The Relationship Between the Scope of Essential Health Benefits and Statutory Financing: An International Comparison Across Eight European Countries

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1 Int J Helth Policy Mng 2016, 5(1), doi /ijhpm The Reltionship Between the Scope of Essentil Helth Benefits nd Sttutory Finncing: An Interntionl Comprison Across Eight Europen Countries Philip J. vn der Wees *, Joost J.G. Wmmes, Gert P. Westert, Ptrick P.T. Jeurissen Originl Article Abstrct Bckground: Both rising helthcre costs nd the globl finncil crisis hve fueled serch for policy tools in order to void unsustinble future finncing of essentil helth benefits. The scope of essentil helth benefits (the rnge of services covered) nd depth of coverge (the proportion of costs of the covered benefits tht is covered publicly) re corresponding vribles in determining the benefits pckge. We hypothesized tht more comprehensive helth benefit pckge my increse user costshring chrges. Methods: We conducted desktop reserch study to ssess the interreltionship between the scope of covered helth benefits nd the height of sttutory spending in smple of 8 Europen countries: Belgium, Englnd, Frnce, Germny, the Netherlnds, Scotlnd, Sweden, nd Switzerlnd. We conducted trgeted literture serch to identify chrcteristics of the helthcre systems in our smple of countries. We nlyzed similrities nd differences bsed on the dimensions of publicly finnced helthcre s published by the Europen Observtory on Helth Cre Systems. Results: We found tht the scope of services is comprble nd comprehensive cross our smple, with only mrginl differences. Cost-shring rrngements show the most vrition. In generl, we found no direct interreltionship in this smple between the rnges of services covered in the helth benefits pckge nd the height of public spending on helthcre. With regrd to specific services (dentl cre, physicl therpy), we found indictions of n ssocition between coverge of services nd cost-shring rrngements. Strong vritions in the volume nd price of helthcre services between the 8 countries were found for services with lrge prctice vritions. Conclusion: Although reducing the scope of the benefit pckge s well s incresing user chrges my contribute to the finncil sustinbility of helthcre, vritions in the volume nd price of cre seem to hve much lrger impct on finncil sustinbility. Policy-mkers should focus on vriety of mesures within n integrted pproch. There is no silver bullet for ddressing the sustinbility of helthcre. Keywords: Helthcre Reform, Essentil Helth Benefits, Cost-Shring Copyright: 2016 by Kermn University of Medicl Sciences Cittion: vn der Wees PJ, Wmmes JJG, Westert GP, Jeurissen PPT. The reltionship between the scope of essentil helth benefits nd sttutory finncing: n interntionl comprison cross eight Europen countries. Int J Helth Policy Mng. 2016;5(1): doi: /ijhpm Article History: Received: 22 April 2015 Accepted: 7 September 2015 epublished: 12 September 2015 View Video Summry *Correspondence to: Philip J. vn der Wees Emil: philip.vnderwees@rdboudumc.nl Key Messges Implictions for policy mkers Reduction of the scope of the benefit pckge nd n increse of user chrges hs limited impct on the reduction of the volume nd cost of cre t the mcro level. Supply constrints my hve much lrger impct on reducing the volume of cre nd thus the long-term finncil sustinbility of public helthcre provision. Policy-mkers should focus on vriety of mesures within n integrted pproch, including considertions for services covered, costshring rrngements, stimulting evidence-bsed prctice, the monitoring nd reduction of unwrrnted vrition, nd control mechnisms for the price of helthcre services. Implictions for public Coverge for helthcre services funded by public revenues in our smple of 8 Europen countries is comprble nd comprehensive, with only mrginl differences. It is the cost-shring rrngements for citizens tht vry the most, nd they imply different thresholds for individul ccess to specific helth services in the selected countries. Rdboud Institute for Helth Sciences, Celsus Acdemy for Sustinble Helthcre, nd Scientific Institute for Qulity of Helthcre, Rdboud University Medicl Center, Nijmegen, The Netherlnds

2 Bckground Rising helthcre costs re leding to mjor sustinbility issues in helthcre systems round the world. In ddition, the globl finncil crisis hs reduced the vilbility of helth system resources. As result, mny Europen countries hve implemented policy tools to ddress these finncil chllenges. 1,2 In the United Sttes, criteri for essentil helth benefits hve been developed to cover helth services tht re mediclly effective nd ffordble for purchsers. 3 Helthcre spending is function of price nd quntity (volume), nd controlling costs therefore requires controlling the price nd/or volume. 4 Strtegies for enhncing the finncil sustinbility of helth systems my be imed t reducing the demnd for helthcre, reducing the supply of helthcre provisions, or controlling the price of helthcre services. However, proposed policy tools such s reducing the scope of essentil services covered, reducing popultion coverge nd user chrges for essentil services, risk undermining importnt gols of the helth system, such s ccess nd solidrity. 1 The scope of essentil helth benefits (the rnge of services covered) nd depth of coverge (the proportion of costs of the covered benefits tht is publicly covered) re hypothesized s corresponding vribles in determining the benefits pckge. In other words, generous benefits pckge (wide rnge of service coverge) my correspond with high privte finncil contributions (low coverge depth), while limited benefits pckge my correspond with high coverge depth. 5,6 Understnding the potentil interreltionships between these vribles my help policy-mkers enhnce the finncil sustinbility of helthcre. Both reduction in the scope of the benefits pckge, nd n increse in user chrges for helth services re often dvocted s (effective) mens for cost control. In n effort to sfegurd the finncil sustinbility of publicly supported helthcre, countries hve employed vriety of inititives in redefining the benefit pckge. In Englnd, The Ntionl Institute for Helth nd Cre Excellence (NICE) hs developed list of do not do recommendtions with the im of excluding specific services. 7 In Austrli, the Comprehensive Mngement Frmework ws developed to ssess helth services for effectiveness, sfety, nd monetry vlue. 8 In the Netherlnds, there is n ongoing debte bout the further estblishment of rigorous evlutions of essentil helth benefits. 9 In the United Sttes, essentil helth benefits re offered under the Affordble Cre Act (ACA), with ltitude t the stte level to define essentil benefits by choosing benchmrk pln modeled on existing stte plns. 10,11 User chrges re n often-cited policy mesure for costcontinment. The RAND Helth Insurnce Experiment in the Unites Sttes showed tht user chrges reduced the use of medicl cre, lthough this reduction ws relted to both inpproprite (unnecessry) nd pproprite (necessry) use of cre. 12 User chrges hve the potentil to reduce overuse or unnecessry cre. 13 As such, user chrges re n ttempt to better mtch demnd nd supply. 14 As response to the globl finncil crisis, t lest sixteen countries reported introducing or incresing user chrges for vriety of services. 2 However, the impct of vrying user chrges on pproprite use of cre is s yet uncler. In this study, we hypothesized tht the scope of helth benefits is relted to the level of user chrges for covered benefits. The im of our study ws to ssess the interreltionship between the scope of coverge nd the finncil rrngements of sttutory finnced helthcre in Europen countries. Policy-mkers cn use such informtion to further ddress issues relevnt to enhncing finncil sustinbility, nd for modifying essentil helth benefits, for exmple through mpping possible trde-off effects between publicly funded benefits nd privte contributions. We specified 2 reserch questions to ddress our objectives: 1. Wht re the scope of helth benefits nd the finncing of sttutory finnced helthcre within Europen countries? 2. Wht is the interreltionship between the scope of helth benefits nd finncil rrngements of sttutory finnced helthcre? Methods Study Design nd Setting We conducted desktop reserch study to compre smple of Europen countries with vried helthcre systems nd chrcteristics. Our smple included 8 countries: Belgium, Englnd, Frnce, Germny, the Netherlnds, Scotlnd, Sweden, nd Switzerlnd. Three of these countries (Englnd, Scotlnd, nd Sweden) operte Ntionl Helth Service (NHS), while 5 countries (Belgium, Frnce, Germny, the Netherlnds, nd Switzerlnd) operte system of socil helth insurnce (SHI). This smple shows vritions in pproches to helthcre coverge, such s ntionl vs. regionl pproches, public vs. privte finncing, nd (mnged) competition vs. no competition. Tble 1 summrizes the min chrcteristics of the helthcre systems in these 8 countries. Outcomes We developed outcomes bsed on the dimensions of publicly finnced helthcre s published by the Europen Observtory on Helth Cre Systems. These dimensions were initilly developed in the Helth BASKET study, 4,5 nd were further specified for the series Helth Systems in Trnsition of the Observtory. 15 The 3 dimensions re: (1) popultion coverge, ie, the proportion of the popultion tht is covered for helthcre; (2) service coverge, ie, the scope of helthcre benefits tht re covered; nd (3) cost coverge, ie, the proportion of costs tht is covered for included helthcre benefits (see Figure 1). These 3 dimensions were further opertionlized, resulting in indictors relted to popultion coverge: SHI or NHS, ssignment procedure, percentge of popultion covered; service coverge: open or closed description of benefits, min benefits in public scheme; nd cost coverge: totl spending, public vs. privte funding, cost shring. The focus of our study ws to compre essentil helth benefits for curtive cre, thus excluding long-term cre nd public helth services. However, the distinction between these services is not lwys cler-cut, nd we hve clrified this in the results when relevnt. Literture Review We conducted trgeted literture serch to identify the min chrcteristics of the helthcre systems in our smple 14 Interntionl Journl of Helth Policy nd Mngement, 2016, 5(1), 13 22

3 Tble 1. Chrcteristics of Helthcre Systems in the Selected 8 Europen Countries BE ENG FR GE NL SC SWE SWI SHI/NHS SHI NHS SHI SHI SHI NHS NHS SHI Ntionl/regionl REG REG REG NA NA REG REG REG Benefits in kind/indemnity B/I B B B/I B/I B B B/I Verticl integrtion NO YES NO NO NO YES NO NO Selective purchsing * * * ** *** NO * ** Competition * * * ** *** * * *** Benefits: control government *** *** ** ** ** *** *** * Privte finncing ** * *** ** ** * * *** Abbrevitions: SHI, socil helth insurnce; NHS, Ntionl Helth Service; NA, Ntionl; REG, Regionl; B, Benefits in kind the insurer mkes pyments directly to the helthcre provider; I, Indemnity the insured pys out-of-pocket nd is then reimbursed by the insurer; BE, Belgium; ENG, Englnd; FR, Frnce; GE, Germny; NL, the Netherlnds; SC, Scotlnd; SWE, Sweden; SWI, Switzerlnd. *** = high; ** = verge; * = low. Generl typology bsed on key chrcteristics of helthcre systems. of the helthcre system for the specified outcomes s of the yer We nlyzed similrities nd differences in the 3 dimensions of sttutory finnced helthcre systems to ssess interreltionships between the comprehensiveness of helth benefits nd finncil rrngements. In ddition, we explored 2 min vribles tht my interct with the 3 dimensions of helthcre systems: vritions in volume (use of helthcre services), nd price (costs of helthcre services). Figure 1. The Three Dimensions of Publicly Finnced Helthcre. 15 of countries. We used severl dt sources known for their review of helthcre systems: Helth Systems in Trnsition of the Europen Observtory on Helth Cre Systems, Interntionl Profiles of Helth Cre Systems of The Commonwelth Fund, 24 the Mutul Informtion System on Socil Protection (MISSOC) of the Europen Union (EU), 25 reports of the Civits Helth Unit, nd reports of the Orgniztion of Economic Coopertion nd Development (OECD). 29,30 For quntittive comprisons, we used OECD Helth Dt, 31 3 Interntionl Helth Policy surveys of the Commonwelth Fund, nd SHARE surveys. 35 In ddition, we conducted trgeted literture serch in PubMed nd Google Scholr to find both peer-reviewed publictions nd grey literture. We employed widengle pproch using combintions of the following serch terms: helthcre systems, helth benefits, helthcre ccess, governnce, workforce plnning, helthcre finncing, public finncing, privte finncing, helthcre costs, helthcre premiums, deductibles, co-pyments in combintion with the nmes of the 8 countries in our smple. We lso used policy documents, websites nd informtion from key informnts in our network. The literture for our dt nlysis ws serched until December Dt Anlysis nd Synthesis In compring the smple of 8 countries, we used both qulittive nd quntittive dt to inform the description Results Popultion Coverge Five countries in our smple (Belgium, Frnce, Germny, the Netherlnds, nd Switzerlnd) operte system of mndtory SHI for their residents. In ech of these countries, popultion coverge is more thn 99%. In the Netherlnds nd Switzerlnd, residents re required to contrct with helth insurer of their own choice, bsed on mnged competition of insurers vi ntionl nd regionl helth exchnges, respectively. 36 Residents in Frnce re ssigned to one of the SHI compnies, eg, through their employer. In Belgium nd Germny, helth insurnce is obligtory for ll citizens nd permnent residents. Contrry to the Netherlnds nd Switzerlnd, Germn nd Belgin beneficiries in principle get household insurnce. However, they re lso free to choose their insurers or sickness funds, nd my switch periodiclly. 37 Residents of Englnd, Scotlnd nd Sweden re utomticlly covered through their NHS systems. Service Coverge Service coverge is specified in helth benefits bsket tht describes the publicly finnced cre ccessible to ll residents vi SHI or NHS. Service coverge cn be specified through 2 pproches: () n open specifiction with generl (functionl) description of benefits outlining eligibility for these benefits, nd (b) closed specifiction with detiled (positive) listings of ll benefits tht re covered through public finncing. 6,15 Open systems my lso use negtive listings of services tht re not covered. Belgium nd Frnce hve closed specifiction system with positive listings of covered benefits. Germny lso uses lists of benefits, but these re less detiled nd not vilble for the full spectrum of helthcre. Englnd, Scotlnd, the Netherlnds, Sweden, nd Switzerlnd use negtive listings of Interntionl Journl of Helth Policy nd Mngement, 2016, 5(1),

4 services tht re not covered. Coverge of prescriptions drugs is seprtely described in the 8 countries, with positive listings in 5 countries (Belgium, Frnce, the Netherlnds, Sweden, Switzerlnd), nd negtive listings in 3 countries (Germny, Englnd, Scotlnd). Tble 2 presents the min benefits for dults in the 8 countries of our smple. All countries cover regulr medicl services, nd exclude cosmetic surgery. We found only smll differences between the countries. Exmples of such differences re relted to specific services such s dentl cre, physicl therpy, nd prescription drugs. Routine dentl cre for dults is not covered in the Netherlnds nd Switzerlnd, while these services re covered in the other countries. In the Netherlnds, primry cre nd physicl therpy for dults is prtilly covered (fter 20 tretment sessions) for certin chronic conditions. In Switzerlnd, nine tretment sessions re covered within 3 months upon referrl. In Englnd nd Scotlnd, physicl therpy is fully covered, while Belgium, Germny, Frnce, nd Sweden chrge co-pyments for physicl therpy tretments. The limited coverge for helth services my be relted to potentil coverge outside the curtive cre system. For exmple, in the Netherlnds physicl therpy services for residents in nursing homes re covered through the long-term cre budget. Cost Coverge Finncil dt for helthcre in the 8 countries is listed in Tble 3. The Netherlnds hs the highest reltive costs of totl helthcre with 11.9% of the gross domestic product (GDP), while the costs for the cure sector (ie, without long-term cre nd home cre) in the Netherlnds re, with 7.4% of GDP, the lowest in our smple. Tble 3 lso shows the reltive costs of public vs. privte funding. Privte funding includes privte insurnce, direct pyments for noncovered services, nd cost-shring for covered helth services. Two min groups cn be identified in compring the shres of privte funding. Englnd, Germny, Frnce, the Netherlnds, nd Scotlnd show reltive low percentge, rnging from 9.6% to 11.9%. The shre of privte funding in Belgium, Sweden nd Switzerlnd is higher nd vries from 19.5% to 25.5%. Tble 2. Helth Services for Adults Covered by Public Finncing Services BE ENG FR GE NL SC SWE SWI Primry cre physicin Y Y Y Y Y Y Y Y Medicl specilist Y Y Y Y Y Y Y Y Mternl cre Y Y Y Y Y Y Y Y Hospitl cre Y Y Y Y Y Y Y Y Rehbilittion Y Y Y Y Y Y Y Y Prevention Y Y Y Y Y Y Y Y Dentl cre Y Y Y Y N Y Y N Mentl helthcre Y Y Y Y Y Y Y Y Physicl therpy Y Y Y Y S b Y Y Y Occuptionl therpy Y Y Y Y Y Y Y Y Speech therpy Y Y Y Y Y Y Y Y Medicl devices Y Y Y Y Y Y Y Y Cosmetic surgery N N N N N N N N Abbrevitions: NL, the Netherlnds; BE, Belgium; GE, Germny; ENG, Englnd; FR, Frnce; SC, Scotlnd; SWE, Sweden, SWI, Switzerlnd; Y, Yes; N, No. Comprisons in this tble refer to dults ged without chronic disese or low income. b S=Specifiction: Only covered for certin chronic conditions fter 20 sessions. Sources: Helth Systems in Trnsition, Europen Observtory on Helth Cre Systems; Interntionl Profiles of Helth Cre Systems 2012, The Commonwelth Fund; MISSOC; WHO Medicines Documenttion ( Tble 3. Finncil Dt (2011) Costs BE ENG FR GE NL SC SWE SWI Totl helthcre costs s % GDP Curtive sector s % GDP Curtive sector ($ PPP) Prescription drugs (% helthcre) Per cpit prescription drugs ( ) Finncing of curtive sector b % Collective (government, socil security) c % Privte (OUP d, privte insurnce, other) c % Privte OUP d c Abbrevitions: NL, the Netherlnds; BE, Belgium; GE, Germny; ENG, Englnd; FR, Frnce; SC, Scotlnd; SWE, Sweden; SWI, Switzerlnd; GDP, gross domestic product; PPP, purchsing power prity; OUP, out-of-pocket. We defined curtive cre s combintion of the Orgniztion of Economic Coopertion nd Development (OECD) helth dtbse ctegories: Services of curtive nd rehbilittive cre, medicl goods nd ncillry services to helthcre. b The OECD dtbse did not llow brekdown in finncing for curtive cre for Englnd nd Scotlnd (both United Kingdom), thus the dt represents finncing for broder rnge of services (including long-term cre nd public helth). c The dt for the Netherlnds hs been corrected becuse the deductibles in the OECD dt did not impute s privte finncing. d Following the OECD definition, out-of-pocket expenditure includes direct pyments for cre without insurnce benefit, co-pyments, co-insurnce, nd deductibles. Source: OECD helth dt for Interntionl Journl of Helth Policy nd Mngement, 2016, 5(1), 13 22

5 Cost-shring (user chrges) for covered services vi deductibles or co-pyments serve s thresholds in helthcre systems by mking individuls responsible for shre of the costs. Cost-shring vries considerbly between the 8 countries in our smple, s illustrted in Tble 4. In 2014, the Netherlnds nd Switzerlnd were using mndtory deductible of 360 nd 250, respectively, but beneficiries my opt for higher voluntry deductibles in exchnge for lower premiums. Sweden uses deductible of 122 for helthcre visits, 122 for prescription drugs nd 333 for dentl cre. After these mounts, the government subsidy grdully increses up to 100% for prescription drugs nd dentl cre. Children re wived from deductibles in these 3 countries. All countries in our smple use co-pyments within the publicly finnced benefits pckge, either in percentge of costs for services rendered (Belgium, Frnce, Scotlnd, nd Switzerlnd) nd/or fixed co-pyments (Englnd, Germny, the Netherlnds, Sweden, nd Switzerlnd). All countries in our smple lso provide compenstion to vulnerble groups such s elderly people or those with chronic disese. Additionl (Privte) Insurnce All countries provide dditionl insurnce with lrge differences in uptke by the popultion, rnging from <5% to 90% (Tble 5). These differences re prtly explined by the system chrcteristics. Englnd, Scotlnd, nd Sweden hve low uptke of dditionl insurnce due to utomtic coverge in their NHS system. All countries provide supplementry insurnce, while 3 countries (Belgium, Germny, nd Frnce) lso provide complementry insurnce. Complementry insurnce refers to insurnce tht complements coverge of insured services (co-insurnce) by covering ll or prt of the residul costs not otherwise reimbursed. Supplementry insurnce provides coverge for dditionl helth services not t ll covered s essentil helth benefits. We identified nnul premiums for regulr dditionl benefits rnging from However, such premiums re not lwys publicly reported, nd we could therefore not estblish relible estimtes. Countries with compulsory deductibles (the Netherlnds nd Switzerlnd) prohibit coverge of these deductibles vi co-insurnce. Frnce rises nonrefundble co- Tble 4. Illustrtions of Cost-Shring Within Publicly Finnced Helthcre Compulsory Deductible The Netherlnds 360 Belgium Germny Englnd No No No Cost-Shring (Co-pyments nd Co-insurnce Above Mximum Reimbursement) ~ 95 medicl trnsporttion per yer 69 (<16 yer) nd ( 16 yer) orthopedic shoes per yer 4 per hour mternity cre 20 per session with psychologist 32 per dy for nonmedicl mternity cre 25% of the costs of dentl prosthesis 125 for prosthesis or dentl implnt 25% of the price of hering id 10%-40% co-pyments for most services (depending on preferentil reimbursement nd service type) Co-pyments for medicines up to 80%, depending on reimbursement ctegory nd preferentil reimbursement (0%-25%-50%-60%-80%); however the co-pyments re mximized in some reimbursement ctegories 40 for first hospitl dy; subsequently 13 per dy; plus 0.62/dy for medicines, 7.44 for biologicl testing/sty, 6.20 for rdiology nd 16.40/sty Mximum: depending on level of income; per prescription drug in some reimbursement ctegories 5-10 for medicines 10 per hospitl dy or dy t rehbilittion center (until mx 28 dys) 10% cost-shring physiotherpy + 10 per visit Mximum: 2% income 10 for medicines 240 for dentl trjectory Mximum: people who re not entitled to free subscriptions but expect to need more thn 3 prescriptions in 3 months my opt for prescription prepyment certificte t the cost of 104 per yer. Frnce 50 Co-pyments 85% for drugs ccording to ctegory (0%-35%-65%-85%), depending on medicl benefit nd 20%-50% for different services: generl prctitioner, hospitl, dentist, lbortory seriousness of the pthology Scotlnd No 80% dentl costs with mximum of 450 Sweden b Switzerlnd per generl prctitioner visit per visit to medicl specilist 9 per hospitliztion dy Cost-shring for prmedic cre nd medicl devices differ between regions Mximum: 122 for generl prctitioner/medicl specilist, 220 for devices, 600 for drugs c 10% for ll services 8 for hospitl dmission Mximum: 570 Abbrevitions: SHI, socil helth insurnce; NHS, Ntionl Helth Service. Beneficiries py deductible for rnge of services (medicines, doctors, mbulnce, hospitl), which re deducted from reimbursement nd re not insurble. b Medicines deductible 122; deductible for dentl cre 333. c After the deductible mounts, the government subsidy grdully increses up to 100%. The mximum co-pyment for prescribed drugs is 244 per yer. Sources: Helth Systems in Trnsition, Europen Observtory on Helth Cre Systems; Interntionl Profiles of Helth Cre Systems 2012, The Commonwelth Fund; MISSOC; WHO Medicines Documenttion ( Interntionl Journl of Helth Policy nd Mngement, 2016, 5(1),

6 Tble 5. Additionl (Privte) Insurnce Country % Type Description The Netherlnds 85.0% S b Coverge of dentist, physicl therpy, eyeglsses, lterntive medicine Belgium 70.0% C c /S Co-insurnce; coverge of orthodontist, lterntive medicine, privte room Germny 22.0% C/S Co-insurnce (dentl cre); minor benefits, ccess to better menities, privte room Englnd 13.0% S Inptient or dy cse surgery, hospitl ccommodtion nd nursing cre, inptient tests Frnce 90.0% C/S Co-insurnce; privte room, dentl cre, opticl cre Scotlnd 8.5% S Privte cute hospitl cre Sweden <5.0% S Fster ccess to primry cre services nd shorter wits for surgery Switzerlnd 90.0% S Coverge of dentist, privte room, ccess to senior physicins, choice of hospitl %: percentge of citizens with dditionl insurnce. b S: Supplementry insurnce; provides coverge for dditionl helth services not t ll covered s essentil helth benefits. c C: Complementry insurnce; refers to insurnce tht complements coverge of insured services by covering ll or prt of the residul costs not otherwise reimbursed. pyments for consulttions nd services up to 50 tht cnnot be covered with co-insurnce. Estblishing Price nd Regulting Volume Estblishing the price of helthcre services vries between countries, nd cn be set t the ntionl level (Belgium, Frnce, Scotlnd) or the regionl level (Germny, Sweden, Switzerlnd), or combintion of the 2 (the Netherlnds, Englnd). In most countries, the price of helthcre services is estblished by (qusi)governmentl gencies, except for the Netherlnds nd Switzerlnd. In the Netherlnds, the price of 70% of hospitl services is estblished vi negotitions between individul insurers nd individul provider orgniztions. In Switzerlnd, prices re mostly negotited between insurer ssocitions nd providers t the regionl level. Between countries, we identified differences in responsibilities t the ntionl vs. the regionl level for regulting volume. In Frnce, while price is negotited t the ntionl level nd pproved by government, volumes re negotited by insurers nd providers; this is similr to the Netherlnds. In Scotlnd, price is set t the ntionl level, while volume constrints cn be set by locl NHS bords. Finlly, in Sweden, volumes s well s prices re negotited t the level of county councils. Vritions in Volume nd Price The ctul use of helthcre services vries strongly between the 8 smple countries. Tble 6 illustrtes these differences for severl helthcre services. These differences cn be ttributed to specific services tht show lrge vritions in prctice. The OECD hs studied such vritions in prctice for severl procedures in vrious countries of our smple, showing for instnce considerble vritions in volume for low-vriety, sensitive condition such s totl hip prosthesis. 38 Prices of helthcre services lso vry between the countries in our smple. 39 For exmple, vignette study by the World Helth Orgniztion (WHO) shows considerbly higher stndrdized costs for stroke services in the Netherlnds ( 7100) in comprison with Englnd, Frnce nd Germny s stndrdized costs of ~ No mjor differences were found for the costs of totl hip surgery with ~ 6800 for this subset of countries. 40,41 The reltionship between helth benefits nd the finncing of helthcre In previous prgrphs, we hve described the 3 dimensions of publicly finnced helthcre nd vritions in price nd volume between the countries in our study. Our comprisons showed tht virtully ll residents in our smple of 8 counties re covered for bsic helth benefits (popultion coverge), which corresponds with the overll im of Europen helthcre systems to provide ccessible helthcre for ll residents. 42 Our results lso show tht the scope of covered helthcre benefits is comprble cross the countries in our smple. We found some exmples of differences for coverge of dentl cre, physiotherpy, nd prescription drugs. In ssessing the finncing of curtive helthcre, we found rnge of 7.4% to 9.1% of GDP within the smple of our selected countries. The shre of public finncing of curtive cre rnges from 64.9% to 82.8%. At the mcro level, we did not identify pttern between the scope of services covered nd the height of public finncing. In other words, public finncing of helthcre vried considerbly between countries, while differences in covered helthcre benefits re reltively smll. We did find substntil differences between the countries for costshring, nd identified 2 min groups within our smple: low cost-shring in Englnd, Frnce, Germny, the Netherlnds nd Scotlnd; nd high cost-shring in Belgium, Sweden nd Switzerlnd. In regrds to cost-shring, we lso found no cler reltionship with the scope of services. Potentil Reltionships t the Level of Specific Services We lso ssessed the potentil reltionships between service coverge nd finncing for specific services. Our comprisons indicted tht the countries differed in detils of service coverge in regrds to dentl cre, physicl therpy, nd prescription drugs. We therefore specificlly looked t the reltionships between coverge nd cost-shring of these services. Dentl Cre for Adults Dentl cre for dults is not covered in the benefits pckge of Switzerlnd nd the Netherlnds. Of the 6 other countries in our comprisons, only Germny provides full coverge. The 5 remining countries hve substntil limittions in the coverge of dentl cre for dults. In Belgium, co-pyments re set t 25%. Adult residents in Englnd hve to py 240 for dentl cre service. In Frnce, co-insurnce vries from 30% for routine dentl cre up to 90% for complex services such s orthodontic cre. Scotlnd hs implemented co- 18 Interntionl Journl of Helth Policy nd Mngement, 2016, 5(1), 13 22

7 Tble 6. Illustrtions of Volume of Cre in the 8 Europen Smple Countries NL BE GE FR UK b SWE SWI Inptient cre dischrges per citizens per yer c MRI-scns per 1000 citizens per yer CT scns per 1000 citizens per yer Surgicl procedures per citizens per yer Ctrct surgery Hip replcement Coronry rtery bypss Doctor consulttions per citizen per yer Dentist consulttions per citizen per yer Abbrevitions: NL, the Netherlnds, BE, Belgium; GE, Germny; ENG, Englnd; FR, Frnce; SC, Scotlnd; SWE, Sweden; SWI, Switzerlnd. Additionl dt on the mbultory cre sector is not counted in these sttistics. Additionlly, only one code per procedure ctegory per ptient ws counted. b Seprte dt for Englnd nd Scotlnd is lcking. c The number of ptients tht styed in hospitl t lest one night. Source: OECD Helth Dt Only the most recent dt ws used. pyment of 80% of the costs, with mximum of 450. Sweden hs implemented deductible of 333 for dentl cre, nd residents receive subsidy of for preventive dentl services. With the exception of Germny, ll countries in our smple hve limited the ctul coverge of dentl cre for dults. In the Netherlnds nd Switzerlnd, dentl cre for dults is not covered t ll. In Belgium, Englnd, Frnce, Scotlnd, nd Sweden, residents cover substntil mount of the costs themselves. In other words, we found indictions tht the ctul coverge for dentl cre is ssocited with costshring rrngements. Physicl Therpy In the Netherlnds, physicl therpy is only reimbursed for limited rnge of services: pelvic therpy for incontinence (women s helth), chronic conditions fter the 20th tretment session (ptients py the first 20 sessions themselves), nd for inptient services. In Englnd nd Scotlnd, physicl therpy services re covered in the public helth service, lthough, nd due to limited vilbility, substntil mount of such services re offered in the privte sector where ptients hve to py themselves. In Belgium, vrious co-pyments exist depending on the specific services, nd my dd up to 30% of the costs. Beneficiries in Germny re chrged copyment of 10% plus 10 per visit. In Frnce, the co-pyment is 40%, nd in certin circumstnces insurnce compnies only provide reimbursement fter they hve given written permission. In Switzerlnd, insurnce compnies reimburse the first 9 tretment sessions within 3 months fter referrl to physicl therpy services. The ctul reimbursement depends on locl prices. With the exception of Englnd nd Scotlnd, ll countries in our smple hve implemented limittions to service coverge or cost coverge. This suggests tht the ctul coverge of physicl therpy services is ssocited with costshring rrngements. Prescription Drugs Prescription drugs re covered in the benefits pckge of ll countries in our smple. In the Netherlnds, Sweden, nd Switzerlnd, prescription drugs re subject to deductibles. Beneficiries in Switzerlnd re chrged nother 10% co-pyment on top of the deductible, nd Sweden hs implemented co-pyments rnging from 10%-50% of the costs, with mximum of 600. In Belgium nd Frnce, co-pyments cn be s high s 80% nd 85%, respectively. In Germny co-pyment is 5-10 per prescribed drug, nd in Englnd co-pyments re 10. Only residents in Scotlnd re not chrged co-pyments. This comprison shows tht co-pyments hve been implemented in seven out of the 8 countries in our smple. We found no ssocitions between service coverge nd cost-shring. Discussion At the most generl level, we found no direct interreltionship between the rnges of services covered in the helth benefits pckge, nd the height of public spending on helthcre in our smple of 8 countries. By looking t specific services, we found limited ssocitions between ctul coverge of specific services nd cost-shring rrngements for these services. Access to certin specific helthcre services is either limited by the lck of ctul coverge of such services, or by estblishing thresholds to ccess vi cost-shring. Thresholds of cost-shring cn hve similr impct on the ccessibility of helthcre services. Especilly in countries with SHI, the uptke of dditionl insurnce is high. Only few countries provide co-insurnce for reimbursement of cost-shring. The dt in our smple of countries shows little vrition in the scope of benefits covered t the mcro level. These findings re comprble with dt from the United Sttes which lso showed little vrition t the mcro level between smll group employer plns nd stte nd federl plns, despite the reltively unregulted US mrket. 43 An interntionl survey to mp helth policy responses to the finncil crisis showed tht overll the sttutory benefits pckge ws not rdiclly chnged, but tht some reductions were crried out, usully t the mrgin. 1 At the mcro level, it is difficult for policymkers to completely remove services from the essentil helth benefits pckge, becuse mny services re beneficil to certin subgroups of ptients. 44 The introduction or expnsion of user chrges is more common policy mesure t the mcro level when trying to contin the cost of helthcre; mny countries incresed or introduced user chrges for helth services in response to the crisis. 1 The RAND experiment lredy showed price elsticity between -0.17% nd -0.22%, mening tht n increse of the price due to user chrges leds to reduction of the volume Interntionl Journl of Helth Policy nd Mngement, 2016, 5(1),

8 of cre; lower income groups were more price sensitive. 12 Interntionl reserch in group of Europen countries showed tht higher user chrges led to incresed inequlity between low nd high incomes. 45 The Europen Observtory concluded tht cost shring is unlikely to contribute to sustinbility. 46 If user chrges re imposed, creful ttention to the design of cost-shring policy should be pid, which should be systemtic nd evidence-bsed. Solutions for creting sustinble future finncing of essentil helth benefits my be found t the micro level by stimulting evidence-bsed prctice. In Englnd, NICE hs developed list of do not do recommendtions derived from clinicl prctice guidelines, with the im of excluding low-vlue services for certin subgroups. 7 In the United Sttes nd Cnd, the Choosing Wisely cmpign for reducing unnecessry tests, tretment nd procedures ws strted in 2012, nd hs grown into n interntionl cmpign. 47 Choosing Wisely ims to promote converstions between clinicins nd ptients through evidence-bsed recommendtions. These recommendtions cn be derived from existing clinicl prctice guidelines. 48 Unwrrnted geogrphicl prctice vrition in helthcre ws set on the gend by Wennberg s n importnt cost driver in helthcre. 49 Unwrrnted prctice vrition is vrition in utiliztion tht cnnot be explined by vrition in ptient illness or ptient preferences. 50 A recent systemtic review identified lrge differences in the volume of helthcre between countries, regions, hospitls s well s individul helthcre providers. 51 This my be cused by potentil shortflls in 3 res: underuse of effective cre, misuse in preference-sensitive cre, nd overuse of supplysensitive cre. Severl remedies hve been described to reduce unwrrnted vrition, such s the implementtion of clinicl prctice guidelines to stimulte evidence-bsed prctice, incresing the role of ptients in shred decision-mking to optimize preference-sensitive cre, nd regulting resource cpcity in the helthcre system to reduce supply-sensitive cre. However, the implementtion of such remedies requires more focus in helth policy-mking; dditionlly, the bsence of economic incentives tht rewrd providers for reducing unnecessry cre is considered n importnt brrier. 52 Most countries in our Europen smple control the price of cre t the governmentl level, except for the Netherlnds nd Switzerlnd, where most prices re negotited between privte insurers nd provider orgniztions. These countries hve creted mnged competition in their helth insurnce mrkets, which is somewht nlogous to the United Sttes helth insurnce exchnges tht re operted t the stte nd federl level. However, it is still uncler whether these mechnisms of competition will led to reductions in the price nd/or the volume of helthcre services. 36 Implictions for Policy Although reducing the scope of the benefit pckge nd incresing user chrges my contribute to the finncil sustinbility of helthcre, vritions in volume nd price of cre pper to hve much lrger impct on finncil sustinbility. Our conclusions re confirmed by recent ssessment of the impct nd policy implictions of the economic crisis in Europe, highlighting tht policy mesures imed t reducing the scope of the benefit pckge or incresing user chrges, were only mrginl. 2 Moreover, countries did not report mking chnges to the benefits pckge bsed on evidence of cost-effectiveness. 2 In ddition to the continuous evlution of essentil helth benefits nd cost-shring rrngements, we suggest tht other mesures re needed to enhnce the finncil sustinbility of helthcre regrding the volume nd price of helthcre. Further insights into prctice vritions nd estblishing mechnisms to reduce unwrrnted vrition my contribute to enhncing the finncil sustinbility of helthcre. Supply constrints my hve much lrger impct on reducing the volume of cre, nd thus on the long-term finncil sustinbility of public helthcre provision thn limittions in service coverge. For US policy-mkers, our comprisons of Europen countries re useful for informing decision-mking in regrd to modifying the essentil helth benefits pckge frmework. Monitoring the implementtion is deemed essentil to determine whether sttes differing strtegies re producing the coverge improvements promised by reform. Officils hve to ssess whether enrollees re hving difficult time obtining needed services becuse of gps in coverge or the cost of cre, nd they hve to modify the pckge ccordingly. 53 In the US context, with differing benefit pckges nd cost-shring rrngements, creful design of dditionl privte insurnce products wrrnts ttention in terms of gurnteeing the sustinbility of helthcre. Limittions Our study is subject to severl limittions. First, the 3 dimensions of helthcre (popultion coverge, service coverge, cost coverge) provide simplifiction of sttutory finnced helthcre. The orgniztionl nd finncil structure of helthcre is complex, nd embedded in wider societl structure with mny more interctions. Second, due to the complexity of helthcre systems, comprisons cross countries re subject to cutious interprettions. Although the dimensions of sttutory finnced helthcre tht we used in our study re being employed in mny interntionl comprisons, such model my not reflect the complexity of helthcre in our smple of countries. Third, our dt nlysis focused on the reltionship between the scope of essentil helth benefits nd sttutory finncing t the mcro level, without disggregting to differences t the micro level. Fourth, our smple of Europen countries ws bsed on purposive smpling to reflect the vriety existing in helthcre systems in Europe, nd their min chrcteristics. Therefore, our smple does not provide full picture of helthcre in Europe. Fifth, our study ws explortive in nture, nd did not llow for identifying cusl reltionships. Conclusion The scope of services covered in publicly finnced helthcre is comprble nd comprehensive cross our smple of 8 Europen countries, with only mrginl differences. Costshring rrngements show lrger vritions. Considertions for the inclusion of services in the essentil helth benefits nd for cost-shring seem to evolve independently. However, cost-shring implies thresholds for ccessing 20 Interntionl Journl of Helth Policy nd Mngement, 2016, 5(1), 13 22

9 specific helth services. Both the scope of services nd cost-shring rrngements should be crefully monitored. Unwrrnted prctice vrition nd the price of helthcre services seem much lrger drivers for the sustinbility of helthcre. Our comprisons my not reflect the complexity of the helthcre system, nd there is no silver bullet for ddressing the sustinbility of helthcre. Policy-mkers should focus on vriety of mesures within n integrted pproch, including considertions for services covered, cost-shring rrngements, dditionl privte insurnce, stimulting evidence-bsed prctice, monitoring nd reduction of unwrrnted vrition, nd control mechnisms for the price of helthcre services. For policy-mkers, our comprisons of Europen countries re useful for monitoring the implementtion of essentil helth benefits, s well s to inform decision-mking in regrds to modifying the essentil helth benefits pckge frmework. Acknowledgments This study ws sponsored by the Dutch Ministry of Helth, Welfre nd Sports. 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