User charges

In contrast to the other dimen sions of cover age, user charges policy design varies substan tially across coun tries in terms of the services to which charges apply, the form of user charge applied and the extent to which differ ent people are exempt from charges or protec ted through a formal cap or ceiling (Table 4.4). Most coun tries in the European Region apply user charges to outpa tient prescrip tion drugs, many charge for phys i cian visits in primary and second ary care, some charge for inpa tient stays, and a handful charge for visits to emer-gency depart ments (Thomson et al. 2009; Kutzin et al. 2010).

Countries often intro duce user charges to moder ate demand for health services in the expect a tion that this will control costs. Unfortunately, a large and gener ally consist ent body of evid ence shows how user charges are of limited use as a policy tool because they have little select ive effect: they reduce the use of low- and high- value health services in almost equal measure (Newhouse and Insurance Experiment Group 1993; Swartz 2010). User charges deter people from using appro pri ate and cost- effect ive care – espe cially prevent ive and patient- initi ated services – even where charges are low. This can negat ively affect health, partic u larly among poorer people (Newhouse and Insurance Experiment Group 1993). Additionally, apply ing user charges to cost- effect ive patterns of use, such as obtain ing outpa tient prescrip tion drugs in primary care, has been shown to increase the use of more expens ive inpa-tient and emer gency care (Tamblyn et al. 2001). Overall, there is little evid ence to suggest that user charges lead to more appro pri ate use or success fully contain public spend ing on health care.

Table 4.4 Protection mech an isms for outpa tient prescrip tion drugs in EU27 coun tries, 2012

Type of protec tion Countries Exemption

Children Czech Republic, Germany, Italy, Lithuania, Romania, Slovenia, United Kingdom (England)

Low- income Austria, Cyprus, Czech Republic, Malta, United Kingdom (England)

Chronically ill Czech Republic, France, Greece, Ireland, Malta, Poland, Portugal, Romania, Slovenia, United Kingdom (England)

cover ing user charges Denmark, France, Latvia, Slovenia

Source: Author’s estim ate based on Health in Transition (HiT) reports avail able at www.

european ob servat ory.eu; inform a tion on voluntary health insurance from Thomson and Mossialos (2009) and Thomson (2010).

Note: In the United Kingdom, Northern Ireland, Scotland and Wales do not apply any user charges at all.

88 Economic Crisis, Health Systems and Health in Europe

User charges may contrib ute to enhan cing effi ciency in the use of health services if they are applied select ively based on value. A value- based approach would remove finan cial barri ers to cost- effect ive health services, clearly signal value to patients and providers, and ensure that patient and provider incent ives were aligned (Chernew et al. 2007). Such an approach is most likely to be useful when user charges are already widely used and there is clear evid ence of value (Thomson et al. 2013). To avoid unfairly penal iz ing patients for provider decisions, it is essen tial for value- based user charges to be accom pan ied by meas ures to ensure appro pri ate care deliv ery. In many cases, target ing providers is likely to be much more effect ive than target ing patients.

Research evid ence high lights the import ance of putting in place protec tion mech an isms so that the finan cial burden of user charges weighs least heavily on people with low incomes and people who regu larly use health care. To secure a degree of finan cial protec tion, it is advis able to cap the amount of money patients are required to pay for a given service or a given period of time. Value- based charges and protec tion mech an isms involve signi fic ant trans ac tion costs; these should be factored into the costs of devel op ing and imple ment ing user charges policy.

Changes to user charges policy

Most changes to user charges took place in EU coun tries. Twenty- four coun tries repor ted intro du cing or increas ing user charges, most commonly for outpa tient prescrip tion drugs (Table 4.5). In about half of these coun tries, the changes were repor ted as being only partially in response to the crisis – that is, they may have been planned before the crisis. In Cyprus, Greece and Portugal, however, user charges were increased to fulfil economic adjust ment programme (EAP) require ments. France repor ted a change to its value- based user charges, raising the co- insur ance rate for less effect ive outpa tient prescrip tion drugs. No other country repor ted adopt ing or making greater use of value- based user charges.

Measures to reduce protec tion from user charges were repor ted in eight coun tries: caps on user charges were increased in Finland (travel costs), Latvia (inpa tient care and all care), Portugal (all care) and Sweden (drugs and all care); user charges for outpa tient prescrip tion drugs were applied to groups of people who were previ ously exempt (Chernobyl victims and disabled people in Belarus; pension ers and chil dren under three in Bulgaria, later reversed; haemo-dia lysis patients in Greece, who no longer have free access to drugs not related to haemo dia lysis); and Ireland restric ted tax relief on out- of- pocket spend ing to the stand ard rate of tax and repor ted plans to increase the cap on nursing home charges. Two coun tries repor ted the intro duc tion of regular increases in user charges or caps on user charges, with user charges for inpa tient care set to rise in line with infla tion in Portugal and increases in the cap on all user charges to be linked to the national index of prices and earn ings in Sweden from 2013. A planned measure to expand the number of chronic condi tions exempt from outpa tient prescrip tion charges was dropped in the United Kingdom (England).

Fourteen coun tries repor ted abol ish ing or redu cing user charges, mainly only partially in response to the crisis (eight coun tries) and occa sion ally to

Table 4.5 Reported changes to user charges policy, 2008–13

90 Economic Crisis, Health Systems and Health in Europe

reverse a recent policy change (three coun tries). Fifteen coun tries repor ted meas ures to strengthen protec tion from user charges (reduced charges, exemp-tions, caps), most commonly target ing outpa tient prescrip tion drugs, poorer people or other groups defined as ‘vulner able’. Austria, Belgium, Portugal and Spain strengthened protec tion in three or more areas. In over half of these coun tries, greater protec tion was directly linked to an increase in user charges.¹⁰ Calls to intro duce or increase user charges were rejec ted in Denmark, Serbia, Romania and the United Kingdom (Scotland).