive lists of drugs.

Table 4.3 Benefits repor ted as being restric ted or redefined on an ad hoc or system atic basis, 2008–13

Type of service Ad hoc changes Systematic changes (informed by HTA)