2008年-世界发展银行全球_Evidence_on_Cost-sharing_in_Health_Care___Applications_to_Hungary___Executive_Summary_23页_675kb

Summary of "Evidence on cost-sharing in health care: Applications to Hungary"

Core Content

This document presents an analysis of cost-sharing in healthcare, focusing on its implications for Hungary and comparing it with experiences in OECD and Central and Eastern European (CEE) countries. The study is commissioned by the Hungarian Government to evaluate the effects of cost-sharing on various aspects of healthcare, including financial sustainability, service use, equity in access, and informal payments. It also discusses policy recommendations and the effectiveness of cost-sharing mechanisms in different contexts.

Main Findings

1. Impact of Cost-Sharing on Healthcare Utilization

• Cost-sharing can reduce unnecessary care, mitigating moral hazard.
• However, the effectiveness depends on socio-economic status, type of care, and provider payment incentives.
• In Hungary, after the introduction of cost-sharing in February 2007, there was a 23% decrease in ambulatory care encounters and 29% decrease in hospitalizations compared to the previous year.
• The number of prescriptions also dropped by 1 million in 2007.

2. Financial Sustainability

• Cost-sharing can support financial sustainability by generating revenue for the health insurance system.
• In 2007, Hungary’s health insurance fund reported a surplus of HUF 28.2 billion, with GPs contributing nearly half of the revenue from cost-sharing.
• Cost-sharing combined with supply-side measures (e.g., hospital restructuring) contributed to reducing hospital costs by HUF 6 billion.

3. Informal Payments

• Cost-sharing aims to formalize informal payments, which were previously unregulated.
• In Hungary, 3% of total health expenditures were attributed to informal payments before cost-sharing.
• Cost-sharing is expected to reduce informal payments and keep patient payments within the formal system.

4. Equity in Access

• Cost-sharing with exemption policies is essential to ensure equity in access.
• Exemptions should be transparent and easy to apply to avoid administrative burdens.
• Hungary’s exemption policies cover children, homeless individuals, emergency services, and preventive care.
• Despite cost-sharing, equity in access remains a concern, especially for low-income groups.

5. Cost-Containment Strategies

• Cost-sharing can support cost containment if combined with supply-side reforms and provider payment mechanisms.
• However, the marginal impact of cost-sharing alone is unclear, and its role in cost containment should not be overestimated.

Key Policy Recommendations

• Hungary should monitor and evaluate the impact of cost-sharing on access and equity.
• Household surveys should be used to assess equity in utilization, adjusted for the need for care, particularly for GPs, specialists, and hospitals.
• Telephone and exit surveys should be conducted to gather feedback on formal and informal payments, service satisfaction, and utilization behavior.
• Exemption mechanisms and co-payment ceilings should be reviewed for effectiveness in ensuring equitable access.
• Financial incentives through capitation payments and DRG-based payments could support the government’s supply-side strategy to reduce overcapacity.

Cost-Sharing in Other Countries

OECD Countries

• Most OECD countries use co-payments and co-insurance.
• Transparency and simplicity are key to successful cost-sharing.
• Exemption policies and co-payment ceilings are used to protect vulnerable groups.
• Informal payments are still common, and free care does not eliminate private health expenditures.

Central and Eastern European Countries

• CEE countries have introduced cost-sharing to raise revenues and formalize informal payments.
• Flat user fees are common, applied to outpatient visits, hospital stays, and emergency services.
• Exemptions are provided for low-income groups, children, and the elderly.
• Despite "free care", private health spending remains high, especially in CEE countries.

Empirical Evidence on Cost-Sharing

Argument 1: Moral Hazard Reduction

• Studies from the US, Belgium, Germany, Slovakia, and the Netherlands suggest that cost-sharing can reduce the use of less urgent services.
• However, low-income groups and the elderly are less affected, indicating that cost-sharing may not fully deter necessary care use.

Argument 2: Cost Containment

• In Slovakia, cost-sharing led to improved quality of care and reduced drug prescriptions.
• In Switzerland, cost-sharing encouraged use of generic drugs, leading to revenue increases for generics and price reductions for brand drugs.
• However, the combined effect of cost-sharing with supply-side measures is still unclear and requires further research.

Argument 3: Equity in Access

• Cost-sharing can reduce equity in access, especially for low-income groups.
• Exemption policies are crucial to prevent this.
• In some countries, supplementary insurance is used to cover co-payments, but it often exacerbates inequity and financial instability in the insurance system.

Argument 4: Compliance with Medication

• Limited evidence exists on how cost-sharing affects drug therapy compliance and health outcomes.
• Non-compliance may lead to increased hospitalizations and mortality, but this is not well documented.

Argument 5: Administrative Burden

• Cost-sharing can increase administrative costs for providers.
• However, transparent and simple mechanisms can reduce this burden.
• Exemption policies and administrative efficiency are important to ensure cost-effectiveness and feasibility.

Conclusion

Cost-sharing in healthcare can have both positive and negative effects, depending on its design and implementation. It can reduce unnecessary care and support financial sustainability, but it may also create inequity in access if not accompanied by exemption mechanisms. The study recommends that Hungary continue to monitor and evaluate the impact of cost-sharing and refine its policies to ensure equity and efficiency in healthcare delivery.