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infosantésuisse : Dossier Die europäischen Gesundheitssysteme im Vergleich

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Die europäischen Gesundheitssysteme im Vergleich

Inhalt

1 « Comparaisons internationales des systèmes de santé » – PowerPoint-Dokument in Französisch (2007) 100 « Coûts des systèmes de santé » – Artikel in Französisch (2006) 106 Financing Health Care in the European Union – Studie in Englisch (2009) 330 « La Participation des patients aux dépenses de ante dans 5 pays européens » – Arbeitsdokument in Französisch (2007) 374 Health for all ? – Buch in Englisch (2008) 732 Données de l’OCDE 2009 – Daten aus verschiedenen Ländern in Deutsch, Französisch und Englisch (2009) 777 « Descriptions of health care systems : Germany and the Netherlands » – Studie in Englisch (2007) 784 « La réforme du système de santé aux Pays-Bas » – Artikel in Französisch (2007) 787 Finland – Health System Review – Buch in Englisch (2008) 982 The Finnish Health Care System – Buch in Englisch (2009) 1099 Denmark Health system Review – Buch in Englisch (2007) 1286 Norway and Health, An Introduction – Buch in Englisch (2009) 1326 Health Care in Sweden – Artikel in Englisch (2009) 1330 infosantésuisse-Dossier Schweiz und Niederlande (2009 - 2010) 1336 infosantésuisse-Artikel Die Qualität in Europa (2006) 1337 infosantésuisse-Schwerpunktthema Europa (2007) 1365 Links 1367 infosantésuisse-Schwerpunktthema Europa (2010)

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Health Systems in Transition Vol. 9 No. 6 2007

Denmark Health system review

Martin Strandberg-Larsen Mikkel Bernt Nielsen Signild Vallgårda • Allan Krasnik Karsten Vrangbæk

Editor: Elias Mossialos

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Editorial Board Editor in chief Elias Mossialos, London School of Economics and Political Science, United Kingdom and European Observatory on Health Systems and Policies Editors Reinhard Busse, Berlin Technical University, Germany Josep Figueras, European Observatory on Health Systems and Policies Martin McKee, London School of Hygiene and Tropical Medicine, United Kingdom and European Observatory on Health Systems and Policies Richard Saltman, Emory University, United States Editorial team Sara Allin, European Observatory on Health Systems and Policies Cristina Hernandez Quevedo, European Observatory on Health Systems and Policies Anna Maresso, European Observatory on Health Systems and Policies David McDaid, European Observatory on Health Systems and Policies Sherry Merkur, European Observatory on Health Systems and Policies Philipa Mladovsky, European Observatory on Health Systems and Policies Bernd Rechel, European Observatory on Health Systems and Policies Erica Richardson, European Observatory on Health Systems and Policies Sarah Thomson, European Observatory on Health Systems and Policies International advisory board Tit Albreht, Institute of Public Health, Slovenia Carlos Alvarez-Dardet Díaz, University of Alicante, Spain Rifat Atun, Imperial College London, United Kingdom Johan Calltorp, Swedish Association of Local Authorities and Regions, Sweden Armin Fidler, The World Bank Colleen Flood, University of Toronto, Canada Péter Gaál, Semmelweis University, Hungary Unto Häkkinen, Centre for Health Economics at Stakes, Finland William Hsiao, Harvard University, United States Alan Krasnik, University of Copenhagen, Denmark Joseph Kutzin, World Health Organization Regional Office for Europe Soonman Kwon, Seoul National University, Korea John Lavis, McMaster University, Canada Vivien Lin, La Trobe University, Australia Greg Marchildon, University of Regina, Canada Alan Maynard, University of York, United Kingdom Nata Menabde, World Health Organization Regional Office for Europe Ellen Nolte, London School of Hygiene and Tropical Medicine, United Kingdom Charles Normand, University of Dublin, Ireland Robin Osborn, The Commonwealth Fund, United States Dominique Polton, National Health Insurance Fund for Salaried Staff (CNAMTS), France Sophia Schlette, Health Policy Monitor, Germany Igor Sheiman, Higher School of Economics, Russia Peter C. Smith, University of York, United Kingdom Wynand P.M.M. van de Ven, Erasmus University, The Netherlands Witold Zatonski, Marie Sklodowska-Curie Memorial Cancer Centre, Poland

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Health Systems in Transition Written by Martin Strandberg-Larsen, Department of Public Health, University of Copenhagen Mikkel Bernt Nielsen, Department of Public Health, University of Copenhagen Signild Vallgårda, Department of Public Health, University of Copenhagen Allan Krasnik, Department of Public Health, University of Copenhagen Karsten Vrangbæk, Department of Political Science, University of Copenhagen Edited by Elias Mossialos, European Observatory on Health Systems and Policies

Denmark:

Health System Review

2007

The European Observatory on Health Systems and Policies is a partnership between the World Health Organization Regional Office for Europe, the Governments of Belgium, Finland, Greece, Norway, Slovenia, Spain and Sweden, the Veneto Region of Italy, the European Investment Bank, the Open Society Institute, the World Bank, the London School of Economics and Political Science, and the London School of Hygiene & Tropical Medicine.

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Keywords: DELIVERY OF HEALTH CARE EVALUATION STUDIES FINANCING, HEALTH HEALTH CARE REFORM HEALTH SYSTEM PLANS – organization and administration DENMARK © World Health Organization 2007, on behalf of the European Observatory on Health Systems and Policies All rights reserved. The European Observatory on Health Systems and Policies welcomes requests for permission to reproduce or translate its publications, in part or in full. Please address requests about this to:

Publications WHO Regional Office for Europe Scherfigsvej 8 DK-2100 Copenhagen Ø, Denmark

Alternatively, complete an online request form for documentation, health information, or for permission to quote or translate, on the WHO/Europe web site at http://www.euro.who.int/PubRequest

The views expressed by authors or editors do not necessarily represent the decisions or the stated policies of the European Observatory on Health Systems and Policies or any of its partners.

The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the European Observatory on Health Systems and Policies or any of its partners concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Where the designation “country or area” appears in the headings of tables, it covers countries, territories, cities, or areas. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement.

The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the European Observatory on Health Systems and Policies in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. The European Observatory on Health Systems and Policies does not warrant that the information contained in this publication is complete and correct and shall not be liable for any damages incurred as a result of its use.

Printed and bound in the United Kingdom by TJ International, Padstow, Cornwall.

Suggested citation: Strandberg-Larsen M, Nielsen MB, Vallgårda S, Krasnik A, Vrangbæk K and Mossialos E. Denmark: Health system review. Health Systems in Transition, 2007; 9(6): 1–164.

ISSN 1817-6127 Vol. 9 No. 6

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Contents

Preface.............................................................................................................v Acknowledgements...................................................................................... vii List of abbreviations......................................................................................ix List of tables and figures................................................................................xi Abstract....................................................................................................... xiii Executive summary.......................................................................................xv 1. Introduction...........................................................................................1 1.1 Overview of the health system.......................................................1 1.2 Geography and sociodemography..................................................1 1.3 Economic context...........................................................................4 1.4 Political context..............................................................................5 1.5 Health status....................................................................................6 2. Organizational structure......................................................................19 2.1 Historical background...................................................................19 2.2 Organizational overview...............................................................25 2.3 Decentralization and centralization..............................................26 2.4 Population coverage......................................................................29 2.5 Entitlements, benefits and patient rights.......................................30 3. Planning, regulation and management................................................39 3.1 Regulation.....................................................................................39 3.2 Planning and health information management.............................42 4. Financial resources.............................................................................51 4.1 Revenue mobilization...................................................................53 4.2 Allocation to purchasers...............................................................59 4.3 Purchasing and purchaser–provider relations...............................60 4.4 Payment mechanisms....................................................................62 4.5 Health care expenditure................................................................64 iii

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Physical and human resources............................................................69 5.1 Physical resources.........................................................................69 5.2 Human resources..........................................................................80 Provision of services...........................................................................93 6.1 Public health.................................................................................93 6.2 Patient pathways...........................................................................98 6.3 Primary/ambulatory care............................................................100 6.4 Secondary/inpatient care.............................................................104 6.5 Pharmaceutical care....................................................................105 6.6 Rehabilitation/intermediate care.................................................108 6.7 Long-term care............................................................................109 6.8 Services for informal carers........................................................ 111 6.9 Palliative care..............................................................................112 6.10 Mental health care.....................................................................115 6.11 Dental health care.....................................................................120 6.12 Alternative/complementary medicine.......................................122 6.13 Maternal and child health.........................................................124 6.14 Health care for specific populations.........................................125 Principal health care reforms............................................................127 7.1 Analysis of recent reforms..........................................................127 7.2 Recent developments..................................................................130 Assessment of the health system......................................................133 8.1 Objectives of the health system..................................................133 8.2 Distribution of the health system’s costs and benefits across the population................................................................133 8.3 Efficiency of resource allocation in health care..........................135 8.4 Technical efficiency in the production of health care.................136 8.5 Accountability of payers and providers......................................137 8.6 The contribution of the health system to health improvement...137 Conclusions.......................................................................................139 Appendices.......................................................................................143 10.1 References.................................................................................143 10.2 Principal legislation..................................................................158 10.3 Useful web sites........................................................................159 10.4 HiT methodology and production process................................160

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Preface

he Health Systems in Transition (HiT) profiles are country-based reports that provide a detailed description of a health system and of reform and policy initiatives in progress or under development in a specific country. Each profile is produced by country experts in collaboration with the Observatory’s research directors and staff. In order to facilitate comparisons between countries, the profiles are based on a template, which is revised periodically. The template provides detailed guidelines and specific questions, definitions and examples needed to compile a profile. HiT profiles seek to provide relevant information to support policy-makers and analysts in the development of health systems in Europe. They are building blocks that can be used: • to learn in detail about different approaches to the organization, financing and delivery of health services and the role of the main actors in health systems; • to describe the institutional framework, the process, content and implementation of health care reform programmes; • to highlight challenges and areas that require more in-depth analysis; • to provide a tool for the dissemination of information on health systems and the exchange of experiences of reform strategies between policy-makers and analysts in different countries. Compiling the profiles poses a number of methodological problems. In many countries, there is relatively little information available on the health system and the impact of reforms. Due to the lack of a uniform data source, quantitative data on health services are based on a number of different sources, including the v

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World Health Organization (WHO) Regional Office for Europe Health for All database, national statistical offices, Eurostat, the Organisation for Economic Co-operation and Development (OECD) Health Data, the International Monetary Fund (IMF), the World Bank, and any other relevant sources considered useful by the authors. Data collection methods and definitions sometimes vary, but typically are consistent within each separate series. A standardized profile has certain disadvantages because the financing and delivery of health care differ across countries. However, it also offers advantages, because it raises similar issues and questions. The HiT profiles can be used to inform policy-makers about experiences in other countries that may be relevant to their own national situation. They can also be used to inform comparative analysis of health systems. This series is an ongoing initiative and material is updated at regular intervals. Comments and suggestions for the further development and improvement of the HiT series are most welcome and can be sent to: info@obs.euro.who.int. HiT profiles and HiT summaries are available on the Observatoryâ&#x20AC;&#x2122;s web site at www.euro.who.int/observatory. A glossary of terms used in the profiles can be found at the following web page: www.euro.who.int/observatory/glossary/ toppage.

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Acknowledgements

he Health Systems in Transition profile on Denmark was written by Martin Strandberg-Larsen (PhD Fellow, Department of Public Health, University of Copenhagen), Mikkel Bernt Nielsen (Research Assistant, Department of Public Health, University of Copenhagen), Signild Vallgårda (Associate Professor, Department of Public Health, University of Copenhagen), Allan Krasnik (Professor, Department of Public Health, University of Copenhagen) and Karsten Vrangbæk (Associate Professor, Department of Political Science, University of Copenhagen). Hans Okkels Birk (Part-time Lecturer, Department of Public Health, University of Copenhagen) wrote the section on capital investments and provided critical input into Chapter 4 on financial resources. Ellen Westh Sørensen (Professor, Department of Pharmacology and Pharmacotherapy, University of Copenhagen) wrote the sections on pharmaceuticals and pharmaceutical care, which have been subsequently reviewed and commented on by Merete W Nielsen (Assistant Professor, Department of Pharmacology and Pharmacotherapy, University of Copenhagen) and Jørgen Clausen (Chief Economist, Department of Economics and Political Affairs, Danish Association of the Pharmaceutical Industry). The section on palliative care was commented on by Mogens Grønvold (Associate Professor, Department of Public Health, University of Copenhagen), and Christina Novinskey (London School of Economics and Political Science) helped with the editing and copy-editing of the first draft. The current series of HiT profiles has been prepared by the staff of the European Observatory on Health Systems and Policies. The European Observatory on Health Systems and Policies is a partnership between the vii

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WHO Regional Office for Europe, the Governments of Belgium, Finland, Greece, Norway, Slovenia, Spain and Sweden, the Veneto Region of Italy, the European Investment Bank, the Open Society Institute, the World Bank, the London School of Economics and Political Science, and the London School of Hygiene & Tropical Medicine. The Observatory team is led by Josep Figueras, Director, and Elias Mossialos, Co-director, and by Martin McKee, Richard Saltman and Reinhard Busse, heads of the research hubs. Jonathan North managed the production of the profile, with the support of Nicole Satterley (copy-editing), Shirley and Johannes Frederiksen (layout) and Aki Hedigan (proofreading). Administrative support for preparing the HiT profile on Denmark was undertaken by Caroline White. Special thanks are extended to the WHO European Health for All database, from which data on health services were extracted; to the OECD for the data on health services in western Europe; and to the World Bank for the data on health expenditure in central and eastern European countries. Thanks are also due to national statistical offices which have provided national data. The data used in this report are based on information publicly available in August 2007.

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List of abbreviations

AIDS BMI CAM CIS COPD CPR CT CVU DACEHTA DALE DDB DIHTA DKK DMFT DRG DSI EHR EU EU12 EU15 FBR FTDB GDP GNP GP HALE HIV HTA ICD IMF

Acquired immunodeficiency syndrome Body mass index Complementary and alternative medicine Commonwealth of Independent States Chronic obstructive pulmonary disease Personal identification (register and number) Computed tomography Centre(s) for Advanced Education Danish Centre for Evaluation and Health Technology Assessment Disability-adjusted life expectancy Demographic Database Danish Institute for Health Technology Assessment Danish krone (unit of currency) Decayed, missing and filled teeth Diagnosis-related group(s) Danish Institute of Health Services Research Electronic health record(s) European Union Countries that joined the EU in May 2004 and January 2007 European Union Member States before May 2004 Prevention Register Fertility Database Gross domestic product Gross national product General practitioner Healthy life expectancy Human immunodeficiency virus Health technology assessment (WHO) International Classification of Diseases International Monetary Fund ix

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IT IVF LPR MMR MRI OECD OTC PLO PPP SBR SIF SSI SUSY TB VAT VHI WHO WTO XML

Information technology In vitro fertilization National Patient Register Immunization against measles, mumps and rubella Magnetic resonance imaging Organisation for Economic Co-operation and Development Over-the-counter (pharmaceuticals) Organisation of General Practitioners in Denmark Purchasing power parity Hospital Use Statistics Register National Institute of Public Health National Serum Institute Danish Health and Morbidity Survey Tuberculosis Value-added tax Voluntary health insurance World Health Organization World Trade Organization eXtensible Markup Language

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List of tables and figures Tables

Table 1.1 Table 1.2 Table 1.3 Table 1.4 Table 1.5 Table 1.6 Table 1.7 Table 1.8 Table 2.1 Table 2.2 Table 4.1 Table 5.1 Table 5.2 Table 5.3 Table 5.4 Table 5.5 Table 6.1 Table 6.2 Table 7.1

Population/demographic indicators, 1970–2004 (selected years) Macroeconomic indicators, 1996–2006 (selected years) Average life expectancy at birth in Denmark, Norway, Sweden and the United Kingdom in 1970–1994 and 1995–2000 Mortality and health indicators, 1960–2002 (selected years) Main causes of death, 1995, 1997 and 1999 (ICD 10 Classification) The 10 most common diagnoses on discharge from hospital, 2000 Healthy life expectancy and disability-adjusted life expectancy (DALE), 2000–2002 Decayed, missing and filled teeth (DMFT) at age 12 years, 1975–2003 (selected years) Trends in the evolution of the health care sector, 1936–2003 (selected years) Political bodies, administrative bodies and health care responsibilities Trends in health care expenditure, 1980–2003 (selected years) Activity in somatic hospitals, 1996–2005 (selected years) Activity in psychiatric hospitals, 1997–2003 Pharmaceutical consumption in Europe, 2002 Health care personnel per 1000 population, 1980–2003 (selected years) Intake of other health care personnel for 2001 and 2002 Number of full-time specialist professionals involved in the delivery of mental health care, 2001–2003 Reproductive health, 1991–2004 (selected years) Overview of major reforms and policy initiatives with a substantial impact on health care, 1970–2007

4 5 7 8 10 11 12 17 25 28 64 70 70 75 86 88 119 124 128

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Figures

Fig. 1.1 Fig. 1.2 Fig. 1.3 Fig. 1.4 Fig. 1.5 Fig. 1.6 Fig. 1.7 Fig. 2.1 Fig. 4.1 Fig. 4.2 Fig. 4.3 Fig. 4.4 Fig. 5.1 Fig. 5.2 Fig. 5.3 Fig. 5.4 Fig. 5.5 Fig. 5.6 Fig. 5.7 Fig. 5.8 Fig. 5.9 Fig. 6.1 Fig. 6.2 Fig. 6.3

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Overview chart of the health system Map of Denmark Average life expectancy (in years) for men and women, 1901–2003 Mortality for different age groups, 1985–2005 Number of men and women who are overweight or severely overweight, 1987, 1994, 2000 Share of daily smokers as a percentage of the total population, 1953–2004 (selected years) Levels of immunization for measles in the WHO European Region, 2005 Organizational chart of the statutory health system Financing flow chart Health care expenditure as a share (%) of GDP in the WHO European Region, 2004, WHO estimates Trends in health care expenditure as a percentage of GDP in Denmark and selected other countries, 1998–2004, WHO estimates Health care expenditure in US$ PPP per capita in the WHO European Region, 2004, WHO estimates Beds in acute hospitals per 1000 population in Denmark, selected countries and EU averages, 1990–2005 Internet access by the Danish population, 2004 (%) Number of people treated with prescribed medicinal products in the primary health care sector, by sex and age Price index for medicines, 2003 Number of physicians per 1000 population in Denmark, selected countries and EU averages, 1990–2005 Number of nurses per 1000 population in Denmark, selected countries and EU averages, 1990–2005 Number of physicians and nurses per 1000 inhabitants in the WHO European Region, 2005 or latest available year (in parentheses) Number of dentists per 1000 inhabitants in Denmark, selected countries and EU averages, 1990–2005 Number of pharmacists per 1000 population in Denmark, selected countries and EU averages, 1990–2005 Group 1 patient pathway in the statutory health care system Organization of the distribution system for pharmaceuticals, 2006 Percentage of the population having received different forms of alternative treatment in 2003

2 3 7 10 13 14 18 27 52 65 66 67 71 73 76 77 81 82 83 84 86 98 106 123

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Abstract

he Health Systems in Transition (HiT) profiles are country-based reports that provide a detailed description of a health system and of policy initiatives in progress or under development. HiTs examine different approaches to the organization, financing and delivery of health services and the role of the main actors in health systems; describe the institutional framework, process, content and implementation of health and health care policies; and highlight challenges and areas that require more in-depth analysis. Denmark is a small country with 5.4 million inhabitants; however, it is one of the wealthiest countries in the world. It is a monarchy with fairly autonomous local governments, consisting of 5 regions and 98 municipalities. Population health, as measured by life expectancy, is relatively low in comparison to other European countries, but it has recently increased. The Danish health care sector is dominated by the public sector and is financed by local and state taxes. Somatic and psychiatric health care, carried out at public hospitals, and primary health services, which are delivered by general practitioners (GPs) and other practising health professionals, are administered by the regions. The regions are financed by the State and to a certain extent by the municipalities. The regions own and run most hospitals, and practising health professionals are self-employed and reimbursed by the regions, mainly using a fee-forservice mechanism. The municipalities are responsible for elderly care, social psychiatry, prevention and health promotion, rehabilitation and other types of care that are not directly related to hospital inpatient care. Access to health care is fairly equal when health status is taken into account. For all citizens with residence permits, access to health care is free of charge at hospitals and from GPs, whereas access to pharmaceuticals, dentists and some other services require co-payment. During recent years, the focus of health care reforms has been on xiii

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patient choice, waiting times, quality assurance and coordination of care. A major structural reform in 2007 has changed the political and administrative landscape of health care, dramatically reducing the number of regional and local units and transferring health care responsibilities for prevention and rehabilitation from the regional to the local level.

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Executive summary

enmark is a small country and relatively prosperous country in northern Europe. Like the other Scandinavian countries, Denmark is characterized by a strong welfare state tradition, with universal coverage of health services mainly financed via taxation. Access to the health system, including diagnostic and treatment services, is free for all citizens except for certain services such as dental care, physiotherapy and medicine requiring patient co-payment. Equity and solidarity are important underlying values in the system, and surveys show a persistently high level of patient satisfaction. The system has a relatively good track record in terms of controlling expenditure and introducing organizational and management changes, such as transition to ambulatory care, and introduction of activity-based payment. The Danish health system is governed by a combination of national state institutions, regions and municipalities. All three levels have democratically elected assemblies and there is a tradition of decentralization of management and planning to the regions and municipalities. National-level institutions include the Parliament, the Government and various state bureaucratic institutions. The state level is responsible for the overall legal framework for health care, and for coordinating and supervising the regional and municipal delivery of services. Five regions are responsible for delivering both primary and secondary health services. Most hospitals are owned and operated by the regions, and hospital doctors are salaried employees of the regions. Practising doctors are private, rather than state practitioners, but receive almost all of their income from services paid by the regions.

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Several current and future challenges can be identified. Danes have shorter life expectancy than many other Europeans. This has mostly been attributed to lifestyle issues, but health system performance has also been questioned, particularly in areas such as cancer care and cardiovascular disease. Coordination of care has also emerged as a general issue with potential for improvement, and waiting times have been a persistent political concern. More generally, the Danish system, like many other European health systems, faces challenges of guaranteeing access and quality while at the same time keeping costs under control. An ageing population and rising expectations regarding service are contributing factors in challenging the sustainability of the public health system. Activity-based payments, performance management and benchmarking, elements of managed competition and administrative reforms are some of the general policy responses that have been introduced to meet the challenges. Free choice of hospital was introduced in 1993, partially in response to waiting time issues. More recent initiatives have been an administrative reform in 2007, the introduction of a 1-month general waiting time guarantee and guaranteed access to hospital specialists within 48 hours of cancer diagnosis. The administrative reform of 2007 created larger regions and municipalities and changed the distribution of tasks and responsibilities. The underlying rationale was to facilitate centralization of service delivery at the hospital level and to give municipalities a stronger role in prevention and rehabilitation. Financing of regional health services was changed from predominantly regional taxation combined with some state grants, to a combination of state grants and municipal co-payments. The rationale behind this was to create more direct state control and to provide incentives for municipalities to step up their efforts in prevention, health promotion and rehabilitation. Financing Until 2007, the Danish health system was financed through progressive general income taxes at the national level and through proportional income and property taxes at the regional and local levels. The national-level tax revenue was redistributed to the counties and municipalities via block grants, based on objective criteria and some activity-based financing for hospitals. The system was designed to support solidarity in financing and equity in coverage. Since 2007, financing has been obtained through earmarked proportional taxation at the national level. Most of this revenue (80%) is redistributed to the regions via block grants, based on objective criteria (social and demographic indicators), and 20% is redistributed to the new municipalities which will use these funds xvi

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to co-finance regional hospital services for their respective populations. The system remains based on the general principles of solidarity, combined with some redistribution across the population. The earmarking of health care taxes is a new feature in Denmark and is intended to create greater transparency within this sector. However, it reduces the potential for redistribution of funds across sector areas. There is an increasing level of user payments for Danish health care, mostly involving payments for pharmaceuticals, dental care and physiotherapy, and it is related to a fast-growing private health insurance market, which has been partly established through labour market agreements for groups of employees. There is even some support for introducing more co-payments, such as patient fees for GP consultations, in order to reduce unnecessary utilization of services. These trends could lead to major changes in the health care financing patterns in Denmark over time, threatening the system’s general principles of solidarity, equity and tax-based financing of health care services. Principles of equity The current system is based on the principle of universal, free and equal access to health services. Although utilization patterns vary somewhat across regions, these objectives seem to be met to a fairly large extent. In practice, some groups, such as the homeless and mentally disabled, immigrants, and drug and alcohol abusers, appear to have a more unstable utilization pattern than other groups. The high individual costs for adult dental care seem to result in social inequity in the utilization of this kind of service, leading to social differences in dental health status. The use of private practising specialists shows a geographic and social bias as services are mostly offered in affluent urban areas. Patient choice appears to favour patients with a higher level of education and stable employment. There is some speculation that the increasing use of activitybased financing will divert investments and activity away from fields such as internal medicine and geriatrics to areas where increases in activity are easier to demonstrate. However, the evidence base for this is limited. Current resource allocations for health care, by and large, seem to meet the needs of the population. The reduction in waiting times and the general waiting time guarantee, related to the “extended free choice”, together ensure access to health care within relatively short periods. The waiting time guarantee ensures access to treatment within the public system or at private facilities in Denmark or abroad, in the event of expected waiting times exceeding 1–2 months. Patient satisfaction surveys continue to demonstrate remarkably high satisfaction figures for both GPs and hospital services. Equal access and utilization according xvii

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to need are likely to remain a strong focus in the Danish health sector in the future. However, ever increasing demands for new technology and expected changes in population age distribution and disease patterns might foster political initiatives to reduce access to publicly funded services through new financial and structural reforms. Quality and efficiency of Danish health care International comparisons of survival rates among some patient groups (i.e. patients with lung cancer and ovarian tumours) seem to indicate that the quality of some diagnostic and curative services is not optimal. This may be due to a lack of staff, equipment or skills or to structural problems in the Danish health system related to scale, specialization and coordination. There is an ongoing process leading to fewer and larger hospitals and to centralization of highly specialized care. A recent reform has given more power to the National Board of Health regarding the planning of such highly specialized services. There are also some issues of personnel coverage in peripheral areas, but the regional authorities are seeking to remedy such issues through the use of non-native doctors and nurses. Recent years have seen special emphasis on psychiatric care and common life-threatening diseases such as cancer and cardiovascular problems. Psychiatric conditions are, however, fairly low priority, as is the treatment of musculoskeletal ailments, despite general statements to the contrary in national health policy. There is no evidence of significant shifts in the balance between primary, secondary and tertiary care. However, a stated objective of the current structural reform is to create incentives for the municipalities to place more emphasis on prevention, health promotion and rehabilitation outside of hospitals. The health system is generally considered to provide good “value for money”. Consecutive government reports have indicated that the relationship between overall expenditure levels and service levels, including most available indicators on waiting times and quality, is acceptable in comparison to other European countries. This is a result of the many different initiatives aimed at controlling expenditure, raising productivity and improving quality. The use of global budgeting and hard budget constraints is a pervasive feature of the system. In recent years, this has been combined with internal contracts and some activitybased payments to encourage higher activity levels and stronger productivity. A recent government report points to gradually improving productivity within the sector and a 2.4% increase from 2003 to 2004. Hospitals are compared to average productivity at national and regional levels, showing only limited variation across the regions. There is limited information on the efficiency of the xviii

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primary sector, but it is assumed that combined per capita and fee-for-service payment provides incentives towards both the optimization of activity levels and composition. Doctorsâ&#x20AC;&#x2122; fees are negotiated with the public authorities on a regular basis and activity profiles are monitored regularly. GP gatekeeping has been a significant feature of the Danish system for many years, along with the general principle of treating patients at the lowest effective care level as opposed to providing free access to more specialized units. General policies are in place to promote the generic substitution of pharmaceuticals, and all regional authorities have implemented policies to monitor and influence the use of medicines in their health facilities. Efforts to reduce the general cost of pharmaceuticals have not been very successful, despite some positive results regarding drug pricing. Potential savings have been more than counterbalanced by the wider use of new and expensive pharmaceuticals and changes in indications for treatment of hypertension, high cholesterol, and so on. Some experiments with substituting doctors with nurses in selected areas have been carried out but the most important efficiency drive has been a massive and largely successful effort to convert inpatient treatment to outpatient or ambulatory treatment. Accountability of payers and providers is mainly achieved through hierarchical control within the political-bureaucratic structures at national, regional and municipal levels. The budgeting and economic management processes include accountability assessments at all levels. Annual negotiations between the State and the regional and municipal authorities involve evaluation of needs, outputs and new activity areas. Regional and municipal public management is based on contracting, incentives and monitoring measures to control the performance of hospitals and other public organizations. The activities of practising primary and secondary care doctors are monitored by the regional authorities, which also fund the activities in accordance with nationally negotiated fee schedules. Quality is monitored via internal management procedures, national measures of patient satisfaction and various national and regional initiatives to develop standards, clinical guidelines, clinical databases, and so on. Since 2007 all hospitals have been included in the Danish model for quality assurance and external accreditation takes place at regular intervals. A national system for reporting unintended events has been established. Health technology assessments (HTAs) are performed at national, regional and local levels. The HTA practice has become institutionalized via a national institute and several regional resource centres. HTA is recommended for major decisions, but has not yet been implemented across the board. Patient rights have been extended and formalized during recent years, and there are mechanisms for sanctioning professional misconduct and abuse. xix

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Public health As in other western European countries, mortality caused by heart diseases has declined remarkably during recent decades, partly due to better survival levels among patients with heart conditions. Survival of some types of cancer has increased due to better interventions. Denmark is, however, still lagging behind other Nordic countries as far as general mortality is concerned, as well as in relation to some cause-specific mortality rates. This is probably due to a combination of health care factors, environmental factors and lifestyle changes. It has been argued that the Danish populationâ&#x20AC;&#x2122;s functional ability and quality of life have improved as a consequence of more advanced treatments both through surgery and pharmaceuticals, but there is little evidence to support this assumption. A recent study analysing mortality amenable to health care in 19 industrialized countries indicates that the Danish system is performing at an average level. Its performance is not as good as that of other Scandinavian countries (namely Norway and Sweden) but better than some other countries, such as the United Kingdom, Portugal, Ireland, the United States, Austria, New Zealand and Greece. In spite of rather weak Danish public health intervention regarding tobacco consumption, there has been a gradual, but recently stagnating, decline in tobacco consumption. Alcohol consumption is also high, despite efforts to improve this aspect of public health through general campaigns. These efforts, however, have been counteracted by a reduction in alcohol taxes. The present increase in obesity and related diseases, such as diabetes, has become a public health issue, but there have not been any major policy interventions to this effect. Health inequalities are increasing between educational and occupational groups in Denmark. However, there is no evidence indicating that these inequalities are due to unequal access to, or utilization of, health care services, except in specific services such as dental care, where high co-payments apply. Rather, they are caused by unfavourable social and environmental conditions and health behaviours among some population groups, which cannot be addressed by the current, ongoing public health interventions.

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1.1

Denmark

Introduction

Overview of the health system

1.2

Geography and sociodemography

he defining feature of the Danish health system is decentralized responsibility for primary and secondary health care, as illustrated in Fig. 1.1. At the state level the Ministry of Health has a governing role over municipal organization and management, as well as the supervision and partial financing of the municipalities and regions. In the field of health care, the Ministry is in charge of the administrative functions that are related to the organization and financing of the health system, psychiatry and health insurance as well as the market authorization of pharmaceuticals and supervision of the pharmacy sector. Prevention and health promotion are also part of the Ministry’s remit. Figure 1.1 provides further details of the Ministry’s responsibilities. The regions own and run hospitals, and partly or fully finance private practitioners such as general practitioners (GPs), specialists, chiropractors and physiotherapists. They also provide reimbursement for pharmaceutical care. At the local level, the municipalities are responsible for disease prevention, health promotion and rehabilitation outside hospitals, as well as other areas of health care, as illustrated in Fig. 1.1. For an expanded description of the structure of the health system, see Section 2.2 “Organizational overview”.

Denmark is one of the Scandinavian countries. The mainland is located north of its only land neighbour, Germany, south-west of Sweden, and south of Norway. Denmark also encompasses two off-shore territories, Greenland and 1

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Fig. 1.1

Denmark

Overview chart of the health system

Central Government

National Board of Health

Medical public health officers

Danish Medicines Agency The National Serum Institute a

Patients’ Complaints Board Ministry of Health

Complaints Board for Patients´ Injury

Knowledge and Resource Center for Alternative Medicine The Danish National Committee for Biomedical Research Ethics The Danish Council of Ethics

Public General and Psychiatric Hospitals Regions

Maternity Care Payment to private practitioners and pharmaceuticals District Psychiatry Disease prevention and health promotion Child preventive care

Municipalities

Nursing home and home care Treatment of drug and alcohol abusers Dental care for children and disabled Social psychiatry

Private owners

Primary care providers and clinics with an agreement with the regions Primary care providers and clinics without an agreement with the regions Pharmacies Private hospitals

Source: Authors’ composition. Note: a The Patients’ Complaints Board and the Complaints Board for Patients’ Injury are two separate institutions. The Patients’ Complaints Board is responsible for processing complaints regarding health professional activities in the health care system. The Complaints Board for Patients’ Injury handles patients’ applications for compensation regarding injuries caused by malpractice in the health care system. 2

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the Faroe Islands, granted home rule in 1979 and 1948, respectively. It is a country consisting of a mainland peninsula and a number of islands (Fig. 1.2). The climate is temperate. Denmark is a small country with few inhabitants, but with a high population density (Table 1.1). The demographic development is similar to other western European countries, with an increasing proportion of elderly people and a low birth rate. Fig. 1.2

Map of Denmark

Norway Skagerrak

Skagen

Sweden

Ålborg Kattegat

Jutland Århus

Helsingør Horsens Vejle Esbjerg Fredericia Roskilde Odense

Funen Åbenrå

North Sea

Copenhagen

Zealand

Bornholm

Lolland Falster

Baltic Sea

Germany 0 0

50 km 50 mi

Poland

Source: CIA, 2005.

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Table 1.1 Population/demographic indicators, 1970–2004 (selected years)

Total population Population, female (% of total) Population, ages 0–14 (% of total) Population, ages 65 and above (% of total) Population growth (%) Population density (people per km2) Fertility rate, total (births per woman) Birth rate, crude (per 1000 people) Standardized death rate (per 1000 people) Age dependency ratio (population aged 0–14 and 65+ divided by population aged 15–64 years x100) Distribution of population (% urban)

1970 4 920 966

1980 5 122 065

1990 5 135 409

2000 5 330 020

2004 5 397 640

50.28

50.62

50.72

50.58

50.53

23.36

21.11

17.15

18.41

18.85

12.15

14.34

15.59

14.83

14.91

–

4.09

0.26

3.79

1.27

114.6

118.9

119.2

123.7

125.2

1.95

1.55

1.67a

1.77

1.72a

14.39

11.19

12.35

12.59

12.46b

9.58

9.22

8.74

7.52

7.49c

0.55

0.49

0.50

0.51

–

85c

–

Sources: European Union, 2005; Statistics Denmark, 2005; WHO, 2005. Notes: a 2002; b 2003; c 2001.

1.3

Economic context

Denmark is one of the richest countries in the world. It is characterized by a fairly equal distribution of income across the population (Table 1.2). Until the 1950s, agriculture provided the biggest share of export and national income; since then, industry and services have dominated, with the latter growing the most rapidly. Except for oil, natural gas and fertile soil, the country is poor in natural resources. The general level of education of the population is fairly high, with 32% and 18% of the population between 20 and 69 years having attended secondary and tertiary education, respectively. Unemployment has decreased since the mid-1990s; however, it is still high among some ethnic minority groups.

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Table 1.2 Macroeconomic indicators, 1996–2006 (selected years) GDP, million US$ at exchange rate GDP per capita, US$ at exchange rate Value added in industry (% of GDP) Value added in agriculture (% of GDP) Value added in services (% of GDP) Labour force (thousands of persons) Unemployment, total (% of labour force) Gini coefficient

1996

1998

2000

2002

2004

2006

184.394

173.674

160.144

173.984

243.639

275.227

35.036

32.743

29.992

32.375

45.110

47.759*

–

27.2

25.5

–

2.9

2.6

2.2

–

69.9

72.3

–

2.822

2.848

2.853

2.849

2.883

2.875*

6.9 –

5.4 –

4.6 –

4.7 0.25

5.7 –

5* –

Sources: OECD, 2007; CIA, 2007. Notes: GDP: Gross domestic product; *2005, latest available.

1.4

Political context

Denmark is a constitutional monarchy and a parliamentary democracy. The Government is the executive body and the Parliament is the legislative body. Over the decades, the high court has dealt with what could be referred to as political issues, but plays a minor role in this sense. The minimum percentage of the votes necessary for a party to be represented in the Parliament is 2% and at the time of writing there are seven political parties, plus four representatives for Greenland and the Faeroe Islands. The three largest parties are the Liberal Party, the Social Democrats and the Danish People’s Party. There is a long tradition in Denmark of minority governments consisting of two or three parties. The current Government, which has been in power since 2001, is made up of a coalition between the Liberal Party and the Conservative Party, and is supported by the Danish People’s Party. It has replaced a coalition government consisting of the Social Democrats and the Social Liberals. The regional political level includes five regions. One of the main responsibilities of this level of government is the health care sector. The local level consists of 98 municipalities. The municipalities are accountable for schools, social services, prevention and health promotion, as well as health care services. Denmark has been a member of the European Union (EU) since 1973. It is also a member of the United Nations, the World Health Organization (WHO), the World Trade Organization (WTO) and the Council of Europe. 5

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Denmark participates in the following international conventions: the Convention against Torture and Other Cruel, Inhuman and Degrading Treatment or Punishment; the International Covenant on Civil and Political Rights; the Convention on the Elimination of All Forms of Discrimination against Women; the International Convention on the Elimination of All Forms of Racial Discrimination; the International Covenant on Economic, Social and Cultural Rights; the International Convention on the Protection of the Rights of All Migrant Workers and Members of Their Families; and the Convention on the Rights of the Child, with the Optional Protocols on the involvement of children in armed conflict and on the sale of children, child prostitution and child pornography.

1.5

Health status

From an international perspective, health status in Denmark can generally be characterized as good in terms of morbidity and mortality indicators. However, over recent decades, the population health status has progressed at a lesser rate than in other European countries. Nevertheless, life expectancy trends show that there was a marked improvement in the population’s health status during the latter half of the 1990s. Life expectancy As Fig. 1.3 and Table 1.3 show, the average life expectancy in Denmark has increased substantially during the 20th century, albeit with somewhat different developments for men and women. Historically, male life expectancy has remained almost stagnant since the early 1950s, only beginning to grow again during the 1990s. Female life expectancy, however, rose rapidly until the 1970s, with smaller increases from then on. Until 1995, the overall average life expectancy in Denmark increased at a slower pace than in other western European countries. However, from 1995 onwards, the average life expectancy increased significantly and at a higher pace than in most other western European countries. Table 1.4 shows that, when including the whole period between 1995 and 2002, the average life expectancy increased by 1.7 years for women and by 2.1 years for men. During these eight years the increase in Danish life expectancy was equivalent to that experienced in the previous 25 years. The increase in life expectancy is mostly noticeable among men, which could be primarily attributed to a decline in the infant mortality rate over the same period of time (Ministry of the Interior and Health 2004c). 6

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Fig. 1.3

Denmark

Average life expectancy (in years) for men and women, 1901–2003

Men

2001–2003

1996–2000

1991–1995

1986–1990

1981–1985

1976–1980

1971–1975

1966–1970

1961–1965

1956–1960

1951–1955

1946–1950

1941–1945

1936–1940

1931–1935

1926–1930

1921–1925

1916–1920

1911–1915

1906–1910

1901–1905

Women

Sources: DIKE, 1997; Statistics Denmark, 2005.

Table 1.3 Average life expectancy at birth in Denmark, Norway, Sweden and the United Kingdom in 1970–1994 and 1995–2000 Country Denmark Norway Sweden United Kingdom EU average

1970 73.3 74.2 74.8 72.0 –

1994 75.4 77.9 79.0 76.9 –

Change 2.1 3.7 4.2 4.9 –

1995 75.3 77.9 79.1 76.8 76.6

2000 76.9 78.8 79.9 78.1 77.9

Change 1.6 0.9 0.8 1.3 1.3

Sources: OECD, 2004; WHO, 2005. Note: EU: European Union.

In 2000 the Ministry of the Interior and Health carried out an extensive survey to reveal the less favourable health developments in Denmark. The survey concluded that the health status of women is lagging. For example, mortality rates, especially among women aged 35–64, have been less favourable in Denmark. Middle-aged women in Denmark have, on average, a 40–50% higher mortality rate than women in other EU countries. In particular, the increase in the incidence of cancer in women (primarily that of the breast and the lung) gives cause for concern. However, cardiovascular diseases and 7

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Table 1.4 Mortality and health indicators, 1960–2002 (selected years) 1960 1970 1980 1990 1995 1997 1998 2000 2001 2002 Life expectancy at birth (female) Life expectancy at birth (male) Life expectancy at birth (total) Mortality rate, adult female (per 1000 female adults) Mortality rate, adult male (per 1000 male adults) Mortality rate under 5 (per 1000 live births) Infant mortality rate (per 1000 live births)

74.4

75.9

77.3

77.7

77.8

78.4

78.6

79.3

79.5

70.4

70.7

71.2

72.0

72.7

73.3

73.7

74.5

74.7

74.8

72.2

73.3

74.3

74.9

75.3

78.9

76.2

76.9

77.0

77.2

–

9.9

11.4

12.0

11.4

10.9

11.0

–

11.9

12.3

12.1

11.3

11.0

10.6

10.5

–

16.9

10.4

8.9

6.3

6.2

5.7

–

21.5

14.2

8.4

7.5

5.1

5.3

4.7

5.3

4.9

4.4

Sources: OECD, 2004; National Board of Health, 2005b.

alcohol-related diseases in women have also contributed to this lagging health status. By contrast, the evolution of the mortality rate amongst Danish men is parallel to that of men in other EU countries (Ministry of the Interior and Health 2004c). Mortality and morbidity Most of the decline in Danish mortality rates during the 20th century has been among infants, children and young people. Infant mortality rates are now among the lowest in Europe. While life expectancy for a newborn boy has increased by 20 years over the last century, it rose by 4 years for a man aged 50 years or older. Declining mortality rates among children, young and middle-aged people are largely due to a decline in infectious diseases, including tuberculosis (TB). In the 1930s, 60% of those dying from TB were aged between 15 and 44 years. During the 1960s, people aged over 65 mainly died from cancer and cardiovascular diseases, which is still the case today. Causes of death have also differed according to gender, with mortality rates increasing among men due to cardiovascular diseases until the mid-1960s and decreasing among women since the early 1950s. During the late 1980s, Denmark had a lower mortality rate caused by cardiovascular diseases than Norway and Sweden, although the rate was still high compared to the rest of the EU. Smoking, especially among women, is more common in Denmark than in many other EU countries and alcohol 8

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consumption is higher than that of other Scandinavians, but lower than that of the French and the Austrians. Danes also have the highest calorie intake of all EU citizens (according to figures based on the amount of food sold) (Ministry of Health 1998). Taken together, however, these lifestyle factors still do not sufficiently explain Denmark’s poor progress in increasing longevity. Figure 1.4 illustrates the mortality trends for five age groups during the period 1985–2005. Mortality for the age group under 24 years has decreased substantially during the 1990s. The number of deaths in this age group was reduced by almost a third during this period. Since 1995, the mortality rate for all age groups has decreased, including for those 70 years and older, which experienced a slight increase in the first half of the 1990s. In 1999, the mortality rate for this age group (70+) was very similar to that of 1990 and 6% lower than that in 1995. In the first half of the 1990s, the mortality rate was unchanged for the age group 30–49 years and thereafter began to decrease significantly – approximately 20% from 1995 to 2001. The mortality rate decreased by 23% over the entire period, and it decreased significantly in the last few years of the 1990s for the age group 50–69 years. Mortality rate differences between social classes are much less pronounced among women. If the average mortality rate is 100, male mortality varies by occupational group from approximately 72 to 125 (with some outliers, such as merchant seamen and fishermen at approximately 2000), whereas the range of variation for women only lies between 90 and 110. In fact, female skilled workers and white collar workers have a lower mortality rate than women in the highest occupational groups (Ministry of Health 2000). See “Inequalities in health” later in this chapter for further elaboration on these findings. Recent research into general morbidity amongst Danish citizens (see Table 1.5) shows a rise within the population in the last few years. This rise has been demonstrated in both women and men, and across all age groups. The percentage of the population reporting to be suffering from one or more longstanding illnesses is also increasing. The most common of the long-standing illnesses are musculoskeletal diseases, respiratory diseases, cardiovascular diseases, diseases of the nervous system and sensory diseases. The most common complaints and symptoms reported during a 14-day period are pains or aches in the neck, the shoulders, the back, the limbs, the hips or the joints, headaches, tiredness, and colds, including head colds or coughing (Ministry of the Interior and Health 2002b). Two groups of illnesses stand out from the others. First, asthma, hay fever and other allergies and head colds, and, second, musculoskeletal diseases (Ministry of the Interior and Health 2002b). Regarding prevention, both of these 9

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Fig. 1.4

Denmark

Mortality for different age groups, 1985–2005

120

110

100

40 1985

1990 0–24

1995 25–44

2000

45–64

65–74

2005 75+

Source: National Board of Health, 2005b. Notes: 2005 data are provisional; Index 1985=100. Table 1.5 Main causes of death, 1995, 1997 and 1999 (ICD 10 Classification)

I. All causes II. Perinatal conditions (P00-P96, A33) III. Communicable diseases Infectious and parasitic diseases (A00-B99) Tuberculosis (A17-A19) IV. Noncommunicable conditions Circulatory diseases (I00-I99) Malignant neoplasms (C00-C97) Trachea/bronchus/lung cancers (C33-C34) Mental disorders (F01-F99) Other diseases of the digestive system (K00-K92) V. External causes (V01-Y88)

1995 62 815 176 656 637 19 46 045 24 926 15 701 3 506 935

1997 59 606 168 383 376 7 42 945 22 003 15 254 3 427 1 234

1999 58 722 124 469 465 4 43 122 21 459 15 444 3 376 1 751

977

1 027

1 092

2 464

2 425

2 453

Source: WHO, 2005. Notes: ICD; WHO International Classification of Diseases. 10

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Table 1.6 The 10 most common diagnoses on discharge from hospital, 2000 1 2 3 4 5 6 7 8 9 10

Diagnoses Diseases of the circulatory system Neoplasms Injury, poisoning and other consequences of external causes Pregnancy, childbirth and puerperal conditions Diseases of the digestive system Diseases of the respiratory system Symptoms and other ill-defined conditions Diseases of the musculoskeletal system Diseases of the genitourinary system Diseases of the nervous system and sense organs

Total 141 926 105 152

% 12.7 9.4

101 203

9.0

90 724 88 167 85 647 68 833 55 145 54 566 25 928

8.1 7.9 7.6 6.1 4.9 4.9 2.3

Source: National Board of Health, 2005c.

groups have been given priority in recent years. The main diseases diagnosed in hospitals are cardiovascular diseases, tumours and injuries (see Table 1.6). Morbidity rates were reported by the National Institute of Public Health in 1987, 1994 and 2000. The Danish Health and Morbidity Survey (SUSY) in 2000 was based on a representative sample of approximately 22 500 people over the age of 16. As many as 78% of those surveyed considered their individual health status to be “good” or “very good” (the top two grades in a 5-grade scale) (Kjøller & Rasmussen 2002). The earlier surveys show a similar trend, with a positive health response ranging from 78% to 80%. These figures are found to be greater in Denmark than in most other EU countries. Approximately 5% more men than women considered themselves to be in “good” or “very good” health. A pronounced difference was also found between individuals, depending on their level of education. A total of 60% of Danes with fewer than 10 years of formal education considered themselves to be in “good” or “very good” health, compared to 86% with 13 or more years of formal education. Almost 40% of Danes suffered from a long-standing illness in 2000, compared to 33% in 1987. In 2000 approximately 12% suffered to such an extent that the illness seriously restricted their daily activity. Approximately 20% reported experiencing emotional problems that adversely affected their daily routine in terms of work or leisure during the four weeks prior to the survey (National Institute of Public Health 2002). Table 1.7 shows details of the population’s healthy life expectancy (HALE) and disability-adjusted life expectancy (DALE) at the turn of the century.

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Table 1.7 Healthy life expectancy and disability-adjusted life expectancy, 2000–2002 Indicator/Years Expectation of lost healthy years at birth (females) Expectation of lost healthy years at birth (males) HALE at birth (years, females) HALE at birth (years, males) HALE at birth (years, total population) Percentage of total life expectancy lost (females) Percentage of total life expectancy lost (males) DALE (years)

2000 8.4 5.3 70.1 68.9 69.8 10.7 7.2 69.8

2001 8.7 5.5 70.8 69.3 70.1 70.9 7.3 70.1

2002 8.4 6.3 71.1 68.6 69.8 10.5 8.4 69.8

Sources: WHO, 2005 ; WHO Regional Office for Europe, 2005. Notes: HALE: Health-adjusted life expectancy; DALE: Disability-adjusted life expectancy.

Factors affecting health status Several factors affect the health status of the Danish population. Among these are diet and obesity, tobacco use, alcohol consumption and a lack of physical activity. Diet and obesity The 2000 SUSY survey shows differences in diet between age groups and gender (Kjøller & Rasmussen 2002). More women than men have a daily consumption of steamed vegetables, salad/raw vegetables and fruit, while more men than women include potatoes in their diet. Daily intake of salad is most common within the age group 45–66. The consumption of fish at least once a week is equally distributed between the sexes. The survey concludes that variety in diet is proportionally associated with age, that is, the older a person is the more variety they have in their diet. Between 1955 and 1999 the amount of protein in the average Danish diet generally increased, and the consumption of carbohydrates and dietary fibre has decreased. The dietary fat content increased from 36% in 1955 to 43% in 1989 and then decreased to 38% in 1995. The dietary fat content is, however, still too high according to national dietary guidelines (National Institute of Public Health 2002). Between 1987 and 2000 the proportion of people over the age of 16 who were severely obese (body mass index, BMI ≥30) increased from 6% to 9.5% (National Institute of Public Health 2002). As illustrated in Fig. 1.5, the share of people living in Denmark that are moderately overweight (BMI≥25) has also increased, with 40% of men and 25% of women characterized as overweight in 2000. By comparison, only 35% of men and 17% of women were overweight in 1987. The increase in those who are severely overweight is especially high 12

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amongst men between 16 and 24 years old and women between 25 and 44 years old. It has been shown that the level of education has an impact on obesity. Fig. 1.5 50

Number of men and women who are overweight or severely overweight, 1987, 1994, 2000

Women

Men

Women

Overweight

Men

Severely Overweight 1987

1994

2000

Source: Ministry of the Interior and Health, 2004b. Notes: Overweight: BMI ≥25; Severely overweight: BMI ≥30.

Those with a lower level of education are associated with a higher incidence of being severely overweight. Those who have less than 10 years of education are more than twice as likely to be severely overweight than those with a minimum of 15 years of education. Tobacco use Tobacco use in Denmark is the cause of 12 000 deaths per year (Juel 2001). Approximately 4 500 people die from smoking-related cancer each year. This corresponds to approximately one third of all cancer deaths in Denmark per year (Peto, Lopez, Boreham, Thun 2006). Figure 1.6 illustrates the evolution of daily smokers among men and women in Denmark from 1950 to 2004. In 2004, 25% of the Danish population above the age of 13 were daily smokers, with smokers accounting for 23% of females 13

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and 28% of males. These figures have decreased in comparison to 1997 figures, where 29% of the population were female smokers and 35% were male smokers. Overall, a decrease is observed for both sexes throughout the entire period. However, from the 1950s until the 1970s the percentage of female smokers increased (PLS Rambøll 2004). Approximately nine out of ten Danish smokers smoke on a daily basis. While Danish males smoke at a comparative rate to the EU average, Danish females have one of the highest proportions of daily smokers in the EU (Ministry of the Interior and Health 2004c). The share of daily smokers is largest in the age group 45–66 years, where 40.6% of the men and 36% of the women are smokers. The overall share of daily smokers is highest in groups with less education and lowest in groups with more education (National Institute of Public Health 2002). The use of tobacco has not decreased at the same rate that the number of smokers has. Smokers with a low level of tobacco use, in particular, have given up smoking, and those with a high level of tobacco use (more than 15 cigarettes daily) continue to smoke. However, the number of heavy smokers has decreased in the period 1994–2000, especially for the age group 25–44 years.

Fig. 1.6

Share of daily smokers as a percentage of the total population, 1953–2004 (selected years)

20 1953

1963

1970

1975

Source: PLS Rambøll, 2004.

1980

1985

1990

Men

Women

1992 Total

1993

1997

2002

2003

2004

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Alcohol consumption Statements based on sales have shown that the Danish population’s average alcohol consumption increased rapidly through the 1960s. From the middle of the 1970s, the increase stagnated and, since then, the average alcohol consumption has stabilized. Since 1975, Danish men and women aged 14 and above drink, on average, 12 litres of pure alcohol per person per year. In 1999, the average intake was 11.3 litres of pure alcohol per person per year (National Institute of Public Health 2002; WHO 2005). A large share of the Danish population drink alcohol on a regular basis. In a survey conducted by the National Institute of Public Health for the year 2000, almost eight out of ten (78.1%) adults reported drinking alcohol within the previous week. The weekly alcohol consumption among Danish men and women differs. A total of 85.1% of male respondents reported an intake of alcohol within the previous week, while only 71.8% of the females surveyed reported a similar intake (National Institute of Health 2002). The recommended maximum level of alcohol units set by the National Board of Health (21 units per week for men and 14 for women) is exceeded by 14.8% of men and 8.7% of women. Compared to other age groups, both men and women in the 16–24 years age group have a relatively large percentage of alcohol intake beyond the recommended maximum level. The drinking pattern within this age group also differs from the other age groups because they consume three quarters of their alcohol at the weekend. The intake of alcohol on weekdays increases with age. People with a higher level of education tend to drink more alcohol during the weekdays. The shares of people drinking on weekdays and exceeding the recommended maximum level of alcohol have generally increased compared to 1994 data, but a decrease has been observed among those who are 25–44 years old (National Institute of Health 2002). Physical activity Among the Danish population, 16.3% have sedentary spare time activities and 23% reported being physically active at a moderate to hard level in 2000. It is primarily the older groups and those with the lower levels of education that take part in sedentary activities, and the younger and more highly educated that are more physically active. The share of people engaging in sedentary activities has, however, decreased among the elderly population and has not changed among the younger population. The percentage of the population engaging in moderate to hard physical activity in 2000 remains unchanged compared to that of 1994 but is slightly higher than that of 1987. Among the working population, the percentage of the population with sedentary work as their main occupation 15

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has increased by 36.9% from 1987 to 2000, while the share engaging in hard physical work has decreased by 32.3% during the same period. This decrease is reported strictly for men only (National Institute of Public Health 2002). Inequalities in health Inequalities in health have received increasing attention in Denmark in recent years. A comprehensive national study of mortality and life expectancy between 1987 and 1998 found that Danes with no vocational training had a mortality rate that was almost 80% higher than that of Danes with a higher level of education. Even when smoking, drinking and lack of exercise were adjusted for, the mortality rate of those with no vocational training was still 50% higher. This is largely due to less favourable living conditions, unhealthier work environments and a much higher mortality rate for permanently unemployed people (Juel 1999). Surveys of the expected number of years lived without long-standing illness reveal a similar trend to that found with mortality and education. A comprehensive study of illness patterns among Danes aged 30â&#x20AC;&#x201C;64 was carried out between 1986 and 1991. Among women, managers (typically office personnel in key positions) can expect to spend as much as 83% of their working life without long-standing illness. Women who are salaried employees, white-collar workers, the self-employed and unskilled workers can all expect to spend between 72% and 74% of their working lives without a long-standing illness. The percentage for unemployed women is only 45%. Male managers can expect to be without a long-standing illness for 76% of their working life, salaried employees and white-collar workers between 72% and 74%, and skilled and unskilled workers for 62%. The percentage for unemployed men is as low as 39%. The proportion of working life spent without a long-standing illness, therefore, varies significantly with occupational status, across occupational groups and according to gender, whereby women experience good health for a longer time than their male colleagues (Ministry of Health 2000). Decayed, missing and filled teeth at age 12 years The trend of decayed, missing and filled teeth (DMFT) at the age of 12 years has decreased steadily since 1975, as illustrated in Table 1.8. In 2003, the share of children of 12 years of age with DMFT was 0.9% compared to 5.2% in 1975. The relatively small percentage of DMFT, compared to international figures, is partly explained by free access to dental care for those aged 18 years or younger (either at a Municipal Dental Health Service or at a private practice dentist on a fee-for-service basis, paid by the municipalities). The effort to promote health education has also strengthened the daily use of a toothbrush 16

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Table 1.8 Decayed, missing and filled teeth (DMFT) at age 12 years, 1975–2003 (selected years) DMFT (%)

1975 5.2

1980 5.0

1985 2.1

1995 1.2

Sources: von der Fehr, 1994; National Board of Health, 2005a.

2000 1.0

2003 0.9

Note: DMFT: Decayed, missing and filled teeth.

and fluoride toothpaste in children. Surveys have shown that good oral hygiene habits in childhood are retained in adolescence (Lissau, Holst & Friis-Hasche 1990). For more information on Dental health care see Section 6.11. National vaccination programmes and levels of immunization General vaccination programmes are carried out by GPs and financed by the regions on a fee-for-service basis. Primary vaccinations for children are given in conjunction with health examinations, which are offered as part of the prevention programme for children. These vaccinations are financed by the regions and are free of charge for children between five weeks and five years of age. Coverage for diphtheria, tetanus, pertussis, polio and Hib-infection (Haemophilus influenzae type b) is relatively high in Denmark. However, there have been problems with the measles, mumps and rubella (MMR) vaccination due to parents’ doubts about adverse effects and complications as a result of the vaccine. In 1996, 85% of all children aged 15 months received the MMR vaccination in Denmark, but this figure was less than 80% in the City of Copenhagen. In 2003, the percentage of children receiving the combined vaccination reached 96% in Denmark as a whole and 95% in the City of Copenhagen (National Serum Institute 2005). This improved coverage can be explained by the fact that half of the Danish counties have taken initiatives to increase coverage since the mid-1990s, including public information programmes and postal invitations to parents from GPs. In 1997, 16% of children in Denmark were not immunized against measles (see Fig. 1.7 for further details). By international standards, this is a high proportion, and was a cause of concern for the Danish health authorities. In 2005, however, only 5% were not immunized against measles, which is a relatively small proportion by international standards.

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Fig. 1.7

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Levels of immunization for measles in the WHO European Region, 2005

Western Europe Monaco (2004) Andorra (2004) Finland Spain Netherlands Israel Sweden Luxembourg Denmark San Marino Germany Portugal Turkey Austria Norway Iceland Greece (2004) Belgium Italy Cyprus Malta France (2004) Ireland United Kingdom Switzerland Central and south-eastern Europe Hungary (2004) Poland Slovakia Lithuania Albania Czech Republic (2004) Romania The former Yugoslav Republic of Macedonia Bulgaria Estonia Serbia Croatia Latvia Slovenia (2004) Bosnia and Herzegovina CIS Kazakhstan Uzbekistan Belarus Turkmenistan Kyrgyzstan Russian Federation Azerbaijan Republic of Moldova Ukraine Armenia Tajikistan Georgia Averages CIS average EU average EU Member States before May 2004

99.0 97.6 97.0 96.8 96.3 96.0 95.4 95.4 95.0 94.1 93.3 92.6 91.0 91.0 90.0 90.0 88.0 88.0 87.2 86.3 86.0 86.0 84.2 82.1 82.0 99.9 98.2 98.0 97.2 97.2 96.9 96.7 96.4 96.2 95.9 95.6 95.5 95.0 94.0 90.0 100.0 99.3 99.0 99.0 98.9 98.6 98.2 96.9 95.7 94.1 94.0 91.6 98.0

91.3 89.7 70

Percentage

Source: WHO Regional Office for Europe, January 2007. Notes: CIS: Commonwealth of Independent States; EU: European Union.

100

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Organizational structure

ost of the activities carried out by authorized health professionals are organized and financed by the public sector, with free access to health services for all residents in the country. A large part of the public health care system is organized and financed by the regions, which are responsible for hospitals and health care professionals that are self-employed but mainly financed through taxes. The central State’s role is almost exclusively regulatory, supervisory and fiscal. The municipalities are responsible for health and social care, including dental care for children and the disabled; and, from 2007, for a large share of rehabilitation, disease prevention, health promotion and treatment of alcoholism and drug users. Besides the self-employed health professionals, who are reimbursed by taxes and user charges, there are a few private hospitals and clinics, which are reimbursed by taxes, private insurance and user charges, and pharmacies licensed by the State. The activities of the non-authorized health sector are not well documented.

2.1

Historical background

In Denmark there is a long tradition of public welfare politics (Vallgårda 1989; Vallgårda 1999b; Vallgårda 1999a). This also applies to a decentralized management of welfare tasks. Before the 18th century, landlords, or the artisan masters, were responsible for providing care for their subordinates when they were ill or in need of help in other respects. However, this did not mean that help was always given. Gradually, changes in societal behaviour occurred as a result of the dissolution of the feudal social relations and the increasing power of the central State. A new political ideology, namely cameralism, which stressed the importance of a big and industrious population, gained ground in 19

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the 18th century and created an impetus towards improving the health of the population. Most of the tasks aimed at health care and relief for the poor were taken over or established in the 18th and 19th centuries by towns and counties, not the central State. The central State laid down the guiding principles, but most welfare measures were carried out by the local authorities, and this is still the case. The Danish health care sector was financed mainly by taxes, which were raised by parishes, towns and counties and governed by the same authorities. Philanthropy and charity, organized through the church, only played a relatively minor role in welfare provision in Denmark and the other Nordic countries, compared to many other European countries. The fact that the public authorities also played the role of benefactors is probably one of the reasons why people’s attitudes toward the State are much more positive in Scandinavia than in other western European societies. The roots of the Danish welfare state date back to the 18th century, long before the establishment of the social democrats and other pro-welfare state parties, and the rise of organized philanthropy. With the introduction of public relief for the poor at the end of the 18th century, limiting the number of citizens entitled to help due to poor health became an issue. Improving the population’s health was considered both to improve the national economy in general and to reduce public spending. A number of measures were implemented to improve the population’s health, such as the education of midwives; inoculation for smallpox; the improved education of physicians and surgeons; and the undertaking of public health and the treatment of poor people by state-employed district doctors. The first hospitals were built by counties and towns. The hospitals were very small and their purpose was to provide the sick (mainly patients with venereal and other contagious diseases) with care and shelter. An exception was the state hospital, Frederiks Hospital, in Copenhagen (300 beds) where patients with contagious diseases were not admitted. It was established in 1757 as a teaching hospital for surgeons and physicians. During the 19th century, the number of private medical practitioners increased. Everyone who could afford it was treated by doctors in their homes, and even extensive surgery was performed in private homes. Trained midwives were employed all over the country and they helped the poor, free of charge. Public health measures were taken, such as improving sewerage and water supply, housing improvements, food control and control of working conditions. Public health boards were set up from the middle of the 19th century. From that point on the state regulation of health care increased and in 1803 the predecessor of Sundhedsstyrelsen (the National Board of Health) was established. From 1838, all Danish doctors were educated in both surgery and medicine, which previously had been separate entities. Thus, all doctors were trained in the same way and by the same teachers, creating a unified and homogeneous 20

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profession, where all were educated at the University of Copenhagen. In 1936, a medical school was opened in Århus and in 1966 another one was established in Odense. In 1857, the Danish Medical Association was founded, and the proportion of doctors enrolled soon increased. Approximately 60% of medical doctors were members of the Association in 1900 and practically all doctors were members by 1920. Since GPs constituted the largest section of the profession until the late 1930s, they did so as part of the Association as well. However, the influence of the GPs in the Association has been smaller than their numbers would indicate. The Association has been increasingly influential over time and, until the 1980s, it participated in almost all governmental committees on health care. With politicians becoming increasingly interested in, and having different opinions on, health care politics, the Danish Medical Association lost some of its influence (Vallgårda 1992). Many doctors working on the National Board of Health also held posts within the Association, thus strengthening the link between the Association and the Government. Nurses have been an organized entity since 1899 and have often been represented in committees, too. The Danish medical profession has been a part of the State, rather than a policy-making body outside of it. Several measures developed by the profession have since been taken over by the State, such as the system of approving medical specialties. Public hospitals were built during the 19th century in almost all Danish towns by the towns and counties themselves and financed primarily by real estate (property) taxes and, to a lesser extent, charity and use charges (which were sometimes paid by the patients themselves but more often by their employers or the authorities for relief for the poor). Originally, the hospitals were intended for and used by the poor, but this gradually changed at the end of the 19th century. While the lower social classes still constitute the majority of hospital patients, it seems that currently this is mainly due to poorer health among the lower social classes (Steensen & Juel 1990). Specialized hospitals have been rare in Denmark, with the exception of psychiatric, fever and TB hospitals. From the 1930s onwards, the State has subsidized hospitals to an increasing degree. Yet, county councils continued to be responsible for the hospitals and to make decisions on hospital policy. The State has exerted only little formal influence in this area. Of the private hospitals, a few Catholic hospitals existed on a non-profitmaking basis; however, they have been gradually taken over by the counties. During recent decades, a few private hospitals have been established on a profit-making basis. The presence of this new type of private hospital and clinic has increased since the beginning of the 1990s. There are less than 500 beds in private hospitals; approximately 2% of the hospital beds are private. The private hospitals, however, have caused political conflict and been discussed numerous 21

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times in the Danish Parliament. They are considered by some to be a threat to the equity principles of the Danish health system, while others claim that they offer a good supplement and provide an innovative element to it. Health insurance developed during the second half of the 19th century. Health insurance organizations were created by a combination of artisans and other groups. The artisans organized their own help funds as a continuation of the guilds funds, which were established by members to provide mutual help. Other groups organized health insurance funds for the poorer people within the population, established either by themselves or by those who were financially better off. Philanthropic activities were motivated by the desire to prevent illness and thereby prevent labourers and crofters becoming dependent on relief for the poor. State subsidies were given to insurance schemes from 1892. However, detractors maintained that state subsidies would reduce the motivation for philanthropic support. The late 19th century in Denmark was characterized by the establishment of associations, consisting of workers organizing themselves into labour unions and the social democratic party; farmers establishing cooperatives; and smallholders and day labourers organizing themselves into groups. Health insurance schemes covered the insured and their children. Married women were independent, contributing members from the start. Members of the insurance schemes were initially required to pay half of their hospital user charges; however, this payment was later reimbursed by the insurance scheme. Accordingly, for insurance scheme members, hospital admissions were free at the point of use. User charges were only a small part of hospital expenditure, with the rest financed by taxes. The insurance schemes also paid for the care provided by GPs, which is one of the reasons for the high number and equal distribution of GPs in Denmark. Historically, there were more doctors in Denmark per 1000 inhabitants than in any other Scandinavian country. In fact, in 1930, there were twice as many doctors in Denmark than in Sweden. It was not until the late 1960s and 1970s that Norway and Sweden reached the Danish level. Initially, membership of the health insurance schemes was taken up exclusively by the lower income classes. In 1900, these schemes only covered 20% of the population, whereas in 1925 they covered 42%. In 1973, however, when the insurance schemes were abolished, the coverage was at 90%. What is more, contributions to the schemes could be considered an earmarked tax. Social insurance schemes of this type did not exist in other public service areas, such as social security and pensions, as they did in Germany. From 1973 onwards, health care was financed by taxes, with the exception of those services or products paid by the patients themselves; these included dentist bills (in part), optical lenses and a share of the costs of prescription drugs. 22

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During the 1930s and 1940s – not least as a reaction to the falling birth rate – free health examinations were introduced for pregnant women, infants and preschool children. School medical services, which had previously only existed in cities and towns, were implemented throughout the country. Today, all of these examinations still exist. General health examinations have not been introduced for other groups; however, some specific examinations, such as systematic screening for cervical and breast cancer, are offered in most regions. Danish welfare politics in general, and especially health care policies, have been characterized by a consensus regarding the basic institutional structure (Vallgårda 1999b). Since the 1940s, there has been an agreement among the political parties that access to health care should be independent of where one lives and of economic resources. From 1945 to 1970, health care policy was characterized by a strong medical influence and consensus. Health care matters were discussed in technical rather than political terms. Since the 1970s, however, controversies have been much more frequent, as in several other countries over this period. Differences between the political parties also became more visible in this area, as they began to include specific health policies in their programmes. Thus, the authority of the medical profession was weakened. The 1970 reform of the political and administrative structure reduced the number of counties and municipalities. It also placed the responsibility for the largest part of the health care sector on the counties, whereas previously this responsibility had been divided between the towns, counties, the State and the health insurance schemes. In 2007, a reform has been implemented reducing the number of municipalities to 98 and establishing five regions with the responsibility for providing hospital and outpatient care for citizens. The acts on health care mainly set out the general legislative framework, letting the local and regional authorities decide on matters relating to actual performance. Ensuring local self-governance has for a long time, and in many different respects, been given a higher priority in formal legislation than ensuring an equal level of quality and provision of health care. This, however, has changed with this most recent reform, which holds equal standards of care throughout the country as one of its main priorities. In the 1970s public awareness of rising public expenditures began to increase (Vallgårda 1992). Public expenditure as a share of gross national product (GNP) rose from 28% to 42% between 1960 and 1971, a period when general economic growth was rapid. Concern about the increase in public expenditure promoted a reorientation of health care politics, where more attention was subsequently given to primary health care, disease prevention and health promotion. The effect of health care on mortality was questioned as well. From the middle of the 1970s, cost-containment became a political issue and the increase in health care expenditure slowed. New management methods were introduced 23

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in hospitals and, with them, more nonmedically trained managers were hired, which reduced the influence of the increasing number of doctors to some extent. From the 1980s, the politics of care for the diseased and disabled elderly changed from an institutional system to a home care-based one. The number of home nurses and other facilities increased substantially, while beds in nursing homes decreased, in spite of a rising number of elderly inhabitants in Denmark. Then, a slower increase in resources to health care led to an intensified debate about prioritizing. No national model or priority plan has ever been discussed, but different counties elaborated their own prioritizing criteria during the 1990s. During the same period, health technology assessment (HTA) and, largely, quality assurance were taken up in the health care sector and supported by the national authorities. Gradually, disease prevention and health promotion have received more political focus at both the central government level – with government programmes in 1989, 1999 and 2002 – and at local levels, in counties and local communities, which have launched campaigns against heart disease and employed people with the task of promoting prevention activities. For more information on the 2002 government health programme, see Section 6.1 on Public health. Since the 1990s, health care expenditure has risen again. Also, the debate on prioritization has subsided and the focus has shifted to efficiency and quality. Since the early 1990s, more economic incentives have been gradually introduced into the hospital sector. In 1993, free choice of hospital was introduced and in 1998 it was decided that hospitals should be reimbursed according to diagnosis-related groups (DRGs) for patients living in other counties. Since 1973, hospitals have received resources according to their budgets; however, in 1999 it was decided that only 10% of resources would be allocated in relation to activities based on DRGs and from 2004 this figure changed to 20% (Ankjær-Jensen & Rath 2004). Quality assurance methods and accreditation have played an increasing role in hospital management. Patient rights have also been strengthened through legislation on rights and complaint systems (see Subsection 2.5.2 on Patient rights and empowerment). Additionally, waiting times have been a big political issue since the mid-1990s. As such, a maximum 2-month waiting guarantee was introduced in 2002 and then reduced to one month in 2007. Thus, if the patient cannot be guaranteed treatment within one month, he/she may chose to be treated at another hospital, including privately and in other countries. Table 2.1 shows some trends of the health care sector, including a decrease in the number of hospitals and hospital beds and in the length of stay; an increase in the number of doctors and nurses; a slight increase in admissions; and a steep increase in outpatient visits, both to hospital outpatient departments and 24

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Table 2.1 Trends in the evolution of the health care sector, 1936–2003 (selected years) Indicator Number of general hospitals Number of psychiatric hospitals Number of doctors per 1000 Number of hospital nurses per 1000 Number of hospital beds per 1000 (general hospitals) Number of hospital beds per 1000 (psychiatric hospitals) Hospital admissions per 1000 (general hospitals) Outpatient visits per 1000 (general hospitals) Average length of stay in days (general hospitals) Number of GP consultations per 1000

1936 160 – 0.8 1.1

1960 142 17 1.2 2.0

1981 113 16 2.2 3.2

2003 57 10 3.6 5.6

6.0

3.7

–

0.3

69 – 28 –

114 – 16 –

178 656 10 4 500

218 1 025 5.5 6 500

Sources: Ministry of the Interior and Health, 2004a; National Board of Health, 2005d; Vallgårda, 1992. Note: GP: General practitioner.

GPs. Overall, these trends indicate a change in the role of hospitals towards one providing more diagnosis and treatment and less care. The purpose of the 2007 reform was to ensure greater equality in hospital treatment across the country, by increasing the influence of the National Board of Health on hospital planning. The number of regional authorities was reduced from 14 counties to 5 regions, which do not have the right to levy taxes. The municipalities received more responsibility for rehabilitation, disease prevention and health promotion, as well as the care and treatment for disabled people, and alcohol and drug users. Communities contribute to the regions through payments both per capita and by activity, the latter according to citizens’ utilization of the regional health services.

2.2

Organizational overview

The defining feature of the Danish health system is its decentralized responsibility for primary and secondary health care. However, important negotiation and coordination channels exist between the State, regions and municipalities, and the political focus on controlling health care costs has encouraged a trend towards more formal cooperation. See Fig. 2.1 and Table 2.2 for an overview of the organization of the system. 25

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State level Responsibility for preparing legislation and providing overall guidelines for the health sector lies with the Ministry of Health. Each year the Ministry of Health, the Ministry of Finance and the regional and municipal councils – represented by the Danish Regions and the National Association of Local Authorities – take part in a national budget negotiation to set targets for health care expenditure. These targets are not legally binding. The National Board of Health, a central body established in 1803 and now connected to the Ministry of Health, is responsible for supervising health personnel and institutions, and for advising different ministries, regions and municipalities on health issues. Regional level The five regions are governed by councils, which are elected every four years. They are financed by the State and the municipalities. The regions own and run hospitals and prenatal care centres, and they also finance GPs, specialists, physiotherapists, dentists and pharmaceuticals. Reimbursements for private practitioners and salaries for employed health professionals are agreed through negotiations between the Danish Regions and the different professional organizations. The Ministry of Health, the Ministry of Finance and the National Association of Local Authorities also participate in these negotiations. Municipal level The 98 municipalities are also governed by councils elected every four years (at the same time as regional council elections). They are responsible for providing services such as nursing homes, home nurses, health visitors, municipal dentists, prevention and health promotion, and institutions for people with special needs (i.e. people with disabilities, treatment for drug- and alcohol-related problems and school health services). These activities are financed by taxes, with funds distributed through global budgets, and carried out by salaried health professionals. Salaries and working conditions are negotiated by the National Association of Local Authorities and the different professional organizations.

2.3

Decentralization and centralization

With the exception of a few central state hospitals, health care in Denmark has been the responsibility of the towns and counties since the beginning of the 18th century, so there is a long tradition of decentralized administration in the health sector (see Section 2.1 on Historical background). The 1970 reform 26

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Fig. 2.1

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Organizational chart of the statutory health system

State level Parliament Government Ministry of Health National Board of Health

Regions

Regional level 5 Regions Regional councils

National Association of Local Authorities

Municipal level 98 Municipalities Municipal councils Subcommittees

Sources: National Association of Local Authorities, 2005; Vallgårda & Krasnik, 2007. Note: a The Danish regions and the National Association of Local Authorities are not part of the formal political and administrative system. The associations provide counselling for their members and negotiate with professional organizations and the central Government.

of the public administrative structure, which reduced the number of counties from 24 to 14 and the number of municipalities from over 1300 to 275, led to both centralization and decentralization of responsibilities. While many state tasks were transferred to the counties, responsibility for the hospitals moved from local hospital boards to the county councils. Ironically, though, since this reform, the State’s tendency to intervene in the administration of the health care sector has increased over time. Consequently, tension has been rising with regard to the counties’ autonomy. The 2007 reform allocated new tasks and responsibilities to both the State and the municipalities, and thereby involved a certain level of both centralization and decentralization. In 1976, responsibility for psychiatric hospitals and care for disabled people was decentralized from the State to the counties as part of an effort to develop closer coordination between somatic and psychiatric care, and, more generally, to establish smaller units that would be closer to the population. The counties also developed closer coordination with municipal social services, which gradually led to their handling the special needs of psychiatric patients. The process of decentralizing psychiatric treatment is continuing today, with the aim of delivering flexible and well-coordinated services. Deconcentration of state functions in health care is rare. One of the few examples of this is the case of public health officers, who have been employed by the State from the beginning of the 18th century and who work at the regional level. GPs were initially 27

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Table 2.2 Political bodies, administrative bodies and health care responsibilities Political bodies

Administrative bodies

State Parliament and its health committee

Regions 5 regional councils with committees

Municipalities 98 municipal councils with subcommittees

Government represented by Ministers of Health, Finance, Welfare and Labour Ministry of Health

Hospital administration

Social and health administration

National Board of Health and a number of other boards and institutions

Private

Administration for the reimbursement of private practitioners

Ministry of Finance Ministry of Welfare

Activities

Ministry of Labour Regulation and legislation

Hospitals

Nursing homes

Prenatal centres Home nurses Surveillance of the health sector Special Health visitors and health institutions for hazards disabled people Children’s dentists Public health District officers psychiatry Home dental service for the Annual budget physically/ negotiations mentally with the Danish disabled Regions and the National School health Association of services Local Authorities Home help Source: Vallgårda & Krasnik, 2007.

General practitioners Specialists Physiotherapists Dentists Pharmacies Chiropractors Private hospitals Occupational health units

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paid through the many local health insurance schemes; these were, however, gradually centralized and finally taken over by the counties in 1973. A serious consequence of decentralization is the unequal access to health care across the different counties. Danish politicians appear to consider local self-governance (and its potential for innovation) to be more important than geographical equity. Decentralization in Denmark has been shown to lead to differences in waiting times, in the availability of medical technology and in the rates of specific diagnostic and curative activities, such as systematic screening for breast cancer or the use of expensive drugs for ovarian cancer. One of the goals of the 2007 reform is to ensure equal standards of care throughout the country by increasing the power of the state bodies in planning and quality management.

2.4

Population coverage

Denmark has a tax-based, decentralized health care system providing universal coverage for all residents in the country. However, to be entitled to free access to health care an individual must be registered as a resident for more than six weeks. All those who have the right to tax-financed health care receive a health certificate card. The right to health care services is regulated by law with no option of opting out of the publicly funded system. People over the age of 16 who have the right to tax-financed services can choose between Group 1 and Group 2 coverage (see Subsection 2.5.2 on Patient choice). With regard to many services, a personâ&#x20AC;&#x2122;s rights depends on which group they have chosen (see Section 2.5 on Entitlements, benefits and patient rights). Children under the age of 16 are covered by the same form of coverage as their parents. A considerable proportion of the Danish population is covered by additional voluntary health insurance (VHI) (see Subsection 4.1.4 on Voluntary health insurance). Special rules for accessing health services apply for tourists, foreigners, legal immigrants, asylum seekers and illegal immigrants. Tourists and foreigners temporarily staying in Denmark must pay for health care services on a feefor-service basis. To receive reimbursement, a European Health Insurance Card or evidence of private health insurance must be shown at the point of use (Ministry of the Interior and Health 2004d). Legal immigrants are covered by the tax-financed system and they have the same rights as residents with Danish citizenship. Asylum seekers are not residents and do not have these entitlements; they may be treated by basic primary services and emergency hospital services, but they would have to apply for specialized treatment in the case of lifethreatening and painful chronic diseases, which are all financed by the Danish 29

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Immigration Service. Illegal immigrants are only entitled to acute treatment and are not otherwise covered by the tax-financed system (see SectionÂ 6.14 on Health care for specific populations).

2.5

Entitlements, benefits and patient rights

2.5.1

Entitlements and benefits

All Danish residents have free access to GPs, ophthalmologists, ear, nose and throat specialists, and emergency wards. Access to specialists and hospital care is free at the point of use with a referral from a GP. Free access includes ambulance transport and palliative care. In Denmark, treatment is left up to medical judgement and there is no minimum package of care. There have been some efforts to establish a list of priorities but an explicit priority-setting system has not been implemented. Formal restrictions on access are decided by the Parliament and the individual hospitals, and they only exist for a few treatments (i.e. infertility treatments). Entitlement to some vaccinations, health examinations for children and pregnant women, and health visits to elderly residents are also regulated by law. Co-payments exist for long-term nursing home care, dentists, physiotherapists, pharmaceuticals, and so on. Eyesight tests and glasses are paid for by patients; however, hearing tests and aids are free. People with low income may be reimbursed for co-payments by the social security system. An increasing number of Danes buy private insurance to cover these co-payments, to gain access to private hospitals and clinics and as an extra financial safeguard in case of sickness. Many employers offer private insurance to their employees, which is a contributing factor to the overall increase in private insurance (see Subsection 4.1.4 on Voluntary health insurance). Treatments not authorized by the National Board of Health are not reimbursed by the public system or by most private insurance companies. Sickness pay is the responsibility of the employer during the first two weeks of absence and the responsibility of the municipality thereafter. Many employees have a collective agreement which entitles them to their salary for a longer period, although sickness pay from the municipality generally stops after 54 weeks. It is more common for salaried people to have an agreement with their employer that entitles them to their salary during sickness and maternity leave, than wage earners. All pregnant women are entitled to maternity benefits from the municipality for four weeks before the expected birth and 14 weeks after the birth. The 30

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following 32 weeks of benefit may be shared between the father and the mother. For maternity leave, many employees have an agreement to be paid their salary for 26 weeks or more. Relatives of chronically or terminally ill patients are entitled to salary or compensation from the community. In the case of disability and reduced working capability, a national supplementary disability pension is granted. This type of pension may be temporary or permanent and it is co-financed by the State and the municipalities. Insurance bodies and pension funds often offer their members supplementary benefits in case of disability and acute serious disease. Health checks are often required before taking out insurance or entering a pension fund and membership may be denied. Insurance companies are not allowed to ask for or to see predictive genetic testing. However, they are allowed to ask and should be informed about serious diseases in the family, including those that are hereditary. They cannot request HIV testing, but if the HIV status is known the person must inform the insurance body about it. Currently, there are no plans for changing the entitlements and coverage of publicly financed health care and benefits. The rules about entitlement are decided by the Government and their implementation is decided by health care institutions and individual health professionals. The role of HTA and other forms of evidence guiding these decisions are not regulated by the authorities. When it comes to health care, it is principally a medical judgement that decides entitlement. Private insurance coverage is decided through contracts between the companies and the policy-holders. 2.5.2

Patient rights and empowerment

Patient rights In 1998, the Danish Government agreed on an act regarding a patient’s legal position. The act set out comprehensive legislation, regulating the fundamental and general principles for the individual patient’s rights (Legal Information 1998). The aims of the act are to help ensure that the patient’s dignity, integrity and self-determination are respected; and to support the trust relationships between the patient, the health system and the various personnel involved. The act also contains rules on information about consent and life testimonials, and information regarding patient cases and professional confidentiality, along with access to health information (Vallgårda & Krasnik 2004).

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Patient choice Since 1973 residents over the age of 16 have been able to choose between two coverage options known as Group 1 and Group 2. The default is Group 1 and approximately 99% of the Danish population were in this group in 2004 (Association of County Councils 2005). In Group 1, members are registered with a GP of their own choice, practising within 10 km of their home (5 km in the Copenhagen area); otherwise, a GPâ&#x20AC;&#x2122;s written acceptance of their willingness to carry out home visits during the day is needed. Group 1 members have free access to general preventive, diagnostic and curative services. Patients may consult emergency wards, dentists, chiropractors, ear, nose and throat specialists or ophthalmologists without prior referral, but their GP must refer them for access to all other medical specialties, physiotherapy and hospital treatments. Consultation with a GP or specialist is free of charge, while dental care, podiatry, psychology consultations, chiropractice and physiotherapy are subsidized. Patients seeking care from specialists other than ear, nose and throat specialists or ophthalmologists, and without a GP referral, are liable to pay the full fee. An individual in Group 1 has the possibility to change GPs after six months and after contacting the local authority. In Group 2, individuals are free to consult any GP and any specialist without referral. The region will subsidize the expenses up to the cost of the corresponding treatment for a patient in Group 1. The same rules apply to treatment by podiatrists, psychologists, dentists, chiropractors and physiotherapists. Hospital treatments are free. Only a minority of the population (1%) chooses this group, probably due to the level of general satisfaction with the referral system. Changing group is possible once an individual has been in either Group 1 or 2 for 12 months (Association of County Councils 2005). The majority of hospitals in Denmark are general hospitals. There are very few specialized hospitals other than psychiatric hospitals. A legislative reform in 1993 gave patients the freedom to choose to be treated at any hospital in the country as long as treatment takes place at the same level of specialization. This is in accordance with the fundamental principle that health services should be provided at the most appropriate level of specialization (i.e. less specialized cases should not be referred to more highly specialized units). This legislative reform was a key step towards allowing patients more influence over their care and treatment. However, according to a national study, which assessed the impact of the reform, patients prefer treatment close to their place of residence, which contradicts the original intention of the reform (Birk & Henriksen 2003). In 2002, a new piece of legislation regarding waiting time guarantees was implemented. Patients who are not offered treatment at public hospitals within two months of referral are free to choose treatment at private hospitals or clinics anywhere in the country and at hospitals abroad. In 2007, this guarantee was 32

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changed to one month as of 1 October. The non-public treatment expenses are paid by the patient’s region. As a precondition for the use of the extended free choice, the chosen non-public hospital or clinic has to have an agreement with the region (Association of County Councils 2005). In the case of cancer and certain other diseases (i.e. coronary heart disease), waiting time guarantees are defined for specific procedures, and, if the hospital is not able to treat the patient locally within the case time limits, it is obliged to look nationally or even internationally for alternative hospitals. If the hospital is unable to do this, then the case is referred to the National Board of Health for assistance in seeking alternative solutions within the case time limits, which are defined by the waiting time guarantees. However, due to heavy public and political criticism of the lack of fulfilment of these procedures, the Director of the National Board of Health resigned from his post in November 2006. Since 2003, referral to highly specialized services can be carried out on a direct referral basis by a medical doctor, independent of his/her place of work. The new legislation states that the patient must be referred to a highly specialized health service, if a qualified medical judgement is carried out and considers accordingly that the patient needs such treatment. Before this legislation, the county was required to produce an economic guarantee prior to referral to a highly specialized health service, including a secondary examination of the case by the county’s own hospital service. Currently, only patients with strictly defined needs for specialized treatment are accepted at the highly specialized health services. Information for patients Patients are informed about the age and gender of GPs before choosing a doctor, but other than this, no information is available. A patient that needs hospital treatment has a few different options available for them to obtain information about hospital characteristics (e.g. waiting lists). When the patient is referred to a hospital, the hospital is obliged to send a notice letter to the patient. This letter should inform the patient of his/her specific examination and treatment and of the hospital’s possibility to examine and treat the patient within one month. If the waiting time exceeds one month, then the hospital provides patients with information about the option of choosing another hospital, including those that are private or based abroad. Patients can also obtain information and guidance on hospital choice and waiting times through their GP and through patient offices, which exist in every region. A number of web sites have been established by the National Board of Health, the Danish Regions and the Ministry of Health in order to give patients further access to information. The sites provide information regarding public and 33

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private hospitals, specialists and clinics as well as selected hospitals abroad, which have existing arrangements with the regions. The typical content of the information includes waiting times in weeks to examination, treatment and after-care in the different hospitals and the number of operations conducted at specific hospitals (Ministry of the Interior and Health 2007). Information on quality aspects of hospitals has been published on the home page of the Ministry of Health since November 2006. This information includes ratings (1–5 stars) based on patient satisfaction, and standards of hygiene, safety, and so on. This rating system, however, has been criticized for its limited scope, unclear weighting of the different elements, and its ratings of hospitals as a single unit rather than as individual departments. A number of initiatives have been introduced to strengthen patient rights in the health system. The National Board of Health is in charge of securing the patients’ dignity, integrity and right of self-determination (National Board of Health 2005a). In 1992, a law was passed on patient rights, which obliges doctors to inform patients of their condition, treatment options, and the risk of complications. It also prohibits doctors from initiating, or proceeding with, any given treatment that is against the will of the patient (unless mandated by law). In addition, the patient has the right not to receive information. This law was extended in 1998, regulating the basic and general principles of the individual patient’s right of self-determination and public security related to the health system and regarding medical examination, treatment and care. Issues covered are the patient’s right to continuous information, which is adapted according to age and the disease(s), given throughout examinations and treatment and communicated with respect to the patient. Furthermore, the rules also determine doctors’ rights to share information with third parties, to give patients right of access to documents, to hold case records and to have total professional confidentiality (Legal Information 2005a). Complaint procedures A complaint system has been established regarding professional treatment in the health service: the Patients’ Complaints Board is a public authority that has the role of expressing patient criticism about the professional conduct of medical staff and submitting particularly serious cases to the public prosecutor with the purpose of taking such cases to court. The board deals with complaints about treatment and care, information and enquiries about consent, the drawing up of medical certificates, the compiling of case records, decisions about the right of access to documents and violations of professional confidentiality rules. The board also attends to the reports about professional activities from such agencies as the National Board of Health and the Danish Medicines Agency. 34

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Finally, the board deals with complaints made about previous decisions by the local psychiatric patient’s board of complaints regarding grievances other than the loss of liberty (Patients’ Complaints Board 2005). For decisions based on criticism, the Patients’ Complaints Board assesses whether the individual health personnel have fulfilled the commonly acknowledged professional standards. In 2003, the Patients’ Complaints Board received 2850 complaints, compared to 2949 in 2002 and 2721 in 2001. Compared to the number of patient contacts in the health care system, these are relatively few complaints. In round figures, there are more than 1.1 million discharges from hospitals per year, more than 4 million outpatient treatments and more than 34 million patient contacts in public practices. A large proportion of complaints are concerned with doctors, corresponding to 85% in 2003. The board settled 2219 cases in 2003, of which every fourth case ended with criticism of one or more health professionals. Ten cases were sent to the prosecution with the request to charge for a criminal offence (Patients’ Complaints Board 2003). Patient safety and compensation In June 2003, an Act on Patient Safety was agreed on, with effect from January 2004. The Act aims at promoting patient safety by establishing a system of reporting adverse events. The system was at first based on three types of occurrence: (1) serious occurrences; (2) surgical and invasive operations; and (3) use of medicine (Danish Society for Patient Safety 2007). However, this has been changed, and all occurrences are now to be reported. It is quite an extensive process to develop and there are still many challenges to be overcome. Patients can receive compensation for health care-related harm from treatment at public hospitals through the Patient Insurance Scheme, which was set up in 1992. The insurance provides compensation to patients or a patient’s relatives as well as subjects or donors for somatic damages and some psychiatric damages caused during treatment in the health care system. In 1995, this insurance was expanded to include damages caused by biomedical experiments in the primary health care sector. In 1999, the insurance was extended again, to cover treatment at all public and private hospitals (but not private profit-making hospitals) as well as specialists and selected hospitals abroad, which the regions use in accordance with the Law on Health of 2005 (Legal Information 2005a). The Patient Insurance Scheme is based on the following principles. • A patient’s right to compensation does not depend on a doctor or any other health person to incur personal responsibility for the damage. 35

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• Compensation is provided through an obligatory insurance scheme, which is financed by the hospital owners. • The size of compensation is regulated through the Law of access to complaint and compensation within the health services (Legal Information 2005b). Other compensation schemes include the Danish Dentist Society Insurance Schemes and the Danish Chiropractor Society Insurance Schemes. The Council for Adverse Drug Reactions offers general guidance to the Danish Medicines Agency and proposes recommendations and solutions to the Agency for improving the prevention and monitoring of adverse reactions. The main task of the Council is to monitor and assess the reporting of adverse reactions in practice. Further, it proposes recommendations and inspires the Danish Medicines Agency’s information and communication tasks with regard to adverse reactions for consumers, patients and health care professionals. The most important source of information on adverse drug reactions is spontaneous reports. The Agency recommends that all patients who experience adverse drug reactions not mentioned on the package leaflet should contact their GP. GPs are then required to report all presumably serious or unexpected adverse drug reactions or reactions to medical products to the Danish Medicines Agency. Moreover, GPs are obligated to report any known and non-serious adverse drug reactions for the duration of the first two years a medicinal product is on the market. It is also possible for the patient or the patient’s relatives to report adverse drug reactions directly to the Agency. In Denmark, direct-to-consumer advertising of prescription drugs is permitted under strict legislation. In an announcement in 2003, it was stressed among a long list of restrictions that advertising of drugs should not give the impression that it is not necessary to consult a GP; that there are no sideeffects; that the product is better than another drug; that it is recommended by scientists; that it mainly or solely addresses children; that it contains references to examinations; or that a person’s well-being depends on their use of the drug. These advertising restrictions do not include advertising for vaccination campaigns, which are approved by the Danish Medicines Agency (Danish Medicines Agency 2005b). Patient participation/involvement Patients’ participation takes place in three ways in Denmark: (1) through organized patient groups, nationally, regionally or locally; (2) through patient counsellors; and (3) indirectly, through feedback from national surveys. A number of patient groups exist, which were formed around concerns about particular diseases or health problems, such as heart disease, cancer, arthritis, diabetes, or sclerosis. Since the mid-1990s, many of these groups 36

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have explicitly taken on policy advocacy as an important function. The groups are very active and they influence public debate. Approximately 200 active patient groups exist in Denmark. They act as the patients’ voices in the media towards the authorities and politicians, frequently giving input on the health debate so that patients’ views are not neglected. They also provide information, help and support related to health and sickness, and dialogue with the relevant authorities at all levels. The largest, best-known and most well-funded groups have a strong track record of involvement in health policy. This is often achieved through the formation of coalitions with doctors or across patient groups. Patient organizations that are entirely at the grassroots level and work independently of the health care professional sector tend to be much smaller, with non-paid volunteer staff. It is therefore a far greater challenge for them to navigate the different decision-making structures at the national, regional and municipal levels, and to have a greater influence. The larger groups are backed by larger membership numbers and operating budgets, which enable them to maintain a professional staff. These organizations are generally invited to participate in parliamentary hearings that are relevant to their causes and concerns, while this is quite rare for the smaller organizations. In every region, a patient guidance system exists. The system’s primary task is patient guidance on provider and treatment choice, complaint and compensation rules, and waiting lists, and so on. Patient guidance also assists in clearing up misunderstandings, which in many cases could otherwise lead to a complaint being filed. Nurses primarily act as guidance counsellors and function as problem solvers in a close dialogue with patients, relatives and the hospital personnel. Guidance counsellors are obligated to be neutral and impartial (Association of County Councils 2005). A survey conducted by the Danish Ministry of Finance in 2000 analysed the population’s view of the public sector, including satisfaction with health care services. In general, Danish citizens are mostly satisfied with GPs (4.2 on a scale from 1 (very dissatisfied) to 5 (very satisfied)) and less satisfied with emergency medical services (3.5) (Ministry of Finance 2001). This survey is carried out every second year. Results from the 2004 survey show that 90% of patients are satisfied with their stay in hospital, 93% are satisfied with doctors and 95% are satisfied with the health personnel. This is a small increase compared to results from 2000 and 2002. Patients report great trust towards the doctors and health personnel professionalism, good communication between the patient and health personnel and there is evidence of a strengthened dialogue between hospitals and GPs since previous surveys. Other results have shown changes that are even more significant. From 2000 to 2004, there was a significant increase in patients’ evaluation of the content of written materials: 96% of the patients receiving the written material evaluated the content to be “very good” 37

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or “good” in 2004, compared to 87% in 2000. Furthermore, patients answered more positively in 2004, compared to 2000 and 2002, to questions regarding the waiting times (which prolonged the hospital stay) between referral and admission and during admission. Patients also increasingly believe that their GPs are informed to a “very good” or “good” level by the hospital regarding their admission. There was an increase of 6.7%, from 71% in 2000 to 77.7% in 2004. More specifically, the only statistically significant decline (from 60.2% to 58.0% (The Counties, Copenhagen Hospital Co-operation (H:S) & Ministry of the Interior and Health 2005)) between 2000 and 2004 was found in the responses to the question on whether patients were told whom to contact with any questions during admission.

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Planning, regulation and management

olicy development takes place at central, regional and local levels. The 2007 reform implies a more important role for the central level. With the reform, the influence of the National Board of Health on hospital planning was strengthened with the purpose of ensuring more equal treatment across the country. Implementation of policies and provision of services still take place at the regional and local levels. The National Board of Health has an advisory function over the political bodies at all levels, and it has a supervisory function over all authorized health professionals and institutions, except practitioners of complementary and alternative medicine (CAM). The Parliament and the Government, with few exceptions, outline the general policies, and make decisions on the overall organizational structure, financial framework of activities and responsibilities of the health care sector. Most health care institutions, hospitals, nursing homes and school health clinics are owned and managed by the regions or municipalities. GPs, specialists, dentists and physiotherapists are self-employed and reimbursed by the regions based on taxation. Pharmacies are privately owned but strictly regulated, and pharmaceuticals are subsidized by the regions.

3.1

Regulation

There is no national health plan for the development of the health care sector. 3.1.1

Regulation and governance of third-party payers

The main financing of the health care sector comes from municipal and central state taxation. The central State subsidizes the regions and municipalities and 39

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does not act as a purchaser or directly finance the providers. The municipalities contribute taxes comprising 20% of the overall regional income. The subsidies, and a counterbalancing system that transfers money from richer to poorer municipalities, are calculated according to formulas, which are based on allocated resources and needs. The role of the central State is mainly to regulate and contain expenditure and to provide some general guidelines for the health care sector. An increasing number of citizens take out private health insurance, which is organized by profit-making companies, in order to receive reimbursement for medical expenses, such as their utilization of private clinics. A rising number of companies offer private health insurance with variable coverage and the market is not particularly transparent for the average consumer. The private profit-making health insurance market is unregulated. 3.1.2

Regulation and governance of providers

In terms of organization, the five regions are responsible for providing hospital, somatic and psychiatric care, and for financing private practitioners (such as GPs, practising specialists, dentists, physiotherapists, chiropractors, and so on) for their public sector work. Private practitioners are self-employed but reimbursed for their services by the regions. However, only those who have a prior agreement with the regions are reimbursed, based on a negotiated number of doctors per 1000 inhabitants. Very few doctors work without such an agreement. A few private profit-making clinics and small hospitals are also paid by the regions for attending to patients, according to contracts or waiting time guarantees. Furthermore, the municipalities employ health care providers, who mainly take care of children and the elderly. Regarding stewardship and regulation, the central Government sets the overall direction of health care and increasingly – but still only to a limited extent – defines specific targets for the health care sector. For some decades it has tried to regulate the establishment of highly specialized departments and functions (such as heart transplants), and during recent years has set targets for waiting times, introduced screening programmes, improved treatment for cancer patients, and so on. With the recent reform, the central authorities have been given the means to govern these activities more efficiently. The Ministry of Finance negotiates the level of taxation with the municipalities, thus setting the financial framework of the activities. It also participates in negotiations between professional organizations and unions about salaries, working conditions, fees and the number of practitioners with regional contracts. 40

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There is a licensing system for health care professionals but not for health care facilities. Instead, health care facilities are supervised by the National Board of Health. The National Board of Health has a system of locally based medical officers, which supervise health professionals. Medical doctors (physicians and surgeons) have been licensed since the 17th century, midwives since the early 18th century, and nurses since 1933. During recent decades, a number of new health provider groups have achieved authorization such as laboratory technicians, physiotherapists, opticians, surgical appliance makers, and so on. The National Board of Health grants the licences and, in case of malpractice or other undesired behaviour, has the authority to withdraw them. There is no relicensing system. Education of doctors, specialists, nurses and other health professionals is regulated and supervised by the central State as a means to secure highquality care. Undergraduate education of medical doctors, psychologists, pharmacists and other academic staff is the responsibility of the Ministry of Science, Technology and Innovation. Postgraduate training of doctors is the responsibility of the National Board of Health. Education of most other health professionals is the responsibility of the Ministry of Education (see Section 5.2 on Human resources). Drugs are licensed by the Danish Medicines Agency. This body also supervises pharmacies and is responsible for licensing medical equipment, according to the EU regulations. A number of state agencies are responsible for securing the safety of the citizens. The National Institute of Radiation Hygiene under the National Board of Health is responsible for supervising utilization of X-ray machinery and radioactive substances. The Danish Working Environment Authority is responsible for supervising the working environment and prevention of occupational hazards. The Danish Environmental Protection Agency is responsible for environmental safety. Finally, the Danish Veterinary and Food Administration is responsible for supervising food safety. A national model for quality assessment and improvement, the Danish Health Care Quality Assessment Programme, was established in 2002. Its main objective is to monitor all publicly financed health care activities. In 2005, it was established as an independent institution. Its principal task is to provide ongoing feedback to individual health care institutions, including processed indicator data. The programme also promotes periodic accreditation, publication and benchmarking of assessments and indicators. National strategies for quality improvement have been published since 1993. The 2004 Law of authorization of health professionals and of health care activities made the reporting of adverse events compulsory, with the purpose 41

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of preventing consequential events. These reports do not allow the sanctioning of health care personnel or institutions. According to a 2004 law, organizations of CAM providers may – provided they fulfil certain requirements – obtain permission from the Minister of the Interior and Health to let their members describe themselves as registered CAM providers. Otherwise, the activities of CAM providers are regulated by the Law of authorization of health professionals and of health care activities, which forbids anyone other than authorized doctors to perform a number of activities. 3.1.3

Regulation and governance of the purchasing process

There is practically no division between purchasers and providers in hospitals. Hospitals receive 80% of their funding from budgets and 20% from activitybased remuneration according to a DRG system. The Government is planning to increase the activity-based proportion to 50% over the coming years. Thus, the regional councils influence hospital activities through budgets and direct political decisions concerning the establishment of activities, departments or hospitals. Self-employed private practitioners are reimbursed according to their activities and GPs are also reimbursed through capitation. The levels of reimbursement and capitation are negotiated between the practitioners’ organizations and the Danish Regions. The regions limit the number of providers through an agreement, but cannot generally limit the activities of providers.

3.2

Planning and health information management

Planning is an integrated part of the Danish health system. The planning system reflects the decentralized nature of the Danish health system, with the regions and municipalities as planners and providers of health care services and the State as the provider of the overall framework of the system. Decisions regarding the supply of different health services are mainly made at the regional level but with State involvement in certain areas. For example, services such as health examinations for children and pregnant women along with the provision of highly specialized services are determined by the State, whereas the supply of other hospital facilities in various areas is determined at the regional level. Further, the number of GPs practising in each region is agreed on between the regions and the Organisation of General Practitioners in Denmark (PLO) through annual negotiations. 42

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As health care is largely a regional responsibility, most national legislation concerning the health sector does not specify how the system should be organized or which services should be provided. Legislation concerning health care at the local level is slightly more specific. The more specific rules given by the central Government pertain mostly to preventive activities such as vaccination schemes and health check-ups for children and pregnant women. The decentralized structure requires careful coordination between the municipalities, the regions and the State in order to secure coherence in the long term and to strengthen prevention and health promotion as well as quality development within the health care sector. The goal of coherence was formalized through legislation enacted in 1994, which required counties and municipalities to develop a joint health plan every four years for the coordination of all preventive and curative health care activities within the health care sector, and, to some extent, between the health care sector and other public sectors (e.g. the social sector) (National Board of Health 2005a). The health plans were required to include a statement on the health status of the population, a description of the available services and an indication of the nature and extent of cooperation with municipalities and with other counties. The coordination process varied from county to county, but was often based on meetings, seminars and jointcommittee work, and focused on specific subjects, such as children, the elderly and mental health. All health plans should be submitted to the National Board of Health for comments. The plans have contributed to an increased awareness of intra- and intersectoral coordination and to the establishment of new relations within the sector. However, the health plans have been criticized for being solely an administrative task, and disconnected from functional levels (Seemann 2003; Strandberg-Larsen, Nielsen & Krasnik 2007). With the recent structural reform and redrawing of geographical and administrative boundaries within the Danish health system, the risk of unintended fragmentation of the system is present. Furthermore, the post-reform organizational structure increases the demand for careful coordination between the municipalities and the regions since the responsibilities for providing health services have been divided to an even greater extent than before. Fragmentation is thought to be avoided mainly by strengthening the principal agentâ&#x20AC;&#x2122;s obligation to cooperate through mandatory health agreements. Following the reform, the Health Act was revised. A statutory cooperation between municipalities and regions was established in the form of mandatory regional health care agreements to try to ensure the required coherence between treatment, prevention and care. The obligatory health care agreements include arrangements regarding hospital discharges for weak and elderly patients, on the social service available for people with mental disorders, and on prevention and rehabilitation. The health care agreements are anchored in the regional consultative committees consisting of representatives from the 43

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region, the municipalities within the region, and private practices. The regional consultative committees can be used to resolve disputes (e.g. about the service level, professional indications and referral criteria in the area of training) and to create the basis for a continuous dialogue about planning. The health care agreements should comply with centrally defined requirements, and tangible proof that the cooperation lives up to the requirements should be made publicly available. Overall, there have been substantial improvements with the new health agreements in terms of formalizing a more coordinated care system. Moreover, the health agreements have been planned to a greater degree, treating the process as one of continuous learning and adaptation. However, the same pitfalls from the previously used health plans can not be said to have been avoided with the new system (Strandberg-Larsen, Nielsen & Krasnik 2007). Economic management and planning of the health sector take place within a framework of negotiation between the different political and administrative levels. The annual national budget negotiation results in agreement on resource allocations, such as the recommended maximum level of municipal taxes, the level of state subsidies to the regions and municipalities, the level of redistribution or financial equalization between municipalities, and the size of additional grants earmarked for specific areas that need additional resources (see Chapter 4 on Financial resources). The annual national budget negotiation has been increasingly used by the central Government as a means of reaching an agreement on the development of the health sector and setting the overall economic framework. The central Government has some influence over the direction of the health sector by highlighting priority areas, such as heart surgery, cancer treatment and waiting lists, and making earmarked grants available to assist the regions and municipalities in achieving targets, such as reducing waiting times for surgery, increasing the number of heart bypass operations and expanding psychiatric services. Although these targets are not legally binding, the practice of earmarking funds reduces local autonomy to set priorities. The regions have, therefore, frequently expressed dissatisfaction with this practice, claiming that it contradicts the fundamental principle of decentralized health care in Denmark. The decentralized structure of the health system allows the regions to influence the planning and management of the system in a way that reflects local preferences. The regions can broadly influence the provision of health care in three ways. First, the regions collectively regulate the number of people employed by hospitals and the number of private practitioners entitled to reimbursement from the regions. The agreements arising from negotiations between the regions 44

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and GPs contain detailed rules regarding the number of doctors per 1000 inhabitants. In this way, the regions are able to limit access to practitioners and exert some control over expenditure. The Danish Regions, further, act as one body in negotiations for hospital management, thus limiting the influence of any individual regional council. Hospital management has changed in recent years following the appointment of more professional managers such as economists, lawyers and other university-educated administrators. This has affected hospital power structures and it is claimed to have reduced the influence of clinical practitioners. Economic rationale plays a more prominent role in the system today, both as a result of the focus on cost-containment and the introduction of new managers. Second, the regions’ collective negotiations with professional organizations are a key means of controlling the activities of private practitioners. Giving priority to an activity by associating it with a fee appears to be an effective incentive. An example of this is the recent introduction of special fees for preventive advisory talks. Third, the regions can determine the size, content and costs of hospital activities through detailed budgets. These budgets enable them to specify which treatments should be offered and which technical equipment should be bought. The regions’ planning capacity is reduced by: (1) choice, which allows hospital patients access to treatment in other regions; (2) waiting list guarantees, which force them to prioritize these goals; and (3) various initiatives, which have been introduced by centrally conceived legislation or agreements (Vrangbæk 1999). 3.2.1

Health technology assessment

HTA in Denmark is oriented toward public opinion, in that various public interest groups have participated in the development of the HTA over the years and, particularly, in formulating the 1996 national HTA strategy. Statements from Danish consensus conferences are directed mainly towards the public and decision-makers in politics and administration. In Denmark, HTA is decentralized. This corresponds with the national strategy for HTA, which explicitly states that HTA should be applied at all levels of the health service as a systematic process in planning and operational policy, and as an underlying process for the routine clinical decisions of health professionals (National Board of Health 1996). The purpose of HTA is to obtain a relevant basis for decision-making – from politics to clinical practice – regarding the use of new technologies in the health 45

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system. Decisions for the general use of technologies in the health system should be made with a broad-based, systematic and well-documented information. Staff at all levels of the health service are responsible for identifying and drawing attention to areas where HTA is needed. This responsibility includes the need for new technology assessments as well as the evaluation of existing technologies. In areas where an independent national intervention is necessary, HTA projects are to be undertaken as a basis for planning and operational decision-making. Implementation of independent national projects should take place in cooperation with research councils, health authorities and professional organizations (Jorgensen, Hvenegaard, Kristensen 2000). On 1 April 2001, the Danish Institute for Health Technology Assessment (DIHTA) and the Danish Hospital Evaluation Centre merged to form the Danish Centre for Evaluation and Health Technology Assessment (DACEHTA) (National Board of Health 2005a). The Centre is situated as a separate entity within the framework of the National Board of Health, and receives advice from two boards. The Centre’s Advisory Board is made up of 23 members representing the main stakeholders of the Danish health system at political, administrative and industry levels. The Scientific Advisory Board, which has 12 members, gives multidisciplinary advice to the Centre. The DIHTA annual budget of DKK 25 million is part of the Ministry of Health’s budget framework. The key aims of DACEHTA include: (1) to carry out HTAs and evaluations of public health services with the aim of improving quality, standards and value for money; (2) to integrate HTA principles into the running and planning of the public health service at all levels; (3) to realize the intentions behind the National Strategy for Health Technology Assessment which was issued by the National Board of Health; and (4) to follow the strategic plans within the field of evaluation. DACEHTA has created a strategic plan, which describes the overall visions and guidelines for the work carried out by the Centre (Danish Centre for Health Technology Assessment 2005). DACEHTA collaborates with the health authorities at regional level in evaluating and analysing medical equipment, pharmaceutical products, investigations, treatment and care methods, methods for rehabilitation, health education and prevention. The Centre initiates and carries out HTA in cooperation with clinical departments, GPs, health administrators, clinical scientists, health services researchers and representatives from the medical industry. DACEHTA has a small multidisciplinary staff of 11 full-time experts and 8 external part-time experts, who are mainly occupied with advising, administration and coordination of projects. Between 1997and 2003, DACEHTA (DIHTA before 2001) published 48 reports or assessments, 21 external reports, 46

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6 PhDs, 3 graduate theses, 38 scientific articles, and 44 articles, letters and other materials (National Board of Health 2005a). The reports cover topics including beta-interferon treatment for multiple sclerosis; incidence, treatment and prevention of back pain; influenza vaccination of elderly people; colorectal cancer; arthritis; and the treatment of gallstones. Several of these reports have helped to create an ongoing and lively public debate on priorities in health care. There is no regulatory mechanism in the Danish health service requiring the use of HTA in policy decisions, planning or administrative procedures. At the national level, however, a number of comprehensive assessments of health technology have formed the basis for health policy decisions. However, the conclusions of HTAs are often disregarded due to political or an individual health professional’s priorities. A primary concern regarding HTAs is that assessments are time-consuming and thorough tasks, which can be difficult to fit into a short-term political process that often demands quick decisions. 3.2.2

Information systems

A number of public registers exist within the health care field concerning the population’s use of health care benefits, disease incidence and prevalence, causes of death, and so on. The registers are mainly compiled for administrative purposes and the information regarding individuals is used for treatment and statistical research purposes. More specifically, the data can be used for the management of health expenses or the planning of activities within the health system. The registers and their data are very important for both epidemiological and health services research in Denmark. The most commonly used registers are labelled according to a personal identification number (CPR) and contain information on individuals, including their family relations, education and income status (Vallgårda & Krasnik 2007). This provides researchers with the opportunity to collect and combine information at an individual level from different registers for the analysis of statistical associations. Such coupling of registers is under strict regulation, due to data sensitivity. Data validity in the major registers is generally high; however, problems can occur when, for example, health professionals have to register diagnosis or treatment codes. The key registers that can be identified in Denmark are listed here. (a) Registers based on contact with the hospital system are the National Patient Register (LPR), the Psychiatric Central Register, the Medical Birth Register and the National Board of Health Register for Legal Abortions. The LPR is a 47

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unique register containing all hospital admissions, outpatient treatments, and casualty department visits across all of the public and private hospitals in the country (National Board of Health 2005a). (b) Specific disease registers are the Cancer Register, the Malformation Register and the Artificial Insemination Register (for in vitro fertilization (IVF)). (c) Registers concerning the population’s health status in general are the Causes of Death Register and the Work Accident Register. (d) Administrative registers with relevance to the health sector are the CPR Register, the Health Reimbursement Register and the Sickness Benefit Register. The Health Reimbursement Register contains information about health services that are provided by GPs, practising specialists, dentists, physiotherapists, psychologists, and so on. However, it does not include information about symptoms or diagnoses of patients. All information in the registry is connected to the citizens’ unique CPR numbers, which makes it possible to link information from this registry with information from the LPR and the Causes of Death Register. In this way, it is possible to analyse complex health-related matters relating to specific population groups (Vallgårda & Krasnik 2007). (e) Other registers of importance for public health science include: the Demographic Database (DDB), the Prevention Register (FBR), the Hospital Use Statistics Register (SBR) and the Fertility Database (FTDB). The DDB is focused on registering when changes take place, for example, moving home, marriage or migration. The FBR is established in coordination with Statistics Denmark, the Ministry of Health and the National Board of Health with the aim of highlighting the health conditions in Denmark. This information is gathered from several different registers, such as the LPR, the Causes of Death Register and the Health Insurance Statistics Register from Statistics Denmark. The SBR contains information regarding people who have been admitted to somatic hospital departments. This information is also coupled with information on social conditions. Finally, the FTDB includes information regarding demographic and social data of the population during their fertile years (12–49 years for women and 12–64 years for men) (Statistics Denmark 2005). See www.dst.dk, www.im.dk, www.sst.dk and www.regioner.dk for further information on registers. To conduct research projects based on register data, permission from the Scientific Ethical Committee and the Data Protection Agency is required. The Danish Law of a scientific ethical committee system and biomedical research projects (Legal Information 2003) sets out the legal framework for the scientific ethical assessment of research projects in overall terms. Consent is required and is fundamental to the rules governing the scientific ethical assessment of research projects and to the committee system. The implementation of the 48

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Law on professional confidentiality and handling of personal information, etc. (Law on Health of 2005) is monitored by the Data Protection Agency. It is the Agency’s task to ensure that data are used in agreement with the Act and with the rules issued in pursuance of the Act. Therefore, data collected in relation to a project must be reported to the Data Protection Agency when the project involves handling of sensitive personal information. According to the Act this entails collection, registration, systematization, storage, adjusting, selecting, searching, use of data, passing on, promoting or coordinating without blocking, erasing or terminating data. 3.2.3

Research and development

Denmark has a rich tradition of medical research. Training for researchers has been formalized and the funding system includes the growing use of independent quality assessments. However, the Government encourages more international partnerships, broader research cooperation and extended information technology (IT) networks. A number of public institutions carry out research in Denmark. There are nine universities, which occupy a central position in the research system and whose tasks include carrying out research, providing higher education, responsibility for training PhD students as well as disseminating knowledge. Government research institutions, including a broad, varied group of institutions placed under nine ministries, comprise another element of public research. During the period 2006–2007, the number of such institutions has been reduced dramatically due to a governmental plan to fuse these types of institutions with the universities. The State finances 75% of public sector research. The rest is financed by private organizations, regional and local governments and international sources, such as the EU (Danish Council for Research Policy 2005). Research is also conducted at university hospitals. Denmark, however, is still lagging behind in terms of the objectives of the Barcelona Declaration regarding the total share of the country’s GDP to be invested in research. Some of the most important governmental research institutions involved in health-related research are listed here. • Statens Serum Institut (SSI) (National Serum Institute) is a research organization partly integrated within the Danish health service and involved in prevention and control of infectious diseases and congenital disorders (National Serum Institute 2005). • The National Institute of Public Health (SIF) has become part of the University of Southern Denmark. Its primary purpose is to research the health 49

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and morbidity of the Danish population and the functioning of the health system, as well as to educate (National Institute of Public Health 2005). • The Danish National Centre for Social Research conducts research and carries out commissioned projects in the area of welfare state policies, and disseminates the results (Danish National Centre for Social Research 2005). • The Danish Institute of Health Services Research (DSI) is an independent non-profit-making research institute. It aims at providing an improved basis for the planning and management authorities within the health services. This is achieved through collection, examination and dissemination of information, by carrying out research and development tasks, and through theoretical and practical counselling (DSI 2005). Besides these national research institutions, some smaller institutions are financed by individual regions in order to carry out health research at regional level. One example is the Research Centre for Prevention and Health in Glostrup. In 2007 there were more than 27 000 academically trained researchers in Denmark. Since the mid-1990s the number of researchers, including PhD students, has increased by approximately 7000. The reform of researcher training was an important factor behind these increased numbers. Researcher training in Denmark is a 3-year postgraduate programme, leading to a PhD Degree. Universities have formal responsibility for researcher training, but training can also be carried out in cooperation with a government research institution or a hospital. The number of enrolled PhD students has tripled to more than 5000 since the mid-1990s. Approximately one third of all university research is carried out by research students. The reform of researcher training has made a decisive contribution to the internationalization and renewal of Danish research (Ministry of Science, Technology and Innovation 2005). The number of peer-reviewed journal articles is not registered and gathered by a single institution. The Regional Councils and the National Board of Health have requested the establishment of such an institution but this has not yet been implemented. However, each university and governmental research institution records its own publications.

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Financial resources

he Danish health system is mainly financed by state and municipal taxes. Other sources of finance include user charges for some health goods and services and VHI, which is taken out to partially cover user charges. Figure 4.1 gives an overview of the system’s financing arrangements. The most significant resource allocation mechanisms are listed here. • National level: the national budget negotiation takes place once a year between the Ministry of Health, the Ministry of Finance and the regional and municipal councils, which are represented by the Danish Regions and the National Association of Local Authorities. • Regional/local level: political budget negotiations take place within the regional and municipal councils within nationally specified ceilings. In 2003, the total health expenditure per capita was US$ 2763 in purchasing power parity (PPP), of which 83% was public expenditure. The main portion of health-related public expenditure is spent on hospitals. The average growth rate of the total expenditure on health between 1998 and 2003 was 2.8%. Total health expenditure as a percentage of GDP has risen moderately during the period 1995–2003, corresponding to an average yearly increase of 0.1%. This rise was preceded by a decline in total health expenditure as a percentage of GDP during the period 1980–1995. The public proportion of total health expenditure was fairly stable between 1995 and 2003 (OECD 2006).

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Fig. 4.1

Denmark

Financing flow chart State taxes

State government

Block grants

Activity-based subsidy

Regional councils Co-payment for health services (per capita and activity-based)

Municipal taxes

Municipal councils

Voluntary premiums

Voluntary health insurance Global budgets

Municipal health services Disease prevention and health promotion Social psychiatry School health care and dental care for children and disabled Treatment of drug and alcohol abusers

Regional health services

Out-of-pocket payments

General practitioners Specialists

Fee-for-service

Pharmaceuticals

Subsidies

Dentists Hospitals Prenatal and maternity care District psychiatry

Population Private hospitals Private health goods Direct payments

Patients

Source: Authors’ compilation.

Capitation and fee-for-service

Fee-for-service Global budgets and activity-based financing

Global budgets Fee-for-service (special agreements)

Reimbursement

Taxes

Care for elderly and disabled

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4.1

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Revenue mobilization

The historical evolution of public and private expenditure on Danish health care is described in Section 2.1 on Historical background. The current revenue mobilization is dominated by public taxation at both state and municipal levels. The Local Government Reform and the Financing Reform, which came into effect on 1 January 2007, had some important implications regarding income tax distribution between the municipalities and the central Government. Most significantly, the number of taxation levels was reduced from three to two; this is because the previous 14 counties were merged into 5 new regions, which were not given power to levy taxes. As of 1 January 2007, the municipalities took over the portion of the county revenue that does not correspond to the new state health contribution of 8% of income. This means that the municipalities have been allowed to raise their tax revenue by four percentage points. State taxes are henceforth a combination of personal income tax, valueadded tax (VAT) (a single rate of 25%), energy and excise duties, labour market contributions (8% on all personal income), corporate income tax and the abovementioned health contribution (8%). Personal income tax accounts for almost half of the State’s total tax revenue and is payable on wages and almost all other forms of income, including profits from personally owned businesses. It is calculated according to a progressive scale, with a basic rate of 5.5%. The medium and top rates (6% and 15%, respectively) are levied on earned and capital income. A tax ceiling ensures that income taxes collected at state and municipal levels cannot exceed 59% of income. Aside from the state health contribution, some taxes are partly motivated by health concerns (e.g. excise duty on motor vehicles, energy, spirits and tobacco products). In the 1990s, the national Government introduced a green excise duty that is levied on pollution and the consumption of scarce goods, such as water, oil, petrol and electricity. In 2007, the average municipal tax rate was 24.6%. Municipal taxes are levied proportionately on income and real estate (property). Every year, the central Government agrees on maximum municipal taxation rates with the National Association of Local Authorities. The central Government also distributes additional resources to the municipalities through block grants, if municipalities raise their service level or take over tasks from the state subsidies based on the size of their tax revenue. Because the population’s income and need for public services vary from area to area, a certain amount of redistribution or financial equalization is necessary to compensate for discrepancies and to make sure the tax rate is associated with the municipal council’s chosen service level and not the tax base or the population’s need for 53

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public services. Redistribution between municipalities is devised according to a formula, which accounts for the following objective criteria: age distribution; the number of children in single parent families; the number of rented flats; the rate of unemployment; the number of people with only basic or no education; the number of immigrants from non-EU countries; the number of people living in socially deprived areas; and the proportion of elderly people living alone. Likewise, the size of the State’s block grant to each region depends on sociodemographic criteria. In 2001, the Government introduced a tax freeze as a central part of its economic policy. 4.1.1

Main source of finance

See Section 4.1 on Revenue mobilization. 4.1.2

Second most important source of finance

State and municipal taxes are the main sources of health care financing in Denmark, but patients also make substantial out-of-pocket payments at the point of use. Private expenditure mainly covers the costs of pharmaceuticals, vitamins, dentists, spectacles, unauthorized or alternative treatments, VHI and accident insurance. 4.1.3

Out-of-pocket payments

Patients pay out-of-pocket payments for part of the cost of dental care and physiotherapy. For dental care, the reimbursable amount depends on the procedure performed, but it is usually only a small part of the total cost. High co-payments for dental care have caused some controversy in Denmark, as it is claimed that they are reducing equity of access to these services. Expenditure on pharmaceuticals in hospitals is reimbursed in full, whereas pharmaceutical expenditure in the primary health care sector is subject to different levels of co-payment. Under the new reimbursement system, an individual’s annual pharmaceutical expenditure is reimbursed at the following levels: below DKK 520 – no reimbursement; DKK 520–1260, 50% reimbursement; DKK 1260–2950, 75% reimbursement; above DKK 2950, 85% reimbursement (Danish Medicines Agency 2005a). Chronically ill patients with permanent or high drug utilization levels can apply for full reimbursement for any expenditure above an annual ceiling of DKK 3805 (Danish Medicines Agency 2005a). Special rules for pensioners have been abolished, although 54

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pensioners who find it difficult to pay for pharmaceuticals can apply to their municipality for financial assistance. Patients with very low income can receive partial reimbursement, on a case-by-case basis, under the Ministerial order of Law on social security pension (Legal Information 2007a) and the Ministerial order of Law on social service (Legal Information 2007b). In addition, many individuals purchase VHI to cover the cost of paying for pharmaceuticals (see Subsection 4.1.4 on Voluntary health insurance). Pharmacists are required to substitute the most inexpensive, or close to the most inexpensive, generic medicine for the medicine prescribed by the physician to help reduce the burden of out-of-pocket payments (and the burden on public expenditure) related to pharmaceuticals. This should take place if the prescriber has not clearly stated to the contrary. It is not known how much is spent on unauthorized or alternative treatments and pharmaceuticals in Denmark. According to a national survey carried out in the year 2000, 21% of respondents had used unauthorized or alternative treatments during the previous year; women aged between 25–44 and 45–66 were the most frequent users of alternative treatment, and zone therapy, massage, herbal medicine and acupuncture were the most frequently used treatments (National Institute of Public Health 2003) (see Section 6.12 on Alternative/ complementary medicine). User charges for GP and hospital visits have been discussed as a means of reducing unnecessary utilization of health services, but they have so far been rejected for fear of reducing utilization by poor individuals who are most in need of health care. Out-of-pocket payments are not tax deductible. 4.1.4

Voluntary health insurance

For the past century, a large proportion of health care in Denmark has been financed through a system of VHI schemes (see Section 2.1 on Historical background). The counties took over these schemes in 1973 and, since then, most health care has been financed through taxation. However, a small VHI scheme still exists, which covers treatments that are only partially reimbursable or not publicly reimbursable at all. The purchase of such VHI is becoming increasingly popular. In 2002, the contribution of VHI to total expenditure on health was 1.6%: a 0.2% increase from 1998. Private (out-of-pocket) expenditure on health care accounted for 17% of total health expenditure in 2002, compared to 16.6% in 1998 (OECD 2004). Since opting out of the tax-based financing of the public health care services is not possible, VHI is mainly used as a complementary or supplementary scheme alongside the statutory health care system in Denmark. 55

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Complementary VHI provides full or partial coverage for services that are excluded or only partially covered by the statutory health care system. For example, it provides coverage for the reimbursement of pharmaceuticals, dental care, physiotherapy and corrective lens co-payments. Approximately 28% of the population purchased complementary VHI in 1999, making complementary VHI the most common type of VHI in Denmark (Thomson & Mossialos 2004). The purpose of supplementary VHI is to increase consumer choice and access to different health services. Traditionally, this means guaranteeing superior accommodation and amenities in hospital – rather than improved quality of care – and faster access to treatment that generally has long waiting times, such as elective surgery. This type of VHI is of growing importance in Denmark and mainly covers access to private hospitals in Denmark and abroad. The demand for supplementary VHI in Denmark is fuelled by general conditions in the Danish labour market (including strong competition for employees and high levels of personal income tax) and the fact that companies benefit from tax deductions when purchasing VHI for employees (Mossialos & Thomson 2002). Over the past few years, demand may also have been fuelled by the critical tone of public debate on the statutory health care system. Quality and waiting times are perceived to be problems in Denmark and, although these perceptions are not always accurate or evidence based, insurers have been able to benefit from these concerns. Supplementary VHI in Denmark favours those who are employed, as many policies are tied to job contracts. In general, supplementary VHI has less significance for children, unemployed people, students, the elderly and those with pre-existing conditions or chronic illnesses. For these reasons, supplementary VHI introduces greater inequality into the health system (which is, otherwise, unacceptable in Denmark) and stimulates the demand for private health care, which has generally been very limited (Mossialos & Thomson 2002). The VHI market is dominated by Health Insurance “denmark”, a mutual (non-profit-making) association that covers approximately 29% of the total population and had a 99% share of the VHI market in 2004 (Health Insurance “denmark” 2007). Health Insurance “denmark” offers individual insurance policies; however, premiums are not tax deductible. The role of Health Insurance “denmark” is primarily to cover co-payments, and, in some cases, it pays for non-publicly reimbursed health care. Four different types of coverage are offered (Health Insurance “denmark” 2007). The first type of coverage, Group 1, provides coverage for expenses related to private hospital care, medication, medical aids, chiropractice, chiropody, physiotherapy, dental treatment, eye care, glasses, contact lenses, funeral aid and visits to sanatoria. Approximately 7.1% of the total Danish population were covered in Group 1 in 2004. Group 2 is designed for people who choose to pay a greater amount of their health expenses 56

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in exchange for a freer choice of both GPs and specialists. Group 2 members are reimbursed for expenses relating to GPs and specialists, in addition to receiving Group 1 coverage. Only 0.8% of the total Danish population were covered by this scheme in 2004. The third type is called Group 5. It covers medication, dental care, glasses and contact lenses. This group is mainly aimed at young people, who generally have less need for coverage. Thus, the coverage and the premium are lower compared to the two types already mentioned. Group 5 is by far the largest, comprising 22.6% of the total Danish population in 2004. The fourth type is a basic insurance, designed for people with no acute need for medical care. As a member of the Basic Insurance group, medical costs will not be refunded; however, members may switch to one of the other types of coverage whenever necessary, without having to requalify. A total of 3.6% of the Danish population are members of this type (Health Insurance “denmark” 2005). VHI is provided through annual or long-term contracts and benefits are paid in cash. Applications for coverage may be rejected if applicants do not fulfil the requirements, which mainly regard health status and are set out by Health Insurance Denmark. In recent years, private profit-making insurance companies have gained access to the market. Similar to Health Insurance “denmark”, these companies offer coverage for private hospital care in Denmark or abroad. According to the trade organization, Insurance & Pension, the number of private insurance contracts more than doubled from approximately 120 000 in 2002 to almost 300 000 in 2004 (Mandag Morgen 2005). Private health insurance is primarily distributed through company agreements in the form of group insurance. Schemes that provide a lump sum in case of “critical illness” have been the biggest successes for these insurance companies. Such schemes can be used for private hospital care or any other purpose and often form part of collective and business arrangements between employers and employees. Interest in private insurance comes from a combination of the employees pressuring employers for an agreement and companies seeing it as a modern personnel and pension policy. Insurance varies depending on the company, according to the content and degree of coverage. The typical minimum coverage includes some private hospital treatments plus preliminary examinations and after-care. If treatment cannot be conducted in a private hospital in Denmark, then it is offered abroad. The five largest private profit-making insurance companies in Denmark are Codan Care, Danica, PFA, Topdanmark and Tryg (Danish Association of the Pharmaceutical Industry 2005). Three types of private health insurance exist in Denmark: user-payment insurance, critical illness insurance and hospital insurance. User-payment 57

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insurance is individual insurance offered by Health Insurance “denmark”. Critical illness insurance is accident insurance, which can be subscribed to with Health Insurance “denmark” but it is also a part of several collective agreements between employers and employees. Hospital insurance is usually paid by employers. Several commercial insurance companies offer this kind of insurance. Generally, it covers all hospital treatment expenses. The premiums of VHI policies, which are sold by the dominant mutual association Health Insurance “denmark”, are usually group-rated and vary according to the level of coverage chosen. Commercial premiums are based on age and employment status. The maximum age limit for coverage is 60 and pre-existing conditions are excluded from the coverage. There is no regulation of premiums and no tax relief for policies purchased by individuals. Employers purchasing policies on behalf of their employees may deduct the cost of these premiums from their taxes. Almost all policies sold by Health Insurance “denmark” are purchased by individuals, while over 80% of the commercial policies are purchased by employers or groups (Thomson & Mossialos 2004) Employer tax relief for employer-paid insurance policies is likely to fuel demand for VHI in future. There are no cross-subsidies with the statutory health care system. Generally, the Danish population is not concerned with the growth of private health insurance. Approximately two thirds of the population find the act of companies offering health insurance to their employees to be positive. Only one third of the population finds it troubling and sees it as a potential risk for privatization to damage the Danish welfare model in the long run. The part of the population in favour of private health insurance is equally distributed in gender, age, education and type of work. People in the age group 15–29 years, people with less education and people earning yearly wages that are greater than DKK 500 000 are, in particular, very positive towards the growth of private health insurance (Mandag Morgen 2005). Although the level of private insurance coverage in Denmark is relatively low today, the market for VHI is expected to grow in the long run. This may undermine people’s willingness to contribute to the public health care system and it may increase inequity in access to health care, especially if the poor or unemployed cannot afford to subscribe to VHI schemes.

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4.2

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Allocation to purchasers

Resource allocation decisions are made at several levels. The most significant resource allocation mechanism at national level is the national budget negotiation that takes place once a year between the Ministry of Health, the Ministry of Finance and the regional and municipal councils, which are represented by the Danish Regions and the National Association of Local Authorities. At this annual negotiation, the following allocations are decided upon: • the recommended maximum level for municipal taxes; • the level of state subsidies to the regions and municipalities, in the form of general block grants, whose size depend on several objective factors, with the most important factors being the population’s demographic characteristics (regions and municipalities) and the size of municipal tax revenues (the municipalities only) (a minor part of the grants is distributed between the regions, based on the productivity of their hospitals, which is measured in DRG-points produced). • the level of redistribution or financial equalization between municipalities, which compensates for variations in the tax base of different areas; • the size of the one-off or permanent grants, which are earmarked for specific initiatives that require additional resources (e.g. the Second National Cancer Programme or other initiatives including heart surgery and mental illnesses). Although the regions and municipalities are responsible for providing the majority of health services in Denmark, they must stay within the health care expenditure limits that were agreed on during annual negotiations. Since most regional and municipal health care spending is financed through income taxes (81%) or real estate (property) (6%) taxes, the central Government’s strongest economic control instrument over the municipalities is their opportunity to limit or extend these revenues. If expenditure exceeds the limits – even though the municipalities are not legally bound by the annual negotiations – the national Government may penalize individual or all municipalities or regions by withholding grants, which account for 13% of total municipal health care financing. In practice, however, there are few instances of significant tax increases beyond agreed levels. Room for negotiation during the annual negotiations has been very limited since the introduction of the tax freeze on all taxation levels in 2001.

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4.3

Denmark

Purchasing and purchaser–provider relations

Financial resource allocation between the integrated purchasers and providers in the hospital sector of the Danish health care system has been subject to major changes. In the past, many county politicians and managers were very sceptical of activity-based financing, probably because their counties experienced massive deficits before the introduction of global budgeting in the 1970s. Another possible reason for this scepticism is the combination of unlimited demand for health care (which is provided free at the point of delivery) and very limited extra tax revenue (which is provided to the counties for treating a greater number of patients). However, activity-based financing was eventually introduced in the 1990s. Since the counties experienced massive deficits in the 1970s, the predominant method for allocating resources to hospitals has been prospective global budgets, which were fixed by the county councils. These budgets were based on past performance and modified when new activities were introduced, which included changes in tasks and areas of specific need. During the 1980s and 1990s, counties developed their budgetary process by increasingly including non-economic measures, such as activities (e.g. discharges, bed-days and the number of ambulatory visits) and service levels (e.g. standards for various gauges of waiting time). Some counties also wanted to include clinical quality and performance measurement management in this target, but did not succeed as the proposed measures were considered too simple. These performance measures supplemented global budgets, which continued to make up the main component, and were mostly intended to raise awareness of the relationship between costs and activity, and to create incentives for increased activity and improvement in hospital services. They were not intended to introduce competition between hospitals, and little emphasis was placed on publishing the hospitals’ results to the public. This was probably due to the fear that hospital administrations might manipulate performance data or that below-standard performances might create anxiety among voters and encourage patients to choose hospitals in other counties. Performance measures varied from county to county and, in some cases, even from hospital to hospital. Although hospital budgets are “soft” in the sense that they are not legally binding and do not include specific sanctions if targets are not achieved, persistent failure to fulfil a budget may result in replacement of managers. Another initiative to improve effectiveness has been to delegate management and financial responsibility to lower levels (e.g. from hospital to department 60

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level). It is hoped that this will increase cost-awareness and allow the better utilization of information at each organizational level. Department-level budgets are fixed through annual negotiations between the regions, hospital administrators and departments. The procedure varies across the regional level. Individual hospitals may make contracts with each department. If an inhabitant has utilized regional services such as heart transplants, or exercised his/her right to a free choice of hospital, the county or region where these services were delivered is reimbursed by the inhabitant’s own region. Before the introduction of activity-based financing, this reimbursement was passed on to the hospitals involved or, more often, kept by the regions as part of their general income. For this reason, hospitals usually did not regard reimbursement for treatment of patients from other counties as an incentive. The system of politically controlled global budgeting and contracts, combined with cost-containment efforts at the regional level, has proven to be an effective way of controlling expenditure on hospital services. However, the system provides limited economic incentives to increase efficiency at the point of service delivery and limited general incentives to increase activity if demand rises, which possibly contributes to waiting list problems for some treatment types (Pallesen 1997). Finally, global budgeting encourages hospitals and departments to view their economic budget as a “right”. It also makes it difficult to establish whether the current resource allocation mechanism is efficient or not, and to reallocate resources between hospitals and departments. A number of different initiatives, at both state and regional levels, have been introduced to counter the negative consequences of global budgeting. These initiatives are characterized by adding increasingly more performance measures in hospital budgets or by gradually introducing more market-oriented steering mechanisms into the health care sector. Activity-based financing has been gradually introduced as a resource allocation mechanism in Denmark. In 1997, extra funds were allocated to the counties so that they could experiment with activity-based financing. As part of the budget agreement for 1999, and in conjunction with the “free choice of hospital” scheme introduced in 1993, full DRG payments for patients treated at hospitals outside their home region were introduced. This has increased the incentive for regions to treat patients from other regions since, in many cases, DRG rates are higher than the deliberately low rates that were initially applied to the “free choice” scheme. At first, only marginal rates were used, for fear that this element of activity-based financing may lead to increases in health care costs; however, this has turned out not to be the case. It is still not clear to what extent this change has led to greater competition between regions. However, a survey conducted in 2002 concluded that 70% of hospitals reported having 61

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launched initiatives to attract patients from other regions to their services. The survey also showed that the share of patients from other regions that were treated in hospital departments increased by 32% between 1996 and 2000 (AnkjærJensen & Rath 2004). Since 2004, the global financing system, which is based on an adaptation of the DRG system, has been combined with negotiated activity targets for each hospital. Under this system, each hospital receives an upfront budget corresponding to 80% of the DRG rates related to the case mix in the negotiated activity target (the “baseline”), with the remaining 20% being allocated according to actual activity. Hospitals and departments that produce less DRGs than their baseline will thus receive less funds. Departments and hospitals that produce more DRGs than their baseline will experience a rise in income; however, there is a limit as to how much the extra income can exceed the baseline. This thereby combines the advantages of global budgeting with the advantages of activity-based financing. Implementation of the new scheme has varied between counties (Ankjær-Jensen & Rath 2004). The Government is planning an increase in the activity-based financing from 20% to 50% of the hospital budgets during the coming years. This increase means that the economic consequences of producing less DRGs than the baseline will become stronger for the individual hospital or department. In order to avoid hospitals and departments from discriminating against patients on the basis of their place of living, their activity is measured in DRGs independent of where patients live.

4.4

Payment mechanisms

4.4.1

Paying health care personnel

Salaries for staff employed by hospitals, nursing homes and municipal health schemes are fixed through negotiation between trade unions, professional organizations, the Danish Regions and the National Association of Local Authorities. Approximately 60% of Danish doctors work in hospitals as salaried employees. A further 10% are involved in nonclinical work such as administration, teaching and research. Approximately 23% of doctors work as GPs (Ministry of the Interior and Health 2005b). GPs licensed by a region derive almost all of their income from that region, according to a scale of fees that is agreed on by the Organisation of General Practitioners and the Danish Regions. Their remuneration is a mixture of capitation, which makes up on 62

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average a third of their income, and fee-for-service payments for services rendered (per consultation, examination, operation, etc.), including special fees for out-of-hours consultations, telephone consultations and home visits. This combined fee system has been developed over the last century. Its objective is to create incentives for the GPs to treat patients by themselves rather than to refer those who could be treated in general practice to hospital. At the same time, it provides economic security and remuneration for general services, for which fees are not paid otherwise. While the fee-for-service mechanism should increase GPs’ productivity, capitation aims at preventing GPs from providing unnecessary treatment. In 1987, the city of Copenhagen changed from an area using a mostly capitation-based system to one using the combined fee system used in the rest of the country. As a result of this change, the volume of activities which were specifically remunerated increased and referrals to specialists decreased (Krasnik et al. 1990). Priority setting also influences the contract between the GPs and Danish Regions. For example, a comparatively high fee for preventive consultations is supposed to encourage GPs to offer longer consultations focusing on broader health and prevention activities such as education regarding smoking or dietary habits, weight control, and so on. Before the introduction of this quite high fee, GPs who used extra time to discuss such topics with their patients were “punished” compared with GPs who stuck to a quick examination of each patient. Practising specialists licensed by the regions are also remunerated by region, although they only receive fee-for-service payments. In order to visit a specialist a patient must be referred by a GP; that is, unless the patient is willing to pay for the treatment on their own. Almost all specialists’ income is paid by the region. Very few doctors are employed in the private profit-making sector, but those that are work either at clinics or small hospitals or in the pharmaceutical industry. Paying providers a fee for the services rendered is intended to promote productivity, but there is little evidence concerning the efficiency of this payment mechanism. It has proven very difficult to control the regional expenditure for these services and it has, during some periods, even increased more rapidly than hospital expenditure – probably due to the strong activity-based financing element. There are limits on GPs’ and specialists’ income from the counties, but these limits are much weaker than those in the hospital sector. Health care personnel employed by the municipalities (nursing home staff, home nurses, health visitors and municipal dentists) are paid a fixed salary. Public health professionals are employed at public (at both state and municipal levels, and within research institutions) and private institutions involved in the administration, planning and provision of health care. Public health professionals are mainly paid on the basis of fixed salaries. For details 63

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of the payment of dentists and dental auxiliaries, see Section 6.11 on Dental health care.

4.5

Health care expenditure

The national data on health care expenditure differ from the approach applied by the Organisation for Economic Co-operation and Development (OECD) in terms of method of measurement and the extent of services included. In this section, OECD data are primarily used to improve the possibility of crosscountry comparison, and despite recognition of the methodological difficulties that are also embedded in this approach. Danish health care expenditure as a percentage of GDP is slightly lower than the EU average for the Member States belonging to the EU before May 2004 (see Fig. 4.2, Fig. 4.3 and Fig. 4.4).

Table 4.1 Trends in health care expenditure, 1980–2003 (selected years)

Total health expenditure, US$ PPP per capita Total health expenditure as a % of GDP Public expenditure on health as a % of total expenditure on health Private expenditure on health as a % of total expenditure on health Out-of-pocket payments, US$ PPP per capita Out-of-pocket payments as a % of total expenditure on health Private insurance – % of total expenditure on health Mean annual real growth rate in total health expenditurea Mean annual real growth rate in GDP

1980

1985

1990

1995

2000

2002

2003

943

1 275

1 554

1 843

2 353

2 583

–

9.1

8.7

8.5

8.2

8.4

8.8

9.0

87.8

85.6

82.7

82.5

82.4

82.9

8.0

12.2

14.4

17.3

17.5

17.6

17.1

17.0

107

173

249

300

373

396

–

11.4

13.6

16.0

16.3

15.9

15.3

–

0.8

1.3

1.2

1.6

–

2.3

4.3

2.0

–

1.0

2.8

3.0

1.7

2.3

Sources: Ministry of Finance, 2001; Ministry of the Interior and Health, 2005b; OECD, 2004. Notes: a 2003 prices; PPP: purchasing power parity; GDP: gross domestic product. 64

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Fig. 4.2

Denmark

Health care expenditure as a share (%) of GDP in the WHO European Region, 2004, WHO estimates Western Europe

11.6 10.9 10.8 10.0 9.9 9.9 9.8 9.8 9.8 9.5 9.3 9.2 9.0 8.7 8.7 8.1 7.8 7.8 7.7 7.5 7.5 7.2 7.1 6.9 6.2

Switzerland Germany Iceland France Norway Monaco Portugal Netherlands Greece Sweden Belgium Malta Denmark Italy Israel United Kingdom Spain San Marino Turkey Finland Austria Ireland Andorra Luxembourg Cyprus

Central and south-eastern Europe

Bosnia and Herzegovina Slovenia Hungary Croatia Bulgaria Czech Republic The former Yugoslav Republic of Macedonia Albania Lithuania Poland Latvia Slovakia Romania Estonia

9.3 8.7 8.4 7.9 7.7 7.2 7.0 6.6 6.5 6.4 6.4 5.8 5.7 5.5

CIS

7.5 6.3 5.8 5.6 5.4 5.4 5.3 4.5 4.0 3.9 3.8 3.7

Republic of Moldova Belarus Ukraine Armenia Uzbekistan Kyrgyzstan Russian Federation Tajikistan Georgia Kazakhstan Turkmenistan Azerbaijan Averages EU Member States before May 2004 EU average CIS average

9.3 8.7 5.3 0

% of GDP

Source: WHO Regional Office for Europe, January 2007. Notes: CIS: Commonwealth of Independent States; EU: European Union.

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Fig. 4.3

Denmark

Trends in health care expenditure as a percentage of GDP in Denmark and selected other countries, 1998–2004, WHO estimates

5 1998 Denmark United Kingdom

1999

2000 Germany EU average

2001

2002 Norway EU15

2003

2004

Sweden EU12

Source: WHO Regional Office for Europe, January 2007. Notes: EU: European Union; EU15: European Union Member States before May 2004; EU12: countries that joined the EU in May 2004 and January 2007.

In Denmark, health care expenditure as a percentage of GDP fell in the 1980s; however, it has slowly risen since 1995 (see Table 4.1). The relatively high health care expenditure as a percentage of GDP in 1980 was largely due to a change in the definition and calculation of health care expenditure to include expenditure on nursing homes. In the 1980s, there was a trend towards rising private expenditure as well, which was driven by a political effort to contain public expenditure (see Section 2.1 on Historical background). The public proportion of total health expenditure, however, has been fairly stable during the period 1995–2003 (OECD 2004).

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Fig. 4.4

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Health care expenditure in US$ PPP per capita in the WHO European Region, 2004, WHO estimates Western Europe

Monaco Luxembourg Switzerland Norway Iceland San Marino Netherlands Germany France Belgium Sweden Denmark Ireland Andorra United Kingdom Italy Austria Finland Greece Israel Spain Portugal Malta Cyprus Turkey Central and south-eastern Europe Slovenia Hungary Czech Republic Croatia Slovakia Lithuania Poland Estonia Latvia Bulgaria Romania The former Yugoslav Republic of Macedonia Albania Bosnia and Herzegovina CIS Belarus Russian Federation Kazakhstan Ukraine Armenia Turkmenistan Republic of Moldova Georgia Kyrgyzstan Uzbekistan Azerbaijan Tajikistan Averages EU Member States before May 2004 EU average CIS average

4 797 3 992 3 954 3 862 3 508 3 172 3 056 3 052 3 016 2 922 2 875 2 838 2 619 2 581 2 531 2 424 2 365 2 275 2 106 1 972 1 908 1 903 1 686 972 589 1 760 1 334 1 333 897 829 816 810 776 751 635 566 411 409 359 740 571 393 361 321 224 202 193 177 169 160 82 2 645 2 268 444 1 000

2 000

3 000

4 000

5 000

US$ PPP Source: WHO Regional Office for Europe, January 2007. Notes: PPP: Purchasing pwer parity; CIS: Commonwealth of Independent States; EU: European Union.

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Physical and human resources

5.1

Physical resources

Infrastructure and capital investment

5.1.1

Denmark

he regions are responsible for providing hospital care and they own and run hospitals and prenatal care centres. They also finance GPs, specialists, physiotherapists, dentists and pharmaceuticals. Health care is largely a regional responsibility, and most national legislation concerning the health care sector does not specify how it should be organized or which services should be provided (see Section 3.2 on Planning and health information management). The number of beds in somatic and psychiatric hospitals in Denmark has declined substantially since the 1990s (see Tables 5.1 and 5.2), reflecting a trend in almost all western European countries (see Fig. 5.1). Somatic activity has increased since the mid-1990s, parallel with a reduction in the number of hospitals. The number of discharges increased from 1996 to 2005, with an average yearly rise of 1.3%. This should be looked at along with the average length of stay, which has decreased by 1.6 days during the same period. There has been a fall in the number of bed-days from approximately 6 million in 1996 to approximately 5 million in 2005, which corresponds to an average annual fall of 2% (Ministry of the Interior and Health 2006). The number of discharges from psychiatric hospitals increased during the period 1997–2003, with an average yearly rise of 2.2%. The number of psychiatric hospitals was stable from 1997 until 2001, where it began to vary noticeably; from 2000 to 2001, the number of psychiatric hospitals was reduced from 12 to 9 and then subsequently increased to 10 and 14 hospitals in 2002 and 2003, respectively (Ministry of the Interior and Health 2006). 69

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Table 5.1 Activity in somatic hospitals, 1996–2005 (selected years) Hospitals Discharges Bed days Beds Average length of stay (days) Bed occupancy rate (%)

1996 1998 2000 2002 2004 2005 79 76 61 58 52 – 980 000 996 000 1 029 000 1 062 000 1 089 000 1 102 000 5 990 000 5 738 000 5 567 000 5 471 000 5 111 000 4 998 000 20 476 19 472 18 484 18 166 16 668 16 410 6.1

5.8

5.4

5.2

4.7

4.5

80.1

79.5

81.7

79.0

82.2

83.5

Sources: Ministry of the Interior and Health, 2004b; Ministry of the Interior and Health, 2006.

Table 5.2 Activity in psychiatric hospitals, 1997–2003 1997 1998 1999 2000 2001 2002 2003 Hospitals 12 12 12 12 9 10 14 Discharges 35 526 36 769 38 626 38 982 40 691 40 815 40 423 Bed days 1 440 000 1 433 000 1 442 000 1 406 000 1 373 000 1 330 000 1 280 000 Beds 4 029 3 999 4 022 3 894 3 886 3 799 3 676 Bed occupancy 97.9 98.3 98.2 98.9 96.8 95.9 95.4 rate (%) Outpatient 450 000 483 000 532 000 564 000 567 000 746 000 643 000 visits Source: Ministry of the Interior and Health, 2006.

The relative reduction in the number of beds is most significant in psychiatry, largely due to a policy of deinstitutionalization. During the period 1980–1990, the number of psychiatric beds was dramatically reduced from 8182 to 4906. The general decline in the number of beds in both somatic and psychiatric hospitals is associated with a large increase in the number of outpatient visits. Many diagnostic and therapeutic procedures can take place without inpatient admission, or before and after an inpatient stay. Capital investment The regional and local authorities are responsible for conducting estate condition surveys. There is no central assessment of overall estate conditions. In the primary health care sector, the GPs and practising specialists own or rent their practice as independent contractors. No central or regional estate condition surveys are conducted at this level. 70

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Fig. 5.1

Denmark

Beds in acute hospitals per 1000 population in Denmark, selected countries and EU averages, 1990â&#x20AC;&#x201C;2005

2 1990

1991

1992

1993

Denmark Sweden EU15

1994

1995

1996

1997

1998

Germany United Kingdom EU12

1999

2000

2001

2002

2003

2004

2005

Norway EU average

Source: WHO Regional Office for Europe, January 2007. Notes: EU: European Union; EU15: European Union Member States before May 2004; EU12: countries that joined the EU in May 2004 and January 2007.

The task of ensuring functional sustainability and appropriate space utilization of existing buildings is the responsibility of the decentralized levels and the State is rarely involved. Supervision over fire and safety compliance in hospitals lies with the local authorities. Regional capital investments are funded through general revenue with the exception of occasional grants, which are provided as direct transfers from the central Government to earmarked investments in health areas with special political focus, such as medical equipment to improve cancer care services. The financing of large-scale buildings is accomplished through a combination of general revenue, savings and loans. However, the central administration sets limitations on the economic activities of the regions, regarding the level of expenditure and borrowings. These limitations vary over time and they are generally based on political considerations. From 2007, the Ministry of Health must approve investments above a certain level. A redistribution of funds between municipalities has been implemented to ensure equitable geographic distribution of capital. The redistribution is devised according to a formula that accounts for the following factors: age distribution; the number of children in 71

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single parent families; the number of rented flats; the rate of unemployment; the number of people with a low level of education; the number of immigrants from non-EU countries; the number of people living in socially deprived areas; and the proportion of elderly people living alone. The influence of the private health care sector is marginal and its size is not regulated. 5.1.2

Information technology

Denmark, with 22 fast Internet connections per 100 inhabitants in 2005, was among the countries in Europe with the highest number of fast Internet connections, despite the relatively high user costs (Ministry of Science, Technology and Innovation 2005). In 2002, within a 3-month study period, 55% of the population had made contact with the public administration services using the Internet. Most commonly, people sought information from a public sector web site (40%), or engaged in other activities, such as downloading forms (16%) and sending information to authorities (13%) (Statistics Denmark 2004). In recent years, access to the Internet has generally increased. In 2004, 83% of the population had access to the Internet from home and/or work compared to 73% in 2001. The increase in home-based connections was particularly significant, reaching 70% of the population in 2004 compared to 59% in 2001. Access to the Internet from work was at 58% in 2004, compared to 53% in 2003 (Statistics Denmark 2004). Access to the Internet has increased for all age groups during the period 2001–2004. The most significant increase was among those aged 60–74 years, from 31% in 2001 to 53% in 2004 (Fig. 5.2). However, those in the group aged 16–39 years continue to have the highest percentage of access, with 96% in 2004. Concerning educational status, access to the Internet increases with the level of education. In the group with “higher education”, 96% had access compared to 71% within the group with “basic school” education. Students, white-collar workers and self-employed individuals all have a high degree of access to the Internet, with 96% for the first two groups and 91% for the latter. The unemployed group has significantly less access to the Internet (51%) compared to the other groups (Statistics Denmark 2004; Ministry of Science, Technology and Innovation 2005). In Denmark, a National Strategy Group has been established for the development of an IT strategy in health. This group is made up of the Ministry of Health, the National Board of Health, the Danish Regions and the National Association of Local Authorities. A National Strategy (2000–2002) for implementing IT in the hospital system was first published in 1999 and 72

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Fig. 5.2

Denmark

Internet access by the Danish population, 2004 (%) Women Men

Higher education Upper (secondary) school Lower (primary) school 60–74 years 40–59 years 20–39 years 16–19 years Unemployed Self-employed White-collar worker Blue-collar worker Student 0

100

Sources: Statistics Denmark, 2004; Ministry of Science, Technology and Innovation, 2005.

then subjected to hearings. Subsequent revisions of this document produced a National IT Strategy for the Danish health care service, which provided a common framework for the full computerization of the health sector during the period 2003–2007 (Ministry of the Interior and Health 2003b). These initiatives included the implementation of electronic health records (EHRs) in the Danish health care sector, and the spread of EHRs within the health system has taken place in recent years. However, the implementation process of the full strategy has not been very successful and available information suggests that the objectives have not been met so far. Exploiting the possibility of sharing data among systems that are already in use in the health care sector, through integrated information systems and EHRs and using common standards, is a major priority of the IT strategy. In 1998, the Danish Electronic Health Record Observatory was launched by the Ministry of Health, with the purpose of supporting the national health IT strategy by monitoring and assessing the development, implementation and application of EHRs in hospitals. The EHR Observatory is also part of the National IT Strategy 2003–2007. Explicit goals of the Strategy were: to install EHRs in all hospitals by January 2006; to ensure EHRs are based on the national information model for EHRs; to implement large-scale national eXtensible Markup Language (XML) communication between and within hospitals by 2005; and to establish an Internet-based secure health network by 2005 (BrunnRasmussen, Bernstein, Vingtoft, Andersen & Nohr 2003). Health professionals 73

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and IT experts have criticized the fact that the former counties have established different EHR systems and approaches, which they regard as a serious drawback, due to waste of resources and lack of coordination. Considering the complexity of the problems and the decentralized approaches that have been taken during the initial phases, full and functional EHR coverage of the Danish health care sector is not expected any time in the near future. A central initiative of the National IT Strategy is the creation of a common public health portal. Such a portal is intended to provide a common basis for communication and information in a cooperating health care sector. In addition, it is meant to provide citizens with an electronic access point to the health care sector (Lippert & Kverneland 2003). Currently, IT has been introduced to and, to some extent, used in all parts of the health care sector. Denmark ranks among the countries with the most widespread use of electronic communication within the health care sector. This is particularly attributable to collaboration between the central and regional health authorities on the establishment of the Danish health care data network for the communication of clinical messages, such as medical prescriptions from a GP to the pharmacy and referrals from a GP to the hospital. In 2002, approximately 2.4 million messages per month were exchanged among more than 2500 parties including hospitals, pharmacies, laboratories, GPs, and so on. Furthermore, IT is expanding within each part of the health care sector. In 2002, more than 87% of GPs used electronic medical patient records (Ministry of the Interior and Health 2003b). Within hospitals, IT systems are used to register patient data such as patient files, patient administrative systems, laboratory systems, blood bank systems and diagnostic imaging and booking systems. The patient administrative systems, which are extended throughout the entire health system, deliver data to central registers (such as the National Patient Registry). More than half of the local authorities have introduced electronic care systems, supporting the tasks of health recording, administration of drugs, and documentation and planning. 5.1.3 Medical equipment, devices and aids There is very limited national information available from hospitals and primary care facilities on existing medical equipment and its use in the Danish health system. The only available data include the number of magnetic resonance imaging (MRI) units, computed tomography scanners (CT), and radiation therapy equipment. The number of MRI units increased from 13 units in 1990 to 55 units in 2004, corresponding to a 423% increase. During the same period, the number of CT scanners increased from 22 to 79 scanners corresponding 74

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to a 359% increase. Finally, from 1981 to 2004 radiation therapy equipment increased from 25 to 35 units (OECD 2006). 5.1.4

Pharmaceuticals

Pharmaceutical expenditure Pharmaceutical expenditures for Denmark and selected European countries are illustrated in Table 5.3. As shown, Denmark’s per capita consumption of pharmaceuticals is well below that of other western European countries (measured as sales in ex-factory prices and including both prescription and non-prescription medicines and in both the primary care and hospital sectors). Pharmaceutical consumption in Denmark is lower than in any other western European country as well, at only 0.4% of the country’s GDP. Pharmaceutical expenditure in the primary health care sector in 2005 was DKK 11 935 million (calculated in terms of pharmacy retail price, including prescription charge and VAT) and in the hospital sector this was DKK 4398 million (calculated in terms of hospital pharmacy settling price, including VAT). Expenditure on over-the-counter (OTC) pharmaceuticals was DKK 1876 million. OTC pharmaaceuticals are also was sold through authorized retail outlets (DKK 205 million) (Danish Medicines Agency 2006). Table 5.3 Pharmaceutical consumption in Europe, 2002

Country

Austria Denmark Finland France Germany Greece Ireland Italy Luxembourg Spain Sweden

Pharmaceutical expenditure per inhabitant, US$ (PPP)

Share of public health care expenditure on medicine, %

Public health expenditure on medicine as a % of GDP

358 239 309 570 408 278 259 484 355 354 329

17.3 5.8 11.1 18.4 18.8 20.7 12.3 15.4 11.2 22.2 10.6

0.9 0.4 0.6 1.4 1.2 1.0 0.7 1.0 0.6 1.2 0.8

Public sector’s share of medicine expenditure (reimbursement share), % 74.9 52.5 53.0 67.0 74.8 71.5 84.2 52.1 82.5 73.6 69.3

Source: OECD, 2004. Notes: PPP: Purchasing power parity; GDP: Gross domestic product. 75

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In 2005, sales of medicinal products in the hospital sector accounted for 27% of total sales. In the primary care sector, pharmaceutical expenditure was financed by the regional health authorities (56%), patient co-payments (39%) and municipalities (4%). Pharmaceutical consumption was DKK 1137 per 1000 inhabitants per day in 2003 (DKK 1092 from the primary health care sector and DKK 45 from the hospital sector). Figure 5.3 shows the number of people being treated with prescribed medicinal products in the primary health sector (by sex and age). The constant increase in pharmaceutical consumption, which was observed throughout the 1990s, is still prevalent in Denmark today. This is partly due to the growing elderly population. During the last decade of the 20th century, a considerable number of new medicines were marketed; of these, most were either modifications of existing drugs, or pharmaceuticals for the treatment of previously untreatable ailments. This has attracted new consumer groups. Furthermore, it is increasingly common to use a combination of several drugs instead of single substances in the treatment of many diseases (e.g. hypertension, rheumatoid arthritis and gastric ulcers). Fig. 5.3

Number of people treated with prescribed medicinal products in the primary health care sector, by sex and agea

Source: Personal communication from Ellen Westh Sørensen (Department of Social Pharmacy, University of Copenhagen), 2006. Note: a Population as of 1 January 2006. 76

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The steady rise in the level of pharmaceutical expenditure has focused political attention on the pharmaceutical market for many decades, but particularly since the late 1980s. In spite of several initiatives to control costs (such as price freezes, price cuts, generic substitution and reference pricing), the level of pharmaceutical expenditure continues to rise today. Price levels In Denmark, the pricing of medicinal products is not controlled. Figure 5.4 shows the price index for medicines in some European countries in 2003. These indexes were calculated based on an assortment of Danish medicines, by comparing the package prices of a medicine in Denmark to those in another country where the same packages were available. Denmark, Finland and Sweden all have the same level, whereas Italy and Norway’s price indexes are lower. Iceland, together with Ireland, Great Britain, Germany and Liechtenstein, all pay a higher price than Denmark for the same medicines. Pharmaceutical cost–containment methods Generic substitution is one of the tools used to contain the growth of pharmaceutical expenses. Pharmacists are required to substitute the least expensive, or close to the least expensive, generic medicine for the medicine Fig. 5.4

Price index for medicines, 2003

Source: Jørgensen & Keiding, 2004. Note: Index: Denmark=100. 77

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prescribed by the physician, when that the prescriber has not clearly stated to the contrary or the patient has not refused the substitution. Generic substitution slows down increasing drug costs 2-fold: by the actual change to a less expensive generic drug; and by stimulating price competition among interchangeable medicines. Generic substitution is possible among products containing the same quantity of the same active substance, if their biological equivalence has been proven and marketing authorizations granted. During recent years, some important medicines (including citalopram, simvastatin, omeprazol and felodipin) have lost their patent protection. This, along with generic substitution, has led to heavily decreased prices and a relatively small increase in pharmaceutical expenditure. Another approach to controlling pharmaceutical expenditure is parallel imports of pharmaceuticals, which has been practised since the beginning of the 1990s. Denmark has a high proportion of generic and parallel import products on the market. Parallel importing of pharmaceuticals has been permitted since 1990. Generics (including leading brand name (original) products make up 10–11% of the total pharmaceutical market. In 2003, the number of packages prescribed with generic competition was 27% of the total number of packages. In 1999, this figure was 23%. The use of generic and parallel-imported products was promoted from 1993 through a reference pricing system for reimbursement. Under this system, reimbursement was based on the average price of the two least expensive versions of a specific product. In 2005, the basis for reimbursement was changed to the lowest price paid in the EU. In 1999, the Institute for Rational Pharmacotherapy was founded to guide doctors in rational prescribing. It also has the function of elaborating treatment guidelines with respect to cost. Each region employs local groups of pharmacists and GPs to monitor prescription patterns and advise GPs on rational prescribing. The Institute for Rational Pharmacotherapy coordinates educational activities for local-level groups as well. It also established a national formulary for medical doctors for rational choice of treatments in 2003. Practice guidelines are produced by the medical colleges for various specialties and by the Danish College of General Practice. The Institute for Rational Pharmacotherapy aims to provide objective information and guidelines on the rational use of pharmaceuticals, both in pharmacological and economic terms. However, marketing authorization is based on chemical, pharmaceutical, clinical and safety criteria, without any assessment of need or cost–effectiveness; this means that there is no essential 78

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drugs list in the Danish pharmaceutical sector. Instead, consumption is partly regulated through the reimbursement system. Reimbursement In Denmark, reimbursement for an individual medicine is based on its main indication; however, other secondary indications also warrant reimbursement. Some pharmaceutical products are only reimbursed for certain diseases. The medicine’s therapeutic effect, value added, and side-effects are also factors considered when deciding on reimbursement. Price comparisons and economic evaluations also form part of the decision-making process. The Danish Medicines Agency decides on the reimbursement status of each pharmaceutical product. The Danish Medicines Agency is a parallel board to the National Board of Health under the Ministry of Health. It is responsible for legislation concerning pharmaceuticals and medical devices, the approval of new products, clinical trials, deciding which drugs should be reimbursed, and licensing companies that produce and distribute pharmaceuticals. The regional health authorities advise the Danish Medicines Agency before they make any decision on whether or not to reimburse a particular drug. In general, reimbursement is granted for drugs that have a definite and valuable therapeutic effect and when they are used for a well-defined indication. The total trade of medicinal products assigned reimbursement in 2005 equalled DKK 9.3 million (Danish Medicines Agency 2006). For pharmaceutical products without general reimbursement, an individually based subsidy may be obtainable by submitting an application, through a patient’s own physician, to the Danish Medicines Agency. The cost of public reimbursement for medicines in the primary health sector has increased steadily over the years. Complementary VHI covering the cost of medication is quite common in Denmark: approximately 1.9 million Danish citizens (29% of the population) are members of the non-profit mutual insurance company Health Insurance “denmark” (Health Insurance “denmark” 2007). Usually, only pharmaceuticals subject to prescription are eligible for reimbursement. Drugs available without a prescription may be included in the list of reimbursable pharmaceuticals, but in such cases reimbursement is only granted to pensioners and patients suffering from a chronic illness that requires continuous treatment with the drug. A prescription would have to be issued for the pharmaceutical in question as well. Even if a drug meets the criteria for reimbursement, certain characteristics of the pharmaceutical, its specific use or the way in which it is prescribed may lead to a non-reimbursement decision. There are no fixed percentages for the reimbursement of medicines but reimbursement relates to the patient’s annual pharmaceutical expenses. From 79

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April 2005 reimbursement is calculated according to the least expensive generic product. Patients with high pharmaceutical expenses are reimbursed for a higher percentage of their expenses. As of 2006, percentage groups were 0%, 50%, 75% and 85%. Expenses below DKK 520 per year are not reimbursed. If the patient’s payment exceeds approximately DKK 3900, the patient can apply for 100% reimbursement for the rest of the year.

5.2

Human resources

5.2.1

Trends in health care personnel

Public health professionals In Denmark, public health was established during the 1980s as a separate medical specialty with a standardized theoretical and practical training programme, including health management, occupational medicine and social medicine. In 1996, the first Danish postgraduate Master of Public Health programme was established and, in 1999, the University of Copenhagen launched a 5-year university programme in public health (Bachelor/Master (Candidatus) Education in Public Health Sciences). This was followed by the University of Southern Denmark in 2001. The first Masters of Science in Public Health from the University of Copenhagen graduated in 2004. Masters of Science in Public Health are qualified to work in public and private companies in the areas of health service planning, administration and case processing as well as in health care analysis, development, guidance, training and research that focuses on disease prevention and health promotion. Private employers include consulting firms working in the areas of social welfare and health, and companies in the pharmaceutical industry. To this may be added national and international organizations such as the Danish Cancer Society, the Danish Heart Foundation, the Red Cross, WHO, the OECD and the World Bank. Universities and institutes of higher education are also employers of Masters of Science in Public Health. The Danish Graduate School in Public Health offers a national PhD education within public health sciences. The Graduate School involves cooperation between 13 institutions comprising the University of Copenhagen, University of Southern Denmark, University of Aarhus, government research institutes, hospital research units, and private research organizations. The Graduate School is organizationally anchored in the Institute of Public Health of the University of Copenhagen.

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Doctors Approximately 11 000 doctors were employed at hospitals in 2003, which is 600 more doctors than in 2001. The average yearly growth rate of doctors employed full time at hospitals increased by 2.8% for the entire country during the period 2000–2003. Approximately 45% of doctors employed in hospitals have permanent positions (Danish Medical Association 2005). The rest are employed in temporary positions as part of their postgraduate educational programme. Temporary positions are set up in specific hospitals and departments by the National Board of Health in an attempt to distribute newly qualified doctors between specialties and geographic areas, according to need and capacity. In this way, the National Board of Health is able to control the number of doctors trained in different specialties. Approximately 3680 doctors are GPs, which corresponds to one per 1575 inhabitants. Recruitment of young doctors into general practice has been supported by an increasing recognition of general practice as a formalized specialty with growing scientific activity, improved social and professional environments (with group practices) and a fair income compared to hospital doctors. Whereas GPs are fairly well distributed across the country, the 1387 Fig. 5.5

Number of physicians per 1000 population in Denmark, selected countries and EU averages, 1990–2005

1 1990

1991

1992

Denmark United Kingdom

1993

1994

1995

1996

Germany EU average

1997

1998

1999

Norway EU15

2000

2001

2002

2003

2004

2005

Sweden EU12

Source: WHO Regional Office for Europe, January 2007. Notes: EU: European Union; EU15: European Union Member States before May 2004; EU12: countries that joined the EU in May 2004 and January 2007.

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full-time practising specialists are concentrated in the capital and other large urban areas (Danish Medical Association 2005). Approximately 1100 doctors do not work in a clinical setting but they are fully employed as medical public health officers or researchers and teachers at public and private institutions. Medical public health officers are responsible for monitoring health conditions in their respective regions and for supporting public authorities by counselling, along with the supervision of health care professionals on behalf of the National Board of Health. The number of doctors in Denmark is increasing, albeit at a slightly lower rate than in other EU countries. This can be attributed to the limited access to medical training programmes in Denmark during the 1970s and 1980s (see Fig. 5.5 and Fig. 5.7). At the time of writing, the recruitment of doctors is becoming increasingly difficult, especially in rural areas that are far from the urban centres.

Fig. 5.6

Number of nurses per 1000 population in Denmark, selected countries and EU averages, 1990–2005

20 18 16 14 12 10 8 6 4 1990

1991

1992

Denmark EU average

1993

1994

1995 Germany EU15

1996

1997

1998

1999

Norway EU12

2000

2001

2002

2003

2004

2005

Sweden

Source: WHO Regional Office for Europe, January 2007. Notes: EU: European Union; EU15: European Union Member States before May 2004; EU12: countries that joined the EU in May 2004 and January 2007.

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Fig. 5.7

Denmark

Number of physicians and nurses per 1000 inhabitants in the WHO European Region, 2005 or latest available year (in parentheses)

Monaco (1995,1995) Greece (2004,2004) Belgium (2003,2004) Switzerland (2005,2000) Italy Iceland (2005,2004) Israel Netherlands Norway Denmark (2004,2004) Austria Malta Portugal France Germany (2005,2004) Andorra Sweden (2004,2002) Spain (2003,2000) Finland (2003,2004) Ireland Luxembourg (2004,2004) San Marino (1990,1990) Cyprus United Kingdom (2002, –) Turkey (2003,2004) Central and south-eastern Europe Lithuania Bulgaria Czech Republic Estonia (2004,2004) Latvia Slovakia (2004,2004) Hungary Serbia Croatia Slovenia (2004,2002) Poland (2004,2004) The former Yugoslav Republic of Macedonia Romania Montenegro Bosnia and Herzegovina Albania (2004,2005) CIS Belarus Georgia Russian Federation Kazakhstan Azerbaijan Armenia Republic of Moldova Ukraine Uzbekistan Turkmenistan (2004,2004) Kyrgyzstan Tajikistan Averages CIS average EU Member States before May 2004 (2004,2004) EU average

6.6 4.9 3.5 4.4 13.4 3.9 8.3 3.9 7.0 3.7 9.4 3.7 6.1 3.7 14.5 3.7 15.3 3.6 9.8 3.5 6.1 3.5 5.5 3.4 4.6 3.4 7.5 3.4 7.7 3.4 3.4 3.2 10.2 3.2 3.7 3.2 7.6 2.8 15.4 2.8 9.5 2.5 5.1 2.4 4.0 2.1 1.4 2.6

16.2

4.0 7.4 3.6 4.0 3.6 8.5 3.2 6.4 3.2 5.4 3.1 6.6 2.8 8.8 2.6 5.4 2.5 5.2 2.3 7.2 2.2 4.6 4.8 2.2 3.7 1.9 1.9 4.9 1.4 4.4 1.2 3.6 4.7 4.5 4.2 3.7 3.6 3.5 3.1 3.0 2.7 2.6 2.5 2.0

3.9

4.1

4.7 5.8 4.4

3.7 3.4 3.2 0

Physicians Nurses

11.9

8.0 6.4 7.2

7.1 7.8 10.2

7.9 7.5 7.0 5

Number per 1000 inhabitants Source: WHO Regional Office for Europe, January 2007. Notes: CIS: Commonwealth of Independent States; EU: European Union.

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Fig. 5.8

Denmark

Number of dentists per 1000 inhabitants in Denmark, selected countries and EU averages, 1990–2005

1.5

0.5

0 1990

1991

1992

Denmark United Kingdom

1993

1994

1995

Germany EU average

1996

1997

1998

1999

Norway EU15

2000

2001

2002

2003

2004

2005

Sweden EU12

Source: WHO Regional Office for Europe, January 2007. Notes: EU: European Union; EU15: European Union Member States before May 2004; EU12: countries that joined the EU in May 2004 and January 2007.

Nurses In Denmark, the total number of nurses was 59 055 in 2003, which is 6578 more than in 1994, corresponding to a 12.5% increase during the period 1994–2003. In 2003, 35 281 nurses worked in full-time positions at hospitals, which is 5666 more than in 1994. The share of nurses working at hospitals has steadily increased during the period 1994–2003. In 2003, 11 210 nurses worked in the outpatient care sector (that is, not in hospitals) and in the social sector and 4209 worked at nursing homes and other institutions (Ministry of the Interior and Health 2005b). According to WHO data (see Fig. 5.6 and Fig. 5.7), the number of nurses in Denmark is relatively small compared to those in neighbouring countries (namely, Sweden and Norway). National data show that there are approximately 750 nurses per 100 000 inhabitants compared to approximately 1440 nurses per 100 000 inhabitants in Norway. Such comparisons, however, are not straightforward due to differences in the classification systems of nurses and other groups of caregiving personnel.

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Dentists and dental auxiliaries In 2004, two thirds of Denmark’s 5272 dentists worked in private practice, while the other third were employed by the municipalities. There was a decline (-2.6%) in the number of dentists during the period 1995–2004 (Fig. 5.8). 1537 dental auxiliaries were employed or available for the labour market in 2004, which corresponds to a 47.9% increase from 1995 figures. Dental auxiliaries now perform some of the tasks previously carried out by dentists (Ministry of the Interior and Health 2006). Psychologists In 1993, psychologists gained public professional authorization from the former Ministry of Social Affairs and a special committee was set up to evaluate psychologist qualifications. This authorization gave private practice psychologists access to public reimbursement for referred patients suffering from mental disorders related to serious illness, violence, attempted suicide, bereavement, and so on. The Danish Association of Psychologists had 7315 members in 2004, of whom 6064 were registered psychologists and the rest students (Danish Association of Psychologists 2005). Physiotherapists, chiropractors, pharmacists and midwives Physiotherapists are either private practitioners, who are partly reimbursed by the regions, or public employees at hospitals and other public health institutions. In 2004, 7580 physiotherapists were employed or available for the labour market, corresponding to a 48.9% increase during the period 1995–2004 (Ministry of the Interior and Health 2006). The Association of Danish Physiotherapists had approximately 8000 members (as reported in 2005), up from 7000 in 2001 (Association of Danish Physiotherapists 2005). Chiropractors have had public authorization since 1992. They are primarily self-employed in the primary health care sector; however, in the last couple of years, they have also been employed at hospitals and as consultants within the regions. Members of the Danish Chiropractors’ Association can also receive partial reimbursement from the regions. In 2004, 380 chiropractors were employed or available for the labour market, corresponding to an increase of 43.4% during the period 1995–2004 (Ministry of the Interior and Health 2006). The Association had 507 members (as reported in 2005), compared to 337 in 2001 (Danish Chiropractors’ Association 2005). Most pharmacists work in private pharmacies under strict government regulation. In 2004, there were 3574 pharmacists (Fig. 5.9). Since 1995, this group has increased by 17.4% (Ministry of the Interior and Health 2006) (see Section 6.5 on Pharmaceutical care). 85

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Fig. 5.9

Denmark

Number of pharmacists per 1000 population in Denmark, selected countries and EU averages, 1990–2005

1 0.9 0.8 0.7 0.6 0.5 0.4 0.3 0.2 0.1 0 1990

1991

1992

1993

1994

1995

1996

Denmark Sweden EU15

1997

1998

1999

Germany United Kingdom EU12

2000

2001

2002

2003

2004

2005

Norway EU average

Source: WHO Regional Office for Europe, January 2007. Notes: EU: European Union; EU15: European Union Member States before May 2004; EU12: countries that joined the EU in May 2004 and January 2007.

Midwives in Denmark are mainly employed by obstetric departments in hospitals, including decentralized outpatient clinics. In 2004, there were 1463 midwives compared to 1095 in 1995 (Ministry of the Interior and Health 2006). Table 5.4 Health care personnel per 1000 population, 1980–2003 (selected years)

Active doctorsa Active nursesb Active dentists Active pharmacists Active midwives

1980 1.8 4.9 0.8 0.3 0.1

1985 2.3 6.2 0.8 – 0.2

1990 2.5 5.7 0.8 – 0.2

1995 2.6 6.4 0.8 0.5 0.2

2000 2.8 6.9 0.8 0.5 0.2

2001 2.8 7.0 0.8 0.5 0.2

2002 2.9 7.1 0.8 0.5 0.2

2003 3.0 7.0 0.8 – 0.2

Sources: WHO, 2005; WHO Regional Office for Europe, 2005. Notes: a The number of physicians at the end of the year includes all active physicians working in health services (public or private), including health services under ministries other than the Ministry of Health. Interns and residents (i.e. physicians in postgraduate training) are also included. The number of physicians excludes: physicians working outside the country; physicians on the retired list and not practising or unemployed; physicians working outside health services (e.g. employed in industry, research institutes, etc.); dentists (stomatologists), who should be defined as a separate group; b The number of nurses includes: qualified nurses; first- and second-level nurses; feldshers; midwives; and nurse specialists. It excludes nursing auxiliaries and other personnel, who do not have formal education in nursing.

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The number of health personnel in 2004 was estimated at 122 651, which is 17 000 more than in 1995, corresponding to a 16% increase. Table 5.4 provides further details of health care personnel numbers since 1980. In 2004 there were 86 914 full-time employed individuals working at Danish hospitals, compared to 83 691 in 1995. Approximately 80% of these had a formal health-related education. Nurses comprised the largest group, with 35% of the total personnel, while doctors comprised 13%. There was a 1.8% increase in full-time employed health personnel during the period 2001–2004 (Ministry of the Interior and Health 2006). 5.2.2

Planning of health care personnel

As it is difficult to foresee the future need for health care personnel, periods of unemployment among doctors in Denmark have been followed by periods of staff shortage. The number of doctors increased dramatically during the 1960s and 1970s due to a large intake of medical students. This led to temporary unemployment among doctors during the 1980s, although expansion of the health sector and a reduction in working hours made it possible for the system to absorb most doctors. At present, there is a shortage of nurses and doctors, particularly in rural areas, which is forcing some regions to recruit doctors from neighbouring countries. To meet the shortages of doctors, the procedure for authorization of doctors not born or raised in Denmark (non-native) has been made more effective. In 2002 and 2003, 215 non-native doctors were granted authorization. However, the intake of medical students is rising, which is in turn increasing concern about the health system’s capacity to ensure an adequate number of postgraduate training posts in the coming years. The intake of medical students has been increasing throughout the 1990s. In 2003, the intake of students was 1139, which corresponds to an average yearly increase of 3.3% from 1995 to 2003. Further, the number of educated doctors in the entire health system is expected to increase by 18% during the period 2000–2025 (Ministry of the Interior and Health 2004b). The recruitment of nurses is currently the most serious staffing problem in the Danish health sector. The lack of nurses is mainly due to low salary levels and heavy workloads. However, this trend is changing and the number of nursing students increased from 2334 in 2001 to 2565 in 2002 (Ministry of Education 2005a).

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The number of students admitted for dental education in 2003 was 163, which is very similar to the number admitted in 2002. In 2002, only 37 dentists were unemployed. Only 142 dental auxiliaries attended educational programmes in 2002, compared to 153 in 2001, with 33 unemployed (National Board of Health 2005a). In Table 5.5, the intake of pharmacists, psychologists, physiotherapists, chiropractors and midwives is illustrated for the years 2001 and 2002. For all five types of health education, the number of students accepted has been relatively stable. The State has an element of control over the supply of health professionals, since the training of authorized health professionals (with a few exceptions) is public. This is the case when there are applicants for all places, which has not always been the case for nurses. The State can also influence health professionals’ qualifications by determining the content of their training. The National Board of Health has particular influence over postgraduate training. The State also decides which professions are to be reimbursed by the regions. There are certain quotas, for example for physiotherapists, and in order to buy a general practice, authorization as a GP is required from the National Board of Health, along with a licence from the regions. Dentists, however, can establish a practice wherever they choose and still be reimbursed by the regions. Table 5.5 Intake of other health care personnel for 2001 and 2002 Education Pharmacists Psychologists Physiotherapists Chiropractors Midwives

2001 204 452 609 50 90

2002 213 461 642 53 102

Source: Ministry of Education, 2005.

5.2.3

Training of health care personnel

Training is regulated centrally by the Ministry of Science, Technology and Innovation, together with a number of councils, such as the Health Training Council and the Social and Health Training Council, which work in cooperation with the Ministry of Health, the National Board of Health and others. Further training in the health sector for specialists is the responsibility of the Ministry 88

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of Health, and it is adjusted continually to meet the needs of the health sector as regards subjects, content and capacity. Undergraduate medical education takes place at the Faculty of Health Sciences at the Universities of Copenhagen, Århus and Southern Denmark. The training programme is six years long. Training takes place at the three universities and hospitals. After completing the final medical examination, medical doctors have to undergo 1.5 years of practical clinical education to obtain permission to practise independently. This consists of six months in both medical and surgical departments and six months in general practice. From 2008 a reform of medical education will reduce the length of the practical clinical education to one year. Postgraduate training programmes for medical specialties, including general practice, are defined by the Ministry of Health based on advice from the National Board of Health and the National Council for Postgraduate Education of Physicians, which replaced the former Danish Board of Medical Specialties in 2001. Members of the National Council represent the regions, the professional associations and colleges, the universities and the regional Councils for Postgraduate Education of Physicians. The Councils are responsible for the regional planning and coordination of physicians’ clinical training. The National Council gives advice on the number and type of specialties, the number of students admitted to postgraduate training programmes, the proportion of students studying each specialty, the duration and content of postgraduate training programmes, and international collaboration programmes. At the time of writing there are 37 specialties in Denmark compared to 42 in 2001. Each specialty has its own specific requirements and objectives, including practical training in hospitals and general practice. The medical colleges and the National Board of Health also run training courses. Because the quality of clinical training, particularly regarding surgical skills, has been heavily criticized, the National Board of Health has set up an inspection system including surveillance and the advising of the individual departments responsible for training (Ministry of Education 2005b). Basic nurse training takes 3.5 years, and training is carried out at public schools of nursing in collaboration with hospitals. The training alternates between theoretical and clinical education. Clinical education is located at hospitals and in municipalities. Two shorter theoretical education courses for health and social helpers (14 months) and health and social assistants (extra 18 months) have been established to provide training for basic nursing care functions in hospitals and nursing homes. The Centres for Advanced Education (CVUs) offer a number of mid-range training education programmes such as, nursing, midwifery and physiotherapy. 89

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CVUs offer basic, supplementary and advanced education as well as development activities, which have become an obligation for every CVU. The main objectives of the CVU’s health care education programmes are to educate people with secondary school education to a professional or Bachelor’s Degree level and to provide further training within the health care fields up to diploma level (University College Øresund 2005). In 2000, a new act regarding mid-range training introduced the “professionalbachelor” level and related “professional-bachelor” title at the mid-range training universities and institutions. The aim was to create a common framework for the mid-range training education programmes and to add to the qualitative development of health education by strengthening the professional level and by placing mid-range education more clearly in the overall picture. Nurses and physiotherapists are only two of the groups that can now obtain a professional Bachelor title (Ministry of Education 2005b). In recent years there has been an increase in Master’s-level education within the field of health, as a supplement to the advanced education system. Among these types of education programmes are the Master of Public Health, Master of International Health, Master of Industrial Medicine Development, Master of Health Pedagogy and the Master of Rehabilitation. These educational training programmes are offered at the Universities of Copenhagen, Århus, Southern Denmark, and the University of Education in Denmark. Several Masters’ courses have also been developed within the field of management and administration in the health system. These are, for example, the Master of Public Administration, the Master of Business Administration and the Master of Hospital Management, and they are offered at the University of Ålborg and Copenhagen Business School. Dentists and dental auxiliaries are trained at the Faculty of Health Sciences at the universities of Copenhagen and Århus. Dentists are offered a 5-year independent undergraduate training programme, while dental auxiliaries are trained in two and half years. Pharmacists and psychologists are all trained at universities. 5.2.4

Registration/licensing

The National Board of Health registers and supervises qualified practitioners and other health care personnel. It is in charge of granting and, if necessary, removing authorization. The Board addresses questions regarding authorization revocation and activity reduction, according to the Law of authorization of health professionals and of health care activities passed by central Government. The Act states that authorization can be revoked or activity can be reduced, 90

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if a qualified health care worker takes an unnecessary risk regarding the patient’s health or has shown serious or repeated unsafe professional activity (see Subsection 3.1.2 on Regulation and governance of providers). The final licence withdrawal occurs in court. This system of authorization helps protect health care professions, while at the same time reassuring the population and the responsible health authorities by ensuring minimum qualifications for health personnel. Further, through regulation of the capacity available for education, it is possible, to a certain degree, to control the number of authorized personnel within the different professional categories and specialties. During recent years an increasing number of professional groups have obtained authorization/ licensing by the National Board of Health. The groups that are able to obtain authorization/licensing today are doctors, nurses, dentists, dental auxiliaries, clinical dental technicians, physiotherapists, chiropractors, midwives, prosthetists/orthotists, radiographers, opticians and contact lens optometrists, clinical dieticians, occupational therapists, medical laboratory technologists, and chiropodists. The regions limit the number of GPs entitled to receive reimbursement as a means of controlling costs. The number of GPs, measured per 1000 population, is negotiated by the regions and the Organisation of General Practitioners. Training for nurses in the Danish education system conforms to EU standards and there is mutual recognition of nurses’ education. The standards are meant to ensure that all nurses in the EU have a certain level of knowledge and experience in medical health care, surgical health care, psychiatric health care, paediatrics and obstetrics health care, health care for the elderly and home health care. Authorization is generally applied for in the country of work. Nurses’ education has been internationalized in order to meet with standards set by the Higher Education Area in the Bologna process. More English language teaching has been introduced in nursing schools and students now have the opportunity to complete some of the requirements of their educational curriculum abroad. Nursing schools in Denmark receive exchange students as well: previously, most students came from Nordic countries but more recently there has been an increase in students of other nationalities (e.g. Chinese students). The number of full-time non-native students, however, is limited due to Danish language demands. Efforts are being made to be able to offer complete entire nursing education in English for Chinese students, but currently only certain modules, or one full semester, are offered in English. However, these gradual changes are not expected to have a significant influence on the number of full-time non-native students in Denmark in the foreseeable future.

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At the time of writing, an EU project, “Tuning Educational Structures in Europe”, is being developed. The project is intended to increase transparency and understanding in nursing education across Member States, to strengthen qualifications and to increase mobility. The project is not meant for the harmonization of nursing education across Europe. Since the 1980s it has been increasingly recognized that management and public health skills are lacking in the Danish health sector. As such, an increasing number of economists, professional managers and lawyers have been employed in health administration. Health professionals with postgraduate management training are also increasingly employed in health administration, which perhaps reflects a tendency towards the diminishing status and influence of the medical profession. Many health professionals have criticized this trend, claiming that economics and management targets are becoming more important than quality of care. Administrative expenses in the Danish health system are moderate compared to health systems that are based on VHI or other, more complex systems of health care organization.

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6.1

Denmark

Provision of services

Public health

ublic health services are partly integrated with curative services and partly organized as separate activities run by special institutions. The main responsibility for surveillance and control of communicable diseases rests with medical public health officers employed by the Ministry of Health. Public health medicine officers work at the regional level, and they must be notified when instances of certain communicable diseases occur. GPs who treat patients for communicable diseases are obliged to report these incidences. Public health medicine officers are also in charge of individual and community interventions to control communicable diseases. While their function is largely advisory, they do have the power to prevent infected children from entering institutions or even to close institutions to avoid the spread of infection. Other measures to prevent epidemics are in the hands of a special regional commission for epidemic diseases or, in the case of infectious foodborne diseases, local food control agencies. For information on immunization services and national vaccination programmes, see SectionÂ 1.5 on Health status. Schools provide sex education, including the use of contraceptives, as part of their general education programme. This education often includes a visit to a special clinic offering advice on family planning. Since 1973, all women have had access to free-of-charge pregnancy terminations on request within the first 12 weeks. All pregnant women have direct access to antenatal services provided by GPs, midwives and obstetricians in hospital obstetric departments. Rates of utilization of these antenatal services are very high overall, although some social and ethnic differences have been detected, indicating a lower utilization rate among lower socioeconomic groups and immigrants. Women can choose 93

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to give birth at home or in hospital, free of charge. Almost 99% of deliveries take place in hospital. In 1986, the National Board of Health issued guidelines for the screening of cervical cancer. These guidelines are still implemented at the time of writing. In 2001, 94% of Danish women in the age group 25–59 years were covered by the programme. Systematic breast cancer screening (mammography) has been recommended for women aged 50–69 years by the National Board of Health, but only introduced in some parts of the country. While no other general screening programmes have been launched, local programmes, such as colon cancer screening, have been established on an experimental basis. A key principle of Denmark’s AIDS policy is that prevention should be carried out without compulsory measures and, if necessary, based on anonymity. The AIDS prevention programme involves close collaboration between the National Board of Health, the regions, the municipalities and private organizations, such as the National Danish Organisation for Gays and Lesbians. The main elements of this programme are general information campaigns on safe sex, psychological assistance to those who are HIV positive and information targeting specific risk groups. From January 2005 a new and more effective HIV surveillance system, called SOUNDEX, was implemented. This new system decodes last names to letters or numbers and helps to prevent duplicate information. This, thereby, allows better information to be obtained on the incidence of HIV and the spread of infection in Denmark. The number of infected people has increased during recent years, which could indicate that the population and particularly the groups at greater risk have been paying less attention to the issue. National responsibility for the prevention of drug abuse lies with the National Board of Health, which develops information and educational material and carries out national campaigns against drug abuse. Local activity is considered more effective, however, and the State therefore provides financial support for local initiatives that are carried out by health, social and educational authorities as well as private organizations. The National Board of Health runs training programmes for key local people involved in tackling drug abuse. A special state agency, the National Working Environment Authority, is responsible for surveillance of, and control and maintenance standards of, occupational health and safety. The Authority provides advice, sets standards and inspects work sites. In 2003, the National Board of Health launched a national action programme aimed at severe obesity. During the period 2005–2008, DKK 83 million has been allocated towards this effort. Further, in 2003 the Government presented a programme called “Better Health for Children and Adolescents”, which is 94

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intended to ensure a greater focus on a healthy children culture (Ministry of the Interior and Health 2003a). A network of health promoting hospitals has been established as a platform for developing preventive activities related to hospital services. This network has developed a health strategy, which includes a number of targets and elements aiming to improve the health status of its citizens. The members of the WHO Healthy Cities Programme include the city of Copenhagen and the smaller city of Horsens in Jutland. A number of institutions regularly perform safety inspections of workplaces, food provision services. and the condition of roads and accommodation, among other things. The most common institutions performing these inspections are the National Food Agency, the Ministry of Housing and Urban Affairs, the Ministry of Transport and Energy, the Ministry of the Environment and the Danish Working Environment Authority. These inspections are largely environmental interventions, but they help to prevent diseases by reducing health risks and by making sure that these places or items are not damaging the health of citizens. Over the past few decades, Denmark has seen the development of unfavourable trends in average life expectancy in comparison to other OECD countries (see Section 1.5 on Health status). These trends became a major health policy issue in 1993. Although it is not possible to explain fully these trends, there are at least three contributing factors. First, unhealthy lifestyles, as major determinants of premature death, are partly responsible: there is a high prevalence of smoking and alcohol consumption, an intake of too many calories and fatty foods and a lack of physical activity. Second, a low investment in health care development such as technology for cancer treatment and heart disease rehabilitation may also be to blame: evidence to support this, however, is not very strong. Finally, socioeconomic factors are likely contributors, and they may explain the very low life expectancy in the city of Copenhagen, and the large socioeconomic inequalities in health and lifestyle factors affecting health status. In response to a low increase in average life expectancy, the Government initiated a 10-year national target-oriented programme of public health and health promotion in 1999. This programme has many similarities to WHOâ&#x20AC;&#x2122;s target-based strategy for the 21st century (Ministry of Health 1999). It is the second of its kind and the result of close cooperation between the Ministry of Health, other relevant ministries and experts in public health, epidemiology and prevention. The overall aim of this programme is to improve public health and reduce social inequality in health in Denmark. It has 17 targets, which are based on the following criteria: they must concern the dominant health problems in 95

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Denmark; there should be reasonable evidence concerning causes, risk factors and the effectiveness of interventions; and there should be a need to strengthen the effort beyond existing activities. The 17 targets concern specific risk factors (e.g. tobacco, alcohol, nutrition, exercise, obesity and traffic accidents); age groups (e.g. children, young people, elderly people); health promoting environments (e.g. primary schools, places of work, local communities, health facilities); and structural elements (e.g. intersectoral cooperation, research and education). The goals of this initiative are to increase average life expectancy by at least two years, for both males and females, and to extend the number of healthy life years through a reduction in chronic diseases. In autumn 2002, the new Government launched the health care programme “Healthy throughout life 2002–2010”. “Healthy throughout life” retains important goals and target groups from the Government Programme on Public Health and Health Promotion 1999–2008. Nevertheless, “Healthy throughout life”, in contrast to the 1999–2008 Programme, specifically focuses on reducing the major preventable diseases and disorders. It also targets improving the quality of life of the population through more systematic efforts in terms of counselling, support, rehabilitation and other patient-oriented measures. A key aspect of the new programme is to provide individuals with the necessary knowledge and tools to be able to promote their own health status and health care. The programme focuses on eight preventable diseases and disorders, namely: type 2 diabetes; cancer; heart disease; osteoporosis; musculoskeletal diseases; allergy diseases; psychological diseases; and chronic obstructive pulmonary disease (COPD). The aim is to rehabilitate people who are already sick, so that further loss of function is reduced. Important elements of the programme are prevention and health promotion, the individuals’ own contribution, and patient guidance, support and rehabilitation. The health care programme has set goals for each of the eight public diseases, and briefly runs through the causes, the opportunities for prevention and the actual status. The Danish programme differs from other Scandinavian programmes in that it focuses strongly on health-related behaviour and less on social and structural factors that influence health. Political responsibility for the health of the population is also less pronounced in the new programme, as compared to previous Danish programmes and to those of Norway and Sweden (Vallgårda 2006; Vallgårda 2001; Vallgårda 2007). A list of indicators has been developed in connection with the “Healthy throughout life” programme. The purpose of this list is to ensure regular monitoring and documentation of trends in the population’s health status and health behaviour, and efforts to promote health and prevent disease. The programme is based on the following key indicators: 96

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• • • • • • • •

life expectancy; the number of healthy life years lost; infant mortality; self-rated health; social differences in mortality; social differences in the quality of life; the prevalence of heavy smoking among children, adolescents and adults; the proportion of the population exceeding the recommended alcohol consumption (based on weekly standards) among children, adolescents and adults; • the prevalence of fat intake, which exceeds 40% of total energy intake; • the level of physical activity at leisure and at work among children, adolescents and adults; • the prevalence of BMI exceeding 30 among children, adolescents and adults; • road, home and leisure accidents among children, adolescents and adults; • serious occupational accidents, including fatal ones; • the prevalence of the use of controlled substances (among young people). The indicator programme was created on the basis of existing data sources. It is to be developed as the data improve, as the strategy comes into effect for the eight major preventable diseases and disorders progresses and as new or alternative targets are given a higher priority in the efforts to improve public health (Ministry of the Interior and Health 2002b). The 2007 reform gave rise to a large number of health prevention and promotion tasks and the responsibility for these belongs to the municipalities. The municipalities are responsible for the aspects of prevention, care and rehabilitation that do not fall under hospital admission, and they are supposed to establish new service solutions for the aspects of prevention and rehabilitation, such as community health centres. The municipalities and the regions are obliged by law to cooperate with each other regarding treatment, training, prevention and care. Obligatory health agreements should also contain accords on prevention and rehabilitation methods as well as on the appropriate hospital discharge for elderly patients.

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6.2

Denmark

Patient pathways

The pathways for Group 1 patients in the Danish health system are illustrated in Fig. 6.1. Depending on the type of examination or treatment needed, the patient has the following five options available: (1) GPs; (2) open specialties (ophthalmologists, and ear, nose and throat specialists); (3) dentists; (4) emergency wards; and (5) pharmacies. The pathway does not differ across the country. In the Danish health care system, GPs act as gatekeepers with regard to hospital and specialist treatment for Group 1 coverage (see Subsection 2.5.2 on Patient rights and empowerment). This means that patients usually start the process of seeking health care by consulting their GP, whose job it is to ensure that they are offered the treatment they need and that they will not be treated at a higher specialization level than necessary. It is usually necessary to be referred to a hospital by a GP, for medical examination and treatment, unless the patient has suffered an accident or has an acute illness. Referral to a specialist for treatment is also necessary by a GP. GPs and specialists are the ones who prescribe medication in the health system. The prescribed medication can subsequently be bought at pharmacies. If referral is necessary, patients are free to choose among any public hospital in Denmark, provided that it offers the necessary services and is at the same Fig. 6.1

Group 1 patient pathway in the statutory health care system

General practitioners P a t i e n t s

Hospitals Practising specialists

Ophthalmologists Ear, nose and throat specialists

Dentists Source: Author’s compilation. 98

Emergency wards

Pharmacies

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level of specialization considered relevant by the referring physician. This is according to the Act on free choice of hospital (Law on Health of 2005) (see Subsection 2.5.2 on Patient rights and empowerment). The GP may advise the patient on which hospital to attend based on information such as waiting time, quality and special needs. The patient can also choose to be treated at a private hospital on a fee-for-service basis; however, he/she will not be publicly reimbursed for these fees. Some people have VHI, which may cover part or all of these fees (see Subsection 4.1.4 on Voluntary health insurance). If the waiting time for either examination or treatment exceeds one month, the patient is entitled to choose to receive these services at private hospitals or clinics and hospitals abroad. As a precondition for the use of the extended free choice, the chosen hospital or clinic must have an agreement with the regions regarding the necessary treatment. The regions also pay for the expenses involved. If the patient needs surgery, rehabilitation is established and it is assessed whether there is a need for additional home care. If rehabilitation or home care are prescribed by the GP or the hospital, they will be provided free of charge by the municipality. GPs are to receive a discharge summary for each patient from the hospital and are responsible for further follow-up, such as referral to physiotherapist. Finally, the patient often has a follow-up hospital visit to check on the outcome of the treatment. Besides referring patients to a hospital or a specialist, GPs refer patients to other health professionals, working within a health care service agreement, and arrange for home nursing to be provided. Patients are called in once or twice a year for regular dental examinations and check-ups, or they may choose to make an appointment when necessary. Dentists who provide services that are reimbursed by the regions are paid a fee-for-service payment to cover part of the expenses. Necessary medicines are prescribed by the dentist and obtained at the pharmacy by the patient. Patients that have had an accident or an acute illness can attend, without referral, open emergency wards, which are often situated at hospitals. Depending on the severity of the injury or illness, patients are examined, treated and medicated or admitted for further examination and treatment and/or operation. If an accident occurs, the patient must attend an emergency ward within 24 hours; otherwise, a referral is needed from a GP. Emergency wards are open 24 hours a day and are free of charge. The necessity of open emergency wards without referral is often debated; and, in recent years, several wards have been closed or changed, so that referral is necessary. Patients may go to pharmacies if they need non-prescription medicines or guidance regarding minor health problems such as coughing, tenderness or 99

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pain in muscles, and so on. Otherwise, they must have a prescription from a GP or specialist. The patient pathways in the Danish health care system are not always free from problems. Lack of coordination regarding the primary/secondary care interface can harm the delivery of integrated care, with unnecessary delays and complications possibly leading to a suboptimal clinical outcome for vulnerable groups, such as the elderly and the chronically ill. Some problems have been identified, such as an unsettled responsibility and lack of mutual understanding between providers, and inadequate communication systems. Seen from the patient’s point of view, this reflects a fragmented health system that is inefficient in terms of continuity, coordination and information exchange (StrandbergLarsen & Krasnik 2006). The Danish Health Care Quality Assessment Programme was established to strengthen the patient pathway. The Programme intends to support a higher level of transparency regarding quality and to promote continuous quality improvement in the patient pathways within the Danish health care service. Its overall aims are to promote good patient pathways, ensuring that patients experience improved quality, and to improve the continuous clinical, professional and organizational quality of the patient pathways. Quality assessment through the programme is mandatory and covers, in principle, all providers of publicly financed health care services in Denmark (National Board of Health 2005a). Private profit-making organizations are also examining the market for providing patient guidance for the strengthening of patient pathways. Such initiatives aim to guide, inform and lead the patient through the health care system via the optimal pathway and health services. The current initiative is especially targeted towards patient groups with severe and chronic illnesses (Dagens Medicin 2005).

6.3

Primary/ambulatory care

The Danish health system can be described as a tripartite health care delivery system consisting of: • private (self-employed) practitioners – GPs, specialists, physiotherapists, dentists, chiropractors and pharmacists, who are financed by the regions through capitation and/or fee-for-service payment, including various levels of patient co-payments for dentists, physiotherapists and GPs, and for specialists who treat Group 2 patients; 100

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• hospitals – primarily managed and financed by the regions (with the exception of a few private hospitals); • municipal health services – nursing homes, home nurses, health visitors and municipal dentists are mainly managed and financed by 98 municipalities (Vallgårda & Krasnik 2007). Primary health care in Denmark is provided by private practitioners and municipal services (Vallgårda & Krasnik 2007). General practitioners GPs play a key role in the Danish health system as the first point of contact for patients and as the gatekeepers to hospitals, specialists, physiotherapists and others. It is up to GPs to decide whether their own competence or practice, given the necessary technology, is sufficient to diagnose and treat the patient. Since 1993, referred patients are entitled to undergo treatment at any hospital (at the same level of specialization) in the country. GPs, therefore, serve an important function in advising patients on which hospital they should choose (Vrangbæk 1999). After referral, GPs have no further influence on the treatment and care of the patient, although hospitals or specialists are required to inform them of patient discharges. The number of patients registered with each GP is limited and fixed through negotiations between the Organisation of General Practitioners, which is part of the Danish Medical Association, and the Danish Regions. For further information on the patient’s choice of GP, see Subsection 2.5.2 on Patient rights and empowerment. In principle, GPs run private practices, either on their own as solo practitioners (approximately a third of all GPs) or in collaboration with other GPs. The trend at the time of writing shows a decreasing number of solo practitioners and an increasing number of group practices. The Ministry of Health is generally encouraging this trend in order to strengthen the potential for teamwork, learning and quality improvement in primary health care. However, in some rural areas, this trend has resulted in patients having to travel greater distances to see a GP. Due to this collaboration between GPs, services are usually available 24 hours a day, as required by the health authorities. Many hospitals also provide open 24-hour emergency services, although some regions have restricted access to these services to only those cases, which have been referred by a GP or brought in by special emergency services. GPs derive their income from the regions, according to a fee scale that is agreed on by the Organisation of General Practitioners and the Danish Regions. They are responsible for the costs of their practice, including building (rented or owned) and staff. These costs are generally covered by their fee structure. 101

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Remuneration for GPs is a mixture of capitation (without risk adjustment), which makes up between a third and half of their income, and fees for services rendered (per consultation, examination, operation, etc.). The fee-for-service payments include special fees for after-hours consultations, telephone consultations and home visits. For more detailed information on the remuneration of GPs and on the way in which remuneration influences their activities (see Subsection 4.4.1 on Paying health care personnel). GPs must have an agreement with the region in order to receive fees from them. The regions may limit the number of practising GPs as a means of cost-containment. The number of practising GPs per region is negotiated by the regions and the Organisation of General Practitioners. There is an even distribution of doctors across the country, with very little variation in the number of inhabitants per GP across regions. In 2003 there were between 1480 and 1651 inhabitants per GP (excluding the island of Bornholm, which formed a so-called regional municipality with only 1332 inhabitants per GP). In this way, the Danish health system has succeeded in achieving relatively short travel distances to GPs and reasonable equity in access to GP services. However, recently, the recruitment of doctors into general practice has again started to become more problematic and some regions are facing difficulties when having to replace retiring GPs, especially in rural areas. Specialists Privately practising specialists that have an agreement with the region are also remunerated by the regions according to specific fees paid for services provided. In 2004, a total of 1387 privately practising specialists – mainly those specializing in dermatology, eye, and ear, nose and throat diseases – were working full-time, primarily in Copenhagen and other urbanized areas (Danish Medical Association 2005). Another 262 specialists were working part-time, privately; of these, most were also employed full-time by a public hospital. A small group of consultants employed by public hospitals are allowed to provide three hours of care per week at the hospital and are paid additional fees for their services from the regions. Previously, these consultants were much more common, but the counties have tried to reduce these types of agreements in order to maximize hospital-based specialist services and to contain costs. A few specialists work on a fully private basis, without a regional licence, and are, therefore, wholly dependent on direct payments from patients. There are no restrictions as to how much private work specialists employed by public hospitals are permitted to undertake. This is probably because only a very small number of specialists choose to engage in such activity. 102

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The regions also reimburse parts of certain services provided by physiotherapists, privately practising dentists, psychologists and chiropractors, for which there are varying levels of patient co-payment. Outpatient visits According to WHO data, the number of outpatient visits in Danish hospitals is relatively close to the EU average (WHO Regional Office for Europe 2005). National figures show that visits to outpatient clinics amount to 0.9 per inhabitant per year; visits to GPs 6.5 per inhabitant per year; and visits to specialists 0.5 per inhabitant per year (Danish Medical Association 2005; Dagens Medicine 2005). Outpatient activity has increased substantially during recent decades as a result of initiatives to increase the efficiency of patient hospital stays. The average length of stay is now shorter than in past decades, and more diagnosis and treatment takes place in outpatient clinics. Visits to GPs and specialists have also increased. Municipal services The municipalities are responsible for nursing homes, home nurses, health visitors, municipal dentists (childrenâ&#x20AC;&#x2122;s dentists and home dental services for the physically and/or mentally disabled), school health services, people carrying out home help services, and the treatment of alcohol and drug users. Professionals involved in delivering these services are paid a fixed salary. Nursing homes are actually categorized as a social service. The number of nursing homes has decreased dramatically in recent years. Nursing homes provide both day care and residential services. It is possible for many chronically and terminally ill patients to stay in their homes and to avoid or delay institutionalization because of the combination of day care services, an increased number of home nurses, extensive home help and GP support. Home help is an offer for citizens who, due to health-related conditions, are not capable of performing daily living activities (e.g. personal care and hygiene, cleaning, and nutritional guidance). Visiting public health nurses call on children several times during their first year, according to individual needs. Public health nurses and school physicians or municipal physicians with special preventive responsibilities provide health examinations for all children when they start school. Public health nurses also offer health examinations once a year or every other year to schoolchildren. Municipal dentists provide free preventive and curative dental care for children and young people under the age of 18 as well as for people with special disabilities. 103

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6.4

Denmark

Secondary/inpatient care

Most secondary and tertiary care takes place in general hospitals owned and operated by the regions. Doctors and other health professionals are employed at hospitals on a salaried basis. Hospitals have both inpatient and outpatient clinics as well as 24-hour emergency wards. Outpatient clinics are often used for pre- or post-hospitalization diagnosis and treatments. Many of the open emergency wards, however, have been closed in recent years and patients with minor emergency problems are encouraged to seek after-hours services with the GP instead. Patients without a referral from a GP or a private specialist are generally only accepted at hospitals in emergency situations. Specialist doctors, like the GPs, work on a private basis and are reimbursed by the regions. They must have an agreement with the region, however, to receive reimbursement. Free access to private specialists, except for eye, and ear, nose and throat specialists, requires a referral from a GP. Like GPs, practising specialists can refer patients to public hospitals. Approximately 1% of the population has chosen Group 2 access under other conditions (see Subsection 2.5.2 on Patient rights and empowerment). There are a few, private profit-making clinics and hospitals where patients may go without referral and pay for the care themselves or with the help of private health insurance. In some cases, the regions have made agreements with private hospitals; generally, so that they may fulfil the waiting time guarantee or have some treatments performed by the private hospital. In such cases, care is free for the patients. In 2003, the number of beds in privately owned hospitals was 281, and there were 155 beds in other hospitals – also privately owned – treating patients with rheumatic or sclerotic diseases. Most public hospitals are general hospitals with different specialization levels. There is no official classification of hospitals according to the level of specialization, technological equipment or performance. There are 14 psychiatric hospitals and a few other “single specialty” hospitals. Contracting is used to a limited extent by the regions. Contracts are entered into either with public hospitals, in the region or in another region, or with private hospitals. There are usually contracts for a number of specific interventions, such as elective surgery. Since Denmark is a small country with good transportation facilities, the location of very specialized services in just a few hospitals does not present a problem. One of the purposes of the 2007 reform is to encourage municipalities to take on more responsibility for disease prevention and rehabilitation. A means to do so, suggested by nurses and allied professions, is to establish health centres in the municipalities to take care of minor health problems. The proposal has 104

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been contested, not least by medical doctors. However, it does form a part of the 2007 reform as a possible way of reorganizing health care. Funds from the Ministry of Health have been allocated to the municipalities for pilot projects based around health centres. A general trend since the 1940s has been to reduce the length of stay at hospitals by making care more efficient, changing routines, improving home nursing, and increasing outpatient activities pre- and post-hospitalizations. On some occasions, the regions have billed the municipalities for patients who were ready to be discharged from hospital but could not be discharged because the municipalities were not ready to provide them with the necessary outpatient care services; this thereby forced the hospital to prolong the patientâ&#x20AC;&#x2122;s stay more than should have been necessary. Since the mid-1980s, municipalities have increased the number of home nurses and decreased the number of nursing homes. Efforts are being made to improve cooperation between GPs and hospitals by appointing coordinators to work closely with hospital departments and report back to the local GPs. The free choice of hospital also seems to have encouraged hospitals to better inform GPs about discharges and about services in general.

6.5

Pharmaceutical care

Distribution of pharmaceuticals Any pharmaceutical product that has marketing approval from the Danish Medicines Agency can be distributed by community and hospital pharmacies. See Fig. 6.2 for the organization of the distribution system for pharmaceuticals. Denmark has three wholesalers distributing drugs to private pharmacies, in addition to some wholesalers that only distribute drugs for veterinary use. Wholesale profits are fixed through individual negotiations between the manufacturers or importers and the wholesalers; the profit level generally is determined through competition. Community pharmacies are organized as a liberal profession but subject to comprehensive state regulation on price and location. Pharmacies are organized in such a way as to ensure that everybody has reasonable access to a pharmacy, even in rural areas where pharmacies may not be profitable. A collective financial equalization system is in place, with which pharmacies with above-average turnovers contribute to pharmacies with below-average turnovers. Pharmacy services are provided by the pharmacy owner and the staff. The staff are composed of pharmacists and pharmaconomists. Their competence includes 105

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Fig. 6.2

Denmark

Organization of the distribution system for pharmaceuticals, 2006

Danish and foreign manufacturers Parallel importers

Gross regional sales

Gross private sales

Hospital production

Pharmacy production

Hospital pharmacies

Pharmacies

Hospital departments

General practitioners Dentists Individuals

Source: Personal communication from Ellen Westh Sørensen (Department of Social Pharmacy, University of Copenhagen), 2006.

handling and checking prescriptions, dispensing medicines and the provision of information regarding the pharmaceuticals. Pharmacy owners must ensure that their staff have the basic education and continuing training to enable them to properly carry out their tasks. The average number of full-time employees (including the owner) per pharmacy was 14.2; in total this is 578 pharmacists, 2597 pharmaconomists (pharmacy assistants), 456 trainees and 667 others. The number of prescriptions handled per pharmacy (or branch of a pharmacy) was 167 000 in 2005, corresponding to 630 prescriptions per pharmacy per day. The number of pharmacies and employed pharmacists is decreasing, while the number of pharmacy assistants is increasing. The number of pharmacies in Denmark has also decreased since the mid-1970s (Danish Pharmaceutical Association 2006). Community pharmacies are comparatively large; in 2006 there were 322 pharmacies in Denmark, of which 55 were branch pharmacies. Pharmaceuticals may also be sold in other types of outlet without pharmacists. Pharmacy outlets 106

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(138) are served only by pharmaconomists. In rural or scarcely populated areas, shops under the supervision of a pharmacy are allowed to act as OTC outlets or delivery facilities (Danish Pharmaceutical Association 2006). The total gross profits of community pharmacies are fixed by the Ministry of Health and the Danish Association of Pharmacists every two years on the basis of current figures and forecasts. In 2005, the total gross profit of the pharmacies was DKK 11.4 billion, exclusive of VAT. The average total gross profit per pharmacy was DKK 43.0 million (Danish Pharmaceutical Association 2006). All community pharmacies provide advice about medicine use, dose dispensing, generic substitution and the administration of individual reimbursement registers. Except for very simple processes, compounding of pharmaceutical materials is centralized at three pharmacies (Herborg, Sørensen & Frøkjær 2007). Many pharmacies offer BMI, blood sugar, blood pressure and cholesterol measurements, and 60% offer inhalation counselling; however, only inhalation services are reimbursed. Extending services in clinical pharmacy is a priority for all Danish pharmacy organizations. The professional strategy is to use the competence of the pharmacy to take co-responsibility for the pharmaceutical treatment of the patient and for patient safety. The 2007 structural reform shifted the responsibility of a major part of primary health care from the regional authorities to the local authorities. This change might result in new services being provided by community pharmacies. In 2006, a few local authorities had made preliminary contracts with pharmacies regarding nursing home services. Research in pharmacy practice and pharmaceutical care is well established. Research trends tend to focus on collaborative health care, on developing and documenting the value of community pharmacy services, and on optimizing services and strengthening implementation (Herborg, Sørensen & Frøkjær 2007). Hospitals can choose to buy drugs from the private pharmacies or through hospital pharmacies. Hospitals buy approximately 90% of their drugs from hospital pharmacies. Where hospitals buy drugs from private pharmacies, the retail price is based on the hospital’s drug purchases in the preceding year. Some hospital pharmacies have established AMGROS, a wholesaler that invites tenders for pharmaceutical contracts. Most hospital pharmacies buy drugs through AMGROS and thereby make use of the opportunity to benefit from lower prices on the basis of large, joint contracts. Since October 2001, other outlets, such as supermarkets and kiosks, have been permitted to sell a selection of non-prescription drugs. The total consumption of OTC drugs has not changed despite this increased number of 107

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outlets. The pharmacies’ share of OTC pharmaceuticals was approximately 90% in 2005 (Herborg, Sørensen & Frøkjær 2007). The issue of price liberalization has been subject to conflicting political interests and lobbying by strong interest groups in the pharmaceutical sector. With the exception of a minor liberalization of the sale of non-prescription drugs in October 2001, there are no further plans to liberalize this sector.

6.6

Rehabilitation/intermediate care

Many actors across different sectors in Denmark are involved in rehabilitation work. Rehabilitation occurs within the health care sector, the social sector, the occupational sector and the educational sector; however, each sector carries out a different aspect of rehabilitation, for example, training or the development of competences, and so on. Rehabilitation is partly provided by public hospitals, which are the responsibility of the regions. Municipalities have the responsibility of providing training and rehabilitation that are not offered in connection with hospital treatment. A few private clinics provide rehabilitation in the form of physiotherapy, occupational therapy and chiropractice therapy. An act passed in January 2004 states that hospitals must appoint a regular contact person to ensure better cooperation between the hospitals and municipalities (Law on Health of 2005) (National Association of Local Authorities 2005). Rehabilitation is provided free of charge at hospitals and in the municipalities. Increasingly, geriatric departments for rehabilitation of elderly people are being set up in regional hospitals. If patients cannot be placed in municipal care as soon as they are discharged because of waiting lists, then the municipalities are liable for any extra hospital expenses incurred. It is hoped that this liability will encourage municipalities to provide care as quickly as possible. Municipalities offer different kinds of rehabilitation settings, such as training in the patient’s home, in a care centre or in the municipality rehabilitation centres. Some municipalities have, in addition to their own rehabilitation centres, an agreement with the regions to provide rehabilitation services as a partnership with joint financing. Training can therefore be conducted at a regional rehabilitation centre, a rehabilitation hospital or within a hospital department. This type of partnership enables service provision in a professional environment with a group of competent professionals, such as doctors and physiotherapists (National Association of Local Authorities 2005). 108

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6.7

Denmark

Long-term care

Long-term care facilities are varied and numerous in Denmark. For example, in addition to conventional nursing homes, there are psychiatric nursing homes, small apartments (providing basic medical care and located adjacent to nursing homes), group homes and foster homes. To initiate long-term placement, the caregiver or community nurse contacts the GP, who in turn visits the patient at home or at the social services office. Upon completion of the assessment, the physician refers the case to a social worker, whose job it is to ensure that the appropriate forms are completed (including a section completed by the family) and then to forward the forms to the social services authorities. In addition to facilitating the application process, the social worker provides information regarding fees for long-term care. If the patient is in the hospital at the time of application, the family contacts the GP, who in turn contacts the appropriate professionals within the hospital. Between 80% and 90% of total placements costs are covered by the Government, with a small contribution made by the individuals concerned. The total cost of care depends on the types of service that a patient decides to use. It takes an average of two weeks to complete an assessment of a patient’s placement needs, and the waiting period ranges from a few weeks to six months (Payne, Wilson, Caro & O’Brien 1999). Municipal level The municipalities deliver social services including social welfare allowances (sickness allowances and disability pensions), care for elderly people, and care for disabled people and people with chronic diseases, including those with mental disorders. They deliver care both outside of hospitals and in community mental health centres. Municipalities are also responsible for providing housing for mentally disabled and homeless people. Such municipal services are financed through taxes and run primarily by salaried professionals employed by the municipal health authorities. Contracting with private non-profit-making agencies, however, is becoming increasingly common, in an attempt to provide services that are more efficient. Privately contracted services include long-term inpatient care in nursing homes, care in day care centres and social services for chronically ill and/or elderly people. Some additional services, such as catering and cleaning, have been contracted out to private profit-making firms. Cooperation between municipalities and regions The distribution of authority and operational health-related tasks between the regions and municipalities is based on the principle that the municipalities 109

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have the responsibility for care and rehabilitation outside of hospitals, disease prevention and health promotion. Since 1994, joint health planning has been a tool for coordination and cooperation between the regions and municipalities. Under the provisions of joint health planning, the regions are obliged to produce health plans covering a 4-year period (see Section 3.2 on Planning and health information management). From 2007, the health plan procedures have been replaced by the so-called health agreements, which define the specific collaboration between the municipalities and the regions (Strandberg-Larsen, Nielsen & Krasnik 2007). Nursing homes Since 1987, nursing homes have been considered as ordinary housing. The rights and duties of nursing home inhabitants, therefore, closely resemble those of the rest of the population. However, following this legislation, no new nursing homes have been set up, and protected housing now provides services according to individual needs. Consequently, the number of people in nursing homes has fallen dramatically, from approximately 51 000 in 1987 to 40 000 in 1996 and then again to 31 500 in 2003 (Statistics Denmark 2005). This has been accompanied by a large increase in the number of home nurses and people carrying out home help services employed by municipalities. Many municipalities provide home care around the clock. Nursing home inhabitants are now individually registered with a GP, whereas in the past each nursing home was assigned its own doctor. Nursing homes and protected housing are financed by their inhabitants, according to complex computations of their financial situation. The expenses of low-income inhabitants are paid using a proportion of their old-age pension allowance. Elderly people The demographic development of a proportionally increasing number of elderly people over the total population in Denmark is expected to pose a serious challenge for municipalities. In order to reduce the financial cost of care for elderly people, health and social authorities are attempting to place more and more emphasis on self-care, increased support for people to remain in their homes for as long as possible, and effective preventive and health promoting activities. However, it seems likely that patient co-payments and contracting services to private non-profit-making agencies will become increasingly popular tools for reducing costs and raising revenue in the future. Municipalities have developed a wide range of services to accommodate the preference of senior citizens to remain independent for as long as possible in their own homes. These services include care and assistance with cleaning, 110

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shopping, washing, the preparation of meals, and personal hygiene. Home care can be used to assist or relieve family members, who are caring for a sick or disabled person. Two forms of home care are available: long-term and temporary help. Long-term care is provided free of charge, whereas temporary home care visits may warrant individual payment, depending on the income of the recipient (Jarden & Jarden 2002). Public health nurses offer day and night services such as patient education, care and treatment, and help in filling out applications for various needs. These services include a change of residence, aid, emergency help, senior centres and senior day care facilities, and they are provided free of charge. All disabled or ill individuals can have an emergency or safety phone system installed in their home, which provides them with direct 24-hour contact to their public health nurse. When elderly people are in need of another living arrangement due to health reasons, a more suitable residence is offered. There is an array of possibilities available for this, based on the individual’s needs and desires. Senior citizen residences, gated communities, assisted living units and nursing homes are all designed specially for the elderly and the disabled, offering a one- or tworoom apartment, elevator services, emergency and contact systems, and social activities. These residences often differ in their management and administration, and some are associated with nursing homes that supply health aides as well. Resident councils provide representation of the residents’ needs in these senior citizen units. A day care centre is offered as an option for those who do not wish to move permanently but who still require extra care. Transportation to and from the day care centre is arranged. There is also the option of using a nursing home for a shorter period as a respite for the family (Jarden & Jarden 2002).

6.8

Services for informal carers

A number of services are available for the informal care of a person with reduced functional capability due to a severe physical or mental condition or a radically chronic or long-term illness. Someone who wishes to be an informal carer for a close relative may be employed by the municipality. However, the following preconditions must be fulfilled to do so: (1) the alternative to home care is day and night care outside the home or the quantity of care needed corresponds to a full-time position; (2) there is an agreement between the parties concerning the care arrangement; and (3) the municipality has approved the suitability of the person in question as an informal carer. The informal carer can be employed 111

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for up to six months with a monthly salary of DKK 14 875 (Danish National Centre for Employment Initiatives 2005), which is approximately three quarters of the average Danish monthly income of DKK 20 072 in 2005 (Statistics Denmark 2005). A person who takes care of a close relative with terminal illness can apply for a compensation of lost earnings. The application should be sent to the municipality. The preconditions of the compensation are: (1) that a doctor assesses the close relative and deems further hospital treatment to be hopeless; and (2) that the condition of the patient does not demand hospital admission. This compensation amounts to 1.5 times the amount the informal carer would have been given as sickness benefit. However, exceeding the informal carer’s normal salary is not allowed (Danish National Centre for Employment Initiatives 2005).

6.9

Palliative care

Palliative care is organized at two levels, basic and specialist care. Basic palliative care is directly integrated into the mainstream health system, and it includes GPs, municipality home care and hospital departments. Specialist palliative care includes palliative teams, hospices and palliative units. This care is mainly contracted out to independent hospice institutions but a few units have been set up in hospitals and are thus integrated into the health care system. The National Cancer Plan, published in 2000, concluded that the development of palliative care in Denmark is behind that of other countries and that resources should be allocated to the improvement of, and education in the field of, palliative care (Cancer Steering Committee 2000). The development of palliative care has historically varied across the country. According to the Association of County Councils’ 2001 report, very few counties had developed palliative care according to the national recommendations (National Board of Health 1999; Association of County Councils, Ministry of Health & National Association of Local Authorities 2001). Only four counties had beds dedicated to palliative care, and there were only 10 hospices in the whole country. The report concluded that more resources and efforts were needed for the education and training of health care professionals to develop palliative care according to the national recommendations. According to English calculations, there should be 12 palliative/hospice beds per 250 000 inhabitants is an appropriate measure. This would correspond to a total of 257 palliative/hospice beds in Denmark (Danish Cancer Society 2005). In 2001, the number of palliative/hospice beds in Denmark was 73: 22 palliative 112

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beds and 51 hospice beds (Association of County Councils, Ministry of Health & National Association of Local Authorities 2001). Thus, according to English standards, Denmark had a deficit of 184 palliative/hospice beds in 2001. Legislation determines the general municipal and regional obligations regarding the care and treatment of terminally ill patients in hospitals, nursing homes and their own homes. Legislation specifically states that access to care compensation, medicine, physiotherapy, psychological assistance, health care commodities and cleaning, among other things, should be provided. According to legislation, the regions are obliged to offer treatment in hospitals including the treatment of terminally ill patients. It is up to the individual region to determine whether it will establish a hospice as a means of complying with its hospital obligations. Hospices are permitted to be built and run in cooperation with another region or with a private promoter; however, its services should always be free of charge for the patients (Association of County Councils, Ministry of Health & National Association of Local Authorities 2001). Patients with great palliative needs fall under the same rules as other patients in the health care system when it comes to access to secondary care facilities. They have to be referred by a GP who is the first point of contact and who functions as a gatekeeper to hospitals, specialists and physiotherapists. It is up to the GP to decide when his/her own field of competence is no longer sufficient or if his/her practice does not have the necessary technology to treat the patient. In principle, however, patients are able to contact some Danish hospices on their own, and to be admitted without referral. Some specialist care services have a broad range of health care professionals (social workers, psychologists, physiotherapists, occupational therapists, complementary therapists, speech therapists, etc.) involved in the delivery of palliative care. Bispebjerg Hospital is one of the hospitals in Denmark that has many different kinds of health care professionals involved in the palliative care unit. Palliative care services do not rely on volunteers to help provide services because this kind of voluntary involvement is not common in Denmark. However, in Bispebjerg Hospital, a development project is experimenting with volunteers to help provide services. Patients and their relatives are explicitly involved in determining palliative care management plans and are dependent on the local availability of palliative care specialists. In 1996, the National Board of Health published guidelines, containing organizational instructions for palliative care, on how to care for seriously ill and terminally ill patients. The guidelines were expanded in 1999 to target professional health personnel and their respective responsibilities. WHOâ&#x20AC;&#x2122;s recommendations for palliative care, which address the health care personnel 113

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performing palliative care, were the point of origin of these guidelines (National Board of Health 2005a). Palliative care, as such, is not mentioned; however, many objectives are set related to understanding and managing serious illness, death and dying from different perspectives. In 1999 and 2001, the National Board of Health, the Danish Regions, the Ministry of Health and the National Association of Local Authorities proposed a strategic plan for a palliative programme, which has since been used to some extent to determine the level of services required for palliative care in the country (Association of County Councils, Ministry of Health, National Association of Local Authorities 2001; National Board of Health 2005a). Overall, palliative care has not developed as intended in the national recommendations from 1999 and, as a result, a national steering group was appointed in December 2003 to investigate the reasons for this slow development and to ensure implementation of the national recommendations in both the regions and communities. Following from recent political pressures, DKK 35 million has been made available for the establishment of 5–10 new hospices. Preconditions for this are that the economic resources should be given only to independent institutions that have a working agreement with the region, and that the hospices should be included under the Act on free choice of hospital. The establishment of these new hospices is an attempt to change the care delivery setting from hospitals to community-based locations. These grants, however, do not fully cover the need for new hospice places. For the coming years, a new reform is being developed that will further change responsibilities in the palliative care area (see Section 7.2 on Recent developments). Information surveys, patient/family surveys or performance indicators containing data on the quality of palliative care services are not widely published in Denmark. However, some surveys do exist that contain information which could be used indirectly as a measure of the quality of palliative care services (Goldschmidt et al. 2005; Strömgren et al. 2005). The palliative care effort in Denmark is still developing and there is thus a need to test different models of organization and cooperation combined with systematic evaluations and research.

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6.10 Mental health care In 1977, responsibility for psychiatric hospitals was transferred from the State to the counties. This led to a major decrease in hospital beds, which took place simultaneously with increased local and district psychiatric outpatient treatment. The development of decentralized psychiatric care emphasizing outpatient treatment and the adjustment of sick individuals to the local environment were facilitated as a result of the appearance of modern psychoactive drugs and a change in the psychological and social treatment of the mentally ill. This organizational change has, as planned, resulted in many mentally ill people living in their homes. However, their integration into wider society has not always been successful, especially in the big cities, where some of these people have ended up homeless or living in shelters (Mental Institute 2005). Full implementation of the organizational change in psychiatric care did not take place until the 1990s, and it was followed by problems relating to coordination and service coherence. Because the provision of services was divided between counties and municipalities, there were many problems embedded in organizational fragmentation. The counties made a number of subsequent organizational changes in order to secure coordination and coherence of services within and between clinical psychiatry and social psychiatry care. Psychiatry has developed from long-term admission to psychiatric departments to shorter admissions and more outpatient and district psychiatric treatments combined with social psychiatric day services. The aim of this change was to integrate the mentally ill better into society. Because it is particularly difficult to integrate the severely mentally ill into society, special admission conditions have been established for this group, based on 24-hour stays. Public services for patients with mental disorders are provided in crosssectoral collaboration between the health and the social care sectors. The regions are responsible for health care services, and the municipalities are responsible for the social psychiatric services. The main responsibility of the regions is a specialized effort towards caring for the long-term mentally ill. The municipalities take care of all other psychiatric tasks. There is, however, partial overlap of some of the social psychiatric services that are provided by the regions and municipalities. This can further complicate efforts to run an effective, coherent system linking decision competence and financing responsibility. Private practising psychiatrists There were 108 full-time private practising psychiatrists in 2000. Patient admission to these private practising psychiatrists tends to be from two sources: a direct approach from the patient without referral (to be fully paid for by the 115

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patient), or referral from a GP (financed by the region). All patients have the right to confidentiality. Information about admission and treatment can only be passed on to a GP with the patient’s approval. Hospital psychiatry In 2002, a total of 3894 beds were available in hospital psychiatric departments. GPs are entitled to admit immediately a patient to a psychiatric hospital. If this requires the use of force, the police may be involved. District psychiatry A district psychiatric unit is established locally, providing outpatient care and interdisciplinary psychiatric treatment. Most treatment is conducted at the mentally ill patient’s residence. The treatment is conducted by district psychiatric teams, which comprise interdisciplinary doctors, nurses, social workers, occupational therapists, psychologists, physiotherapists, and so on. In some regions, these teams are located locally in district psychiatric centres, which are sometimes connected with a day care centre. Other regions have placed the teams in hospitals’ psychiatric departments. The regions also have different district psychiatric services; some strictly provide services only for people with long-term and socially disabling diseases, while others also include services for people with short-term mental illness. A referral is needed for a mentally ill person to seek treatment from district psychiatry care providers. The referral can be obtained from a GP, the hospital or, in some cases, the caseworker. District psychiatry has been criticized for providing insufficient treatment, which is primarily explained by a lack of economic resources and a reduction in the number of beds without simultaneously increasing outpatient care resources. The planned extension of resident institutions outside of hospitals has not yet been executed, despite the fact that a third of the available psychiatric beds have been removed from service. Almost all of Denmark is served by district psychiatric services, with approximately 120 units across the country (Association of County Councils 2005). The current focus is still on the development of the level of care and education of personnel. Social psychiatry The municipalities have the primary responsibility for social psychiatry, and the regional authorities are responsible for those services requiring special competencies. In 2002 the counties had 2061 occupied day centre 116

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accommodation places (versus 3256 day and night accommodation places). The municipalities are also responsible for the mentally ill at local nursing homes, as well as providing temporary residence and home care arrangements. In 2001 a total of 4979 individuals were included in the municipalities’ support and contact person arrangements (Ministry of the Interior and Health 2004b). Legislation and strategic programmes From the early 1990s, mental health care has continuously been on the agendas of the Danish Parliament and Government, regions and municipalities. According to legislation, the regions and municipalities have a considerable degree of freedom in the organization and management of mental health care services. Treatment in psychiatric departments is regulated by the law, which includes details on the patient’s loss of freedom and the use of force in psychiatric care (Ministry of the Interior and Health 2004b). The current legislation amended the legislation from 1938, and places more focus on the rights of patients. According to the current Act, the health authorities are obligated to offer hospital stay, treatment and care, corresponding to accepted psychiatric hospital standards; bed and personnel nomination; possibilities for stays outside of the hospital; and occupational, educational and other activity services. However, the State has had a greater influence on the county and municipality management of psychiatry through economic and psychiatry agreements. In 2003, a plan for the treatment of the mentally ill was agreed on for the period 2003–2006, which provided DKK 250 million a year for four years. The plan focused to a large extent on increasing the quality of services to the mentally ill (Association of County Councils 2005). The latest development within the psychiatric field has been the establishment of new organizational forms with outgoing and interdisciplinary teams for treatment of the mentally ill in their homes or within their living arrangements. Fieldwork teams for psychotic patients and for young schizophrenic patients are some examples of these new organizational forms, which are targeted towards the most challenging group of mentally ill patients in order to create a uniform and coherent service. This service can include treatment, various social psychiatric services, educational services, and so on (Ministry of the Interior and Health 2004b). There is a well-established system of appeals and advocacy in place for mental health care. The Mental Health Act states that treatment must be a collaborative effort between the patient and professionals. A plan must be prepared and implemented within seven days of admission for all patients. The patient, if capable, must be consulted on, and accept, the plan. Patients 117

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are also given access to a list of approved advocates from outside of the hospital. Advocates support the patient if a complaint is raised or if the patient is to be subjected to physical restraint. Although the use of physical restraints is still widespread, it is more common in Denmark than many other countries, but measures to minimize this are being taken at the time of writing. Discrimination and social stigma The regional authorities have established different programmes to tackle discrimination and social stigma from which individuals with mental health disorders often suffer (Association of County Councils 2005). The Danish Mental Health Fund, the primary aim of which is to disseminate knowledge about mental disorders and to minimize prejudice existing within the field, has established a nationwide programme against depression (Danish Mental Health Fund 2005). One of the many goals of this programme is to focus on discrimination and social stigma in order to minimize the burden of the mentally ill. The programme is coordinated by the Danish Mental Health Fund and based in the regions. A great deal of the nationwide effort against depression has been undertaken through regional and local projects. The projects depend on the needs and situation of the local area, but they generally offer courses, themes, public meetings, and activities in the workplace, schools, educational institutions, and so on. As an integrated part of the nationwide effort, the Danish Mental Health Fund runs a project aimed at children and adolescents, primarily those aged 14–19 years (Danish Mental Health Fund 2005). The fund has a bus, which is driven around the country with free information and education about psychiatry, mental disorders and problems with a special focus on children with mentally ill parents. The Ministry of Health and the former Ministry of Social Affairs created a proposal regarding a common set of fundamental values within the field of mental health. The aim was to establish positive interplay between the services provided in both the health and social care sectors for people with long-term mental disorders. Special efforts are made to provide services that are meaningful and coherent for the users and their families as well as for professional personnel (Ministry of the Interior and Health & Ministry of Social Affairs 2004). Refugees and asylum seekers No specific public services are provided to deal with the particular problems that are faced by refugees and asylum seekers. Red Cross Denmark, however, offers three hours of psychological consultation per individual. If that individual needs further consultation, they have to apply to the Danish Immigration Service to 118

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obtain it. The Danish Immigration Service is unfortunately quite restrictive in this area, and can put the involved individual in a difficult position (see Section 6.14 on Health care for specific populations). Families and care Families are not legally obligated to provide care for fellow family members with mental health problems. Each region assesses the individual situation and decides which arrangements are best for the patient. However, in recent years, the focus has been on creating a set of common values, to be applied nationwide (Association of County Councils 2005). Availability of specialist professionals The number of specialist professionals in the delivery of mental care is illustrated in Table 6.1. Psychiatric beds The number of beds in hospital and district psychiatry services was 3799 in 2002. This is approximately one fifth of the beds available in Danish somatic hospitals (see Subsection 5.1.1 on Infrastructure and capital investment). This relative reduction is most significant in psychiatry, largely due to a policy of deinstitutionalization. The general decline in the number of beds in psychiatric hospitals has been associated with a large increase in the number of outpatient visits. Many diagnostic and therapeutic procedures now take place without inpatient admission or before and after inpatient stay. The rate of deinstitutionalization and the insufficient development of community mental Table 6.1 Number of full-time specialist professionals involved in the delivery of mental health care, 2001–2003 Profession Doctors Psychologists Nurses Psychiatric nursing aids Social and health care assistants Social workers Social workers helping to advise the mentally ill Physiotherapists and occupational therapists Other health care personnel

2001 1 069 366 2 918 991 2 079 328 230 463 363

2002 1 165 394 3 172 923 2 296 284 297 440 296

2003 1 179 444 3 260 1 020 2 223 287 289 442 123

Source: Association of County Councils, 2005.

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health care systems are partly responsible for what is known as “revolving door psychiatry” in Denmark. The increased risk of suicide, compulsory hospitalization and abuse among psychotic patients in Denmark can, to a certain extent, be explained by the rate of deinstitutionalization and patient dropouts in community psychiatry, despite the fact that one of the basic principles in outpatient treatment is continuity (Aagaard & Nielsen 2004). Priorities for mental health care The main priority in Danish mental health care is to provide treatment for the mentally ill according to severity, with first priority given to individuals suffering from, for example, schizophrenia and severe depression. However, the regions have established a pilot project, which examined whether milder illnesses, such as anxiety and abuse, should also be included as priority areas (Association of County Councils 2005). Over the coming years, the distribution of responsibility in mental health care is to be reformed, along with the organizational structure of mental health services (see Section 7.2 on Recent developments).

6.11 Dental health care In Denmark, oral health care for children and adolescents is provided by the Municipal Dental Service. According to the 1986 Act on dental care, the system also provides health promotion, systematic prevention and curative care free of charge (Danish Parliament 1986). Dental health for children and adolescents is essentially school based and, as a result of outreach activities, the participation rate is nearly 100%. The 1972 Act on children’s dental care created the first concrete framework for preventive and health promoting activities for children and adolescents (Danish Parliament 1971; Ministry of the Interior 1974). These Acts have ensured the continued expansion of a public health programme within the framework of primary health care. An important element of the Danish Act on children’s dental care was that municipalities were mandated to take on the responsibility to report oral health data to a national recording system (the SCOR-system), which is developed and implemented by the National Board of Health. The system was established to evaluate the evolution of oral health status nationally, regionally and locally (Hansen, Foldspang & Poulsen 2001). Information derived from the register shows that an improvement in dental health among children and adolescents occurred primarily from the late 1970s and throughout the 1980s, concurrent with the introduction of populationoriented preventive programmes (Petersen & Torres 1999). 120

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The aim of the dental health service is to develop good oral health habits through oral self-care at home and a coherent prevention and care system within the population so that teeth, mouth and jaws can be maintained and function for life. The objectives, therefore, include aspects of behaviour, care and health. The means used to reach the goals of the Municipal Dental Health Service include health promotion, prevention, regular check-ups and dental treatment of oral disease (Danish Parliament 1971). Great importance is also attached to individual needs and contact with key people associated with the care of children. Dental care is free for children and young people below the age of 18 under the Municipal Dental Health Service or with a private practising dentist, who is reimbursed based on fees paid by the municipalities. This latter option, however, is only used by a small minority. The municipal children and youth dental care includes periodic check-ups and treatments (e.g. in connection with caries). Municipal children and youth dental care services also refer children to orthodontists if necessary. Dental health care for adults is offered by private dental practitioners. The adults are responsible for a substantial part of the payments; however, some of the payments, in particular the curative services, are covered by the regions. If a person is covered by private health insurance, for instance Health Insurance “denmark”, dental care is further subsidized. Prices are regulated through negotiations between the Association of Dentists and the Danish Regions every third year, and through negotiated changes in the salaries of public sector employees (Health Care Reimbursement Negotiating Committee & Danish Dental Association 2004). There is no direct monitoring of the quality of dental health services in Denmark. However, the dentist has to negotiate with the regions, which look at the services provided and assess the overall composition of services. Complaints about the quality of a dental service are to be sent to the National Board of Health. The Board does not generally monitor dental health services, but it does take action against the dentist concerned if there has been a substantiated complaint (Danish Dental Association 2005). Denmark has had a tradition for several decades of community-oriented preventive oral health care programmes, in particular in relation to children. The Danish Municipal Dental Health Service is a school-based programme, which includes comprehensive clinical oral care, prevention and oral health education for children and parents. School-based activities encompass oral health education in the classroom, diet control, supervised oral hygiene instructions, fissure sealing of permanent molars and the effective use of fluorides. In Denmark, only fluoridated toothpaste is available on the market. Increased 121

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control of dental caries has been observed among children and adolescents of varying social and economic backgrounds and across regional and geographical boundaries. From an overall perspective, considerable improvements have been registered. The prevalence rate of dental caries, the average incidence of caries and the number of children with particularly severe caries have all decreased substantially (Petersen & Torres 1999).

6.12 Alternative/complementary medicine In Denmark, a wide choice of alternative treatment exists such as zone therapy, osteopathy, homoeopathy, acupuncture, herbal medicine, and so on. Chiropractice is no longer considered an alternative treatment. The provision of complementary and alternative medicine is regulated by a medical law regarding quackery, but it can be practised freely as long as the law is respected. The law states that authorization is required, and that if the individual without professional qualification calls him/herself a doctor or performs surgery, then a penalty will be executed. Acupuncture is considered a surgical operation and, therefore, can only be conducted by an authorized doctor. Alternative medical products are also governed by regulations. As a response to EU directives regarding the production and sale of homoeopathic medicine, these regulations have been revised in Denmark. All alternative medicines sold in Denmark have to be approved by the Danish Medicines Agency, which sets out regulations on production standards, safety and product efficacy (Johannessen 2001). Complementary and alternative medicine is partly accepted by the mainstream medical profession. The biggest problem lies in the interaction between different preparations and conventional treatments. These interactions have not been fully explored, can be potentially dangerous for the patient and can result in complaints for doctors who have not guided the patient properly. It can be difficult for the doctor to guide a patient if he/she is not aware that patient is using alternative treatments and herbal medicines. Approximately half of the GPs in Denmark use some kind of alternative treatment in their practices (Johannessen 2001). Physiotherapists, psychologists and chiropractors also use alternative treatments to some extent, but they are only used in a few hospitals and often in the form of acupuncture as pain treatment. There are no authorized clinics or hospitals specializing in alternative treatments, but a number of centres for integrated medicine do exist. At these centres, therapists with government-approved therapist education cooperate with alternative therapists of varying education and therapeutic specialties. 122

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Approximately 10% of the adult Danish population attended zone therapy during 2003; it is the most used alternative treatment. A total of 21% of the adult population received an alternative treatment during 2003, which is almost double compared to 1987. As illustrated in Fig. 6.3, zone therapy, massage/ manipulation, homoeopathy and acupuncture are the forms of alternative treatment sought most in Denmark. The age groups 25–44 and 45–66 years mostly attend zone therapy and, within these groups, there are three times as many women as men. The general patterns in the use of alternative treatments indicate that there are relatively few users among people with less education and nonprofessional workers, but there are a much larger number of users among the self-employed (National Institute of Public Health 2003). The only alternative therapy that is reimbursable within the Danish health care system by third-party payers is acupuncture practised by a doctor. The regions and Health Insurance “denmark” provide contributions to this alternative treatment. Alternative therapists are, otherwise, reliant on out-of-pocket payments, details of which are not available. The Knowledge and Research Centre for Alternative Medicine was established in 2000. In the future, it is expected that the Centre will continue to explore complementary and alternative therapies and herbal medicines, to raise knowledge of such therapies and their effects and to engage in dialogue with health care providers, complementary and alternative therapists and health care consumers. In 2004, legislation was introduced on a voluntary self-administrated registration arrangement for alternative therapists.

Fig. 6.3

Percentage of the population having received different forms of alternative treatment in 2003

Zone therapy Massage/manipulation Homoeopathy Acupuncture Relaxation Dietary guidance Healing Magnetic stroking Laying-on of hands Hypnosis Other 0

Source: National Institute of Public Health, 2003. 123

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6.13 Maternal and child health Since the 1930s and 1940s, maternal and child health care has been free of charge and regulated by laws. Pregnant women are offered antenatal care and the number of such visits is regulated by need, which is decided by the health professionals. Care may be administered at separate clinics or at outpatient clinics within hospitals. Health examinations are performed by GPs, midwives and sometimes obstetricians. Antenatal care is organized and financed by the regions, as is delivery-related care, whether the woman chooses to deliver at hospital or at home. Less than 1% of women opt for home deliveries. The municipalities are responsible for providing and financing health checks for infants, which take place in the child’s home, carried out by a health visitor. Preschool children are offered seven free health examinations by a GP, financed by the regions. Health checks for schoolchildren usually take place at school clinics, carried out by a school nurse and a medical doctor. Extra examinations are offered for children with special needs. The acceptance rate for these services is very high, reaching almost 100% for antenatal and infant care, but somewhat lower for preschool health checks. They are also generally considered to be adequate and of high quality. The only major change that has occurred in the services since their inception is that needs assessment has played a role in establishing the type of care and number of consultations to be offered since the 1970s. Adolescent pregnancies are few and their number is not considered a problem. Perinatal death rates continue to decline but are also continuously higher than those in the other Nordic countries (NOMESCO 2005). Maternal deaths are very rare, and syphilis is not particularly prevalent in the population. Table 6.2 Reproductive health, 1991–2004 (selected years) 1991 1993 1995 1997 1999 2000 2001 2002 2003 2004 Adolescent pregnancy rates below 18 years, % Perinatal deaths per 1000 births Maternal deaths per 100 000 Sexually transmitted infections (syphilis, gonorrhoea, HIV)

0.40

0.30

0.20

0.30

7.90

7.50

7.40

8.50

7.20

7.30

7.10

6.20

6.40

4.80a

3.13

7.50 10.16 7.47

6.12

–

3.10

–

447

427

472

553

539

830

Source: NOMESCO, 2005. Note: a preliminary data. 124

–

456

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The number of people that are registered as HIV positive has increased recently, causing some concern, but in general, reproductive health in Denmark is considered to be very good (see Table 6.2).

6.14 Health care for specific populations Special population groups have different kinds of access to the statutory health care system. Recognized refugees are included in regional health care coverage and have the same rights as Danish citizens, although they have to undergo a 6-week period of quarantine before entitlement commences. There are no national plans to offer services for preventive examinations and vaccination programmes for refugees and family reunion refugees. It is up to each municipality to decide whether to implement screening services or preventive initiatives. Asylum seekers are all offered a volunteer screening examination by Red Cross Denmark. This examination is a general health check-up as well as an offer to perform an HIV test and an X-ray for thorax for risk groups. Children are examined for their vaccination status. Asylum seekers are not covered by regional health care and are only directly entitled to: (1) basic primary health care provided by the Red Cross or selected municipalities; and (2) hospital care in case of emergency. If an asylum seeker has a chronic disease, Red Cross Denmark can apply to the Danish Immigration Service for economic support. According to the Danish Immigration Service, this support can only be provided if the treatment is necessary, to relieve pain or to deal with a life-threatening situation. The application is assessed by a medical consultant and case officers from the Danish Immigration Service. Illegal immigrants are only entitled to acute treatment and are not covered by the regions. They are, however, often afraid of being reported to the authorities if they attend the health services for acute care. In Denmark, a network of doctors exists that treats illegal immigrants despite the act being unlawful. Commercial sex workers living illegally in Denmark are also helped by nongovernmental organizations, which treat them for sexually transmitted infections and other problems. Psychological diseases are a major problem among asylum seekers and refugees. They have often been traumatized by war, have been tortured or experienced other events that have had a profound impact on their lives. Red Cross Denmark offers three hours of psychological consultation free of charge. For further consultation, the asylum seeker has to apply to the Danish Immigration Service. However, the Service is quite restrictive in this area, which can put the involved individual in a difficult position. 125

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Access to health care services is generally affected by various barriers, such as lack of knowledge regarding the health system’s functions, language problems, and cultural and structural barriers.

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Denmark

Principal health care reforms

Analysis of recent reforms

able 7.1 provides an overview of the major reforms and policy initiatives that had a substantial impact on health care from 1970 to 2007. For information regarding earlier and more recent reforms, see Section 2.1 on Historical background. Free choice of hospitals and waiting time guarantee An Act on free choice of hospital for patients was introduced in 1993. Once referred by a GP, patients may choose among all public hospitals in Denmark and some private non-profit-making hospitals with the same level of specialization. An “extended free choice” was introduced in 2002. With this, choice was extended to a number of private facilities and facilities abroad for patients with expected waiting times of more than two months. This is a waiting time guarantee and patients’ choice is limited to the hospitals that have an agreement with the region. There has been a slight increase in the utilization of the “free choice” of hospitals, but current official data sources do not represent accurate trends. An official study, based on data from the National Patient Register, shows a growth in the share of non-acute patients treated outside their home county, from 8.0% of all patients in 1997 to 11.3% in 2003 (percentage of non-acute basic-level patients treated in other counties as a percentage of the total number of non-acute basic-level patients) (Ministry of the Interior and Health 2004b). This study includes patients treated at higher levels of specialization outside the county, 127

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Table 7.1 Overview of major reforms and policy initiatives with a substantial impact on health care, 1970–2007 Year

Description

1970

Political and administrative structural reform: the responsibility of a large part of the health care sector is placed with 14 new counties and the cities of Copenhagen and Frederiksberg. The National Board of Health has the responsibility of approving county hospital plans.

1970–1980 The responsibility of state hospitals and those financed by the State is assigned to the counties (with the exception of Rigshospitalet). 1972

The municipalities are obligated to offer free dental care for children. This is extended in 1994 to include the elderly and the disabled.

1973

Counties and municipalities are given the responsibility of managing practising health professionals.

1980

Annual budget negotiations between the State and the counties, and between the State and the municipalities, are introduced.

1985

Hospital plans that are developed by the counties no longer need approval by the National Board of Health but only need to be presented to the Board.

1989

The first coherent, national prevention programme for health is developed in cooperation with all relevant sectors.

1990

Budget agreements between the State and the counties increasingly include specific objectives and demands.

1993

Free choice of hospital is mandated by law, including all counties and the cities of Copenhagen and Frederiksberg.

1994

Counties and municipalities are obligated to coordinate plans for health care services.

1995

The Copenhagen Hospital Cooperation (H:S) is formed. All hospital-related tasks in the cities of Copenhagen, Frederiksberg and Rigshospitalet are transferred to H:S.

1999

As part of the 1998 budget agreement, full diagnostic-related group (DRG) payments for patients treated are introduced at hospitals outside their home county (under the 1993 free choice scheme). 10% of hospital budgets are allocated according to activities by DRG.

2002

A waiting time guarantee, named the “extended free choice”, is introduced. Patients with waiting times of more than two months can choose between a number of private facilities and facilities abroad, provided the patient’s county has an agreement with them.

2003

The 1999 reform is extended to include activity-based financing (20% of budget) in hospitals from 2004.

2005

A major structural reform of the Danish administrative system is passed in Parliament. The reform was implemented in 2007 with 2006 being a transition year.

2007

The waiting time guarantee is reduced from two months to one month.

Sources: Ankjær-Jensen & Rath, 2004; Ministry of the Interior and Health, 2005c.

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but excludes choices made within counties. Thus, there are no exact figures on the extent to which the right to choose a hospital has been utilized. A study group organized by the Ministry of Health in 2004 concluded that there had been a slight increase in the number of “extended free choice patients” from approximately 2000 in the third quarter of 2002 to approximately 6000 in the final quarter of 2004. The extended choice scheme is mostly used for eye surgery, orthopaedic surgery, ear, nose and throat treatment and plastic surgery (Association of County Councils, Copenhagen Hospital Co-operation, Ministry of Finance & Ministry of Health 2004). Although variations in waiting times persist, the limited utilization of this opportunity reflects the generally short waiting times in Denmark. Travel costs, limited information on quality matters, traditions, and patient preferences for treatment close to home may be other explanatory factors for this utilization pattern (Vrangbæk 1999; Birk, Vrangbaek, Winblad & Østergren 2007). The waiting time guarantee has been further reduced to one month as of 1 October 2007. DRG and activity-based financing A Danish DRG system and diagnosis-related prices have been developed from the late 1990s. This has formed the administrative backbone of a number of experiments with activity-based financing as a supplement to the standard block grants and global budgets. “Free choice” patients across regional lines are paid on a full DRG price basis. In most cases this has created incentives for counties to try to retain “free choice” patients by reducing waiting lists. The Government as of autumn 2006 has actively sought to use activity-based financing to create incentives for increased activity when redistributing funds. This seems to have led to increases in activity levels, but possibly also to a bias against some of the areas where the activity level is harder to measure and influence (e.g. geriatrics, internal medicine, etc). The current objective is to gradually increase the level of activity-based financing from 20% to 50% (Ankjær-Jensen & Rath 2004; Ministry of Health 2005c). Danish model for quality development In 2002, the national and regional authorities agreed to implement a national model for quality assurance in health care. The idea was to integrate a number of previously national and regional projects – including clinical databases, clinical guidelines, accreditation schemes and national patient satisfaction surveys – into a comprehensive scheme covering all areas of the health sector. The main components of the model were the development of standards (e.g. general, process-related; specific, diagnosis-related; and organizational) and 129

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measurement indicators. Standards and indicators are supposed to support internal quality assurance, benchmarking and external accreditation. Quality data are published on the Internet to facilitate comparison and choice. So far, it is possible to compare quality for seven diagnosis areas (diabetes, lung cancer, schizophrenia, heart failure, hip fracture, stroke and acute surgery for gastrointestinal bleeding) as well as patient satisfaction ratings for all hospital departments (Danish eHealth Portal 2007; Danish National Indicator Project 2007). The accreditation of hospitals takes place every third year based on previous internal assessments. External accreditation is carried out by independent accreditation experts. So far, the Government has entered into a contract with the American Joint Commission for Accreditation of Health Organizations. The structure of the data builds on the integration of existing and new electronic patient records.

7.2

Recent developments

Structural reform A major structural reform of the administrative system was passed by the Danish Parliament in 2005. The reform was implemented in 2007, with 2006 as a transition year. The reform reduced the number of regional authorities from 14 counties to 5 regions (0.6–1.6 million inhabitants per region) and the number of municipalities from 275 to 98 (37% of the new municipalities have more than 50 000 inhabitants; 38% have 30 000–50 000; 18% have 20 000–30 000; and 7% have fewer than 20 000 inhabitants). Both levels are governed directly by elected politicians. The main responsibility of the regions is to provide health care services, but some environmental and regional development tasks have also been maintained at this level. Most other tasks have been moved to either the State or the municipalities. The new municipalities have assumed full responsibility for prevention, health promotion and rehabilitation outside of hospitals. From an economic point of view, several important changes have been implemented. First, the regions’ right to tax was removed. Health care is now financed by a combination of national earmarked “health taxes” (the new state health contribution), which are redistributed in terms of block grants to regions and municipalities. A total of 80% of the regional health care activities are financed by the State via block grants and some activity-based payments (approximately 5%). The remaining public financing for regional health care activities comes from municipal contributions, which are paid as a combination of per capita contributions and activity-based payments related to the use of 130

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services by the citizens of the municipality. The idea behind the municipal co-financing is to create incentives for municipalities to increase preventative services in order to reduce hospitalization. The impetus behind the new state health contribution is to create greater transparency for taxpayers with regards to their health contributions and priorities. The size of the block grants from the State are calculated according to a formula, which includes the expected health care needs of the population as a central component. The expected need is assessed by combining the number of inhabitants in different age groups and across certain socioeconomic status levels (Strandberg-Larsen, Nielsen, Krasnik & Vrangbaek 2006). The reform passed through the Parliament with a small majority. This is unusual in Denmark, as the norm has previously been that major structural reforms have needed a broad consensus between the Government and the Opposition. Two of the parties behind the reform, including the Conservative coalition government party, had been in favour of dismantling the counties for a number of years. The main arguments for the reform were related to bureaucratic costs and taxation levels. It is not clear, however, whether the reform will lead to major reductions in administrative costs. Significant implementation costs are currently being incurred. Another main driver of the reform was the perception that larger catchment areas were needed to support future specialization and to secure structural adjustments. Many observers have pointed to the ambiguous evidence on the benefits of scale and specialization in health care (Christensen, Nielsen, Holm-Petersen & Lassen 2005). Other observers have pointed out that the counties were performing well in terms of controlling expenditure levels, increasing productivity and making gradual structural adjustments (Søgård 2004), and that the evidence behind benefits of scale in hospital treatment is unfounded. Most observers agree that the strengthening of the municipal level is beneficial; however, there is some fear that the municipalities will not have sufficient competences to plan and carry out their new tasks and that they will prioritize activities that directly reduce hospital admissions over general, longterm preventive programmes. No independent experts have argued in favour of the changes in financing scheme (Pedersen, Christiansen & Bech 2005).

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8.1

Denmark

Assessment of the health system

Objectives of the health system

8.2

Distribution of the health system’s costs and benefits across the population

n official government report from 2003 outlines the objectives of the Danish health system as follows (Advisory Committee to the Minister for the Interior and Health 2003): • free and equal access to treatment • choice • high quality • coherent patient pathways • consideration for diversity in patient needs and preferences • efficient use of resources • efficient macroeconomic control of expenditure • democratic control. In this chapter, we investigate recent policies and the status regarding these objectives, where evidence is available.

Financing health services Until 2007, the Danish health system was financed through progressive general income taxation at the national level and proportional income and property taxes at the regional level (see Chapter 4 on Financial resources). The national-level 133

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tax revenue was redistributed to the counties via block grants based on objective criteria and some activity-based financing for hospitals. The system was designed to support solidarity in financing and equity in coverage (Gundgaard 2006; Wagstaff et al. 1999). Since 2007, financing has taken place through earmarked proportional taxation at the national level (see Section 7.2 on Recent developments). Most of this revenue (80%) is redistributed to the regions via block grants based on objective criteria (social and demographic indicators). The remaining 20% is redistributed to the new municipalities, which in turn co-finance regional hospital services for their population. The system continues to be based on principles of solidarity and redistribution across the population. The earmarking of health taxes is a new feature in Denmark and is intended to create greater transparency for taxpayers with regard to the health sector. However, this mechanism also reduces the potential for redistribution across sector areas. There is an increasing level of user charges in Danish health care. These are mostly related to payments for pharmaceuticals, dental care and physiotherapy, and also to a fast growing private health insurance market, which is partly established by labour market agreements for groups of employees. Some argue in favour of introducing more co-payments, such as patient fees for GP consultations, as this may reduce the unnecessary utilization of services. Increases in private financing of health services may lead to major changes in the patterns of health care financing in Denmark over time, which could threaten the general principles of solidarity and equity in the tax-based financing of health care services. Provision of benefits At the time of writing, the system is based on the principles of universal, free and equal access to health care. Although utilization patterns vary somewhat across the regions, these objectives have largely been met. In practice, some groups (such as the homeless, the mentally disabled, immigrants, and drug and alcohol abusers) appear to have a more unstable utilization pattern than other groups. The high individual costs of dental care for adults seem to result in social inequity in the utilization of this kind of service, which has also led to social differences in dental health status. The use of private practising specialists reveals a geographic and social bias, as services are mostly established in affluent urban areas. The utilization of patient choice appears to favour patients with higher education and stable employment. There is some speculation that the increasing use of activity-based financing will divert investments and activities away from areas such as internal medicine and geriatrics and towards areas 134

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where increases in activity are easier to demonstrate. However, the evidence base for this claim is limited. Equal access and utilization of services according to need will probably remain a strong focus in the Danish health sector in the near future. However, ever increasing demands as a result of new technology and expected changes in age distribution and disease patterns of the population might foster political initiatives to reduce access through new financial and structural reforms.

8.3

Efficiency of resource allocation in health care

Allocative efficiency In general, current resource allocation for health care meets the needs of the population. The reduction in waiting times, along with the waiting time guarantee and “extended free choice” of hospital, ensure access to health services within relatively short periods. The waiting time guarantee ensures access to treatment in the public system or at private facilities in Denmark or abroad, if expected waiting times exceed one month. Patient satisfaction surveys continue to demonstrate remarkably high levels of satisfaction with both GPs and hospital services. However, international comparisons of survival rates among some patient groups (i.e. patients with lung cancer and ovarian tumours) seem to indicate that the efficiency of some diagnostic and curative services is not optimal. This may be due to a lack of staff, equipment or skills, or to structural problems in the Danish health care system related to service coordination and specialization. There are also some issues of personnel coverage in peripheral areas; however, regional authorities are actively seeking to remedy such difficulties by employing non-native doctors and nurses. Recent years have seen special emphases placed on psychiatric care and common life-threatening diseases, such as cancer and heart problems. Psychiatric diseases and treatments for musculoskeletal ailments are given low priority despite general statements to the contrary in national health policy. There is no evidence of significant shifts in the balance between primary, secondary and tertiary care. However, a stated objective of the current structural reform is to create incentives for the municipalities to place more emphasis on prevention, health promotion and rehabilitation outside of hospitals.

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Denmark

Technical efficiency in the production of health care

The health system is in general considered to provide good “value for money”. Consecutive government reports have indicated that the relationship between overall expenditure levels and service levels, including available indicators on waiting times and quality, is acceptable in comparison with other European countries (Advisory Committee to the Minister for the Interior and Health 2003; Ministry of the Interior and Health 2004b). Efficiency in this area is a result of many different initiatives, which aimed at controlling expenditure, raising productivity and improving quality, over the decades. The use of global budgeting and hard budget constraints is a pervasive feature of the system. In recent years, this has also been combined with internal contracts and some activity-based payments in order to encourage higher activity and stronger productivity. A recent government report highlights the gradually improving productivity in the sector, with a 2.4% increase from 2003 to 2004 (Ministry of the Interior and Health 2005d). Productivity is measured at the system level and for the individual units on an annual basis. It is measured as the relationship between DRG production values (output) and expenditure (input). Hospital productivity is compared to average productivity at national, regional and county levels (Ministry of the Interior and Health 2005a). There is limited information on the efficiency of the primary care sector; however, it is generally assumed that the combined per capita and fee-for-service payment mechanisms provide incentives to optimize both activity levels and composition. Fees are negotiated with the public authorities on a regular basis and activity profiles are monitored regularly. GP “gatekeeping” has been a significant feature of the Danish system for many years, along with the general principle of treating patients at the lowest effective care level, as opposed to providing free access to units that are more specialized. There is a general policy to promote the generic substitution of pharmaceuticals, and all regional authorities have implemented policies that monitor and influence the use of drugs in their health facilities. Efforts to reduce the general costs of drugs have not been particularly successful, in spite of some positive results in terms of drug pricing. Any potential savings have been more than counterbalanced by wider use of new and more expensive drugs and by changes in the treatment indications of hypertension, high cholesterol, and so on. There has been some experimentation with substitution of doctors with nurses, but the most important efficiency drive has been a massive, and largely successful, effort to convert inpatient treatment to outpatient or ambulatory treatment. 136

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8.5

Denmark

Accountability of payers and providers

Accountability of payers and providers is largely ensured by hierarchical control within political-bureaucratic structures at national, regional and municipal levels. The budgeting and economic management processes include accountability assessments at all levels. Annual negotiations between the State and the regional and municipal authorities involve a detailed evaluation of needs, results and new activity areas. Regional and municipal public management is based on contracting, incentives and surveillance measures, to control the performance of hospitals and other public organizations. The activities of practising primary and secondary care doctors are monitored and funded with the nationally negotiated fee schedules, by the regional authorities. Quality is monitored by state-employed medical health officers via internal bureaucratic procedures, national measures of patient satisfaction and various national and regional initiatives to develop standards, clinical guidelines, clinical databases, and so on. All hospitals have been included in the general Danish model for quality assurance since 2007, and external accreditation takes place at regular intervals (see Section 7.2 on Recent developments). A national system for reporting inadvertent events has been established as well. HTA has become an integrated part of the system, along with other types of evaluation at local or regional levels. HTAs are performed at national, regional and local levels. The HTA practice has become institutionalized via a national institute and several regional resource centres. HTA is recommended for major decisions, but has not yet been implemented comprehensively. Evaluations may be performed by local or regional initiatives, in addition to the nationally mandated quality assurance programme. Patients rights have been extended and formalized during recent years (see Subsection 2.5.2 on Patient rights and empowerment). These rights are generally respected and there are mechanisms in place for sanctioning professional misconduct and abuse.

8.6

The contribution of the health system to health improvement

The contribution the health system has made to the health of the population is difficult to assess. It depends on the measure of health utilized and the time span under consideration. For instance, the decline in mortality stagnated in Denmark during the 1950s and at the same time health care costs started to 137

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increase substantially. However, in recent decades, mortality caused by heart disease has declined remarkably, partly due to better survival among heart patients. In addition, survival rates for some types of cancer have increased due to better interventions. That said, Denmark is still lagging behind other Nordic countries regarding general mortality and some cause-specific mortality figures; this is probably due to a combination of health care, environmental and health behaviour factors. There is also reason to believe that people’s functional abilities and quality of life have improved because of enhanced surgical and pharmaceutical treatments; however, there is little quantitative evidence to support this assumption. A recent study on amenable deaths in 19 industrialized countries indicates that the Danish system is performing at an average level. It is not performing as well as other Scandinavian countries (namely, Norway and Sweden) but it is performing better than countries such as the United Kingdom, Portugal, Ireland, the United States, Austria, New Zealand and Greece (Nolte & McKee 2003). Although the method used in the WHO World Health Report 2000 for evaluating the performance of health systems is far from perfect and widely debated, it indicated a rather poor ranking of Denmark (Nolte & McKee 2003). In spite of the rather weak public health interventions regarding tobacco consumption, there have been some changes in the population’s behaviour, showing a gradual decrease in the Danish population’s high tobacco consumption. However, a new, stricter legislation largely banning smoking in places of work was implemented as of 15 August 2007. Alcohol consumption is also high in Denmark. The public health effort continues to focus on general campaigns in this area, which have been counteracted by a reduction in alcohol taxes. The increase in obesity and related diseases such as diabetes has become a public health issue in recent years, but major interventions are yet to be put into practice. Health inequalities are increasing between educational and occupational groups, as is the trend in many other western European countries (Mackenbach et al. 2003). There is, however, no evidence indicating that this is due to unequal access to or utilization of health care services; that is, with the exception of specific instances such as the high co-payment for adult dental care. It is rather caused by unfavourable social and environmental conditions and health behaviours in some population groups, which cannot be modified by the ongoing types of public health interventions in effect at the time of writing.

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Conclusions

he general picture that emerges from the bulk of the evidence presented here is of an integrated, yet decentralized public health system, which appears to have delivered sustainable good value for money. A predominantly political and administrative governance system has found a dynamic balance between the objectives of equity, efficiency, cost-containment and relatively high levels of service and quality. Various policy tools have been implemented to achieve this balance. However, the countryâ&#x20AC;&#x2122;s continued ability to strike an acceptable balance in this respect has been drawn into question. As in all Western health systems, there are increasing demands for individualized services at a high level of quality, an ageing population, rapid development of technological possibilities and the resulting pressures on health expenditures. At the same time, health care has become more politicized and is subject to increasing attention by both the voting population and political parties. It is generally understood that elections can be lost or won on health sector issues. The media-fuelled public perception of waiting time problems, the relatively poor life expectancy in Denmark compared to other Scandinavian countries and the identification of substandard results in some critical treatment areas such as heart disease and cancer have contributed to greater scepticism than was previously evident in the population towards both health professionals and health administration. Signs of this can be found in the media coverage of health issues, while the national patient satisfaction surveys show remarkably high, albeit slowly declining, rates of satisfaction with the system. Various pressures and the changing political dynamics have led to the introduction of many new reform initiatives in the sector. The reforms have strengthened the position of patients and are gradually changing the managerial dynamics to combine professional and decentralized political governance with various national monitoring, control and incentive schemes. Several aspects 139

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of these developments are worth considering: first, a gradual change in the dominant medical thinking from a local clinical focus to global, evidence-based approaches; second, the evidence-based transparency systems are introduced in a more or less uneasy alliance with the managerial demands for accountability and control through auditing; and third, economic incentives are used more consciously as an instrument to affect behaviour at department, hospital, and regional and municipal levels. This is gradually changing the “rules of the game” and the mix of values and cost–benefit assessment within the system. Furthermore, the free choice of hospitals was introduced in 1993 as a goal in its own right, and as an instrument intended to put pressure on the public hospital system. That element of choice has been combined with a waiting time guarantee, which extends the principle of choice to a set of private providers both in Denmark and abroad, if expected waiting times exceed one month from referral to treatment. The Danish health system has thus gradually moved from a predominantly hierarchically managed and supply-driven system to one based on a combination of supply and demand governance and mixed with a stronger role for economic incentives and emerging openings for more entrepreneurial behaviour, both within the public sector and by private actors. Some of the specific policies to strengthen the position of users/patients include the general waiting time guarantee of one month from referral to treatment, free choice of hospitals, and improved general patient rights to information and dialogue. Added to this is an ongoing focus on better coordination of patient pathways from initial diagnosis to treatment and rehabilitative followup. Incentive-based policies include the partial introduction of activity-based financing for hospitals and the introduction of municipal co-financing of regional health services. Other performance-oriented policies aim to develop detailed monitoring and control systems for service and quality. A combination of user assessments, self-evaluation and external accreditation is the chosen approach in the Danish national programme for quality assessment, which is to be implemented in all parts of the health system in the years to come. A structural reform took effect on 1 January 2007. This reform reconfigures the administrative landscape within which health governance takes place. The previously existing 14 counties have been replaced by 5 regions, with largely the same responsibilities for primary care and hospital services but, importantly, without the independent right to raise taxes. Both the introduction of larger regions and the shift to predominantly state-funded health care can be regarded as a recentralization of powers. This is further underlined by the strengthening of the National Board of Health with regard to planning of specialty treatment capacity. However, the general tendency towards more centralized power in 140

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health governance is combined with a new role for the municipalities as cofinancers of health services and as the main responsible administrative level for rehabilitation, prevention and health promotion. The municipal co-financing is a unique feature in Denmark, which is intended to create incentives for the municipalities to focus their attention on prevention and substitution of hospital services with various forms of outpatient care. The municipal capacity to do this has been questioned, but it seems that most municipalities are actively working on the development of new health functions. A main argument for embarking on the structural reform was to improve coordination and create patient pathways that function more smoothly. This may be the outcome within the larger regions, while the coordination across regions and municipalities may become problematic as a result of the new financial relationships and potential conflicts of interest. Special coordination councils are supposed to take care of this, but results will only gradually emerge over the years to come. Structural changes are not limited to the administrative level. The new regions as well as the new municipalities are now actively seeking to develop a new delivery infrastructure. In all regions this means political backing for a series of mergers and closures of hospitals and departments in an effort to reap benefits of scale and scope. Some of these aspirations are likely to be successful, while there is less evidence that anything useful can be gained from other mergers and structural changes. The overall effects of the reform will become apparent in the coming years, although it will be difficult to evaluate effects in a clear causal pattern. It is considered likely that a “blame game” will emerge between the regions and the State, as the regions have incentives to increase demands for funding, and are more likely to be backed by their population, than in the previous situation where higher service levels were immediately linked to higher regional taxation. Equity remains a core value in the Danish health sector, but it coexists with long-standing elements of private ownership in general and specialist practices, as well as supplementary health insurance, particularly to reimburse co-payments. Several developments may lead to a slow de facto erosion of the equity principle. First, the rapid spread of voluntary supplementary health insurance will allow some segments of the population more direct access to private health providers. This is likely to lead to a greater role for both private and public entrepreneurship as new actors enter the market and public health organizations attempt to respond to challenges by creating more differentiated service concepts. Second, the demands for more individualized services in the public health sector, combined with increasing focus on lifestyle and self141

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inflicted conditions, may be part of a broader cultural change in the perception of health services. Another factor that is gradually changing the political landscape is the internationalization of health care, and particularly the development of internal EU markets for people, services and goods. Mobility of health professionals and cross-border patient mobility are gradually making an impact in the Danish health system. Cross-border patient mobility challenges national planning capacity and changes the conditions of the national health policy situation. Attracting health professionals from abroad may be a solution to the shortages of skilled staff in the Danish system, but it also creates new challenges in terms of communication, cultural barriers and quality control.

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10 Appendices

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of the Government of Denmark, 2002–2010]. Copenhagen, Indenrigs- og Sundhedsministeriet. Ministry of the Interior and Health [Indenrigs- og Sundhedsministeriet] (2003a). Bedre sundhed for børn og unge [Better health for children and the young ones]. Copenhagen, Indenrigs- og Sundhedsministeriet. Ministry of the Interior and Health [Indenrigs- og Sundhedsministeriet] (2003b). National IT-strategi for sundhedsvæsenet 2003–2007 [National IT strategy for the health care sector 2003–2007]. Copenhagen, Indenrigs- og Sundhedsministeriet. Ministry of the Interior and Health [Indenrigs- og Sundhedsministeriet] (2004a). Nøgletal for amterne på sundhedsområdet [County key figures on health care]. Copenhagen, Indenrigs- og Sundhedsministeriet. Ministry of the Interior and Health [Indenrigs- og Sundhedsministeriet] (2004b). Strukturkommissionens betænkning, nr. 1434, bind III, bilag, sektorkapitler [Recommendation of the commission of administrative structure, recommendation no. 1434, vol. III, suppl., sector chapters]. Copenhagen, Indenrigs- og Sundhedsministeriet (http://im.dk/publikationer/strukturkom_ bind_III/index.html, accessed 12 June 2007). Ministry of the Interior and Health [Indenrigs- og Sundhedsministeriet] (2004c). Sundhedssektoren i tal, 2002/2003 [The health care sector in figures, 2002/2003]. Copenhagen, Indenrigs- og Sundhedsministeriet. Ministry of the Interior and Health [Indenrigs- og Sundhedsministeriet] (2004d) [website]. Staying in Denmark. How do you get help in case of illness? – EEC rules on health care during temporary stays in Denmark. Copenhagen, Indenrigsog Sundhedsministeriet (http://im.dk/im/site.aspx?p=34&t=ForsideVisartikel &Articleid=4169, accessed 13 August 2007). Ministry of the Interior and Health [Indenrigs- og Sundhedsministeriet] (2005a). Løbende offentliggørelse af produktivitet i sygehussektoren - første delrapport [Current publication of productivity in the hospital sector]. Copenhagen, Indenrigs- og Sundhedsministeriet. Ministry of the Interior and Health [Indenrigs- og Sundhedsministeriet] (2005b). Sundhedssektoren i tal, april 2005 [The health care sector in figures, April 2005]. Copenhagen, Indenrigs- og Sundhedsministeriet. Ministry of the Interior and Health [Indenrigs- og Sundhedsministeriet] (2005c). Evaluering af takststyring på sygehusområdet [Evaluation of case-based financing in the hospital sector]. Copenhagen, Indenrigs- og Sundhedsministeriet. Ministry of the Interior and Health [Indenrigs- og Sundhedsministeriet] (2005d). Produktivitet i sundhedsvæsenet - åbenhed og fokus [Productivity 152

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in the health care sector - openness and focus]. Copenhagen, Indenrigs- og Sundhedsministeriet. Ministry of the Interior and Health [Indenrigs- og Sundhedsministeriet] (2005e) [website]. Copenhagen, Indenrigs- og Sundhedsministeriet (http://www.im.dk, accessed 4 November 2005). Ministry of the Interior and Health [Indenrigs- og Sundhedsministeriet] (2006). Sundhedssektoren i tal, Juni 2006 [The health care sector in figures, June 2006]. Copenhagen, Indenrigs- og Sundhedsministeriet. Ministry of the Interior and Health [Indenrigs- og Sundhedsministeriet] (2007) [website]. Frit valg af sygehus [Free Choice of Hospital]. Copenhagen, Indenrigs- og Sundhedsministeriet (http://www.sst.dk/upload/informatik_og_ sundhedsdata/sundhedsstatistik/registre/patientinfo/fritvalg_jan_2007.pdf, accessed 13 August 2007). Ministry of the Interior and Health, Ministry of Social Affairs [Indenrigs- og Sundhedsministeriet & Socialministeriet] (2004). Fælles værdigrundlag for den offentlige indsats i social- og sundhedssektoren for mennesker med en sindslidelse - et udkast [Common values for the efforts of the public social and health care sector regarding people with a mental disorder - a draft]. Copenhagen, Indenrigs- og Sundhedsministeriet & Socialministeriet. Mossialos E, Thomson S (2002). Voluntary health insurance in the European Union: a study for the European Commission. Copenhagen, WHO Regional Office for Europe, on behalf of the European Observatory on Health Systems and Policies. National Association of Local Authorities [Kommunernes Landsforening] (2005) [web site]. Copenhagen, Kommunernes Landsforening (http://www. kl.dk, accessed 4 November 2005). National Board of Health (1996). The Health Technology Assessment Committee national strategy for health technology assessment. Copenhagen, National Board of Health. National Board of Health [Sundhedsstyrelsen] (1999). Faglige retningslinier for den palliative indsats: omsorg for alvorligt syge og døende [Professional guidelines for palliative care: care for the severely ill and terminal care]. Copenhagen, Sundhedsstyrelsen (http://www.sst.dk/publ/publ1999/palliativ_ indsats/indhold.html, accessed 4 November 2005). National Board of Health [Sundhedsstyrelsen] (2005a) [web site]. Sundheds A-Å/ patient rettigheder [Health A-Z/patient rigths]. Copenhagen, Sundhedsstyrelsen (http://www.sst.dk/Sundhed3A/Patientrettigheder.aspx, accessed 4 November 2005). 153

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National Board of Health [Sundhedsstyrelsen] (2005b) [web site]. Dødsårsagsregister [Causes of Death Registry]. Copenhagen, Sundhedsstyrelsen ( h t t p : / / w w w. s s t . d k / I n f o r m a t i k _ o g _ s u n d h e d s d a t a / R e g i s t r e _ o g _ sundhedsstatistik/Beskrivelse_af_registre/Doedsaarsagsregister.aspx, accessed 4 November 2005). National Board of Health [Sundhedsstyrelsen] (2005c) [web site]. Landspatientregister [National Patient Registry]. Copenhagen, Sundhedsstyrelsen (http://www.sst.dk/Informatik_og_sundhedsdata/Registre_ og_sundhedsstatistik/Beskrivelse_af_registre/Landspatientregister.aspx?, accessed 4 November 2005). National Board of Health [Sundhedsstyrelsen] (2005d). Sygehusstatistik 2002 [Statistics of the health services]. Copenhagen, Sundhedsstyrelsen (http:// www.sst.dk/publ/publ2005/SESS/Sygehusstatistik/Sygehusstatistik_2002.pdf, accessed 12 June 2007). National Institute of Public Health [Statens Institut for Folkesundhed] (2003). Zoneterapi - den hyppigst anvendte form for alternative behandling [Zone therapy - the most frequently used type of alternative therapy]. Ugens Tal for Folkesundhed, uge 23, 2003 [Weekly Update on Public Health, Week 23, 2003]. Copenhagen , Statens Institut for Folkesundhed, Syddansk Universitet [National Institute of Public Health, University of Southern Denmark] (http:// niph.dk, accessed 12 June 2007). National Institute of Public Health [Statens Institut for Folkesundhed] (2005) [web site]. Forside [Home page]. Statens Institut for Folkesundhed, Syddansk Universitet [National Institute of Public Health, University of Southern Denmark] (www.si-folkesundhed.dk, accessed 14 June 2007). National Serum Institute [Statens Serum Institut] (2005) [web site]. Copenhagen, Statens Serum Institut (www.ssi.dk, accessed 4 November 2005). Nolte E, McKee M (2003). Measuring the health of nations: analysis of mortality amenable to health care. BMJ, 327(7424):1129. NOMESCO (2005). Health statistics in the Nordic countries 2003. Copenhagen, Nordic Medico-Statistical Committee. OECD (2004). Health data 2004 [online database]. Paris, Organisation for Economic Co-operation and Development (http://www.oecd.org, accessed 4 November 2005). OECD (2006). Health data 2006 [online database]. Paris, Organisation for Economic Co-operation and Development (http://www.oecd.org, accessed 12 June 2007).

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OECD (2007) Health data 2007 [online database]. Paris, Organisation for Economic Co-operation and Development (http://www.oecd.org, accessed 12 July 2007). Pallesen T (1997). Health care reform in Britain and Denmark: the politics of economic success and failure [PhD dissertation]. Politica, University of Århus. Patients’ Complaints Board [Sundhedsvæsenets Patientklagenævn] (2003). Afgørelser og Praksis. Årsberetning 2003 [Decisions and practice, annual report 2003]. Copenhagen, Sundhedsvæsenets Patientklagenævn (http:// patientklagenaevnet.dk/public/dokumenter/prak_03.pdf, accessed 12 June 2007). Patients’ Complaints Board [Sundhedsvæsenets Patientklagenævn] (2005) [web site]. Copenhagen, Sundhedsvæsenets Patientklagenævnet (http://www.pkn.dk, accessed 4 November 2005). Payne KA, Wilson CM, Caro JJ, O’Brien JA (1999). Resource use by dementia patients and caregivers: an international survey of medical and social services and processes of long-term care. Annals of Long-Term Care, 7[7]:263–276. Pedersen KM, Christiansen T, Bech M (2005). The Danish health care system: evolution not revolution in a decentralized system. Health Econ, 14(Suppl. 1):S41–S57. Petersen PE, Torres AM (1999). Preventive oral health care and health promotion provided for children and adolescents by the Municipal Dental Health Service in Denmark. Int J Paediatr Dent, 9(2):81–91. Peto R, Lopez AD, Boreham J, Thun M (2006). Mortality from smoking in the developed countries 1950–2000, 2nd ed. (http://www.ctsu.ox.ac.uk, accessed 11 June 2007). PLS Rambøll (2004). Monitorering af danskernes rygevaner 2004 [Monitoring the smoking habits of the Danes 2004]. Copenhagen, Sundhedsstyrelsen, Kræftens Bekæmpelse, Hjerteforeningen, Danmarks Lungeforening [National Board of Health, Danish Cancer Society, Danish Heart Foundation and Danish Lung Association]. Seemann J (2003). Sundhedsplanlægning i et interorganisatorisk perspektiv [Health planning from an interorganizational perspective]. Copenhagen, Forskningscenter for Ledelse og Organisation i Sygehusvæsenet (FLOS) [Research Centre for Management and Organisation in the Hospital Sector (FLOS)].

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Søgård J (2004). Om sundhedsvæsenet [About the health services]. In: Bakke JF, Petersen UH, eds Hvorhen Danmark? Perspektiver på kommunalreformen [Where now Denmark? Perspectives on the local government reform]. Copenhagen, Nyt fra samfundsvidenskaberne. Statistics Denmark [Danmarks Statistik] (2004) [web site]. Befolkningens brug af internet 2004 (serviceerhverv) [Internet access of the Danish population 2004 (service trade)]. Copenhagen, Danmarks Statistik (http://dst.dk/HomeUK.aspx, accessed 4 November 2005). Statistics Denmark [Danmarks Statistik] (2005) [web site]. Copenhagen, Danmarks Statistik (http://www.dst.dk, accessed 4 November 2005). Steensen J, Juel K (1990). Sygehusindlæggelser og sociale forhold [The social distribution of hospital admissions]. Copenhagen, Dansk Sygehusinstitut og Dansk Institut for Klinisk Epidemiologi [DSI – Institute of Health Services Research & Danish Institute for Clinical Epidemiology]. Strandberg-Larsen MS, Krasnik A (2006). The coordination of cancer care from the perspective of primary care providers – an assessment in a selected region of Denmark at the baseline for the second national cancer plan. Social Medicinsk Tidsskrift, 83(suppl.):125–126. Strandberg-Larsen M, Nielsen MB, Krasnik (2007). Are joint health plans effective for coordination of health services? – An analysis based on theory and Danish pre-reform results. International Journal of Integrated Care (In Press). Strandberg-Larsen M, Nielsen MB, Krasnik A, Vrangbaek K (2006). Is Denmark prepared to meet future health care demands? Eurohealth, 12(4):7–10. Strömgren AS et al. (2005). A Longitudinal study of palliative care: patientevaluated outcome and impact of attrition. Cancer, 103(8):1747–1755. The Counties, Copenhagen Hospital Co-operation (H:S), Ministry of the Interior and Health [Amterne, H:S, Indenrigs- og Sundhedsministeriet] (2005). Patienters oplevelser på landets sygehuse 2004 [The experiences of patients from hospitals in the country 2004]. Københavns Amt, Enheden for Brugerundersøgelser [Copenhagen County, Unit of Patient Evaluation] (http:// www.frederiksberghospital.dk/frederiksberg.nsf/pics/LPU2004.pdf/$FILE/ LPU2004.pdf, accessed 4 November 2005). Thomson S, Mossialos E (2004). The regulatory framework for voluntary health insurance in the European Union: implications for accession countries. In: den Exter A, ed. Health and accession. Rotterdam, Erasmus University. University College Øresund, Center for Higher Education (2005) [web site]. Copenhagen, University College Øresund (http://www.cvuoeresund.dk, accessed 4 November 2005). 156

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Vallgårda S (1989). Hospitals and the poor in Denmark, 1750–1880. Scandinavian Journal of History, 13:95–105. Vallgårda S (1992). Sygehuse og sygehuspolitik i Danmark. Et bidrag til det specialiserede sygehusvæsens historie 1930–1987 [Hospitals and policy in Denmark. A contribution to the history of specialised hospitals 1930–1987]. Copenhagen, DJØF’s forlag. Vallgårda S (1999a). Who went to a general hospital during 18th and 19th centuries in Copenhagen? European Journal of Public Health, 9(97):102. Vallgårda S (1999b). Rise, heyday and incipient decline of specialisation. Hospitals in Denmark 1930–1990. International Journal of Health Services, 29:431–457. Vallgårda S (2001). Governing people’s lives. Strategies for improving the health of the nations in England, Denmark, Norway and Sweden. European Journal of Public Health, 11(4): 386–392. Vallgårda S (2007). Public health policies: a Scandinavian model? Scandinavian Journal of Public Health, 35(2):205–211. Vallgårda S, Krasnik A (2004). Sundhedstjeneste og sundhedspolitik – en introduktion, 3. udgave [Health services and health policy – an introduction, 3rd edition]. Copenhagen, Munksgaards Forlag. Vallgårda S, Krasnik A (eds) (2007). Sundhedsvæsen og sundhedspolitik [Health care services and health policy]. Copenhagen, Munksgaard Danmark. Vallgårda S, Krasnik A, Vrangbæk K (2001). Health care systems in transition: Denmark. Copenhagen, WHO Regional Office for Europe, on behalf of the European Observatory on Health Systems and Policies. von der Fehr FR (1994). Caries prevalence in the Nordic countries. International Dental Journal, 44(4 Suppl. 1):371–378. Vrangbæk K (1999). Markedsorientering i sygehussektoren [A marketoriented hospital sector]. Copenhagen, Institut for Statskundskab, Københavns Universitet [Department of Political Science, University of Copenhagen]. Licentiatserien 1999/4. KOMMISSION Statskundskab. Wagstaff A et al. (1999). Redistributive effect, progressivity and differential tax treatment: personal income taxes in twelve OECD countries. Journal of Public Economics, 72(1):73–98. WHO (2005) [web site]. WHO Statistical Information System (WHOSIS). Geneva, World Health Organization (http://www.who.int/whosis/en/, accessed 4 November 2005).

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WHO Regional Office for Europe (2005). European Health for All database (HFA-DB) [online database]. Copenhagen, WHO Regional Office for Europe (http://www.euro.who.int/hfadb, accessed 4 November 2005). WHO Regional Office for Europe (2007). European Health for All database (HFA-DB) [online database]. Copenhagen, WHO Regional Office for Europe (http://www.euro.who.int/hfadb, accessed 9 August 2007). World Bank (2005). World Development Indicators 2005. Washington DC, World Bank (http://devdata.worldbank.org/wdi2005/Cover.htm, accessed 12 June 2007).

10.2 Principal legislation Law of health [Sundhedsloven]. Law no. 546, 24-6-2005. Law of authorization of health professionals and of health care activities [Lov om autorisation af sundhedspersponer of om sundhedsfaglig virksomhed]. Law no 451, 22-5-2006. Ministerial order of Law of the central administration of health services [Bekendtgoerelse af lov om sundhedsvæsenets centralstyrelse]. LBK no. 790, 10-9-2002. Law on pharmaceuticals [Lov om lægemidler]. Law no. 1180. 12-12-2005. Law of access to complaint and compensation within the health services [Lov om klage- og erstatningsadgang inden for sundhedsvæsenet]. Law no. 547, 24-6-2005. Ministerial order of Law on infectious diseases [Bekendtgoerelse af lov om foranstaltninger mod smitsomme og andre overfoerbare sygdomme]. LBK no. 640, 14-6-2007. Law of a scientific ethical committee system and biomedical research projects [Lov om et videnskabetisk komitesystem og behandling af biomedicinske forskningsprojekter]. Law no. 402, 28-5-2003. Ministerial order of Law on use of force in psychiatric treatment [Bekendtgoerelse af lov om anvendelse af tvang i psykiatrien]. LBK no. 1111, 1-11-2006. Law on psychiatric treatment according to a legal proceeding [Lov om retspsykiatrisk behandling]. Law no. 1396, 21-12-2005.

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10.3 Useful web sites www.cancer.dk

Danish Cancer Society

www.cvuoeresund.dk

Centre for Higher Education, University College Øresund

www.dagensmedicin.dk

Dagens Medicin

www.dp.dk

Danish Association of Psychologists

www.dsi.dk

Danish Institute of Health Services Research

www.dst.dk

Statistics Denmark

www.dtfnet.dk

Danish Dental Association

www.europa.eu

Europa – Gateway to the European Union

www.fleksjob.dk

CABI – Danish National Centre for Employment Initiatives

www.fysio.dk

Association of Danish Physiotherapists

www.sum.dk

Ministry of Health

www.kiropraktor-foreningen. dk

Danish Association of Chiropractors

www.kl.dk

National Association of Local Authorities in Denmark

www.laegemiddelstyrelsen.dk

Danish Medicines Agency

www.dkma.dk

Danish Medicines Agency

www.lifdk.dk

Danish Association of the Pharmaceutical Industry

www.mm.dk

Mandag Morgen

www.oecd.org

Organisation for Economic Co-operation and Development

www.pkn.dk

Patients’ Complaints Board

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www.plo.dk

Organisation of General Practitioners in Denmark

www.psykiatrifonden.dk

Danish Mental Health Fund

www.psykisk-institut.dk

Mental Institute

www.regioner.dk

Danish Regions

www.retsinfo.dk

Legal Information of the Danish State

www.sfi.dk

Danish National Centre for Social Research

www.niph.dk

National Institute of Public Health

www.ssi.dk

National Serum Institute

www.sst.dk

National Board of Health

www.sygeforsikring.dk

Health Insurance “denmark“

www.uvm.dk

Ministry of Education

www.optagelse.dk

Ministry of Education

www.videnskabsministeriet.dk

Ministry of Science, Technology and Innovation

www.who.int

World Health Organization

10.4 HiT methodology and production process The Health Systems in Transition (HiT) profiles are produced by country experts in collaboration with the Observatory’s research directors and staff. The profiles are based on a template that, revised periodically, provides detailed guidelines and specific questions, definitions, suggestions for data sources, and examples needed to compile HiTs. While the template offers a comprehensive set of questions, it is intended to be used in a flexible way to allow authors and editors to adapt it to their particular national context. The most recent template is available online at: http://www.euro.who.int/observatory/Hits/20020525_1. Authors draw on multiple data sources for the compilation of HiT profiles, ranging from national statistics, national and regional policy documents, 160

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and published literature. Furthermore, international data sources may be incorporated, such as those of the Organisation for Economic Co-operation and Development (OECD) and the World Bank. OECD Health Data contain over 1200 indicators for the 30 OECD countries. Data are drawn from information collected by national statistical bureaux and health ministries. The World Bank provides World Development Indicators, which also rely on official sources. In addition to the information and data provided by the country experts, the Observatory supplies quantitative data in the form of a set of standard comparative figures for each country, drawing on the European Health for All (HFA) database. The HFA database contains more than 600 indicators defined by the WHO Regional Office for Europe for the purpose of monitoring Health for All policies in Europe. It is updated for distribution twice a year from various sources, relying largely upon official figures provided by governments, as well as health statistics collected by the technical units of the WHO Regional Office for Europe. The standard HFA data have been officially approved by national governments. With its January 2007 edition, the HFA database started to take account of the enlarged European Union (EU) of 27 Member States. HiT authors are encouraged to discuss the data in the text in detail, especially if there are concerns about discrepancies between the data available from different sources. A typical HiT profile consists of 10 chapters: 1. 2.

Introduction: outlines the broader context of the health system, including geography and sociodemography, economic and political context, and population health. Organizational structure: provides an overview of how the health system in a country is organized and outlines the main actors and their decision-making powers; discusses the historical background for the system; and describes the level of patient empowerment in the areas of information, rights, choice, complaints procedures, safety and involvement. Financing: provides information on the level of expenditure, who is covered, what benefits are covered, the sources of health care finance, how resources are pooled and allocated, the main areas of expenditure, and how providers are paid. Regulation and planning: addresses the process of policy development, establishing goals and priorities; deals with questions about relationships between institutional actors, with specific emphasis on their role in regulation and what aspects are subject to regulation; and describes 161

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7. 8.

9. 10.

• • • • •

162

Denmark

the process of health technology assessment (HTA) and research and development. Physical and human resources: deals with the planning and distribution of infrastructure and capital stock; the context in which information technology (IT) systems operate; and human resource input into the health system, including information on registration, training, trends and career paths. Provision of services: concentrates on patient flows, organization and delivery of services, addressing public health, primary and secondary health care, emergency and day care, rehabilitation, pharmaceutical care, long-term care, services for informal carers, palliative care, mental health care, dental care, complementary and alternative medicine, and health care for specific populations. Principal health care reforms: reviews reforms, policies and organizational changes that have had a substantial impact on health care. Assessment of the health system: provides an assessment based on the stated objectives of the health system, the distribution of costs and benefits across the population, efficiency of resource allocation, technical efficiency in health care production, quality of care, and contribution of health care to health improvement Conclusions: highlights the lessons learned from health system changes; summarizes remaining challenges and future prospects. Appendices: includes references, useful web sites, legislation.

Producing a HiT is a complex process. It involves: writing and editing the report, often in multiple iterations; external review by (inter)national experts and the country’s Ministry of Health – the authors are supposed to consider comments provided by the Ministry of Health, but not necessarily include them in the final version; external review by the editors and international multidisciplinary editorial board; finalizing the profile, including the stages of copy-editing and typesetting; dissemination (hard copies, electronic publication, translations and launches). The editor supports the authors throughout the production process and in close consultation with the authors ensures that all stages of the process are taken forward as effectively as possible.

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The Health Systems in Transition profiles A series of the European Observatory on Health Systems and Policies

he Health Systems in Transition (HiT) country profiles provide an analytical description of each health care system and of reform initiatives in progress or under development. They aim to provide relevant comparative information to support policy-makers and analysts in the develop ment of health systems and reforms in the countries of the European Region and beyond. The HiT profiles are building blocks that can be used: • to learn in detail about different approaches to the financing, organization and delivery of health care services; • to describe accurately the process, content and implementation of health care reform programmes; • to highlight common challenges and areas that require more in-depth analysis; and • to provide a tool for the dissemination of information on health systems and the exchange of experiences of reform strategies between policy-makers and analysts in countries of the WHO European Region.

How to obtain a HiT

All HiT profiles are available in PDF format on www.euro.who.int/observatory, where you can also join our listserve for monthly updates of the activities of the European Observatory on Health Systems and Policies, including new HiTs, books in our co-published series with Open University Press, policy briefs, the EuroObserver newsletter and the Eurohealth journal. If you would like to order a paper copy of a HiT, please write to: info@obs.euro.who.int

The publications of the European Observatory on Health Systems and Policies are available at www.euro.who.int/observatory

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HiT country profiles published to date: Albania (1999, 2002a,g) Andorra (2004) Armenia (2001g, 2006) Australia (2002, 2006) Austria (2001e, 2006e) Azerbaijan (2004g) Belgium (2000, 2007) Bosnia and Herzegovina (2002g) Bulgaria (1999, 2003b, 2007) Canada (2005) Croatia (1999, 2007) Cyprus (2004) Czech Republic (2000, 2005g) Denmark (2001, 2007) Estonia (2000, 2004g,j) Key Finland (2002) France (2004c,g) All HiTs are available in English. Georgia (2002d,g) When noted, they are also Germany (2000e, 2004e,g) available in other languages: Hungary (1999, 2004) a Albanian Iceland (2003) b Bulgarian Israel (2003) c French Italy (2001) d Georgian Kazakhstan (1999g) e German Kyrgyzstan (2000g, 2005g) f Romanian Latvia (2001) g Russian Lithuania (2000) h Spanish Luxembourg (1999) i Turkish Malta (1999) j Estonian Mongolia (2007) g Netherlands (2004 ) New Zealand (2001) Norway (2000, 2006) Poland (1999, 2005) Portugal (1999, 2004, 2007) Republic of Moldova (2002g) Romania (2000f) Russian Federation (2003g) Slovakia (2000, 2004) Slovenia (2002) Spain (2000h) Sweden (2001, 2005) Switzerland (2000) Tajikistan (2000) The former Yugoslav Republic of Macedonia (2000) Turkey (2002g,i) Turkmenistan (2000) Ukraine (2004g) United Kingdom of Great Britain and Northern Ireland (1999g) Uzbekistan (2001g, 2007)

ISSN 1817-6127

HiTs are in-depth profiles of health systems and policies, produced using a standardized approach that allows comparison across countries. They provide facts, figures and analysis and highlight reform initiatives in progress.

The European Observatory on Health Systems and Policies is a partnership between the WHO Regional Office for Europe, the Governments of Belgium, Finland, Norway, Slovenia, Spain and Sweden, the Veneto Region of Italy, the European Investment Bank, the Open Society Institute, the World Bank, the London School of Economics and Political Science and the London School of Hygiene & Tropical Medicine.

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Norway and Health

IS-1730 E

an introduction

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Title: .

Published:

Norway and Health. An introduction.

04/2009

Reference Number: IS-1730 E

Published by: Contact: Postal adress: Visiting adress:

Norwegian Directorate of Health Secretariat for International Cooperation Pb. 7000 St Olavs plass, 0130 Oslo Universitetsgata 2, Oslo

Tel: 810 20 050 Fax: 24 16 30 01 www.helsedirektoratet.no This booklet may beordered at: Norwegian Directorate of Health att. “Trykksaksekspedisjonen” e-mail: trykksak@helsedir.no We are planning to update this publication at regular intervals. Please send your comments to: f-arkivar@helsedir.no, att. ”Secretariat for International Cooperation”.

Editorial Team:

Sigurd Røed Dahl Lal Manavado Øydis Monsen Harald Siem

Subject contributors:

Bente Hatling, Hospital Services Bente Moe, Community Health Services Bente Nystad, Care and Dental Health Services Freja U. Kärki, Mental Health Gabrielle Katrine Welle-Strand, Substance Abuse Heidi Tomten, Physical Activity Kaja Lund-Iversen, Nutrition Katrine S. Edvardsen, Medical Devices and Medical Products Linda Haugen, Health and Social Services Personnel Michael Kaurin, Health Statistics Øyvind Christensen, Norwegian Patient Register Department Ragnar Salmén, Emergency Preparedness Rita Lill Lindbak, Tobacco Tone P. Torgersen, Environmental Health Toril Laberg, Delta Centre

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Preface

There has been a growing interest abroad in the Norwegian health and care services. This booklet outlines the structure and some key factors that shaped the system into what it is today. It is firmly anchored in the Norwegian traditional political tenet that society is collectively responsible for the welfare of its citizens. Thus, an overarching aim is to provide services of high quality, available within acceptable waiting times and distances, reaching out to everyone regardless of their financial situation, social status, age, gender and ethnic background. During the last four decades, Norway has undergone a substantial socio-economic transformation, and is now among the wealthiest nations in the world. This development has been of great significance to the health status of the nation, the services provided and the public expectations of the health services. A national health system is the result of a dynamic interplay between health needs, public expectations, professions, interest groups and available resources. As all these elements change over time, the system is in constant evolution. To be adequate, a health system in evolution has to contain mechanisms for priority and capacity revision, quality assurance, structural adjustment, and optimal resource utilisation. One major concern in Norway as an egalitarian society is the growing disparity in health between social groups, in spite of universal access to care and services. A comprehensive policy on social determinants of health is developed in order to reduce social inequalities in health. The principal elements of the structure and activities are outlined here, with a slight bias to the work under the responsibility of the Norwegian Directorate of Health. There have been many contributors, which is apparent in the variation in writing style of the chapters. A special note of gratitude goes to Lal Manavado, who initiated this project and contributed extensively throughout the process. We hope this booklet will give you a quick overview that you will find interesting, informative and useful as a first introduction to health in Norway.

Bjørn-Inge Larsen Director General Bjørn-Inge Larsen, (MD, BC, MBA, MPH), is a member (and chair 2009) of WHO Standing Committee of the Regional Committee for Europe for the period 2006-2009.

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Contents Preface

International cooperation on health

Norway, the nation 2.1 Geography 2.2 Demography (2007) 2.3 Government 2.4 Economy 2.5 Health

5 5 7 8 9 9

Health: Financial and human resources 3.1 Manpower 3.2 Registration/licensing of personnel

11 12 12

Health management 4.1 Health at the national level 4.2 Health at the provincial level 4.3 Health at the local level

14 14 17 17

5 Primary health services 5.1 Scope 5.2 Roles 5.3 Financing 5.4 The general practitioners’ scheme 5.5 The health clinics 5.6 Health and care services for the elderly and disabled 5.6.1 Users 5.6.2 Personnel 5.7 Public dental health services 5.7.1 Frequency of use 5.7.2 Costs

18 18 18 18 19 19 20 20 20 20 21 21

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6 Specialist health care services 6.1 Health enterprises 6.2 Allocations 6.3 Patients rights 6.4 Priority-setting 6.5 Pharmaceuticals safe use 6.6 Mental health services 6.7 Alcohol and drug abuse 6.7.1 Main goals 6.7.2 Treatment

22 23 23 24 25 25 25 27 27 27

7 Public health and health promotion 7.1 Strategy to reduce social inequalities in health 7.2 Tobacco use and tobacco control 7.2.1 Strong legislation 7.2.2 Reducing use 7.3 Nutrition 7.4 Physical activity

29 29 29 30 30 31 33

Universal design - The Delta centre

Preparedness 9.1 Aims

34 34

Links

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International cooperation on health

Norway is an active participant in the international efforts to enhance global public health. Over the years, Norway has seen the World Health Organization (WHO) as the central arena for international health. Karl Evang, former Director of health, was one of the founders of the organization in 1948, while former Prime Minister Gro Harlem Brundtland served as Director General from 1998 to 2003. The Director of health, Bjørn-Inge Larsen, is a member (and chair 2009) of WHO Standing Committee of the Regional Committee for Europe for the period 2006-2009. Prime Minister Jens Stoltenberg (2005-) has been actively involved in UN-reform and the intensified campaign to meet the Millennium Development Goals four and five by 2015. Minister of Foreign Affairs, Jonas Gahr Støre, has in collaboration with six other Ministers of Foreign Affairs initiated a process of looking at health and diplomacy, to explore the areas where foreign affairs cover global health issues. This embraces threats like pandemics, trade issues like patent rights and the cost of essential treatment in poor countries, as well as responsible recruitment of health personnel. Last but not least, reconstruction of failed states and humanitarian assistance in emergencies shall also be added to these issues. Mention must also be made of regional health cooperation. Collaboration with the Nordic and Baltic States, as well as Russia, is given high priority. The latter in particular has seen a dramatic upturn since the early nineties. Many health projects and programs related to tuberculosis control, prevention of HIV-infections, child health care and prevention of lifestyle-related disease, have been carried out. The EU plays a significant role in European health cooperation, and although not an EU-member, Norway is involved in a variety of EU activities. A large number of EU directives are implemented in Norway. This is particularly true in the field of food safety. Other areas of cooperation include health preparedness, cross-border patient mobility and participation in EU-programmes. Norway also participates in four health-related EU-agencies: European Medicines Agency (EMEA), European Centre for Disease Prevention and Control (ECDC), European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) and the European Food Safety Authority (EFSA).

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Norway, the nation

Norway is a founding member of the United Nations, NATO and the Council of Europe, but is not a member of the European Union (EU). Norwegian voters turned down EU membership by narrow margins in 1972 and 1994. However, Norway is part of the EU internal market, and has an extensive cooperation on most policy areas through the European Economic Area (EEA) agreement. 2.1 Geography Norway is located in Northern Europe, bordering the North Sea and the North Atlantic Ocean. Half the country lies north of the Polar Circle. It borders Sweden, Finland and the Russian Federation. The country is divided into 19 regional authority areas, counties (fylker), which in turn are divided into more than 430 local authority areas, municipalities (kommuner). The capital is Oslo.The Norwegian climate is temperate and wet along the coast, modified by the North Atlantic Current. The inland climate is dry, and cold in winter. The terrain is mostly high plateaus and mountains broken by fertile valleys. The coastline is deeply indented by fjords. About two-thirds of the country consists of mountains, and there are some 50,000 islands along the coastline. Norway has rich resources of petroleum, natural gas, hydropower, fish, timber, and minerals like iron, copper, lead, zinc, titanium, pyrites and nickel. As for land use, only 3 percent of the land is arable, while 27 percent of the land is forests and woodlands.

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Figure 1 Neighbours and communications

Map by Egil Sire

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2.2 Demography (2007) Norway has a population of 4,799,300 (01.01.2009). Life expectancy at birth Year Male Female 1970 71 77 2007 78,2 82,7 Age Structure 0-14 years 15-64 years 65 years and over

Percent 19 66 15

Population growth rate: 0,38 percent Birth rate: 11,5 births/1,000 population Death rate: 9,4 deaths/1,000 population Infant mortality rate: 3,7 deaths/1,000 live births Total fertility rate: 1,78

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Figure 2 Demographic map

Map by Egil Sire 2.3 Government Norway, officially the Kingdom of Norway, is a constitutional monarchy with a parliamentary system of government. Norway adopted its constitution in 1814, and the King was given executive powers. Today, these are effectively exercised by the government, headed by the Prime Minister. In 1898, all men were granted universal suffrage, followed by all women in 1913. In terms of government, the social democratic Labour party has played a predominant role after the Second World War. The counties, or the provincial councils and the local authorities, have a great deal of political autonomy. They also set their own tax range within limits prescribed by the Parliament. Representatives to the provincial and local councils are elected every four years by proportional representation. A representative usually from the largest political party or coalition is chosen as the chair of the council, and he or she is also the Mayor of the local authority area. 8

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2.4 Economy The Norwegian economy may be described as welfare capitalism, featuring a combination of free market economy and government interventions and regulations. The government controls key areas, such as the petroleum sector. International oil prices are important as oil and gas account for a third of the exports. Surpluses from the gas and oil exports are kept in a Government Pension Fund - Global, which is invested abroad. In 2007, the size of the fund was 373 USD billion. (Norwegian Ministry of Finance, 2007). The Norwegian progressive tax system is based on indirect taxes such as valueadded tax (VAT), personal income tax and corporate tax, including employers´ social security contributions. Food processing, shipbuilding, pulp and paper products, metals, chemicals, timber, mining, textiles, aquaculture and fishing are among the most important other industries. Barley, other grains, potatoes, beef, milk, and fish are among the principal agricultural products of the country. 2.5 Health Selected data on the population’s health: In 2006, cancer and cardiovascular diseases accounted for over 60 per cent of deaths. Cancer is the primary cause of death for people under 70 years of age, while cardiovascular diseases, such as heart attack, are the primary killers for people 70 years and over. This trend is unchanged over the past decade. Owing to the increasing life expectancy, the number of elderly has risen considerably. This has brought a high prevalence of dementia, cancer, heart and lung insufficiencies and musculoskeletal illness among the elderly. As for infectious diseases, 250 to 350 cases of tuberculosis are diagnosed every year. Active tuberculosis among native Norwegians is rare, while immigration in recent years has led to an increase in the incidence of the disease.

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In 2007, 248 new cases of HIV infection were reported, against 276 cases the previous year. The decline can be explained by a reduction in the number of asylum seekers and family unifications from high endemic countries, and a decrease in the number of men having sex with men (MSM) diagnosed with HIV the same year. However, from 2003, there has been a marked and disturbing increase in contamination among MSM, similar to the situation in other parts of Europe. Each year, 400,000 to 450,000 accidents occur that require medical attention. About 53 000 of these require hospitalization. In 2006, accidents accounted for 1824 deaths. As for drug and alcohol abuse, it is estimated that there are about 9,000 to 12,000 heroin addicts out of whom 4,500 are enrolled in medical (methadone) assisted rehabilitation programs in 2006. The highest consumption of alcohol since 1870 was recorded in 2007 (6,6 litres of pure alcohol per inhabitant). However, statistics from 2008 shows a decrease in consumption among youth the last decade. In 2004, 35,000 cases of alcohol and diverse types of substance abuse required medical treatment. In 2006, 2,037 hospital admissions presented cirrhosis as their main or secondary complaint. Compared to the beginning of the 1990s, the birth rate among teenagers for 2007 is reduced by half. In 1990, the birth rate among teenagers (15-19 years) was 17,1 per 1000 women, compared to 9,1 in 2007. In the same age group, about 65 percent of the pregnancies terminate in abortion. The age group 20-24 years has the highest rate of abortion. In 2007, there were 29,3 terminations per 1000 women. Although the general level of health in Norway is high compared to other countries, there is still a marked social gradient in morbidity and mortality.

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Health: Financial and human resources

In 2006, the Norwegian per capita total health expenditure of USD 4,520 (adjusted for purchasing power parity) ranked second among the OECD countries (OECD Health Data 2008). The period between 1997 and 2006 saw a variation in the health expenditure as GDP ratio ranging from 8,4 percent to 10 percent, peaking in 2003, decreasing to 8,7 percent in 2006. In 2007, the total health expenditure, public and private, was 203 billion Norwegian kroner. Norway has one of the largest shares of public financing of health services per capita in the world. As the figure below shows, public expenditure on health as a percentage of GDP is currently 7,6 percent, whilst private expenditure amounts to 1,5 percent. The largest part of public health expenditure is incurred by the curative care provided in hospitals. At the local level, more than 80 percent of public health expenditure is related to care services. In 2006, only 2,7 percent of the total health expenditure was spent on prevention (including administration). Figure 3 Expenditure on health. As a percentage of GDP, OECD Factbook 2008: Economic, Environ

United States

Switzerland

France

Germany

Belgium

Portugal

Austria

Greece

Canada

Iceland

Australia

Netherlands

Sweden

Norway

Denmark

New Zealand

OECD average

Italy

Spain

United Kingdom

Hungary

Japan

Luxembourg

Turkey

Ireland

Finland

Czech Republic

Slovak Republic

Mexico

Poland

Korea

mental and Social Statistics, OECD 2008, www.sourceoecd.org/factbook.

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3.1 Manpower The health authorities have been active, both on the national and international arena, in order to seek a better balance between demand and supply of health care personnel. Important issues are capacity and skills mix on the domestic level, and fair treatment and understanding of the needs in poorer countries. The demand for health personnel at home will be met in the short run with minor adjustments. In 2008, there were four thousand more health and care personnel with university degrees on the job market than ten years earlier. However, there will be a shortage of auxiliary nurses and dentists. There has been an attempt to regulate the supply and distribution of physicians from the end of the 1980s. However, during the 1990s, this regulation was undermined by hospitals; many positions were occupied without official approval. At the same time problems with unoccupied positions in the municipalities increased, especially in rural areas. In 1999, the regulatory system for physicians was changed from a contract-based system to a statutory system. The National Council for Physicians Distribution and Specialist Structure was set up to advise the Ministry of Health and Care Services. The new regulatory regime came into effect in 1999. 3.2 Registration/licensing of personnel The Health Care Personnel Act sets out the regulations with regard to the authorisation and licensing of health personnel. The Norwegian Registration Authority for Health Personnel (SAFH) is responsible for granting professional authorisation, which an applicant need in order to practise within the regulated health personnel categories. Authorisation represents full and permanent approval, while a license imposes one or more limitations with respect to duration, independent or supervised practice, et cetera. www.safh.no Following the European Economic Agreement (EEA), Norway adheres to the EU directive on the recognition of professional qualifications, also in the case of health care personnel. Furthermore, according to the Health Personnel Act, an applicant from a country outside the EEA may also be authorised if she or he has passed a foreign examination that is recognised as equivalent to the Norwegian requirement, or has otherwise been proven to possess the necessary skills. 12

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At present, employment in 36 health professions requires prior authorisation. A peculiarity in Norway is the renewals upon application of doctor’s licence to practice, which expires routinely at 75 years of age.

Table 1 Health professionals in Norway, by profession, 2006. Profession

Auxiliary nurses Dieticians Dental nurses Dental technicians Dentists Dispensers Doctors Ergotherapists Medlab technicians Midwives Nurses Opticians Other professional or paraprofessional Pharmacists Pharmacy technicians Physiotherapists Psychiatric nurses Psychologists X-ray technicians

Number 108 200 258 1 300 700 6 200 1 500 30 300 3 400 6 200 4 100 122 700 1 600 3 000 3 400 4 500 11 700 10 800 5 400 2 900

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Health management

The health administration can be divided into three parts; the national, provincial and local levels. 4.1 Health at the national level The Ministry of Health and Care Services formulates and implements the national health policy with the help of several subordinate institutions. www.hod.dep.no The Norwegian Directorate of Health is a specialized agency under the Norwegian Ministry of Health and Care Services. As such, it is responsible for the compilation of various ordinances, national guidelines and campaigns. It also advises the ministries concerned on health policy and legislation. Its administrative activities involve management of grants for service projects and research, the Norwegian Patient Register and the implementation of certain statutes, while it executes diverse projects designed to promote public health and improve the living conditions in general. www.helsedirektoratet.no The Norwegian Board of Health is an independent authority responsible for the general supervision of the health services of the country. It has a tiered structure, and its central office directs its regional units set up at the province level. The medical officer of a county, who is reporting to the provincial governor, directs the unit. The supervisory authorities are concerned with quality, legal aspects, complaints and the task of ensuring adequate and equitable health services. www.helsetilsynet.no The Norwegian Institute of Public Health (NIPH) is the main source of medical information and advice. The institute is responsible for six out of seven national health registries. The Cancer Registry is a separate administrative unit. The registries are used for research and surveillance purposes. NIPH bears the responsibility for ensuring good utilisation, high quality and easy access to the data in the registers, as well as assuring that health information is treated in accordance with privacy 14

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protection rules. The seven central health registers have been established in accordance with the Personal Health Data Filing System Act. They are: 1. The Cause of Death Register 2. The Cancer Registry of Norway 3. The Medical Birth Registry of Norway 4. The Norwegian Surveillance System for Communicable Diseases (MSIS) 5. The Tuberculosis Registry 6. The Childhood Vaccination Register (SYSVAK) 7. The Norwegian Prescription Database www.fhi.no The Cancer Registry of Norway is a governmental institute for population based cancer research. The Registry has recorded cancer cases nationwide since 1953. A computerized population registry combined with the matching of information from several sources has resulted in accurate and complete cancer registration. This information is used in research projects to establish new knowledge about cancer causes, progression, diagnosis and effect of treatment. www.kreftregisteret.no The Norwegian Medicines Agency is the administrative organ for drugs approval. It authorises and monitors the use and sale of pharmaceuticals, as well as the proper and economical use of them. It licenses the importers of pharmaceuticals and their local distributors. The agency is also responsible for the classification of pharmaceuticals, the drug and doping list, standardisation, pharmaceutical post-marketing control, medical post-marketing control, monitoring adverse drug reactions, supervision of pricing, and the determination of the pharmaceuticals to be included in the national subsidy list. www.legemiddelverket.no The Norwegian Radiation Protection Authority (NRPA) is the technical authority on radiation and nuclear safety, on which it is consulted by various home authorities. It administers statutes concerned with radiation and nuclear safety, and supervises 15

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the medical, industrial and research activities that involve the emission of radiation. NRPA monitors the natural and man-made radiation in the work place and in the environment, and also manages the national nuclear emergency preparedness plan. www.nrpa.no Several Norwegian public institutions collect information for statistical purposes, but Statistics Norway (SSB) is the central body responsible for collecting, analysing and disseminating official statistics, including statistics on health. According to the Statistics Act of 1989, Statistics Norway has the authority to decide what should be official statistics and is responsible for organising all official statistics in Norway. www.ssb.no/english The Norwegian Patient Registry (NPR) is part of the Norwegian Directorate of Health, and is responsible for providing data for planning, evaluation and financing for publicly funded specialized health care. The NPR covers nearly all in-patient and out-patient hospital care. The registry covers mental health and somatic care, and includes activity and waiting lists. Data on specialized treatment for substance abuse and additional data on accidents is also provided. Data on the patient's age, sex and residence, hospital and department, diagnose(s), medical and surgical procedure(s), dates of admission and discharge as well as date of procedure are included in the registry. The unique personal identification number that each citizen possesses is to date not included. However, the Parliament has decided that an encrypted version of the unique personal identification number can be added from March 2007 and onwards. The NPR has data covering 629 specialists who work as private practitioners in the somatic sector, performing 1 772 610 consultations, which amounts to about 35 percent of all publicly financed out-patient consultations in 2007 for somatic illness. Data from the somatic sector for the first quarter of 2008 contain information about 300 000 hospital stays, 191 000 day care episodes and 1 376 000 out-patient episodes. As regards the mental health sector, there are similar data available for 16

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adult in- and out-patient clinics and adolescent in- and out-patient clinics, respectively. Health at the provincial level 4.2 The provincial authorities represented by the county council do not deal with health matters. Specialist services are organized in “health enterprises”, see below. The chief state representative of a province is the governor, who is appointed by the central government. He or she is assisted by an executive board of civil servants, including the County Medical Officer and the Dental Surgeon of the province. Health at the local level 4.3 Local authorities, the municipalities, through its council and administration represent the ground level of the administrative hierarchy. It is entrusted with the provision of a wide variety of primary health services.

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Primary health services

The primary health services in the present form were established through The Norwegian Primary Health Services Act of 1982. The responsibility for the primary health services was given to the 430 local authorities. According to the act, the municipalities are to provide for care and treatment of all persons within its boundaries, including health promotion and prevention, emergency care and immigrant health care. 5.1 Scope The services include general practice, pregnancy and antenatal care, health clinics for mother and child, school clinics, mental health care, nursing homes, rehabilitation, physiotherapy, communicable disease control, preventive medicine, environmental health and health promotion. They are assigned components of the national emergency preparedness plan, and provide for prisoners, refugees and asylum seekers located in the area. 5.2 Roles The municipal council plans and implements these services through a director of primary health services. A municipal medical officer is appointed to advise the local council on health issues. In scarcely populated areas, some municipalities jointly establish and run all or a part of their primary health services. The municipal medical officer is concerned with public health in the municipality. He provides information on available services, prevention of diseases, health promotion and organization of services. He also works to ensure that the building and operation of industrial installations, commercial and other activities pose no threat to public health. In serious cases, activities may be stopped. Health personnel are either contracted to provide services, or employed by the municipality. The former is true for most of the general practitioners (GPs), while nurses and midwives usually are employees. 5.3 Financing Primary health services are financed through grants from the national government, local tax revenues, reimbursements from the National Social Security 18

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System and through out-of-pocket payments. Services of the pre- and antenatal clinics, youth clinics, school clinics, and all consultations for children under 12 years of age are free. The general practitioners’ scheme 5.4 In 2002, the national authorities introduced a regular general practitioners’ scheme, giving individuals the right to choose one general practitioner as family doctor. In 2008, about 3,800 physicians are enlisted in this scheme. They are private practitioners who enter into a contractual agreement with the municipality, and are required to have a regular clientele not exceeding 2,500 persons. In addition to consultation fees, they receive a regular monthly capitation allowance for each person on the list from the municipality. It is part of the agreement that they also serve in health clinics, school clinics, local authority nursing homes, prison health service and emergency units on a part-time salaried basis. Patients may choose a practitioner anywhere, also in another municipality. If dissatisfied, they may change their physician up to two times within a calendar year. 5.5 The health clinics The health clinics comprise four units. Pregnancy clinics and clinics for mother and child provide antenatal services and child health services that extend up to pre-school age. A public health nurse runs the clinics with a physician at hand for consultation when indicated. Midwifes, physiotherapists, psychologists and other professionals may also be engaged at these clinics. The services provided include assessments, follow-ups, referrals, vaccinations, counselling, home visits and provision of information and cooperation with other social services for more comprehensive service packages. Youth clinics provide integrated individual prevention services, covering physical and mental health assessment and advice, nutrition, physical fitness, sexual hygiene, problems of adolescence, contraception, family problems, and rehabilitation of the disabled and the chronically ill. School health services serve school children and youth under 20 years of age. The school clinics provide vaccinations, health promotion and social and psychological support in the school environment. 19

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The clinics for school children are usually located at schools, while the youth clinics are strategically located elsewhere in the municipality. They have flexible hours of consultation. Health and care services for the elderly and disabled 5.6 The most important services include health and medical services, nursing homes, home based care and services, assistance at home and community nursing, relief services for family members and day care and activity centres. There has been a shift away from institutional care in favour of community-based care. Most importantly, this concerns community-based care for the mentally ill and disabled, and functional homes for the physically disabled to facilitate living at home. 5.6.1 Users The services have more than 200,000 users, of which 40,000 live in nursing homes, and more than 160,000 people receive home care services in community care housing or their own home. The number of users aged under 67 has doubled over ten years and totals 50,000. In 2005, around 110,000 man-labour years were employed; half in nursing homes and half in home care services and community care. 5.6.2 Personnel The growing population of the elderly demands new ways of thinking and training of new skills. Towards year 2020 efforts will be intensified to train personnel and invest in appropriate buildings and technology. Special attention is given to patients with dementia. At present, about 66,000 people suffer from this condition, a number that will probably double during the next 35 years. Public dental health services 5.7 The Public Dental Health Services (PDHS) were established in 1950. Local government is responsible for planning and funding of the service. All children aged 0-18 years receive free treatment, except for orthodontic care, for which parents have to pay a partial fee according to the degree of malocclusion .

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5.7.1 Frequency of use About 75 percent of adults use the services every year, and 85 percent visit at least every second year. Since 1996, there have been no set fees in the private sector. A private dental insurance scheme was introduced in 1996 without success. A few companies offer subsidised dental treatment to their employees. In 2006, for a population of 4,6 million there were 1000 full time dentists in the public sector compared to 2700 private sector dentists. There were 339 full time dental hygienists in PDHS and 261 in the private sector. 5.7.2 Costs In 2007, the total cost of dental treatment in PDHS and the private sector combined was EUR 1,285 million. The total cost included EUR 175 million spent in the PDHS, and a further EUR 122 million refund from the State Insurance System to adults for dental treatment as well as orthodontic treatment for children. Out-of-pocket spending on dental care for adults was thus about EUR 1 billion. The oral health of the adult population is considered to be good. In 2006, the national mean DMFT score, number of fillings, in 12 year-olds was 1,6 and 44 percent had no visible caries.

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6 Specialist health care services Specialist health care services include hospitals for patients with somatic or psychiatric/psychological disorders, out-patients departments, centers for training and rehabilitation, institutions for drug addicts, centres for re-education for chronically ill patients and disabled, pre-hospital services and private specialists, laboratories and x-ray facilities. The Norwegian specialist system scores high in international comparison. In a WHO-study from 2004, Norway was ranked third. If asked, four out of five state that they are satisfied with services received.

Figure 4 The four health regions

Map by Egil Sire

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6.1 Health enterprises Major reforms in the specialised health care services were instituted by The Regional Health Authorities Act of 2002. Five regional health enterprises (later reduced to four through a merger) were set up to administer services within each region, with appointed boards responsible for governance and results. Following the reform, responsibility for all the public hospitals, policlinics and the district psychiatric centres in the country was transferred to the state, and a system of enterprise ownership and management was established. The services include all hospital services, ambulance services, emergency call system, laboratories, in-house pharmacies and some medical rehabilitation facilities. Each regional health enterprise directs a set of subordinate units, mostly hospitals, known as health enterprises. In 2007, about 84 public hospitals were part of this system. Private specialist health service facilities may be invited as partners to the system on a contractual basis. Each enterprise is directed by a board of management serving a two-year term. The boards are supposed to run the enterprises like businesses, in particular guaranteeing solvency. Towards the end of the decade, however, there has been great concern regarding the uptake of massive loans by the enterprises. Allocations 6.2 The Norwegian health system is, as mentioned, a tax-based system covering all inhabitants. In consultation with the health authorities, the government makes annual budget allocations for each regional health enterprise. The Ministry of Health and Care Services issues operational directives on general goals to be achieved with those allocations. In consultation with the boards of management of its health enterprises, each regional health enterprise then determines how funds are to be distributed among them. The allocations to health enterprises are accompanied by operational directives from regional health authorities on goals to be reached. 23

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The in-house pharmacies of the state-owned hospitals are administered by four separate Regional Pharmacy Enterprises. In June 1997, Norway introduced the activity-based funding system for the somatic hospital-based health services based on the DRG (Diagnose Regulated Groups) system. The share of activity-based funding is decided by the Parliament. In 2008, the share of activity-based funding was 40 percent, and 60 percent for block grants. 6.3 Patients rights The Patients Rights Act stipulates the right to become a patient and receive necessary treatment, as well as several procedural rights. • • • • • •

All members of the Norwegian population have a right to health care when certain criteria are met The health system as such (municipalities, enterprises) and the individual care provider are responsible for providing adequate health care Health services must meet minimum standards of adequate quality and safety The definition of “adequate standard” will vary with time due to develop ments in medicine, change in ethical values and prevailing best practice within a certain field The patients’ entitlement to necessary healthcare in the specialist health care services extends to the right to have care delivered within a specific, individually determined time limit Budgetary concerns and providers’ priorities cannot be reason to withhold health care treatment

People have several explicit rights as patients, which are based on the principle of patient autonomy and the right to necessary health care: • • •

Patients have the right to participate in the treatment process, be in formed, make their own decisions, and have access to information recorded about them Patients also have the right to confidential treatment of personal informa tion The Patients Rights Act also stipulates free choice of hospital. The patients can not, however, choose the type of treatment or how specialized the treatment should be.

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6.4 Priority-setting Priority in the health sector is regulated by law. It defines “necessary care” by taking into account the seriousness of the condition in case and the expected benefit from treatment. Finally, there must be an acceptable equation as to cost and benefit. The National Council for Quality and Priority-setting advises the Government and the health establishment on issues such as distribution of and access to services, new technology and national guidelines. Cancer, rehabilitation, diabetes and KOLS are to be given special attention in the period 2007-2011, and a special strategy for the improvement of quality in services has been elaborated for the period 2005-2015. A more recent initiative stems from 2008, aiming at better collaboration in the services, in particular between the specialist services and the municipal health services. 6.5 Pharmaceuticals safe use Clinical studies have shown that up to 20 percent of patients do not receive correct medication. Errors may occur in all situations in which pharmaceuticals are being handled: during prescription (at physician level), dispensing (in the pharmacy) and at the patients’ point of actual use. Many patients, especially in the older age-groups, suffer from a multitude of diseases requiring complex drug treatment (“poly-pharmacy”). This increases the risk of drug related problems, like interactions, as well as incorrect use of the medication. In addition, studies have shown that inadequate training of health care personnel, lack of routines, proper instructions or unclear responsibilities increase the risk of incorrect use of pharmaceutical drugs. Correct use of pharmaceutical drugs is promoted through a wide range of recommendations, covering efforts such as paediatric networks, improved dispensing systems and electronic prescriptions. 6.6 Mental health services Estimates of prevalence of mental disorders in Norway vary considerably, according to methods and diagnostic criteria used. Approximately 15-20 percent of the adult population is estimated to have some kind of mental health problems, while 25

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about three percent is estimated to have a serious mental disorder. The rate of suicide is fairly low in comparison with other Northern European countries. Nevertheless, suicide is one of the most important causes of death for people under 45 years of age, responsible for 13 percent of all deaths in this age group. Of the population aged 6-67 years, three percent receive disability pensions based on a psychiatric diagnosis, constituting one third of all people on disability pension. An additional 0,6 percent of the population is on long term sick leave due to a mental health condition. The municipalities play a key role in the provision and co-ordination of services for people with mental health problems. Specialised mental health care is provided by the health enterprises. This includes care for patients with serious mental health problems and concurrent drug or alcohol problems (dual diagnoses). Young persons aged 15-30 years with mental health problems and drug abuse are also referred to specialised mental health units. In 1998, The Norwegian Parliament adopted a reform entitled “National Programme for Mental Health” (1999-2008), including major investments, expansion and reorganizing of services. Central components in the programme are: • • • •

Strengthening the user’s position through involvement at all levels in decision- making processes information programmes for public awareness on mental health issues strengthening community based services with special emphasis on prevention and early intervention expanding and restructuring specialized services for children, adolescents and adults.

In primary health care settings the emphasis has been placed on availability of competent services through • • • •

general practitioners for the whole population recruitment of psychologists establishment of a competency centre for primary mental health services educational programmes in mental health for professionals employed in communities.

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During the National Programme for Mental Health there has been a marked increase in mental health professionals, which has contributed to better accessibility for out-patient clinic consultations for both children, adolescents and adults. The original goal of 50 percent increase (for adults) has been reached with good margins. An additional contribution has been the systematic establishment of outreach teams. Finally, large scale information campaigns for better understanding of mental health problems have been launched to reduce stigma. 6.7 Alcohol and drug abuse The medical and social challenges posed by substance abuse are substantial. In addition to structural policies that regulate price and availability of alcohol, much is invested in prevention through the municipal health services. A National Action Plan on Alcohol and Drugs (2007-2010) has been adopted in order to meet the increasing challenges. 6.7.1 Main goals The aim of the National Action Plan is a policy marked by a clear public health perspective. Main goals include better quality and increased competence, more accessible services and increased social inclusion, binding cooperation, increased user influence and greater attention to the interest of children and family members. 6.7.2 Treatment The treatment system for drug users is part of the general Health Care System. The Regional Health Authorities are responsible for Interdisciplinary Specialised Treatment (IST). IST indicates the necessity of different health and social welfare system professionals being involved in the treatment. There is a lack of IST treatment slots for both in- and out-patient treatment. The treatment system consists of both public and private institutions, financed by the state through contracts. Referral to drug treatment is performed either by the general practitioners or by the social welfare system. The referrals have to be dealt with by the IST services within 30 days (stated by The Patients Rights Act), 10 days for drug using patients below the age of 23 years. 27

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Most of the treatment services covers both alcohol and drug using patients, including patients dependent on prescribed drugs. Medication assisted treatment (MAT) was started on a national scale in 1998. The expansion has been quite rapid, approximately 500 new patients net each year. By the end of April 2008, there were approximately 4,700 patients in MAT with methadone or buprenorphine. Patients rights have been introduced in order to improve the treatment for substance abusing patients. Emphasis has increasingly been on userâ&#x20AC;&#x2122;s involvement in the treatment process.

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Public health and health promotion

The general level of health in Norway is high by international standards. However, the socioeconomic distribution of health still poses serious challenges for Norwegian public health policies. Thus, for instance, although life expectancy for Norwegian men in general is among the best in the world, a male university teacher can statistically expect to live some ten years longer than a male chef. Inequalities among female employees are smaller, but still substantial. 7.1 Strategy to reduce social inequalities in health A 2006 public health white paper, National strategy to reduce social inequalities in health, made the reduction of such health inequalities the central concern of Norwegian public health policy for ten years to come. The strategy was built on the principle that the way to change the social distribution of health is to change the social distribution of health determinants, which are ultimately to be found “upstream”, in the social distribution of resources. More specifically, the strategy operates with four priority areas: 1. 2. 3. 4.

Reduce social inequalities that contribute to inequalities in health – including factors such as income, childhood conditions, education, employment and working environment; Reduce social inequalities in health-related behaviour – such as nutrition, physical activity, smoking and substance abuse – and in the utilisation of health services; Targeted initiatives to promote social inclusion; and Develop knowledge and cross-sectoral tools.

Some of these areas are described further below or elsewhere in this document. No less important, however, are the factors outside the traditional limits of the health sector, such as income, education and employment. Thus, a main task in the years to come is cross-sectoral cooperation on issues of socioeconomic distribution. 7.2 Tobacco use and tobacco control Approximately 6,700 people die from smoking related diseases every year (in particular cardiovascular diseases, cancer and lung diseases), representing 16 percent of all deaths in Norway.

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Historically, smoking peaked in Norway around 1970. Since then, there has been comprehensive plan for tobacco control with a designated government agency. Smoking prevalence has declined significantly, while the use of smokeless tobacco has risen since 2000. 7.2.1 Strong legislation The Norwegian Tobacco Act entered into force in 1975, requiring health warnings on tobacco packaging, 16 year age limit and a ban on advertising of tobacco products. Today Norway is still considered a country with strong tobacco legislation. The EU Directive 2001/37/EC concerning the manufacture, sale and presentation of tobacco products is implemented in national legislation. Like Sweden, Norway has an exception from the EC ban on the sale of tobacco for oral use (moist snuff). The age limit for buying tobacco is 18 years. Since 1988, there has been legal protection from exposure to tobacco smoke in workplaces, only allowing separate smoking rooms. Since 2004, Norway has a complete ban on smoking in bars and restaurants. Norway was the first country to ratify the WHO Framework Convention on Tobacco Control (FCTC), which entered into force in 2005. 7.2.2 Reducing use The main goal of the National strategy for Tobacco Control 2006-2010 is to promote health in all segments of the population and to ensure more years of healthy life by reducing the use of tobacco. Reducing tobacco use is mainly done in two ways:

•

Preventing the uptake of tobacco use: Most important are restrictive measures like legislation and high prices, as well as educational programmes in school and communication measures.

•

Smoking cessation: The quit line answers 11 000 calls a year, also offering follow-up calls. Help can also be found through health personnel and cessation courses around the country. Nicotine replacement therapy is available over the counter in general stores.

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In the years 1998-2008 daily smoking prevalence among adults decreased from 33 to 21 percent. There has been a remarkable development among young people, where smoking prevalence is cut in half in just five years.

Men, smoking daily Women, smoking daily Men, using smokeless tobacco daily Women, using smokeless tobacco daily

50 40 % 30 20 10 0 1973

1978

1983

1988

1993

1998

2003

2008

Figure 5 Daily prevalence of smoking and use of smokeless tobacco. Men and women 16-74 years. Statistics Norway.

7.3 Nutrition In Norway, the population in general has abundant access to food and, at the outset, good opportunities to be able to eat a healthy and varied diet. Developments in the food market are increasing the diversity of products, but can also make it more difficult for people to put together a healthy diet. The incidence of obesity is increasing due to unhealthy diet and lack of physical activity. Diseases such as type 2 diabetes, cardiovascular diseases, and certain forms of cancer are closely linked to the diet in the population. Social inequalities in diet contribute to the social inequalities in health and disease. Much remains to be done before the diet in all segments of the population meets nutritional recommendations. The diet of many young people and adults still contains too much fat, especially saturated fat, and too much salt and sugar. The consumption of dietary fibre by most people is lower than recommended, and some groups get too little vitamin D, iron and folic acid. The work to improve the population’s diet is outlined in the national nutrition action plan “Recipe for a healthier diet”, for the period 2007-2011. The plan contains 73 specific measures that will promote health and prevent illness by changing eating habits. Five main strategies are implemented:

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1. Improve the availability of healthy food products Universal measures that make it easier for everyone to choose healthy foods is the most effective measure to improve healthy eating habits in a population 2. Consumer knowledge Widely distributed information and communication will help increase the public's knowledge of food, diet and health, which in turn will serve to make it easier for consumers to make informed dietary choices. 3. Qualifications of key personnel Policy makers and professions who directly or indirectly contribute to nutritionrelated activities need to have a sound and relevant level of knowledge about nutrition, diet and food 4. Local basis of nutrition-related activities In recent years, local partnerships for public health have grown to become one of the most important strategies for a healthier lifestyle. Continuous, binding and systematic interdisciplinary and cross-sectional collaboration is necessary for achieving good health 5. Strengthened focus on nutrition in the health care services Nutrition is a necessary part of prevention, treatment and rehabilitation of disease, and a basis and support for other medical treatments. The main topics under consideration in 2008 were development of a sign posting system on foods, marketing of food towards children, healthy meals in kindergarten and schools, provision of vitamin D supplementation to immigrant infants, nutrition among elderly, development of lifestyle intervention and capacity building of key personnel in work places and in the health system. Twelve ministries have collaborated to develop the current national nutrition action plan, and they all have a co-responsibility in implementing the actions. The action plan serves as a tool for decision-makers, professionals, experts and others in the public and private sectors and in the NGO sector.

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7.4 Physical activity During a relatively short course of time, society has gone through immense changes regarding daily demands of physical activity. Today, we have to actively seek out and give priority to a number of those experiences, challenges and skills that constituted an integral part of everyday life in the past. The level of physical activity in the Norwegian population is considered to be too low, and there are marked social differences. The World Health Organization points out that physical inactivity will be the great health challenge in the future. Due to lack of physical activity and unhealthy diet the incidence of obesity is increasing, and diseases such as type 2 diabetes, cardiovascular diseases and certain forms of cancer are closely linked to physical inactivity in the population. To meet the challenge, an Action Plan on Physical Activity (2005-2009) – “Working together for Physical Activity”, was published in 2004. The plan was developed through a co-operation between eight different Ministries, and contains 108 measures. The plan has two main targets: An increase in the number of children and youth who are physically active for at least 60 minutes pr day An increase in the number of adults and elderly people who are moderately physically active for at least 30 minutes pr day An evaluation of the action plan in 2009 will help to decide further actions on promoting physical activity.

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Universal design - The Delta centre

“Delta” is Norwegian for “participate”. The Delta centre is the national resource centre for participation and accessibility for persons with disabilities. The centre’s activities are based on the Government’s policy on persons with disabilities and on the Standard Rules of the United Nations. The main goal of the Delta centre is to ensure that persons with disabilities can actively participate in society on an equal footing with others. Its vision is participation and accessibility for all. The work of the Delta centre is based on the combination of universal design, environmental adaptation and assistive technology as methods to facilitate participation and accessibility for persons with disabilities. The main areas of work are to identify disabling barriers and to show how these can be reduced or removed, to develop knowledge on accessibility and to provide counselling on best practise. User participation is an overarching principle and a strategic method to be employed in all activities at the Delta centre.

Preparedness

Health and social preparedness is directed towards the protection of the citizens’ health and social welfare during crises and other unexpected, extraordinary situations. All preparedness work within the health sector is based on the “principles of responsibility, similarity and proximity”. The organisational unit responsible for a particular task under normal circumstances is obliged by law to prepare for the continuation of its operations during an emergency. The crisis management should be as close to the normal organisation as possible and crises should be handled as close to the scene as the situation permits. 9.1 Aims It follows from the above mentioned principles that the responsibility for the local and regional preparedness lies with the regional municipal authorities. Guidance is given from the Emergency Preparedness Department based in the 34

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Directorate of Health. The aim is to build a robust, well functioning health and social preparedness system in the municipalities, the counties and the health regions. The following elements shall be mentioned: • • • •

Preparation of national plans and guidance material, including the National Influenza Pandemic Preparedness Plan and the National Smallpox Preparedness Plan Supporting regional exercises in the field of health and social preparedness Maintenance of a national stockpile of selected medicines, including antivirals against pandemic influenza and potassium iodide against radioactive iodine, a possible contaminant from a nuclear accident International, particularly inter-Nordic cooperation, in the field of health preparedness

Links Action plan on Physical Activity 2005-2009 – “Working together for Physical Activity”, www.1-2-30.no/bedrehelse/handlingsplanen Norway's National Strategy for Tobacco Control 2006-2010: www.helsedirektoratet. no/tobakk/english Norwegian Directorate of Health: www.helsedirektoratet.no Norwegian Institute for Alcohol and Drug Research, SIRUS: www.sirus.no Statistics Norway: www.ssb.no/english The Cancer Registry of Norway: www.kreftregisteret.no The Delta Centre: www.helsedirektoratet.no/deltasenteret/english The Ministry of Health and Care Services: www.hod.dep.no The Norwegian Board of Health: www.helsetilsynet.no The Norwegian Government: www.government.no The Norwegian Institute of Public Health: www.fhi.no The Norwegian Medicines Agency: www.legemiddelverket.no The Norwegian Radiation Protection Authority: www.nrpa.no The Norwegian Registration Authority for Health Personnel: www.safh.no 35

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Heftet er utgitt av Helsedirektoratet Postboks 7000 St.Olavs plass, 0130 Oslo. Flere eksemplarer kan bestilles fra mailadressen trykksak@shdir.no

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Fact Sheet | health care

PHOTO: Miriam Preis/Image Bank Sweden

Swedes have one of the highest life expectancies in Europe.

Health care in Sweden Everyone in Sweden has equal access to health-care services. The Swedish health-care system is taxpayer-funded and largely decentralized. The system performs well in comparison with other countries at a similar level of development, with good medical results relative to investments and despite funding restrictions. Life expectancy in Sweden continues to rise. In 2008, it was 79 years for men and 83 years for women. This can be partly attributed to falling mortality risks for both heart attacks and strokes. A little more than 5 percent of the population is aged 80 or more. That means that Sweden – along with Italy – has Europe’s largest elderly population as a proportion of the national total. However, the number of children born in Sweden has been increasing steadily since the end of the 1990s, a shift that will reduce the relative proportion of elderly residents. Chronic diseases that require monitoring and treatment – and often life-long medication – place great demands on the system. One positive fact is that Sweden

has relatively few smokers – almost 85 percent of Swedes are non-smokers. Shared responsibility

In the Swedish health-care system, responsibility for health and medical care is shared by the central government, county councils and municipalities. The Health and Medical Service Act (Hälso- och sjukvårdslagen, HSL) regulates the responsibilities of the county councils and municipalities. The act is designed to give county councils and municipalities more freedom in this area. The role of the central government is to establish principles and guidelines for care and to set the political agenda for health and medical care. It does this

using laws and ordinances or by reaching agreements with the Swedish Association of Local Authorities and Regions (SALAR), which represents the county councils and municipalities. Health care decentralized

Responsibility for providing health care is decentralized to the county councils and, in some cases, municipal governments. County councils are political bodies whose representatives are elected by their residents every four years on the same day as national general elections. In line with Swedish policy, every county council must provide residents with good-quality health and medical care, and work toward promoting good health

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Fact Sheet | health care Players within the health-care field There are several authorities and organizations involved in health care at a national level. The National Board of Health and Welfare (Socialstyrelsen) plays a fundamental role as the central government’s expert and supervisory authority. www.socialstyrelsen.se The Swedish Association of Local Authorities and Regions (SALAR) represents the governmental, professional and employer-related interests of Sweden’s 290 municipalities, 18 county councils and the two regions, Västra Götaland and Skåne. www.skl.se The Medical Responsibility Board (Hälso- och sjukvårdens ansvarsnämnd) is a government agency that investigates possible breaches of standards by healthcare professionals. www.hsan.se The Swedish Council on Technology Assessment in Health Care (SBU Kunskapscentrum för sjuk- och hälsovården) carries out assessments of which healthcare measures produce the greatest benefit for patients and how the care system can use its resources most advantageously. www.sbu.se The Dental and Pharmaceutical Benefits Agency (Tandvårdsoch läkemedelsförmånsverket) is a central government agency whose remit is to determine whether a pharmaceutical product or dental procedure is to be subsidized by the state. www.tlv.se The Medical Products Agency (Läkemedelsverket) is the Swedish national authority responsible for regulation and monitoring of the development, manufacturing and marketing of drugs and other medical products. www.lakemedelsverket.se

for the entire population. County councils are also responsible for dental care for local residents up to the age of 20.

health and medical care. The number of patients seeking treatment in other EU countries has grown in recent years, as has the number of health-care profesShared medical care sionals working in other member states. Sweden is divided into 290 municipaliSweden is actively involved in cooperties, 18 county councils and two regions, ation across the EU to improve access to Västra Götaland and Skåne. (One munici- health and medical services. This pality Gotland, an island in the Baltic Sea, includes collaborating on specialized has the same responsibilities for health care care, improving patient safety and as the county councils.) enhancing patient influence. There is no hierarchical relation between municipalities, county councils Patient safety and regions, since all have their own selfThere is also more discussion of health governing local authorities with responsiand medical services outside the EU, parbility for different activities. Around 90 ticularly in organizations such as the percent of the Swedish county councils’ WHO, the OECD, the Council of Europe work involves health care, but they are and the Nordic Council of Ministers. also involved in other areas, such as culMany of the challenges confronting ture and infrastructure. Swedish health care can also be seen in Sweden’s municipalities are responsible other countries. These include issues of for care for elderly people in the home or accessibility, quality, efficiency and in special accommodation. Their remit funding. also includes care for people with physical One prioritized area is patient safety; disabilities or psychological disorders. the Swedish Association of Local Municipalities are also responsible for Authorities and Regions is driving a providing support and services for people national effort together with all the released from hospital care as well as for regions and county councils to ensure school health care. that patients are protected from accidents, incorrect treatments and other International work incidents. Greater mobility among EU citizens has Another goal is to halve the incidence increased the need for cooperation on of health-care-related infection by 2010.

Care within 90 days Waiting times for preplanned care, such as cataract or hipreplacement surgery, have long been a cause of dissatisfaction. As a result, Sweden has introduced a health-care guarantee. In 2005, the county councils and central government agreed to introduce a health-care guarantee. This means that no patient should have to wait more than 90 days once it has been determined what care is needed. If the time limit expires, patients are offered care elsewhere; the cost, including any travel costs, is then paid by their own county council. The situation has improved since the health-care guarantee was introduced. Collated waiting times as of December 31, 2008, showed that 75

percent of patients had received treatment within 90 days. To improve matters further, the central government, in consultation with the Swedish Association of Local Authorities and Regions, decided to allocate an extra SEK 1 billion (USD 140 million) each year starting in 2010 and through to 2012. For county councils to get a share of the billion kronor, they must meet the requirement that 80 percent of their patients receive care within the allotted time. They must also submit information about waiting times to a new national database. | 2

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Fact Sheet | health care PHOTO: Magnus Neideman/SvD/SCANPIX

Learn more High quality of care Comparisons show that Swedish health care performs well compared with care in other countries. This includes the areas of access, quality, outcomes and results. The Swedish system is also efficient compared with other countries. Patient fees The fee for staying in a hospital is SEK 80 per day. Patient fees for primary care vary between SEK 100 and 200 depending on the county council. For specialist visits there is an additional fee of a maximum SEK 300. High-cost ceiling A cost ceiling applies to limit an individual’s costs. After a patient has paid a total of SEK 900 during one year, medical consultations within 12 months of the first consultation are free of charge. There is a similar ceiling for prescription medication, so nobody pays more than SEK 1,800 in a 12-month period. End of monopoly In the spring of 2009, the state-owned company Apoteket AB lost its pharmacy monopoly. This means Apoteket no longer has the sole right to sell medicines. Some of the pharmacies are being sold, and about two-thirds of Sweden’s pharmacies are expected to get new owners. The aim is to increase access and improve service for patients and customers. PHOTO: Elisabet Omsén/Scanpix

SWEDISH MIDWIVES IN FOCUS Sweden has long had trained professional midwives. Research shows that this meant a sharp reduction in mortality among women giving birth. Between 1860 and 1900, mortality fell 75 percent as more parishes employed midwives. Today, maternal mortality in Sweden is among the lowest in the world. There are, on average, 3 deaths per 100,000 children born. The Swedish system of midwives is now attracting international attention. The UN organizations UNFPA and WHO are highlighting the system as a model for achieving the target of halving mortality among mothers by 2015.

Operation waitlists are shorter thanks to the health-care guarantee.

Costs for care Costs for health and medical care account for about 9 percent of Sweden’s gross domestic product (GDP), a figure that has remained fairly stable since the early 1980s. Costs are on par with those in most other European countries. In the US, by comparison, health-care costs are almost twice as high. The bulk of health and medical costs in Sweden are paid for by county council and municipal taxes. Contributions from the national government are another source of funding, while patient fees cover only a small percentage of costs. Primary care most expensive

County council costs for health and medical care, excluding dental care, were SEK 186 billion in 2008. That is an increase of

SEK 9.2 billion or 5.2 percent on 2007.

Primary care accounts for the largest increase in costs, with a greater need for general medical care and physiotherapy than in previous years. More private health-care providers

It is now more common for county councils to buy services from private healthcare providers; 10 percent of health care is financed by county councils but carried out by private care providers. An agreement guarantees that patients are covered by the same regulations and fees that apply to municipal care facilities.

Benchmarking leads to improvements Local taxes are the basis for funding health and medical care, which means opportunities for economic expansion are strictly limited. Cost restrictions mean it is essential to get the most out of existing resources. Benchmarking between county councils has led to improvements, but significant decentralization has meant that there is often a lack of national data. For this reason, the National Board of Health and Welfare and the Swedish Association of Local Authorities and Regions are developing a model to compare targets and evaluate results. The aims include: • Providing a better platform for public debate and political decisions • Making it easier for county councils and

municipalities to manage and streamline health care • Providing the general public and patients with more accessible information. Statistics based on national research have already been produced on issues such as the quality of health care, patient safety, waiting times, patient opinions and costs, and the effects of factors such as lifestyle, food and the environment on health, allowing comparisons between counties. Improvements can already be seen in several areas. One is mortality related to stroke or heart attack, where a decrease for both men and women of more than two percentage points can be seen in almost every county. The percentage of patients who survive breast cancer has been increasing since the project started. | 3

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Fact Sheet | health care

IN BRIEF Sweden’s eight regional hospitals: • Skåne University Hospital, Malmö and Lund • Sahlgrenska University Hospital, Göteborg • Linköping University Hospital • Örebro University Hospital • Karolinska University Hospital, Stockholm • Uppsala University Hospital • Norrland University Hospital, Umeå

How care is organized Most health care today is provided in health centers where a variety of health professionals – doctors, nurses, midwives, physiotherapists and other staff – work. This simplifies care for patients and fosters teamwork. Patients are able to choose their own doctor. There are special clinics for children and expecting mothers, as well as youth clinics that offer advice on a range of issues, including family planning. Free choice

1 Umeå

2 Uppsala Örebro

Stockholm

Linköping

Göteborg 5

People in Sweden have had free choice in health care since 2003. This means that patients can seek treatment anywhere in the country under the same conditions as in their home county. By January 2010, all county councils are to have introduced what is known as the primary choice system in primary care. This was adopted by the Riksdag (Swedish parliament) in February 2009. The system entails patients choosing whether they would prefer to go to a private or public health center. All care providers that meet county council requirements are entitled to start a health center that is reimbursed with public funds from the county council. For instance, they must provide social

workers or psychologists, ordinary home health services, and emergency services until 9 pm. All care centers are paid the same amount for each patient seen. Eight regional hospitals

Sweden has 60 hospitals that provide specialist care, with emergency services 24 hours a day. Eight of these are regional hospitals where highly specialized care is offered and where most teaching and research is based. Six health-care regions

Because many county councils have small service areas, six health-care regions have been set up for more advanced care. This is coordinated by the Committee for National Specialised Medical Care (Rikssjukvårdsnämnden) within the National Board of Health and Welfare. The counties own all emergency hospitals, but health-care services can be outsourced to contractors. For preplanned care, there are several private clinics from which counties can purchase certain services to complement those offered within their own units. This is an important component of the effort to increase access.

6 Lund Malmö

Sweden’s six health-care regions: 1. Northern region 2. Uppsala-Örebro region 3. Stockholm-Gotland region 4. Western region 5. South-eastern region 6. Southern region

Published by the Swedish Institute October 2009 FS 10 More facts can be found on www.sweden.se

Useful links www.sweden.gov.se – The Government Offices of Sweden www.socialstyrelsen.se – The National Board of Health and Welfare www.skl.se – The Swedish Association of Local Authorities and Regions www.sbu.se – The Swedish Council on Technology Assessment in Health Care www.fhi.se – The Swedish National Institute of Public Health www.smittskyddsinstitutet.se – The Swedish Institute for Infectious Disease Control www.lfn.se – The Pharmaceutical Benefits Board www.lakemedelsverket.se – The Medical Products Agency

Copyright: Published by the Swedish Institute on www.sweden.se. All content is protected by Swedish copyright law. The text may be reproduced, transmitted, displayed, published or broadcast in any media for non-commercial use with reference to www.sweden.se. But never photographs or illustrations. For more information on general copyright and permission click here. The Swedish Institute (SI) is a public agency that promotes interest in Sweden abroad. SI seeks to establish cooperation and lasting relations with other countries through strategic communication and cultural, educational and scientific exchanges.

Further information about Sweden: www.sweden.se, the Swedish embassy or consulate in your country, or the Swedish Institute, Box 7434, SE-103 91 Stockholm, Sweden Phone: +46 8 453 78 00 Mail: si@si.se www.si.se, www.swedenbookshop.com

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infosantésuisse : Dossier Die europäischen Gesundheitssysteme im Vergleich (Teil 4) 1/2010 1330 Vergleich des schweizerischen und des niederländischen Gesundheitssystems – Teil I: Das niederländische Versicherungssystem

Die Niederlande verbinden die Vorteile des Marktes mit der Sicherheit des Staates In den nächsten drei Ausgaben von infosantésuisse stellen wir in einer Artikelserie das niederländische Gesundheitssystem vor.* Der erste Artikel wird das System vorstellen, der zweite wird es mit jenem der Schweiz vergleichen und der dritte Artikel wird die Lehren, die aus dem niederländischen Gesundheitssystem zu ziehen sind, untersuchen. Die amerikanische Presse tendiert dazu, die beiden Modelle miteinander zu vergleichen. Sie sieht darin zwei mögliche Inspirationsquellen für die Gesundheitspolitik von Präsident Barack Obama. Ist dieser Vergleich gerechtfertigt?

Das niederländische Gesundheitssystem ist zum grössten Teil privat. Es organisiert sich um die selbstständig praktizierenden Ärzte (Allgemeinmediziner und Spezialisten) und um die Spitäler und Kliniken, die Non-Profit-Organismen gehören – Überbleibsel der karitativen Institutionen des Mittelalters. Im Zentrum des Gesundheitssystems steht die medizinische Grundversorgung. Der Arzt für Allgemeinmedizin nimmt darin die Rolle eines Gatekeepers ein. Die definierten Ziele des Systems sind die Förderung der Pflegequalität, ihrer Effizienz, Zugänglichkeit und Wirtschaftlichkeit. Bereits im 15. und 16. Jahrhundert entstanden in den Niederlanden Grundzüge einer Krankenversicherung, die von Gilden – Gruppen von Bürgern, die gemeinsame Interessen vertraten – organisiert war. Trotz dieses enorm frühen Beginns dauerte es bis zum Zweiten Weltkrieg, bis ein ausgeweitetes soziales Krankenversicherungssystem stand. Dieses System war bis zum 1. Januar 2006 in Kraft: Für die zwei Drittel der Bevölkerung, die unterhalb einer gewissen Wohlhabensgrenze standen, gab es eine Versicherungspflicht. Das vermögendere Drittel der Bevölkerung konnte sich freiwillig einer privaten Versicherung anschliessen. Seit dem 1. Januar 2006 wird diese Unterscheidung nicht mehr ge-

macht. Das Krankenversicherungsgesetz (Zorgverkeringswet – ZVW) hat das niederländische Gesundheitssystem mit der Einführung des Obligatoriums stark verändert. Obligatorium mit Varianten

Seit dem 1. Januar 2006 muss jede in den Niederlanden wohnhafte Person bei einem Versicherer eine Krankenversicherung abschliessen. Im alten System waren rund zwei Prozent der Bevölkerung nicht versichert. Die neue Versicherung sieht auch einen Katalog mit sogenannter Basispflege vor, der vom Staat festgelegt wird. Zugleich kann ein Versicherer einer Person nicht mehr wie früher den Anschluss verweigern, indem er sich auf Risiken wegen des Gesundheitszustands beruft. Die Versicherer müssen jede Person, die eine Versicherung abzuschliessen wünscht, annehmen. Der Versicherte wiederum kann zwischen verschiedenen Versicherungsarten wählen: Bei der «Sachpolice» schliesst der Versicherer mit den Leistungserbringern Verträge ab und bezahlt die Rechnungen direkt (Tiers payant). Der Versicherte seinerseits muss sich an jene Gesundheitsfachpersonen wenden, die mit seinem Versicherer einen Vertrag abgeschlossen haben (Einschränkung in der Wahl des Leistungserbringers). Bei der Police «gegen Rückvergütung» bestimmt der Versicherte selbst seinen Erbringer von Pflegeleistungen (freie Wahl), bezahlt die Rechnungen und lässt sich diese vom Versicherer rückerstatten (Tiers ga-

rant). Diese beiden Systeme können in der Versicherungspolice auch gemischt werden. Zusätzlich zur Grundversicherung gibt es Zusatzversicherungen, welche die Leistungen oder Teile von Leistungen übernehmen, die nicht Bestandteil des Leistungskatalogs sind. Dreiteilige Finanzierungsstruktur

Das Krankenversicherungssystem besteht aus drei Komponenten. Jede davon deckt bestimmte Pflegeleistungen ab und ist spezifischen Versicherungsmodalitäten unterstellt: • Die erste Komponente umfasst die «ausserordentlichen Risiken». Sie ist im allgemeinen Gesetz über besondere Krankheitskosten (AWBZ) definiert, das die Kosten im Falle eines Langzeitaufenthalts für die gesamte Bevölkerung abdeckt. Die Prämie wird mit einem maximalen Plafond prozentual zum Einkommen berechnet. • Die zweite Komponente bezieht sich auf einen Katalog von Basisleistungen und umfasst Konsultationen bei Ärzten für Allgemeinmedizin, Medikamente oder Hospitalisierungen. Jeder niederländische Bürger ist zum Abschluss dieser Versicherung bei einem der privaten konkurrierenden Krankenversicherern verpflichtet. Die Prämien sind teilweise Nominalprämien und teilweise einkommensabhängige Prämien. • Die dritte Komponente betrifft die Zusatzversicherungen. Dieser dritte Block ist weniger streng geregelt, und

Indikator

Wert (Jahr)

Öffentliche Ausgaben in Prozent der gesamten Gesundheitsausgaben Öffentliche Gesundheitsausgaben in Prozent der öffentlichen Gesamtausgaben Direkte Zahlungen in Prozent der privaten Gesundheitsausgaben

64,9 (2005) 13,2 (2005) 21,90 (2005)

Öffentliche Gesundheitsausgaben pro Einwohner (offizieller US-Dollar-Kurs)

2311,0 (2005)

Total der öffentlichen Gesundheitsausgaben pro Einwohner (offizieller US-Dollar-Kurs)

3560,0 (2005)

Private Ausgaben in Prozent der gesamten Gesundheitsausgaben

35,1 (2005)

Finanzierung der privaten Krankenversicherungen in Prozent der privaten Gesundheitsausgaben

55,5 (2005)

Total der Gesundheitsausgaben in Prozent des BIP Quelle: WHO-Statistiken 2006

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9,2 (2005)

Foto: Keystone

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Durch eine schlaue Kombination von Staat und Markt gelten die Niederlande heute als patientenfreundlichstes Gesundheitssystem Europas.

die Prämien sind normalerweise risikoabhängig. Der Abschluss einer Zusatzversicherung ist nicht obligatorisch. Ähnlichkeiten zum Schweizer System

Ab 18 Jahren muss jede Person für die zweite Komponente eine «Nominalprämie» zahlen. Je nach Typ der Versicherungspolice ist dieser Beitrag unabhängig von Alter, Geschlecht, Gesundheitszustand oder Einkommen gleich hoch. Ein Teil der Nominalprämie kann rückerstattet werden, wenn der Versicherer die Gesundheitsdienstleistungen nur selten oder gar nicht in Anspruch nimmt. Nebst der Nominalprämie werden von der Steuerbehörde die einkommensabhängigen Beiträge abgezogen, die dazu bestimmt sind, 50 Prozent der Kosten des Systems zu decken. Der jährliche Plafond liegt bei ungefähr 30 000 Euro. Diese Abgabe wird dem Versicherten von seinem Arbeitgeber oder von der Sozialhilfe rückerstattet. Schliesslich übernimmt der Staat einen Teil der Prämien für Kinder unter 18 Jahren. Er kann auch an die Stelle einer Krankenversicherungsgesellschaft treten und die finanziellen Verpflichtun-

gen übernehmen, die diese nicht erfüllen konnte. Die einkommensabhängigen Beiträge und die vom Staat ausgeschütteten Beträge speisen den Krankenversicherungsfonds, der vom Amt für Krankenversicherungen verwaltet wird. Die Ressourcen des Fonds werden teilweise für den Ausgleich der finanziellen Belastung der Versicherer eingesetzt, weil sie jede zum Abschluss einer Versicherung verpflichtete Person aufnehmen müssen. Damit ist dieser Fonds das Pendant der Gemeinsamen Einrichtung KVG in der Schweiz, welche für den Risikoausgleich zuständig ist. Damit jedermann Zugang zur Versicherung hat, sind von der Regierung Zulagen vorgesehen, welche die Personen mit niedrigerem Einkommen beim Bezahlen der Nominalprämie unterstützt (Prämienverbilligung).

abschliessen. Der Zugang zu den Leistungen wird durch Jahresverträge und durch die Versicherungspflicht gewährleistet. Dieses System kombiniert Marktmechanismen und staatliche Regelung. Anders ausgedrückt drängt der Markt das Gesundheitssystem zu mehr Wettbewerbsfähigkeit, Effizienz und Anpassungsfähigkeit an die Nachfrage, während die Regierung die Qualität und die Gerechtigkeit regelt und kontrolliert. Trotz bereits zahlreicher Reformen bleibt noch viel zu tun. Doch die Niederlande scheinen auf dem richtigen Weg zu sein. Davon zeugt ihr erster Platz im Euro Health Consumer Index (EHCI) 2008 und die von zahlreichen Experten geteilte Meinung, das niederländische Gesundheitssystem sei eines der besten der Welt. maud hilaire schenker

Regulierter Wettbewerb

Das Gesundheitssystem basiert auf einem geregelten Wettbewerb, der sich aus der freien Wahl ergibt. Der Wettbewerb spielt sowohl unter den Krankenversicherern als auch unter den Leistungserbringern, weil die konkurrierenden Krankenversicherer mit bestimmten Leistungserbringern Verträge

* Die drei Artikel werden sich auf das Buch von Robert E. Leu, Frans Rutten, Werner Brouwer, Christian Rütschi und Pius Matter, The Swiss and the Dutch health care systems compared, Gesundheitsökonomische Beiträge, Band 53, NOmos, 2008 stützen.

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Regulierter Wettbewerb und Qualitätsbewusstsein

Das niederländische und das schweizerische Gesundheitssystem* ähneln sich in vielerlei Hinsicht. Auf dem Prinzip der Versicherungspflicht aufbauend, führen beide einen breit gefächerten Leistungskatalog für die Grundversicherung. Beide kennen einen Risikoausgleich. Qualität wird in beiden Systemen, die auf der freien Wahl des Patienten beruhen, gross geschrieben. Doch wie und durch wen wird sie evaluiert? Stösst man hier an die Grenzen dieser Systeme, die oftmals und insbesondere durch die amerikanische Presse als die besten der Welt gerühmt werden? Versicherungspflicht...

Die Einwohnerinnen und Einwohner der Schweiz und der Niederlande sind verpflichtet, eine Krankenversicherung abzuschliessen. Obwohl keine offiziellen Daten vorliegen, wird die Zahl der Nichtversicherten in der Schweiz als sehr tief eingeschätzt (weniger als ein Prozent). In den Niederlanden sind 1,5 Prozent der Bevölkerung nicht versichert. Dieser Unterschied lässt sich dadurch erklären, dass die Schweiz eine aktive Politik zur Identifizierung der nicht versicherten Personen führt. Artikel 6 des KVG teilt diese Aufgabe den Kantonen zu, die für die Einhaltung der Versicherungspflicht sorgen. Ist eine Person erst einmal versichert, muss ihre Krankenkasse sie solange registriert lassen, bis dieser bestätigt wird, dass die betreffende Person bei einem anderen Versicherer angeschlossen ist oder nicht mehr der Versicherungspflicht untersteht (Art. 7 KVG). Beide Länder haben allerdings das Problem, dass einige Versicherte ihre Prämien nicht bezahlen. In der Schweiz sind dies 120 000, in den Niederlanden (mit doppelt so vielen Einwohnern) 240 000 Personen. Die beiden Länder versuchen, die Versicherten vom Nichtbezahlen ihrer Prä-

mien abzuschrecken (mittels Aufschub der Übernahme der Leistungen, Artikel 64a KVG) oder säumige Zahler daran zu hindern, von einem Versicherer zum anderen zu wechseln (parlamentarische Initiative zur Schaffung einer schwarzen Liste). Die Niederlande sind sich unlängst dieser Problematik bewusst geworden und werden wohl in naher Zukunft entsprechende Massnahmen treffen müssen. …und obligatorische Grundversicherung

Die medizinischen Leistungen sind in den Niederlanden und in der Schweiz ähnlichen Kontrollkriterien unterworfen: WZW-Kriterien (Wirksamkeit, Zweckmässigkeit und Wirtschaftlichkeit) für die Schweiz – Notwendigkeit, Wirksamkeit und Kosten-Nutzen-Verhältnis für die Niederlande. Bei der Definition des Katalogs und der Einführung neuer Leistungen gibt es allerdings in keinem der beiden Länder ein systematisches Evaluationsverfahren. Einzig die Medikamente, die Laboranalysen und die Präventionsmassnahmen sind einer systematischen Kontrolle unterworfen und werden auf einer Positivliste aufgeführt (siehe infosantésuisse 6/09, S. 8). In den Niederlanden muss die Institution, welche die Medikamente systematisch kontrolliert, jetzt auch jede von einem Spezialisten erbrachte Leistung kontrollieren. Der Leistungskatalog umfasst die Grundversorgung der Allgemeinärzte (Sprechstunden, Visiten und Medikamente), die Untersuchung durch einen Spezialisten und die kleineren Eingriffe. Es gibt auch eine Positivliste für die kassenpflichtigen Medikamente ohne Kostenbeteiligung. Ein grosser Unterschied zur Schweiz ist die Deckung zahnärztlicher Leistungen. Die paramedizinischen Leistungen (wie Physiotherapie oder Logopädie) sind begrenzt. Der Katalog ist eher implizit gehalten, eine kurze Negativliste schliesst gewisse Leistungen aus. Der Grundversicherungsmarkt

Der Grundversicherungsmarkt ist in beiden Ländern sehr ähnlich. Die Versicherten können zwischen den Anbie-

tern wählen und sie jedes Jahr wechseln, ohne dass sie von einem Versicherer abgelehnt werden können. In letzter Zeit wurden in keinem der beiden Länder auf dem Krankenversicherungsmarkt neue Anbieter verzeichnet. Dies ist nicht weiter erstaunlich, da die Grundversicherer keinen Profit machen können – oder konnten: In den Niederlanden ist das mittlerweile erlaubt, und es wird interessant sein, die Entwicklung dieses Marktes zu beobachten. Eine Besonderheit der Niederlande ist das Angebot an Kollektivversicherungen. Die Arbeitnehmenden eines grossen Unternehmens oder spezifische Patientengruppen können Prämienvergünstigungen aushandeln. Zur Förderung des Wettbewerbs setzen die Niederlande auf eine grössere Vertragsfreiheit der Versicherer, die selbst entscheiden können, welche Leistungsanbieter sie vertraglich an sich binden. Die Ver-

Foto: Prisma

Der zweite Teil unserer Artikelserie über das niederländische Gesundheitswesen beschreibt die Gemeinsamkeiten mit dem schweizerischen System. Beide befolgen dieselben Grundregeln: Versicherungspflicht, Wettbewerb und Qualität.

Guter Käse ist nicht die einzige Gemeinsamkeit zwischen der Schweiz und den Niederlanden. Auch im Gesundheitswesen gibt es erstaunlich viele Parallelen.

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sicherer sind nur noch verpflichtet, im Interesse des Versicherten ausreichende Pflegeleistungen zu führen.

züglich Kosten zusätzlich zur Effizienz zwingt.

Der Risikoausgleich

Die alternativen Versicherungsmodelle

Der Wettbewerb wird auch durch den Risikoausgleich ermöglicht. In den Neunzigerjahren bauten die beiden Länder den Risikoausgleich auf den zwei demografischen Kriterien Alter und Geschlecht auf. Seither haben die Niederlande ihre Variablen jedoch mehrmals revidiert und zusätzlich den Arbeitsmarktstatus, den Wohnort, 20 pharmazeutische und 13 diagnostische Kostengruppen aufgenommen. Die Schweiz ihrerseits hält an ihrem demografischen Schema fest, wird jedoch 2012 einen neuen Indikator einführen: «Aufenthalt in einem Spital oder Pflegeheim im Vorjahr». In den Niederlanden wird der Risikoausgleich prospektiv und retrospektiv berechnet, was die Versicherer be-

Zur Förderung des Wettbewerbs bieten die Versicherer auch alternative Versicherungsmodelle an. In diesem Bereich gibt es zwischen den Vergleichsländern jedoch grosse Unterschiede. Während in der Schweiz 12 Prozent der Versicherten ein alternatives Versicherungsmodell gewählt haben, steckt diese Entwicklung in den Niederlanden noch in den Kinderschuhen. Ein anderer Unterschied liegt darin, dass der Arzt für Allgemeinmedizin in den Niederlanden die Rolle eines Gatekeepers einnimmt. Der Zugang zu Spezialisten ist nur durch Überweisung des Hausarztes möglich. In der Schweiz hingegen erlaubt die Grundversicherung einen direkten Zugang zu den Spezialisten.

Präzisierung zur Finanzierung (siehe infosantésuisse 9/2009) Der Teil der über die Steuern gewährleisteten Finanzierung beläuft sich in den Niederlanden auf fünf Prozent und in der Schweiz auf 30 Prozent. In den Niederlanden erfolgen 50 Prozent der Finanzierung über risiko unabhängige Pauschalprämien und 45 Prozent über einkommensabhängige Prämien in Form von Lohnabzügen (7,2 Prozent für Arbeitnehmer bzw. 5,1 Prozent für Pensionierte und Selbstständige bis 31 000 Euro).

In den Niederlanden können die Versicherer auch Apotheken oder Spitäler kaufen, was in der Schweiz unvorstellbar wäre. Die Qualität

Oberstes Gebot dieser beiden Länder ist Qualität. In den Niederlanden gibt es landesweite Indikatoren, die je länger je mehr zur Anwendung kommen. Die Qualitätskontrollen werden auf interne und externe Weise durchgeführt. Zuständig dafür sind die Gesundheitsfachpersonen, aber auch die Versicherer und die Überwacher aus der Regierung. In der Schweiz gibt es noch keine Qualitätskontrollen. Die Berichte der OECD und der WHO regen die Schweiz jedoch an, sich in diese Richtung zu bewegen. Noch gibt es kein nationales Schema, sondern nur vereinzelte Projekte. Die Systeme der Niederlande und der Schweiz sind sich hierbei in vielen Punkten ähnlich. Der grundlegende Unterschied besteht darin, dass die Projekte in den Niederlanden national koordiniert werden, während sie in der Schweiz kantonal organisiert sind. Die grösste Qualität der beiden Systeme sehen die Experten und die internationale Presse im Gleichgewicht zwischen reguliertem Wettbewerb und massvollem Eingreifen des Staates. maud hilaire schenker

* Die drei Artikel stützen sich auf das Buch von Robert E. Leu, Frans Rutten, Werner Brouwer, Christian Rütschi und Pius Matter, The Swiss and the Dutch health care systems compared, Gesundheitsökonomische Beiträge, Band 53, Nomos, 2008.

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In den Niederladen herrscht nicht nur Wettbewerb unter den Cafés, sondern auch unter den Krankenversicherern.

Vergleich des schweizerischen und des niederländischen Gesundheitssystems, Teil III:

Was wir von den Niederlanden lernen können Die ersten beiden Artikel haben die Gemeinsamkeiten und die Unterschiede des schweizerischen und des niederländischen Gesundheitssystems aufgezeigt. Kann das niederländische Gesundheitssystem, das oftmals als das beste bezeichnet wird, von der Schweiz etwas lernen? Und steht es wirklich derart schlecht um das schweizerische System, dass es komplett neu strukturiert werden und sich am niederländischen Gesundheitssystem orientieren muss?

Der erste Artikel unseres dreiteiligen Dossiers hat das niederländische Gesundheitssystem vorgestellt (infosantésuisse 9/2009) und der zweite die Gemeinsamkeiten der beiden Systeme aufgezeigt (infosantésuisse 10/2009). In diesem dritten und letzten Artikel soll eine Synthese erstellt und versucht werden, Lehren aus den beiden Systemen zu ziehen. Wir fragen nach den Stärken und Schwächen der Systeme und was der Blick über die Landesgrenzen hinaus für ihre Weiterentwicklung bringt.

siert und unterscheidet sich damit erheblich von der Fragmentierung des schweizerischen Systems. In den Niederlanden nimmt der Staat vor allem die Rolle eines Regulators ein. Er erbringt keine Leistungen. Die Spitäler sind zum grössten Teil privat, auch wenn sie als gemeinnützige Institutionen funktionieren. Mit der Reform von 2006 wurde die Spitalplanung abgeschafft. Die Versicherer, zu denen auch ausländische Konkurrenten gehören, dürfen Gewinne erzielen und Kollektivversicherungsverträge anbieten, was in der Schweiz nicht möglich ist. Der niederländische Versicherungsmarkt ist zudem stark konzentriert: Fünf grosse Versicherungsgesellschaften versichern 82 Prozent der 16 Millionen Einwohner. In der Schweiz versichern die zehn grössten Krankenkassen 80 Prozent der Bevölkerung. Das System ist stark dezentralisiert und räumt den Kantonen viel Autonomie ein. So gibt es grosse regionale Unterschiede im Bezug auf die Arzt- und die Spitaldichte, und die Prämien variieren stark von einem Kanton zum andern, sogar innerhalb der Kantone. Ein organisatorischer Unterschied

Ein kultureller Unterschied

Der wichtigste Unterschied zwischen den beiden Ländern ist kultureller Art und betrifft den Grad an Zentralisierung. Das niederländische System ist stark zentrali-

Der zweite grundlegende Unterschied betrifft die Organisation der medizinischen Grundversorgung. In den Niederlanden müssen sich sämtliche Patienten bei einem Allgemeinpraktiker ihrer Wahl

einschreiben. Ausser in Notfällen ist der Zugang zu Spezialisten oder zum Spital nur über den Hausarzt möglich. Die Ärzte für Allgemeinmedizin nehmen so die Stelle von Gatekeepern ein und zeigen sich in Bezug auf die Verschreibung von Arzneimitteln restriktiv. Die Ausgaben der ambulanten Pflege sind verhältnismässig tief. Zudem setzt die Politik auf Wettbewerbsfähigkeit und Effizienz und hält dadurch die Anzahl Spitalbetten und die Zahl der Spezialisten auf niedrigem Niveau. Im Gegensatz dazu verfügt die Schweiz über zahlreiche Spezialisten, zu denen die Versicherten direkten Zugang haben (ausser im Managed Care-Bereich). Gemeinsame strukturelle Punkte

Die beiden Länder haben aber auch zahlreiche Gemeinsamkeiten, insbesondere was die Struktur des Systems betrifft, das auf der Versicherungspflicht basiert. Zudem gibt es in beiden Ländern eine breite Grundversicherung, die von konkurrierenden Versicherern angeboten wird. Beide lassen den Versicherten auch die Möglichkeit offen, alle Jahre ihren Versicherer zu wechseln. Sie hoffen, dass die Versicherten ihre Wahl aufgrund der Prämienunterschiede und der Effizienz treffen. Beide entwicklen im Weiteren alternative Versicherungsmodelle und versuchen, eine Balance zwischen Wettbe-

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nommen werden, die stationäre Pflege in öffentlichen Spitälern hingegen durch staatliche Beiträge subventioniert wird. Vertragsfreiheit und gleiche Finanzierung von ambulantem und stationärem Sektor wären jedoch wichtige Voraussetzungen für die Wettbewerbsfähigkeit und die Effizienz des Systems. Ohne diese Instrumente bleibt der Wettbewerb auf dem schweizerischen Krankenversicherungsmarkt stark begrenzt.

werb und Regulierung durch den Staat zu finden. Der Grad der Freiheit ist für die Versicherer in den beiden Ländern allerdings unterschiedlich. In den Niederlanden können die Versicherer selbst wählen, mit welchen Leistungserbringern sie Vereinbarungen treffen wollen. Im ambulanten Bereich gibt es die vollkommene Vertragsfreiheit, im Bereich der akuten Spitalpflege nur eine stark beschränkte (ungefähr 10 Prozent). In der Schweiz gibt es hingegen einen Kontrahierungszwang und die Versicherer dürfen im Rahmen der Grundversicherung keinen Gewinn erzielen. Lehren aus den Erfahrungen in der Schweiz

Ineffiziente Regulierung Das Schweizer Beispiel zeigt, dass ein grosser Teil der möglichen Wettbewerbsvorteile durch ineffiziente Regulierungen zunichte gemacht wird. So bringt der Wettbewerb unter den Krankenversicherern wenig, wenn diese keinen Spielraum gegenüber den Leistungserbringern haben. Um einem Modell des geregelten Wettbewerbs den Weg zu ebnen, muss das Gesundheitssystem in verschiedenen Punkten verbessert werden. Dazu gehört die Revision des Risikoausgleichs sowie die Einführung der Vertragsfreiheit (die gegenwärtig auf Managed Care beschränkt ist) und damit von mehr Wettbewerb zwischen den Leistungserbringern. Ein weiteres Problem besteht in der Schweiz darin, dass im Bereich der ambulanten Pflege alle Kosten durch die Krankenversicherer über-

Managed Care Die Schweiz zeigt sich jedoch im Bereich Managed Care, wo ihre Erfahrungen bis auf den Beginn der 90er-Jahre zurückreichen, fortschrittlicher. Einzuschränken ist allerdings, dass Managed Care nur in besonderen Fällen zur Anwendung kommt (alle Erbringer von Managed Care-Leistungen müssen auch eine normale Grundversicherung anbieten). Zudem ist empirisch bewiesen, dass nur in Modellen Kosten eingespart werden können, in denen Ärzte ein finanzielles Risiko mittragen (Typ HMO). Diese Modelle sind aber mit einem Marktanteil von nur zwei Prozent am wenigsten verbreitet. Sie müssen dringend gefördert und weiter entwickelt werden. Lehren aus den Erfahrungen in den Niederlanden

Regulierter Wettbewerb Der regulierte Wettbewerb geht vom Prinzip aus, dass die Versicherer effizienter und innovativer arbeiten, wenn die Konsumenten wählen können und dass die Vertragsfreiheit ein Ansporn für die Leistungserbringer bedeutet. Dabei werden gewisse Interventionen des Staates durchaus als positiv betrachtet wie z.B. die Garantie des Zugangs zur Versicherung sowie der Behandlung und der Pflege in der notwendigen Qualität für alle. In der Schweiz reguliert der Staat vor allem Folgendes: Die Versicherungspflicht, den Leistungskatalog, die freie Wahl des Versicherers ohne Vorbehalte, die Prämienverbilligung und den Risikoausgleich. Es fehlen aber wesentliche Elemente, die in den Niederlanden bereits realisiert sind, wie die Vertragsfreiheit, die Optimierung des Risikoausgleichs, die Kontrolle des Wettbewerbs auf allen Stufen, die Möglichkeit einer Gewinnerzielung für die Versicherer, die monistische Finanzierung, ein Qualitätsmonitor.

Notwendigkeit eines politischen Konsenses Das Beispiel der Niederlande zeigt auch, dass die Gesundheitssysteme sich nur kohärent entwickeln können, wenn ein politischer Konsens in Bezug auf die eingeschlagene Richtung zustande kommt. Dieser Konsens bestand in den Niederlanden bei den Reformen von 2006, was die grossen Schritte hin zu einem Modell des regulierten Wettbewerbs ermöglichte. In der Schweiz ist man weit von einem solchen Konsens entfernt. Eine Hälfte der Politik neigt zu einem staatlichen Gesundheitssystem, die andere bevorzugt einen verstärkten Wettbewerb. Grundlegende Reformen werden dadurch blockiert. Qualitätsmonitoring Ein wichtiges Element des Wettbewerbs ist das systematische Qualitätsmonitoring. In den Niederlanden wurden in enger Zusammenarbeit mit dem Niederländischen Verband der Krankenhäuser, dem Verband der Universitätskrankenhäuser, der Ärztevereinigung und der Gesundheitsinspektion Leistungsindikatoren geschaffen. Diese Indikatoren werden jeweils in den Jahresberichten der Krankenhäuser vorgestellt und ermöglichen jährliche Vergleiche zwischen den Krankenhäusern. Sie sind zwar bei weitem nicht so detailliert wie in den USA oder in Deutschland, aber immerhin ein erster Schritt. In der Schweiz gibt es trotz Ansätzen in verschiedenen Kantonen noch kein umfassendes Qualitätsmonitoring. Die Niederlande liegen hier klar vorne, aber es besteht in beide Ländern Handlungsbedarf. Der Vergleich zwischen den beiden Ländern zeigt, dass ein ausgeprägter Föderalismus und eine einseitige staatliche Unterstützung des stationären Sektors der Effizienz des Gesundheitssystems abträglich sind. Die Botschaft an die Schweiz ist klar: Beseitigung dieser beiden Schwachstellen im Rahmen einer Reform des Gesundheitssystems.1 maud hilaire schenker

Robert E. Leu, Frans Rutten, Werner Brouwer, Christian Rütschi und Pius Matter, The Swiss and the Dutch health case systems compared, Nomos, 2008.

15 | Gesundheitswesen 1/10

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Erfahrungen mit Qualitätsmess-Systemen aus Grossbritannien und Deutschland

Europa machts vor Verbindliche Qualitätsmessungen sind in der Schweiz noch Zukunftsmusik. In anderen Ländern sind sie längst Realität, die Erfahrungen damit fast durchwegs positiv. Je ein Experte aus Grossbritannien und aus Deutschland haben an einem Workshop von santésuisse die Mess-Systeme aus ihrer Heimat und deren Erfolge vorgestellt. Die Krankenkasse AOK hat zu diesem Zweck zusammen mit Netzwerkärzten und anderen Experten ein Indikatorenset erstellt, das heute in den Verträgen zwischen der AOK und Ärztenetzwerken zum Tragen kommt. Einzelne, vor allem chronische Krankheiten, aber auch allgemeine Praxismerkmale sind die Kategorien, nach denen die Indikatoren aufgeteilt werden. So entsteht ein Messergebnis, dass Struktur-, Ergebnis- und Prozessqualität gleichermassen berücksichtigt. Speziell an diesem Fall ist auch, dass sich das Qualitätsmesssystem selbst einer Qualitätskontrolle unterziehen musste. Das erfreuliche Ergebnis: Die Ärztenetzwerke, die am AOK-Programm teilnehmen, verschreiben mehr Generika, dafür deutlich weniger Medikamente, deren Wirkstoff umstritten ist. Ebenso werden zum Beispiel Diabetiker nachweislich häufiger nach den Stand der Evidence Based Medicine behandelt. Auch bei den anderen

geprüften Punkten haben die AOK-Netzwerke klar die Nase vorn – sowohl gegenüber Einzelpraxen als auch gegenüber anderen Netzwerken.

Managed Care: Katalysator für die Qualität Gerade das Beispiel aus Deutschland zeigt: Managed Care-Organisationen neigen stärker als einzelne Leistungserbringer dazu, Qualitätsförderungsprogramme zu initiieren oder sich ihnen zumindest anzuschliessen. Diese These vertrat auch Professor Richard Grol, Direktor des niederländischen Centre for Quality of Care Research, unlängst an einer Tagung des Forum Managed Care. Obwohl es, so Grol weiter, keine eindeutigen wissenschaftlichen Beweise für eine höhere Behandlungsqualität in Managed Care-Systemen gäbe, würden vielerlei Indizien doch klar in diese Richtung deuten. Peter Kraft Foto: Prisma

r. Robert Dobler, Betreiber einer Gruppenpraxis im englischen Cambridge, berichtete über die Erfahrungen mit den obligatorischen Outcome-Messungen im National Health System NHS. Während zuvor die Qualitätsmessungen eher unkoordiniert waren und jede Praxis einzeln mit dem NHS die Qualitätsziele aushandelte, ist seit 2004 der so genannte «New Contract» in Kraft: Die ergebnisorientierten Indikatoren sind nun für alle Praxen einheitlich und verbindlich. Die Messungen sind detailliert: Insgesamt gibt es über hundert Indikatoren. Am meisten ins Gewicht fallen klinische Messgrössen, die den Behandlungsablauf auf Übereinstimmung mit der Evidence Based Medicine überprüfen. Aber auch die Organisation, die Patientenzufriedenheit und ausgewählte Zusatzleistungen werden evaluiert. Durch ein ausgeklügeltes Eingabeverfahren werden die Abläufe in der Praxis an das NHS übermittelt, hinzu kommt ein Auditbesuch der Gesundheitsbehörde. Die Patientenzufriedenheit wird ganz konventionell mit einem Fragebogen ermittelt. Das NHS erstellt für jede Arztpraxis eine Punktebilanz, die sich direkt auf die Entlöhnung auswirkt: Bis zu 21 Prozent beträgt der qualitätsabhängige Einkommensanteil. Robert Dobler verhehlte aber auch gewisse Probleme nicht. So könne das Messsystem dazu führen, dass sich die Praxen vor allem auf die Krankheiten konzentrieren, die am meisten Qualitätspunkte einspielen. Dem werde aber mit einer ständigen Überarbeitung und Erweiterung des Indikatorenkatalogs entgegengewirkt.

Qualitätsmessung gleich Qualitätsförderung? In Deutschland gibt es zwar kein verbindliches Indikatorenset. Hingegen sind die Ärzte gesetzlich dazu verpflichtet, ihre Qualität – nach welchem Modell auch immer – periodisch messen zu lassen.

Die AOK arbeitet mit den deutschen Netzwerkärzten in Sachen Qualität eng zusammen.

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infosantésuisse Magazin der Schweizer Krankenversicherer Nr. 4, April 2007

Cox-Bericht: Zwiespältiger Wegweiser für die EU-Gesundheitspolitik Seite 14

Nello Castelli über den Abstimmungskampf in der Romandie Seite 16

IM FOKUS:

Die Gesundheitssysteme unserer Nachbarländer

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Deutschland: Grosse Belastung der Erwerbseinkommen Frankreich: Guter Staat ist teuer Italien: Immer tiefer in die Krise Österreich: Zuoberst auf dem Stockerl – auch mit dem Gesundheitswesen? Skandinavien: Wenig bezahlen – lange warten? Cox-Bericht: Zwiespältiger Wegweiser für die EU-Gesundheitspolitik

KRANKENVERSICHERUNG 6 1 18 19

Drei Fragen an Nello Castelli, Délégué aux relations publiques Suisse romande von santésuisse Claude Longchamp zur Einheitskassen-Abstimmung Das ZVR erleichtert Rechnungskontrolle und Verhandlungen

Deutschland: Grosse Belastung der Erwerbseinkommen Seite 4

GESUNDHEITSWESEN 0 Grafik des Monats 2 21 Von der Eisenbahnkrankheit zum Schleudertrauma 22 Buchtipp: Gesundheitsdaten verstehen

SERVICE 3 2 23 23 24 24 25 25

News aus aller Welt Kurs für übergewichtige Kinder und ihre Familien Testen Sie Ihr Wissen zur Krankenversicherung Prävention von Haut- und Darmkrebs Schweizer Lehrstuhl für Chiropraktik ab 2008 Veranstaltungskalender

Frankreich: Guter Staat ist teuer Seite 6

Italien: Immer tiefer in die Krise Seite 8

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EDITORIAL

infosantésuisse Nr. 4, April 2007

Für einen gesunden und dynamischen Wettbewerb

D Pierre-Marcel Revaz Vizepräsident santésuisse

as Jahr 2006 wartet mit einer unerwarteten Überraschung auf. Seit über 50 Jahren sorgt die Krankenversicherung für politischen Gesprächsstoff, doch das vergangene Jahr hat in der Kostenentwicklung zum ersten Mal einen klaren Einschnitt gebracht. Die Ursache dafür sind verschiedene Massnahmen, die für sich genommen relativ unspektakulär sind. Dazu gehören die Vereinbarungen zu den Medikamentenpreisen, die Förderung der Generika, die Rechungskontrolle durch die Versicherer und deren Bestreben, die besten Leistungen zum bestmöglichen Preis zu erhalten. Die Auswirkungen dieser Entscheide und Massnahmen werden nun klar messbar. Es wäre zu früh für Selbstzufriedenheit, weil die gesetzlichen Rahmenbedingungen weiterhin unverändert sind. Es bleiben grosse Fragezeichen, vor allem bei der Spital- und Pflegefinanzierung. Aber der Silberstreifen am Horizont, der sich in Sachen Kostenentwicklung zeigt, bestätigt den eingeschlagenen Weg: Hin zu einem Gesundheitssystem, das die Aufgaben aller Akteure klar definiert. Die Leistungserbringer bieten effiziente Behandlungen von hoher Qualität an. Der Staat garantiert das soziale Gleichgewicht und setzt die entsprechenden Rahmenbedingungen, damit auch den Ärmsten unter uns der Zugang zu den medizinischen Leistungen nicht aus wirtschaftlichen Gründen erschwert wird. Die Versicherer schliesslich haben die Verantwortung, dass die Solidarität zwischen Gesunden und Kranken intakt bleibt und dass die verfügbaren Mittel klug und mit dem bestmöglichen PreisLeistungs-Verhältnis verteilt werden.

Spannungen unter den Partnern gibt es weiterhin. Sie sind sogar gesund, wenn jeder die Rolle wahrnimmt, die ihm zukommt. Wir wissen um die Stärken und Schwächen unseres Systems. Die Verhandlungen zwischen den Partnern, der Leistungseinkauf und der Vergleich von Preis und Qualität sind der Kern eines wettbewerblichen Gesundheitswesens. Die Produktivität unseres Systems zu steigern ist ein ambitiöses, aber realistisches Ziel. Auseinandersetzen müssen wir uns in Zukunft auch mit der Generationenfrage: Die Belastung von jungen Menschen zwischen 25 und 30 durch die Krankenversicherung ist heute sehr hoch. Häufiger als alle anderen muss diese Altersgruppe Prämienverbilligungen in Anspruch nehmen. infosantésuisse widmet diese Ausgabe den Gesundheitssystemen unserer Nachbarländer. Wir stellen fest, dass all diese Staaten mit Kostenproblemen und mit der demografischen Alterung konfrontiert sind. Es ist also falsch, unser Versicherungssystem für die Probleme des Gesundheitswesens verantwortlich zu machen, wie dies gewisse Kreise aus ideologischen Gründen tun. Die Bevölkerung hat das erkannt und dem gefährlichen Experiment Einheitskasse eine klare Abfuhr erteilt. Nun müssen wir aber die Schwächen des Systems abbauen. Nur so können wir verhindern, dass die Verlierer des 11. März ihre Ziele auf indirektem Weg letztlich doch noch erreichen. Dazu müssen wir den Wettbewerb unter den Akteuren fördern. Nur dieser Weg bringt unserem Gesundheitssystem das beste Preis-Leistungsverhältnis.

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Das deutsche Krankenversicherungssystem vor der Reform

Deutschland: Grosse Belastung der Erwerbseinkommen Das deutsche Krankenversicherungssystem ist wie das schweizerische von einer Mehrzahl von frei wählbaren Krankenkassen geprägt. Vergleichbar ist auch der umfassende Grundleistungskatalog. Unterschiedlich ist vor allem, dass die Krankenversicherung in Deutschland über eine gesetzliche und eine private Krankenkasse möglich ist und dass die gesetzliche Krankenversicherung mit Beiträgen aus den Bruttogehältern finanziert wird.

esetzlich versichert ist, wer ein Jahreseinkommen unter der Pflichtversicherungsgrenze von 47 700 Euro (76 800 Franken) bezieht. Wer ein höheres Einkommen hat oder wer eine selbstständige Tätigkeit ausübt, der kann sich gesetzlich versichern lassen, muss aber nicht. Wer eine private Krankenversicherung (PKV) abgeschlossen hat, bezahlt Beiträge, die von den vereinbarten Leistungen, dem Einstiegsalter und dem Gesundheitszustand des Versicherungsnehmers abhängen. Zudem werden in der PKV Altersrückstellungen gebildet, um die im Alter steigende Prämienlast zu mildern. Privat Versicherte können nur in die gesetzliche Krankenversicherung (GKV) wechseln, wenn sie jünger als 55 Jahre sind und ihr Einkommen unter die Pflichtversicherungsgrenze sinkt. Rund 88 Prozent der Einwohner Deutschlands sind gesetzlich versichert, und nur knapp zehn Prozent privat. Von den rund

72 Millionen gesetzlich Versicherten sind 31 Millionen obligatorisch versicherte Arbeitnehmer, zwanzig Millionen sind kostenfrei mitversicherte Familienangehörige, 17 Millionen sind Rentner und vier Millionen freiwillig Versicherte. Im Folgenden beschränken wir uns auf die Darstellung der gesetzlichen Krankenversicherung.

Finanzierung der GVK Auf den ersten Blick scheint die Finanzierung der Krankenversicherung in Deutschland sozialer als in der Schweiz zu sein, richten sich die Beiträge doch nach der finanziellen Leistungsfähigkeit der Versicherten. Ausserdem sind Familienangehörige ohne Einkommen kostenlos mitversichert. Weil sich aber Bezüger höherer Einkommen durch den Abschluss einer privaten Versicherung der Solidarität entziehen können und weil es eine Höchstgrenze gibt, bis zu der Beiträge zu bezahlen sind,

steht dieser Befund in Frage. Dies umso mehr, als diese Höchstgrenze (Beitragsbemessungsgrenze) schon bei einem Jahreseinkommen von 42 750 Euro (68 900 Franken) liegt. Die gesetzlichen Krankenkassen werden zur Hauptsache aus Beiträgen der Versicherten und der Arbeitgeber finanziert. Bisher haben die einzelnen Krankenkassen ihre Beiträge autonom festgelegt. Sie betragen gegenwärtig etwa 12 bis 16 Prozent des beitragspflichtigen Einkommens. Dies wird sich jedoch ab 2009 ändern (vgl. Kasten). Bis Mitte 2005 haben Arbeitnehmer und Arbeitgeber den Beitragssatz zu gleichen Teilen übernommen. Seither bezahlen die Arbeitnehmer 0,9 Prozent mehr als die Arbeitgeber. Den gleichen Beitrag bezahlen Pensionierte auf ihren Renten. Selbstständige bezahlen im Prinzip den vollen Beitragssatz (Arbeitgeber- und Arbeitnehmerbeitrag), Arbeitslose einen Mindestbeitrag von 116 Euro pro Monat.

Gesundheitsreform 2007

Leistungen und Ausgaben

Die wichtigsten Punkte der im Februar 2007 von Bundestag und Bundesrat (Länderkammer) gegen den Willen der Krankenversicherer, der Ärzte, der Spitäler und der Pharmaindustrie verabschiedeten Gesundheitsreform sind: • Es wird ein Gesundheitsfonds geschaffen, in den ab 2009 alle Beiträge von Arbeitgebern und Arbeitnehmern sowie Steuermittel fliessen. Pro versicherte Person erhält jede Kasse eine Pauschale aus dem gemeinsamen Topf. Kassen mit schlechter Risikostruktur erhalten zusätzlich Beiträge aus dem Risikostrukturausgleich. • Ab 2009 gibt es einen einheitlichen Beitragssatz, den der Staat festlegt. • Kassen, die mit den zugewiesenen Geldern nicht auskommen, können von ihren Versicherten Zusatzprämien verlangen (maximal ein Prozent des beitragspflichtigen Einkommens). • Die Kassen können Wahltarife mit Selbstbehalten und Rückerstattungen anbieten. • Es werden folgende neuen Leistungen bezahlt: Eltern-Kind-Kuren und Rehabilitationsmassnahmen. Zudem müssen die Versicherten regelmässig an Vorsorgeuntersuchungen teilnehmen, sich therapiegerecht verhalten und bei Behandlungsprogrammen mitmachen (im Weigerungsfall erhöht sich der zu bezahlende Eigenanteil). • Es besteht eine Versicherungspflicht für alle (bisher rund 300 000 nicht Versicherte).

Der Leistungskatalog, den der Gesetzgeber bestimmt, ist mindestens so grosszügig wie in der Schweiz. Er umfasst nicht nur alle ambulanten und stationären Heilbehandlungen, die medizinisch notwendig sind, sondern zusätzlich auch Zahnbehandlungen. Die einzelnen Versicherer können den gesetzlichen Leistungskatalog in beschränktem Rahmen durch eigene Leistungen (Satzungsleistungen) ergänzen. Diese betragen aber nur fünf Prozent des gesamten Leistungsumfangs. Die Versicherten können den Arzt frei wählen, aber sie entrichten für den ersten Besuch bei einem Hausarzt im Quartal zehn Euro und beim Besuch eines Spezialarztes ohne Überweisung des Haus-

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unterscheiden sich vor allem im Hinblick auf den Beitragssatz und die erbrachten Zusatzleistungen. Mit der Einführung der Kassenwahlfreiheit für alle Pflichtversicherten Mitte der neunziger Jahre ist auch der Risikostrukturausgleich zwischen den Kassen in Kraft getreten. Zusätzlich zu den Kriterien Alter und Geschlecht, die auch der schweizerische Risikoausgleich kennt, spielen beim deutschen Risikostrukturausgleich auch beitragspflichtige Einnahmen, Beitragssätze und die Anzahl Versicherte mit Berufs- oder Erwerbsunfähigkeitsrente eine Rolle.

Grosse Einkommensbelastung

len je 0,85 Prozent des kassenpflichtigen Einkommens.

136 Krankenkassen Gegenwärtig gibt es in Deutschland 136 Krankenkassen. Die wichtigsten Kassenarten sind die Ortskrankenkassen, die Betriebskrankenkassen, die Innungskrankenkassen und die Ersatzkassen für Angestellte und Arbeitnehmer. Die Kassen sind Körperschaften des öffentlichen Rechts, die sich aber selbst verwalten. Die Verwaltungsräte sind zumeist paritätisch mit Vertretern der Versicherten und der Arbeitgeber besetzt. Für die Versicherten besteht Kassenwahlfreiheit und die Kassen sind verpflichtet, alle Personen und damit auch alle Risiken zu versichern. Sie

Das grosse Problem des deutschen Krankenversicherungssystems: Die steigenden Kosten müssen durch steigende Beiträge auf den Einkommen finanziert werden. So musste auf Anfang 2007 der Beitragssatz im Durchschnitt von 14,26 Prozent auf 14,82 Prozent angehoben werden. Solche Abgaben wirken sich auch auf die Konkurrenzfähigkeit der deutschen Wirtschaft aus, was einer der Gründe für die aktuelle Gesundheitsreform ist. Skeptiker befürchten allerdings, dass diese Reform aufgrund der geplanten Leistungsausweitungen die Finanzprobleme der GVK noch verschärfen wird. Walter Frei

DEUTSCHL AND (in Klammern die Werte der Schweiz): Anteil der Gesundheitskosten am BIP: 10,9 Prozent (11,6 Prozent) Gesundheitsausgaben pro Kopf: 3005 US-Dollar (4077 US-Dollar) Ärzte pro 1000 Einwohner: 3,4 (3,9) Spitalbetten pro 1000 Einwohner: 6,6 (3,9)

Quelle: OECD, Stand 2004

arztes nochmals zehn Euro. Wählt der Versicherte ein Hausarztmodell, dann fallen die Praxisgebühren weg. Zuzahlungen müssen auch beim Bezug von Medikamenten (fünf bis zehn Euro pro Packung) oder bei stationären Behandlungen (10 Euro pro Tag für höchstens 28 Tage) entrichtet werden. Die Bezahlung der Leistungserbringer erfolgt immer über die Krankenkasse (Tiers payant). Allerdings ist bei der Abrechnung mit den Ärzten die kassenärztliche Vereinigung zwischengeschaltet. Sie erhält von den Krankenkassen sämtliche Belege und Zahlungen und honoriert die einzelnen Ärzte im Rahmen eines komplexen Ausgleichverfahrens. 2006 hat die gesetzliche Krankenversicherung 149,5 Milliarden Euro eingenommen und 147,6 Milliarden Euro ausgegeben. Der größte Ausgabenblock der Kassen war die Krankenhausbehandlung mit rund 50 Milliarden Euro (34 Prozent). Danach folgt der Arzneimittelbereich mit knapp 26 Milliarden Euro (17,6 Prozent). Drittgrösster Ausgabenposten war 2006 die ärztliche Behandlung mit 22,24 Milliarden Euro (15,0 Prozent). Die Ausgaben für Zahnbehandlungen betrugen 10,4 Milliarden Euro (sieben Prozent) und für 5,7 Milliarden Euro (vier Prozent), wurde Krankengeld ausbezahlt. Die Verwaltungskosten betragen wie in der Schweiz knapp 5,5 Prozent der Ausgaben. Die Ausgaben für Pflegeleistungen in Heimen und zuhause fallen nicht ins Gewicht, da es in Deutschland für diese Leistungen eine spezielle Versicherung, die soziale Pflegeversicherung, gibt. Sie ist organisatorisch in die Krankenversicherung eingegliedert, indem jeder Krankenkasse auch eine Pflegekasse angeschlossen ist. Die Finanzierung ist gleich geregelt wie jene der gesetzlichen Krankenversicherung: Arbeitnehmer und Arbeitgeber zah-

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Der Schuldenberg der staatlichen Krankenversicherung wird den Reformen wohl noch lange trotzen

Frankreich: Guter Staat ist teuer Das französische Gesundheitswesen ist das am stärksten zentralisierte in Europa. Die Qualität der Versorgung hat einen guten Ruf, und lange bewegte sich auch die Kostenentwicklung in einem erfreulichen Rahmen. Doch nun beschert die konjunkturabhängige Finanzierung dem System seit einigen Jahren gewaltige Verluste, und Paris reagiert mit weiteren Verstaatlichungsschritten auf die Misere. Ob das zum Erfolg führen wird, ist mehr als unklar.

Quelle: OECD, Stand 2004

m Jahr 2000 bezeichnete die WHO Frankreichs Gesundheitswesen als das weltweit beste. Qualität und Versorgungsgerechtigkeit seien in Frankreich höher als irgendwo sonst. Drei Jahre später erlitt das System ein unerhörtes Debakel: 15 000 Menschen starben im Sommer 2003 aufgrund der wochenlangen Hitzeperiode. Die Pflegeheime und Spitäler waren mit der aussergewöhnlichen Situation völlig überfordert – genauso wie die französische Regierung. Weder Präsident Chirac noch die zuständigen Minister nahmen Stellung – sie liessen sich in ihrem Urlaub ungern stören. Zwei Wochen nach der Krise schob die Regierung der Bevölkerung die Verantwortung für das Desaster zu: Fehlende Solidarität und Gleichgültigkeit gegenüber älteren Menschen seien schuld an den vielen Toten. Darauf folgten wütende Proteste, sodass sich die Regierung schliesslich zum Handeln gezwungen sah: Sie erklärte den Pfingstmontag zum unbezahlten Arbeitstag – die zusätzlichen Sozialversicherungseinnahmen sollten in die Problembereiche des Gesundheitswesens gesteckt werden. Seither ist

FR ANKREICH (in Klammern die Werte der Schweiz): Anteil der Gesundheitskosten am BIP: 10,5 Prozent (11,6 Prozent) Gesundheitsausgaben pro Kopf: 3159 US-Dollar (4077 US-Dollar) Ärzte pro 1000 Einwohner: 3,4 (3,9) Spitalbetten pro 1000 Einwohner: 3,8 (3,9)

der Pfingstmontag regelmässig mit weitreichenden Streiks verbunden. Es ist unklar, wie lange Frankreich noch an dieser Massnahme festhält. Das Beispiel zeigt exemplarisch auf: Auch wenn das französische Staatssystem oft als Vorbild für andere Länder gehandelt wird, hat es mit beträchtlichen Schwierigkeiten zu kämpfen.

Paris lenkt – mit grossen Verlusten In Frankreich hat der Zentralstaat im Gesundheitswesen mehr Kompetenzen als in allen anderen europäischen Staaten. Von den Krankenversicherern über die Globalbudgets bis hin zu den regionalen Krankenhausagenturen: Alles steht unter der Aufsicht von Paris. Frankreich verfügt praktisch über eine staatliche Einheitskrankenkasse: Die meisten Erwerbstätigen und Rentenbezüger sowie ihre Angehörigen sind im «Régime général d’assurance maladie» versichert. Ausgenommen sind einige spezielle Berufsgruppen wie Landwirte, Bergarbeiter oder Seeleute: Sie haben spezielle Krankenkassen. Die Krankenversicherung ist in Frankreich eigentlich über Lohnprozente finanziert – doch reichen diese schon lange nicht mehr aus. Deshalb fliessen zusätzliche Steuereinnahmen ins System. Doch auch so schreibt die staatliche Krankenversicherung seit einiger Zeit enorme Defizite: 2005 waren es acht Milliarden Euro, womit der Schuldenberg auf 41 Milliarden anstieg. Durch die Finanzierung über Löhne und Steuern sind die Mittel der staatlichen Krankenversicherung stark von der Konjunktur abhängig – Verluste sind die automatische Folge, wenn das Wirtschaftswachstum mit der

Ko sten z u n a h me im Gesundheitswesen nicht schritthalten kann. Ein weiteres grosses Problem des Systems ist seit 2000 hingegen gelöst: Arbeitslose und Studierende sind nun bei der neu geschaffenen, steuerfinanzierten «Couverture maladie universelle» versichert.

Der tiefe Griff ins Portemonnaie Der Leistungskatalog der französischen Krankenversicherung ist mit jenem der Schweiz durchaus vergleichbar. Allerdings fallen dabei für die Bevölkerung beträchtliche Selbstbeteiligungen an: Im Durchschnitt werden die Leistungen zu 70 Prozent vergütet. Besonders hoch sind die Kostenbeteiligungen bei den Medikamenten (30 bis 65 Prozent) und bei der ambulanten Versorgung (35 Prozent). Die Folge davon: Fast 90 Prozent der Französinnen und Franzosen haben inzwischen Zusatzversicherungen abgeschlossen, welche die Restkosten decken. Damit ist der ursprüngliche Zweck der hohen Selbstbeteiligungen, nämlich die Kostendämpfung, hinfällig geworden. Erstaunlicherweise ist das ansonsten stark zentralisierte französische Gesundheitssystem sehr liberal gegenüber sei-

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Mehr Staat für weniger Kosten? Die Pfingstmontagsregelung ist nur die aussergewöhnlichste unter den vielen Reformmassnahmen, denen das französische Gesundheitswesen andauernd unterzogen wird. In den letzten 25 Jahren gab es 20 Reformen – jedoch stets nur in Teilbereichen und nie substanziell. Durch die riesigen Defizite der letzten Jahre ist klar geworden, dass Flicken hier und Schrauben da nicht mehr genügen. Vor einem Jahr hat die Regierung deshalb ein umfassendes Paket zur Kostendämpfung in die Wege geleitet. Grosse Investitionen in die ambulante Chirurgie sollen die stationären Behandlungskosten senken. Es kursieren Pläne, alle Behandlungsstufen in einem staatlichen Gesundheitsnetzwerk zu vereinen. Schliesslich sollen die Mittel für Gesundheitsförderung und Prävention, die bisher kaum Beachtung fanden, drastisch erhöht werden. Im Bereich der Medikamentenpreise ist Frankreich bereits für seine konsequente Haltung gegenüber der Pharmaindustrie bekannt. Nun wird die Generika-Einnahme mit gezielten Anreizen noch stärker gefördert. Ausserdem sollen Arzneimittel mit geringem Zusatznutzen gegenüber günstigeren Präparaten radikal verbilligt werden. Parallel zu den Massnahmen zur Kostendämpfung treten auch Mehreinnahmen in Kraft: Die Lohn- und Steuerprozente für das Gesundheitswesen sind deutlich erhöht worden – vor allem die Beiträge der Arbeitgeber.

Erfolg ist ungewiss

nen Leistungserbringern. Ausgebildete Ärzte dürfen sich überall frei niederlassen, und die Bevölkerung hat die freie Arztwahl. Private Kliniken sind in Frank reich häufig – auch wenn sie sich meistens auf bestimmte Fachgebiete spezialisiert haben. Diese Privatkliniken können genauso mit der Krankenversicherung ab-

rechnen wie die grossen öffentlichen Spitäler. Das Klinikpersonal arbeitet seit einigen Jahren nach einer strikten 35-Stunden-Woche. Neben Mehrkosten hat dies vor allem Personalmangel zur Folge: Die zusätzlichen Stellen, die seit der 35-Stunden-Woche nötig wären, sind längst noch nicht alle besetzt.

Bereits verwirklicht sind Anreize für den Beitritt zu einem Hausarztmodell: Wer sich verpflichtet, zu Beginn einer Behandlung stets einen Allgemeinpraktiker aufzusuchen, profitiert von wesentlich geringeren Kostenbeteiligungen. Doch weil die Zusatzversicherungen so stark verbreitet sind und die Franzosen die hohen Selbstbehalte auf diese Weise abfangen, ist der Erfolg des Hausarztmodells geringer als erwartet: Etwa die Hälfte der Bevölkerung macht sich diese Sparmöglichkeit zunutze. Ganz allgemein sind französische Gesundheitsökonomen gegenüber der Reform skeptisch: Sie zementiere die bestehenden Staatsstrukturen im Gesundheitswesen und werde, wenn überhaupt, weniger schnell als erhofft zum Erfolg führen. Die Experten rechnen vor: Es dürften mindestens zwanzig Jahre vergehen, bis der Schuldenberg abgebaut ist. Peter Kraft

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Steigende Kosten, sinkende Qualität, dramatisches Nord-Süd-Gefälle

Italiens Gesundheitssystem schlittert immer tiefer in die Krise Bis 1978 war das italienische Gesundheitssystem von der Kassenvielfalt geprägt. Dann folgte die Umwandlung in den noch immer bestehenden staatlichen Gesundheitsdienst. Die Absicht dahinter war, das Nord-Süd-Gefälle in der Gesundheitsversorgung zu überwinden und die Kosten in den Griff zu bekommen. Beides ist dem Servicio Sanitare Nazionale (SSN) bis dato nicht gelungen. Im Gegenteil: Hiobsbotschaften aus dem Gesundheitswesen beunruhigen die Bevölkerung regelmässig – vor allem im Süden des Landes.

Quelle: OECD, Stand 2004

ie Erkenntnis, dass der SSN seine hochgesteckten Ziele nicht erfüllen kann, kam bald und ist bis heute eine Konstante in der italienischen Gesundheitspolitik. Deshalb ist der staatliche Gesundheitsdienst ein ewiger Reformkandidat: Bereits viermal wurde er grundlegend umgestaltet. Der neueste Streich: Seit 2001 haben die 21 Regionen Italiens weit gehende Kompetenzen in der Gesundheitsversorgung. Noch erhalten sie einen fixen Betrag von der Zentralregierung. Bis 2013 soll dieser aber schrittweise abgeschafft werden, so dass die Regionen dann auch die volle Finanzierungsverantwortung tragen werden. Parallel dazu wird ein nationaler Solidaritätsfonds aufgebaut, der die eklatante Versorgungsungerechtigkeit zwischen den Regionen etwas mildern soll. Finanziert wird das italienische Gesundheitssystem seit 1978 durch verschiedene Steuern. Durch die Regionalisierung wird nun die so genannte IRAP, eine regionale Steuer auf Unternehmensgewinne und Angestelltenlöhne, zur Hauptfinanzierungsquelle.

ITALIEN

Lokale Gesundheitsbehörden Das italienische Gesundheitssystem ist auf drei Ebenen organisiert: Seit der jüngsten Reform obliegt dem Zentralstaat nur noch das Setzen der gesetzlichen Leitplanken. Daneben übt Rom eine relativ strikte Kontrolle über den Arzneimittelmarkt und die Forschung aus. Italien hat insgesamt 16 Kliniken, die in staatlichem Auftrag pharmazeutische Forschung betreiben. Die Regionen sind verantwortlich für die Versorgungspläne. Sie verteilen die Gelder an die einzelnen Einrichtungen und überwachen – zumindest auf Papier – deren Effizienz und Qualität. Die eigentliche Gesundheitsversorgung läuft auf lokaler oder sogar kommunaler Ebene: Durchschnittlich 100 000 Einwohner bilden ein «Gesundheitsrayon» (USL). Diese lokalen Gesundheitsbehörden betreiben Krankenhäuser, stellen Hausärzte an und verwalten die Versicherungsdaten der zugewiesenen Einwohner. Durch diese Struktur hat Italien zwar eine hohe Spitaldichte – kein USL kommt ohne Klinik aus. Hingegen gibt es nur relativ wenige Zentrumskliniken mit spitzenmedizinischem Angebot. Diese schliessen mit den USL in ihrem Einzugsgebiet Verträge ab, arbeiten ansonsten aber unabhängig.

(in Klammern die Werte der Schweiz): Anteil der Gesundheitskosten am BIP: 8,4 Prozent (11,6 Prozent) Gesundheitsausgaben pro Kopf: 2392 US-Dollar (4077 US-Dollar) Ärzte pro 1000 Einwohner: 4,1 (3,9) Spitalbetten pro 1000 Einwohner: 3,9 (3,9)

Striktes Hausarztmodell Die Gesundheitsleistungen sind in Italien ausser in Notfällen nur über den Hausarzt zugänglich. Alle Italienerinnen und Italiener schreiben sich bei einem Familienarzt ein. Diese Familienärzte sind entweder direkt von den USL angestellt oder vertraglich eng an sie gebunden. Einem Hausarzt

sind durchschnittlich 1500 Patienten zugewiesen. Für jeden von ihnen erhält er eine Kopfpauschale, was einen Grossteil seiner Entlöhnung ausmacht. Weitere Einkünfte stammen aus Behandlungen ausserhalb des Leistungskatalogs, die direkt den Patienten berechnet werden. Spezialärzte dürfen in Italien nur nach Überweisung des Hausarztes aufgesucht werden. Auch die Spezialisten sind grösstenteils Angestellte der USL. Daneben gibt es auch freiberuflich tätige Fachärzte, die aber hauptsächlich Privatversicherte ausserhalb des staatlichen Gesundheitssystems behandeln.

Wer kann, ist privat versichert Der Leistungskatalog in Italien ist weniger umfangreich als hierzulande. Ausserdem fallen zum Teil hohe Selbstbeteiligungen an. Zwar werden Besuche beim Hausarzt und Spitaluntersuchungen vollständig übernommen. Doch bei den Medikamenten, den ambulanten Behandlungen beim Spezialisten, den Laboranalysen und der Rehabilitation müssen die Patienten beträchtliche Anteile selber bezahlen. Das alles führt dazu, dass sich, wer es sich leisten kann, privat versichern lässt. 30 Prozent der Bevölkerung verschafft sich so Zugang zu nichtstaatlichen Gesundheitsleistungen. Weil Italiens System so strikte verstaatlicht ist, findet kaum eine Zusammenarbeit zwischen dem öffentlichen und dem privaten Sektor statt. Die Leistungen der Privatversicherer ergänzen jene des staatlichen Gesundheitswesens also nicht, sondern ersetzen sie meistens. Italien hat damit eine Zweiklassenmedizin in Reinkultur.

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system nicht Herr geworden. Als ein Journalist Anfang dieses Jahres einen Monat lang als Putzmann getarnt eine römische Poliklinik durchstreifte, brachte er erschreckende Zustände ans Licht: Offene Labors mit gefährlichen Krankheitserregern und radioaktiven Substanzen, Hundekot und gebrauchte Spritzen in den Gängen, während der Behandlung rauchende Pfleger und sogar illegale Organentnahmen dokumentierte der Reporter. Die italienische Regierung reagierte mit einer breit angelegten Untersuchung. Sie musste die Enthüllungen teilweise eingestehen und stellte fest, dass die hygienische Situation umso schlimmer wird, je tiefer man nach Süden kommt. Die Spitaldichte in Süditalien ist niedriger als im Norden, das Alter der Einrichtungen dafür umso höher: Zwei Drittel

Kostenproblem gelöst? Der SSN hat es sich von Beginn weg zum Ziel gemacht, die steigenden Kosten in den Griff zu bekommen. Davon ist man nach dreissig Jahren weiter entfernt denn je: Die Kosten steigen doppelt so schnell wie das Volkseinkommen. Machten die Gesundheitsausgaben 1997 noch 7,6 Prozent des BIP aus, sind es heute fast neun Prozent – und ein Ende dieser Entwicklung ist nicht abzusehen. Zwar hat die Regierung Berlusconi einige einschneidende Reformen umgesetzt: Die Anzahl der Krankenhausbetten wurde um zehn Prozent gesenkt, die Einnahme von Generika durch gezielte Anreize gesteigert und der Leistungskatalog generell gestrafft. Das italienische System schafft es aber nicht, diese Massnahmen in eine Kostendämpfung umzumünzen. Auch die Regionalisierung der Gesundheitsversorgung zeigt kostenmässig bisher keine Wirkung.

Das Ziel verfehlt…

Dramatisches Nord-Süd-Gefälle Das zweite grosse Problem, das vom staatlichen Gesundheitswesen gelöst werden sollte, ist das enorme Nord-Süd-Gefälle in der Gesundheitsversorgung. Auch dieser Misere ist das italienische Gesundheits-

gedeckt werden, wird sich an der Benachteiligung des wirtschaftlich schwachen Südens so bald nichts ändern – im Gegenteil. Für Schwierigkeiten sorgt, vor allem auf Sizilien, auch die Mafia: Mit Geldern der Cosa Nostra können Ärzte Privatkliniken erbauen. Als Gegenleistung rechnen sie dem Staat zu hohe Tarife ab und liefern den so erwirtschafteten Überschuss an die Mafia ab – Geld, das dann der eigentlichen öffentlichen Gesundheitsversorgung fehlt. Die Folgen davon beschreibt eine deutsche Medizinstudentin nach einem Praktikum in Sizilien der Zeitschrift viamedici: «Die medizinische Behandlung und die Krankenhaushygiene entsprechen einem Dritte-Welt-Land. Der Respekt der Ärzte vor den Patienten war gleich null. So bekam grundsätzlich keiner der Patienten seine Diagnose mitgeteilt. Auch der OP-Saal war eine Attraktion für sich. Lediglich eine Haube, ein Mundschutz und Überhandschuhe wurden uns gegeben. Der Mundschutz wurde jedoch wegen der Hitze im OP beim Zunähen abgenommen.»

aller Kliniken stammen aus Zeiten vor dem Zweiten Weltkrieg. Weil die Gesundheitsausgaben neu vor allem durch regionale Steuern auf Unternehmensgewinne

Das Qualitätsproblem beschränkt sich im italienischen Gesundheitssystem nicht nur auf den Süden. Laut einer Studie des italienischen Onkologenverbandes gibt es pro Tag 90 vermeidbare Todesfälle in den Spitälern. Wartezeiten gibt es überall, auch bei lebenswichtigen Operationen. Die Hygiene ist im Norden zwar nicht so katastrophal wie im Süden, aber längst nicht genügend. In allen Regionen sind die Ärzte schlecht bezahlt und wenig motiviert. Der Einwanderungsratgeber justlandet.com widerlegt zwar das Gerücht, in Italien erhielten Spitalpatienten nichts zu Essen – allerdings auf wenig ermutigende Weise: «Essen gibt es jeden Tag kostenlos, obwohl Sie bedenken sollten, dass es ungeniessbar sein kann. Sie brauchen also möglicherweise jemanden, der Ihnen Essen von aussen bringt, um den Aufenthalt in einem öffentlichen Krankenhaus zu überleben.» Die logische Folge: Die privaten Zuzahlungen steigen auch im «goldenen Dreieck» zwischen Mailand, Genua und Turin – eine gute Gesundheitsversorgung ist eine Frage des Geldbeutels. Damit ist genau das Gegenteil dessen eingetreten, was die Staatsmedizin erreichen wollte. Peter Kraft

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Finanzierungsprobleme und geringere Wahlfreiheit in der Alpenrepublik

Österreich: Zuoberst auf dem Stockerl – auch mit dem Gesundheitswesen?

Quelle: OECD, Stand 2004

Sportlich misst sich die Schweiz gerne an Österreich, und allzu oft ziehen wir den Kürzeren. Aber nicht nur Rivalitäten im Sport lassen uns ostwärts über den Rhein schielen, auch in politischen Fragen spielt das Verhalten Österreichs eine gewichtige Rolle. So war in der Diskussion rund um die Einheitskasse immer wieder vom österreichischen Gesundheitssystem und seinen Vorzügen die Rede. Sonnt sich Österreich tatsächlich auch mit seinem Gesundheitswesen auf dem Stockerl vor der Schweiz?

ÖSTERREICH (in Klammern die Werte der Schweiz) Anteil der Gesundheitskosten am BIP: 9,6 Prozent (11,6 Prozent) Gesundheitsausgaben pro Kopf: 3124 US-Dollar (4077 US-Dollar) Ärzte pro 1000 Einwohner: 3,4 (3,9) Spitalbetten pro 1000 Einwohner: 6 (3,9)

ross war die Freude in der Eidgenossenschaft, als sich an der vergangenen Ski-Weltmeisterschaft einzelne Schweizer Athleten endlich wieder einmal vor den österreichischen Mitkonkurrenten klassierten. Nur, die österreichische Dominanz ist noch lange nicht gebrochen und selbst im Fussball schlagen sie uns häufiger als uns lieb ist. Aber nicht nur im Sport, auch in der Gesundheitspolitik positionieren wir uns hinter den Österreichern. Dies behaupteten zumindest die Befürworter der gescheiterten Einheitskassen-Initiative. Ist dem so? Wie teuer ist das österreichische Gesundheitswesen? Wie ist es überhaupt organisiert?

Tiefere Gesamtausgaben? Gemäss OECD-Statistik machen die Gesamtgesundheitsausgaben in Österreich 9,6 Prozent des Bruttoinlandprodukts (BIP) aus. Das Gesundheitssystem ist damit günstiger als jenes der Schweiz mit 11,6 Prozent – dies bei nur leicht geringerer Lebenserwartung und vergleichbarem Leistungskatalog. Allerdings sind in den ausgewiesenen Gesamtausgaben des österreichischen Gesundheitswesens nicht alle Auslagen einbezogen, die üblicherweise in amtlichen Statistiken verbucht

werden. So fehlen die Ärztegehälter der Universitätskliniken, der klinische Mehraufwand, Investitionen für Heeres- und Justizspitäler, Aufwendungen für Kranken- und Hauskrankenpflege sowie Ausgaben für die Ausbildung im Gesundheitswesen. Diese Auslagen werden anderweitig erfasst. Schätzungen gehen davon aus, dass damit der Anteil der Gesundheitsausgaben am BIP um bis zu drei Prozentpunkte unterbewertet wird. Dadurch ergeben sich Gesamtkosten, die «schweizerischen Verhältnissen» entsprechen1.

Dezentrale Organisation Mit neun Bundesländern kennt Österreich ähnlich der Schweiz eine föderalistische Staatsstruktur. Dies spiegelt sich auch in einer dezentralen Gesundheitsverwaltung wider. Der Bund ist für die Gesetzgebung verantwortlich. Oberste gesundheitspolitische Behörde ist das Bundesministerium für Gesundheit und Frauen. Dem Ministerium obliegt unter anderem die Aufsicht über die Träger der sozialen Krankenversicherung. Weitere bundeseigene Unterbehörden existieren nicht, da die Verwaltung von den Ländern und Gemeinden übernommen wird. So liegen die öffentlichen Gesundheitsdienste sowie weitreichende Kompetenzen bei der Finanzierung und Regelung der stationären Versorgung in den Händen der neun Länder.

Keine Wahlfreiheit in der Grundversicherung Die Gesetzliche Krankenversicherung, das Pendant zur obligatorischen Krankenversicherung (OKP) in der Schweiz, ist ebenfalls dezentral organisiert. Diese Pflichtversicherung bietet Schutz gegen Krankheit, Arbeitsunfähigkeit infolge Krankheit

und Mutterschaft. Sie umfasste 2005 rund acht Millionen Personen oder 97,8 Prozent der Bevölkerung. Es gibt in Österreich 19 Krankenversicherer, die im Hauptverband der Österreichischen Sozialversicherungsträger zusammengeschlossen sind. Es herrscht kein Wettbewerb, weil die Mitgliedschaft obligatorisch ist und sich nach Berufsgruppenzugehörigkeit oder nach Arbeits- oder Wohngebiet richtet. In jedem der neun Bundesländer existiert eine Gebietskrankenkasse (GKK). Ferner bestehen sechs Betriebskrankenkassen sowie vier weitere Sozialversicherungsträger, welche die Krankenversicherung als Sparte betreiben. Die GKKs sind in all jenen Fällen zur Durchführung der Krankenversicherung verpflichtet, in denen kein anderer Krankenversicherungsträger zuständig ist.

Vertrags- und Wahlärzte Die meisten medizinischen Leistungen in Österreich werden durch Vertragspartner der Krankenkasse – wie Vertragsärzte oder Vertragsspitäler – erbracht. Die Vertragspartner rechnen ihre Leistungen an den Patienten direkt mit der Krankenversicherung ab. Alle Vertragspartner sind an die ver t r ag l ich vereinbarten Tarife und an die Direktabrechnung zwischen Kasse und Vertragspartner gebunden. Der Patient hat keine Zahlungen zu leisten, welche über die gesetzlich festgelegten Selbstbehalte hinausgehen. In Österreich haben nur 64 Pro-

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zent der Ärzte einen Vertrag mit den Krankenkassen. Will ein Patient einen Arzt aufsuchen, der keinen Vertrag mit der Krankenversicherung abgeschlossen hat (einen so genannten Wahlarzt), ersetzt die Krankenkasse nur 80 Prozent der sonst üblichen Vertragsleistungen. In diesem Sinne besteht in Österreich weder eine freie Arztwahl noch ein Vertragszwang.

Defizitäre, einkommensabhängige Finanzierung Rund 70 Prozent der gesamten Gesundheitskosten werden in Österreich über die öffentliche Hand finanziert, wobei die Krankenversicherer alleine nahezu 50 Prozent der Gesamtkosten tragen. Die restlichen 30 Prozent gehen zu Lasten der privaten Haushalte sowie der privaten Krankenversicherungen. Die Einnahmen der gesetzlichen Krankenversicherung werden über paritätische, einkommensabhängige Beiträge der Arbeitnehmer und Arbeitgeber generiert. Selbstständig Erwerbende und Bauern haben ihre Beiträge an den zuständigen Versicherer zu entrichten. Insgesamt bezahlen die Österreicher 7,5 Prozent der Lohnsumme an die gesetzliche Krankenversicherung, dies bis zu einem Plafond von rund 6000 Franken pro Monat. Dieser tiefe Plafond verhindert eine Reichtumssteuer, belastet aber den Mittelstand stark. Im Gegensatz zur OKP in der Schweiz ist die gesetzliche Krankenversicherung in Österreich chronisch verschuldet. So haben die GKKs 2006 das achte Jahr in Folge rote Zahlen geschrieben. Insgesamt weisen sie seit 1998 eine Unterdeckung des Aufwandes von insgesamt 2,7 Milliarden Franken auf.2

Gesundheitsreform 2005 Damit die Finanzierbarkeit des österreichischen Gesundheitswesens trotz steigender Anforderungen weiterhin sichergestellt bleibt, leitete die Regierung die Gesundheitsreform 2005 in die Wege. Folgende Ziele werden angestrebt: • Überwindung der strikten Trennung der einzelnen Sektoren des Gesundheitswesens und Erreichung einer besseren Abstimmung in der Planung, Steuerung und Finanzierung. • Längerfristige Sicherstellung der Finanzierbarkeit des Gesundheitswesens durch Massnahmen zur Kostendämpfung, zur Effizienzsteigerung und zur Steuerung. • Unterstützung von Vorsorgemassnahmen und flächendeckende Sicherung und Verbesserung der Qualität.

Auf dem Stockerl? In Österreich stehen einer qualitativ guten Versorgung finanzielle Defizite und eingeschränkte Wahlfreiheiten gegenüber. Vorteile gegenüber der Schweiz weist das System nicht etwa auf Stufe der Prämienerhebung oder der Organisation der Krankenversicherung auf – vielmehr sind folgende Punkte von Bedeutung: • Österreich verfügt mit Wien über ein klares Zentrum für Wirtschaft, Forschung und Spitzenmedizin. In

der Schweiz existieren mindestens fünf potenzielle Zentren, wie es der Kampf um die Vorreiterrolle in der Transplantationsmedizin zeigt. • Das Gesundheitssystem in Österreich ist nur in neun und nicht wie die Schweiz in 26 Regionen organisiert. • Die Krankenversicherer können in Österreich Einfluss darauf nehmen, wie viele Ärzte im ambulanten Bereich zu Lasten der Krankenversicherung tätig sind. Österreich hat zweifellos ein qualitativ hoch stehendes und der Schweiz ebenbürtiges Gesundheitswesen vorzuweisen. Obwohl beide Länder im internationalen Vergleich vordere Plätze belegen, ist nicht auszumachen, wer vor wem auf dem Stockerl steht. Eins ist aber klar: beide Systeme haben mit steigenden Kosten zu kämpfen und müssen grundlegende Reformen in Angriff nehmen, wollen sie künftig die Finanzierbarkeit ohne Qualitätseinbussen sicherstellen. Matthias Schenker

Quelle: www.sozialversicherung.at Quelle: Fritz Beske, Leistungskatalog des Gesundheitswesens im internationalen Vergleich, Band I, Kiel, August 2005, S. 163/ 164

Quelle: Pressearchiv WGKK (2006), Unabhängiges Gutachten bestätigt bedrohliche Finanzierungskrise im Gesundheitswesen, www.wgkk.at

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Gesundheitspolitische Träume aus dem hohen Norden platzen beim Blick auf die Wartelisten

Skandinavien: Wenig bezahlen – lange warten Die Gesundheitssysteme sind überall in Skandinavien Teil der grosszügigen Wohlfahrtsstaaten. Trotzdem können sie ihre Kosten erstaunlich niedrig halten. Wie geht das? Arbeiten sie einfach effizienter als andere Systeme? Oder sind sie gezwungen, ohne zusätzliche Steuermittel Leistungen zu kürzen?

ie skandinavischen Länder sind bekannt für ihre gut ausgebauten Sozialstaaten. Während die einen darin ein leuchtendes Vorbild sehen, graut es den anderen vor einem derart langen Arm der Behörden. Tatsächlich greifen die skandinavischen Staaten stark ins Alltagsleben ihrer Bürger ein – sowohl schützend als auch regulierend. Wer in Norwegen eine Flasche Wein kaufen möchte, muss dies vor 16 Uhr tun – danach sind die staatlichen Alkohol-Monopolläden geschlossen. Im dünn besiedelten Norden des Landes muss man je nach dem weite Autofahrten in Kauf nehmen, um spontan einen guten Tropfen fürs Nachtessen zu organisieren. Auch die hohen Steuern auf Alkohol lassen es einen gut überlegen, ob es den Wein heute wirklich braucht. Das erscheint uns nicht allzu sympathisch, wird aber verständlicher wenn man bedenkt, dass die skandinavischen Staaten auf diese Weise die Alkoholproblematik in der Bevölkerung einigermassen in den Griff bekommen haben. Vielleicht sind die unregelmässige Besiedelung, die teilweise grosse Abgeschiedenheit und die extremen klimatischen Verhältnisse Erklärungen für die starke regulierende Rolle des Staates: Er versucht, die unterschiedlichen Bedingungen etwas auszugleichen. Staatliche Lösungen sind deshalb auch für das Gesundheitswesen nahe liegend. Sogar in der dicht besiedelten Schweiz haben ländliche Regionen Schwierigkeiten, genügend medizinische Grundversorger zu finden – wie sollte es also möglich sein, dass sich genügend Ärzte in Lappland niederlassen?

Finnland: Einziges OECD-Land mit sinkenden Kosten Das finnische Gesundheitssystem ist das am stärksten verstaatlichte in ganz Skan-

dinavien. Die Zentralregierung gibt die gesetzlichen Rahmenbedingungen vor, für die eigentliche Gesundheitsversorgung sind jedoch die Gemeinden zuständig. Je nach Grösse betreiben die Gemeinden einzeln oder gemeinsam Gesundheitszentren, in denen hausärztliche Leistungen, aber auch Gynäkologie oder Physiotherapie angeboten werden. Viele Gesundheitszentren haben stationäre Abteilungen für einfachere Erkrankungen, in abgelegenen Regionen funktionieren sie sogar als Spitäler. Die spezialärztliche Versorgung kann nur auf Überweisung eines Hausarztes beansprucht werden und findet in den Krankenhäusern statt. Diese sind im Besitz von Gemeindeverbunden, den so genannten Krankenhausbezirken. Jede Gemeinde muss Mitglied eines Krankenhausbezirks sein. Die Leistungen der Gesundheitszentren und der Spitäler werden hauptsächlich über die Steuereinnahmen der Gemeinden finanziert – der durchschnittliche Gemeinde-Steuersatz in Finnland beträgt denn auch 18 Prozent. Daneben gibt es noch eine staatliche Krankenversicherung, die aus Arbeitgeber- und Arbeitnehmerbeiträgen gespeist wird. Sie vergütet Lohnausfälle bei Krankheit, etwa die Hälfte der Medikamentenausgaben sowie den Transport mit dem Krankenwagen. Finnlands Gesundheitsausgaben liegen mit 7,4 Prozent des Volkseinkommens (BIP) relativ tief. Als einziges OECD-Land hat Finnland seine Gesundheitskosten gemessen am BIP seit 1990 leicht senken können. Allerdings wurde das nur möglich, weil die Spitalkapazitäten massiv gesenkt wurden. Die Folge davon sind erhebliche Wartezeiten – vor allem bei Operationen und spezialärztlichen Untersuchungen.

Der private Gesundheitssektor ist in Finnland praktisch inexistent. Er besteht hauptsächlich aus Ärzten der Gesundheitszentren, die ausserhalb ihrer Arbeitszeit Leistungen anbieten, die vom Staat nicht gedeckt sind.

Schweden: Hohe Selbstbehalte und lange Wartezeiten Wie in Finnland ist der schwedische Zentralstaat nur für die gesetzlichen Rahmenbedingungen und für die Überwachung des Gesundheitswesens zuständig. Für die Gesundheitsversorgung sind die 21 Provinzen verantwortlich. Den Gemeinden obliegt lediglich die Pflege zu Hause und in Heimen. Die Regionen sind relativ frei in der Organisation der Versorgung. Meist arbeiten sie aber mit Gesundheitszentren ähnlich jenen in Finnland. Die Unterschiede: Die stationäre Versorgung findet ausschliesslich in den Spitälern statt, und die Hausärzte der Gesundheitszentren nehmen keine GatekeeperFunktion wahr. Schwedische Patienten können also direkt die Fachärzte in den Kliniken aufsuchen. Weil das schwedische System weniger strikt geregelt ist, gibt es einen grösseren privaten Gesundheitssektor: Etwa 25 Prozent aller hausärztlichen Leistungen werden von Privatpraxen erbracht, die einen Vertrag mit den lokalen Behörden erhalten haben. Das schwedische Gesundheitssystem wird durch Steuern der Provinzen und durch Zuschüsse des Zentralstaats finanziert. Die Selbstbeteiligungen der Patienten sind relativ hoch: Je nach Region sind pro Arztbesuch umgerechnet bis zu 30 Franken zu entrichten. Auch pro Pflegetag in den Krankenhäusern fallen Gebühren an. Medikamente werden erst ab einem Betrag von etwa 350 Franken pro Jahr übernommen – und auch das nur

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teilweise. Ein weiteres Problem sind in Schweden die langen Wartezeiten sowohl für ambulante als auch für stationäre Behandlungen. Das Gesetz garantiert lediglich, dass Patienten innerhalb einer Woche einen Termin bei einem Hausarzt und innerhalb von drei Monaten einen Termin bei einem Spezialisten oder in einer Klinik erhalten. Die Gesundheitskosten liegen in Schweden relativ stabil bei 9,4 Prozent des BIP. Wie in Finnland ist dies aber «erkauft» durch eine Abbaupolitik im stationären Sektor und durch die erwähnten Wartezeiten.

Norwegen: Das freieste aller skandinavischen Systeme Auch Norwegens Gesundheitssystem ist stark regionalisiert: Für die Grundversorgung und die Pflege sind die Gemeinden verantwortlich. Die Finanzierung erfolgt mehrheitlich durch Kommunalsteuern und ergänzend durch Zuschüsse des Zentralstaats. Die Gemeinden entscheiden frei, wie sie die Grundversorgung gewährleisten. In Norwegen gibt es keine Gesundheitszentren. Die meisten Ärzte arbeiten freiberuflich, erhalten von den Gemeinden aber ein Basisgehalt und Kopfpauschalen. Gleiches gilt für Leistungserbringer wie Physiotherapeuten und Hebammen. Die Versorgung durch Fachärzte hingegen findet in den Kliniken statt – verantwortlich sind die 19 Regionen des Landes. Die staatlichen Spitäler sind autonomer als im übrigen Skandinavien. Sie funktionieren als ergebnisorientierte Unternehmen und erhalten von den Behörden lediglich einen Leistungsauftrag. Spezialisten und Spitäler dürfen nur auf Überweisung des Hausarztes aufgesucht werden. Sofern nicht von den Gemeinden abgedeckt, werden die medizinischen Leistungen vom norwegischen Sozialversicherungsfonds übernommen. Er setzt sich zu drei Vierteln aus Arbeitnehmerbeiträgen und zu einem Viertel aus Steuern zusammen. Auch in Norwegen zahlen die Patienten hohe Selbstbehalte: Pro Arztbesuch sind gut 25 Franken fällig, und Medikamente werden nur bei chronischen Krankheiten übernommen. Norwegens Gesundheitskosten sind in den letzten Jahren auf vergleichsweise hohe 10,3 Prozent des BIP gestiegen. Im Gegenzug ist die Ressourcenknappheit im

Spitalbereich weniger ausgeprägt als in Restskandinavien. Zwar kennt auch Norwegen das Problem der langen Wartelisten. Laut dem Gesundheitsministerium konzentriert sich dies aber hauptsächlich auf einfachere Routinebehandlungen. Lebenswichtige Eingriffe können in der Regel prompt durchgeführt werden.

Dänemark: Das falsche Vorbild Dänemarks Gesundheitswesen ist, wie in allen skandinavischen Staaten, dezentral aufgebaut: Der Staat bestimmt die Rahmenbedingungen. Die Regionen sind für die Spitäler, die Pflegeheime und für die medizinische Grundversorgung zuständig. Den Gemeinden bleiben Prävention und die häusliche Pflege. Dänemark kennt wie Norwegen keine Gesundheitszentren, sondern setzt auf niedergelassene Ärzte. Das Hausarztsystem ist das strikteste in ganz Skandinavien: Jeder Däne muss sich auf einen Allgemeinpraktiker im Umkreis von zehn Kilometern festlegen. Ein Hausarztwechsel, sofern auf diesem engen Raum überhaupt möglich, ist kostenpflichtig. Die staatliche Krankenversicherung Dänemarks wird aus Steuermitteln gespiesen. Daneben fallen beträchtliche Selbstbeteiligungen für die Patienten an: Leistungen von Physiotherapeuten, Chiropraktoren oder Psychotherapeuten werden nur teilweise erstattet. Bis zu 85 Prozent beträgt die Selbstbeteiligung bei den Arzneimitteln. Die genaue Höhe der Selbstbeteiligung ist abhängig vom Medikamentenkonsum der vergangenen Jahre. Insbesondere für chronisch Kranke bedeutet das eine grosse Belastung.

Dänemarks Gesundheitswesen hat die Kosten im Griff: Sie liegen seit Jahren bei ungefähr neun Prozent des BIP. Möglich wurde dies durch eine konsequente Abbaupolitik im stationären Sektor: Lange Wartelisten sind die Folge. Seit 2002 können sich Patienten, die länger als zwei Monate auf eine Operation warten müssen, im Ausland behandeln lassen. Dänemark erhält die Gesundheitsversorgung seiner Bevölkerung also nicht mehr autonom aufrecht und wird deshalb auch der Vorbildfunktion nicht gerecht, welche die Befürworter einer schweizerischen Einheitskasse ihm oft zugedacht haben.

Gemeinsamkeiten Die staatlichen skandinavischen Gesundheitssysteme unterscheiden sich also in Nuancen, aber nicht grundsätzlich. Der skandinavische Weg in der Gesundheitsversorgung folgt in allen Staaten diesen Grundsätzen: • In Skandinavien plant, betreibt und finanziert der Staat das Gesundheitswesen. • Das Gesundheitswesen ist stark regio nalisiert, teilweise bis auf Gemeinde ebene. • Die Leistungserbringer sind staatliche Angestellte oder müssen sich um einen Vertrag mit den Behörden bemühen. • Die Kosten werden in allen vier Ländern tief gehalten. • Das Mittel dazu ist ein Abbau im stationären Bereich, die Folgen davon sind lange Wartelisten. • Die Selbstbeteiligungen der Patienten sind in allen Ländern beträchtlich. Peter Kraft

Krankenhausversorgung auf den Lofoten Die Lofoten sind eine norwegische Inselgruppe. Sie liegen über dem Polarkreis auf dem offenen Meer. Neben den einigermassen dicht besiedelten Hauptinseln gibt es Nebeninseln, die nur per Boot zu erreichen sind, über praktisch gar keine Infrastruktur verfügen und deren Bewohner hauptsächlich vom Kabeljau-Fang leben. Doch auch in dieser abgelegenen Region wird eine Spitalversorgung erster Güte angeboten. Für die 24 000 Einwohner des Inselreichs steht eine Klinik bereit, die von Grösse und Angebot her in der Schweiz durchaus als Zentrumsklinik durchgehen würde. Auf den Lofoten gibt es unter anderem alle wichtige chirurgischen Disziplinen, Radiologie, Onkologie, Psychiatrie für Kinder und Erwachsene und eine Geburtsabteilung. Patienten von Fischer-Inseln wie Røst werden von zwei eigens dafür bereitstehenden Flugzeugen eingeflogen. Dieses Beispiel macht verständlich, warum die skandinavischen Länder ihr Gesundheitswesen derart stark regulieren: Dem wettbewerblichen Anspruch, im Vergleich zu anderen Kliniken kosteneffizient zu arbeiten, könnte das Spital auf den Lofoten kaum genügen.

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Der Cox-Bericht an die EU-Kommission: Erfreulich oder alarmierend?

Zwiespältiger Wegweiser für die EU-Gesundheitspolitik Der Cox-Bericht ist eine Studie über die Zukunft der EU-Gesundheitspolitik, an der eine breite Palette von namhaften Experten mitgewirkt hat. Die Autoren empfehlen den EU-Mitgliedstaaten, in ihren Gesundheitssystemen für mehr Wettbewerb und Transparenz zu sorgen. Günter Verheugen, der Vizepräsident der EU-Kommission, hat den Bericht formal angenommen. So weit, so gut? Nicht ganz, denn die Studie wartet mit Forderungen auf, die sich durchaus in einen gefährlichen Bumerang verwandeln könnten.

in hochkarätiges Team aus Vertretern der Weltbank und der europäischen Investmentbank, aus Gesundheitsökonomen von verschiedenen europäischen Spitzenschulen, aus Regierungsvertretern und aus der Industrie zeichnet für die Studie verantwortlich. Benannt ist der Bericht nach dem Studienleiter und ehemaligen Präsidenten des Europaparlaments, Pat Cox. Zentrale Kapitel der Studie sind Gerechtigkeit und Effizienz, Gegenwert für Investitionen im Gesundheitswesen, Patienteninformationen sowie die Finanzierung der Gesundheitssysteme in den neuen EU-Mitgliedstaaten.

den. Schliesslich verlangt die Studie mehr Wettbewerb in zentralen Bereichen: Die Selbstbeteiligungen der Patienten sollen so ausgebaut werden, dass unnötige Leistungen vermindert, notwendige dagegen gewährleistet bleiben. Leistungserbringer sollen den Kostenträgern Angebote unterbreiten, aus denen diese die effizientesten auswählen können. Managed Care soll durch wettbewerbliche Anreize gefördert werden. Der Cox-Bericht fordert für die EU auch Konkurrenz unter den Krankenversicherern. Die Autoren können sich dabei vorstellen, dass die Versicherer nicht um einzelne Kunden werben, sondern mit grossen Versichertenkollektiven verhandeln.

Vernünftige Forderungen… Der Cox-Bericht stellt fest: In Europas Gesundheitssystemen ist es schwer festzustellen, wohin die Gelder fliessen. Eine verbesserte Transparenz und Offenheit bei der Finanzierung sei deshalb unabdingbar, wenn in Zukunft Investitionen gezielt erfolgen sollen. Die vermehrte Anwendung von DRGs in Europa wird dabei ausdrücklich begrüsst. Als trügerischen Mythos bezeichnet der Bericht die Vorstellung, die steigenden Gesundheitskosten seien vor allem eine Folge der immer älteren Bevölkerung. Verantwortlich für die höheren Ausgaben zeichne in erster Linie der medizinische Fortschritt. Deshalb müssten Investitionen in neue Medikamente oder Technologien besondere Beachtung geschenkt werden. Es braucht laut dem Cox-Bericht bessere Evaluationsverfahren, um den Nutzen einer neuen Technologie genauer bestimmen zu können. Allzu oft sei es heute der Fall, dass wichtige Innovationen zu spät, unnötige Neuheiten dafür zu früh eingeführt wür-

…mit Nebengeschmack Offenbar ist die Studie für die EU mehr als ein weiteres Papier. Günter Verheugen, der Vizepräsident der EU-Kommission, erklärte bei der formalen Annahme des Berichts: «Diese neue Studie ist ein wichtiger Beitrag um sicherzustellen, dass die Qualität unserer Gesundheitssysteme der Wettbewerbsfähigkeit unserer Wirtschaft entspricht.» Bereits hat Hannu Hanhijärvi, Leiter des Bereichs Gesundheit beim finnischen Innovationsfonds Sitra, einen Grossauftrag gefasst. Er soll eine Reihe von Programmen leiten, um die Empfehlungen des Cox-Berichts in den europäischen Gesundheitssystemen zu verankern. Das tönt nach mutiger Reformpolitik. Einige Aussagen der Studie – nicht erwähnt in den Zusammenfassungen – machen jedoch stutzig. So wird ein sehr eigenwilliger Zusammenhang zwischen der Wirtschaftskraft eines Landes und dem Gesundheitszustand der Bevölkerung postuliert: Je gesünder die Bevölkerung, desto

mehr floriere die Wirtschaft, sagt der CoxReport. Ursache und Wirkung scheinen hier etwas gar vorschnell vertauscht. Weiter geht die Argumentation: Eine Erhöhung der Ausgaben steigere generell die Qualität des Systems. Portugal habe seit 1970 seine Gesundheitsausgaben gemessen am BIP um fast 300 Prozent gesteigert, wodurch die Anzahl der medizinisch vermeidbaren Todesfälle markant zurückgegangen sei. Die Niederlanden investie-

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ren im Vergleich zu 1970 nur 30 Prozent mehr, und siehe da: Die vermeidbaren Todesfälle haben deutlich weniger abgenommen. Diese Argumentation des Cox-Berichts lässt dabei ausser Acht, dass Portugal und Holland 1970 völlig unterschiedliche Ausgangslagen hatten – sowohl was die Höhe der Gesundheitsausgaben als auch die Anzahl vermeidbarer Todesfälle angeht. In Portugal haben sich die Investitionen gelohnt, den Niederlanden hätte eine ähnliche Erhöhung der Ausgaben viel weniger Zusatznutzen gebracht. Der CoxReport enthält also einen generellen Aufruf zur Kostensteigerung – ungeachtet dessen, welche Qualität das Gesundheitswesen bereits bietet. Dass der Grenznutzen von neuen Investitionen gerade im Gesundheitsbereich irgendwann abnimmt, ist für die Autoren kein Thema.

Die Handschrift von Pfizer

schlägt vor, Innovationen vor der Zulassung am Markt zu erproben. Das lässt aufhorchen: Wenn beispielsweise ein neues Arzneimittel an der breiten Bevölkerung getestet wird, birgt das grosse Gefahren. Zudem: Einmal eingeführt – und sei es nur zu Testzwecken – wird es schwierig sein, die Neuerung wieder vom Markt zu nehmen. Das Evaluationsverfahren, welches der Cox-Report vorschlägt, könnte also Tatsachen schaffen, bevor der Nutzen einer Innovation überhaupt erwiesen ist. Wiederholt moniert der Cox-Report, dass medizinische Innovationen heute zu langsam auf den Markt kämen. Neue Evaluationsmethoden würden die staatlichen Entscheidungsträger befähigen, «ihre Unsicherheit zu überwinden und den Wert der Innovation zu erkennen.»

Industrie- statt Gesundheitspolitik

Foto: Prisma

Erstaunlich: Während die meisten Gesundheitssysteme Europas versuchen, ihre Kosten durch das Weglassen von Fehlinvestitionen zu senken, fokussiert der CoxBericht vor allem auf neue Investitionen.

Erstaunlich ist auch, dass neben unabhängigen Ökonomen und Institutionen mit öffentlichem Auftrag der Pharmariese Pfizer an der Studie beteiligt ist. Als einzige Organisation ist er mit zwei Sitzen im Steuerungskomitee des Cox-Reports vertreten. Dementsprechend widmet sich fast die Hälfte des Cox-Berichts der Evaluation von Innovationen im Gesundheitssektor. Wiederum tönen die Vorschläge auf den ersten Blick vernünftig: Der Cox-Bericht fordert mehr Transparenz in der Zulassung von neuen Medikamenten und Technologien. Einmal zugelassen, soll der Nutzen der Neuerungen regelmässig überprüft werden. Wertvolle Innovationen sollen von den Staaten aktiv identifiziert und gebührend abgegolten werden. Hier ist bereits die Pharma-Handschrift erkennbar. Deutlicher wird die Stossrichtung bei anderen Forderungen: Die Evaluation neuer Technologien soll weniger das Kosten-NutzenVerhältnis berücksichtigen als die «Patientenpräferenz» und die «Akzeptanz der Produkte». Wie aber sollen diese Kriterien bei Produkten, die noch nicht auf dem Markt sind, geprüft werden? Der Cox-Report

Der Europäische Verbraucherverband kritisiert denn auch, dass der Cox-Report in erster Linie einen industriepolitischen Ansatz verfolge. So sei der Bericht nicht dem EU-Kommissar für Gesundheit, sondern mit Verheugen dem Kommissar für Industrie und Betriebe übergeben worden. Der Präsident des europäischen Spitalverbands, Pascal Garel. kritisiert den Bericht als undifferenziert. Er fragt sich, wie die Autoren zu ihren Empfehlungen gekommen seien.

Entwarnung aus Helsinki?

Bringt mehr Geld für die Gesundheitsversorgung automatisch mehr Nutzen?

Immerhin: Hannu Hanhijärvi vom finnischen Innovationsfonds, der die Forderungen des Cox-Berichts in den europäischen Ländern implementieren soll, relativiert: Er führe zurzeit mit mehreren Staaten Gespräche, die eine Vorreiterrolle im ehealth-Bereich einnehmen, sagt er auf Anfrage. Mit ihnen möchte er gemeinsame Pilotprojekte auf die Beine stellen, um die evidenzbasierte Medizin und klinische Leitlinien zu fördern. Die EU-Kommission könne zu einem späteren Zeitpunkt die Koordination und Finanzierung dieser Projekte übernehmen. Allerdings bezweifelt Hanhijärvi, dass daraus obligatorische Richtlinien für die EU-Mitgliedstaaten entstehen können. Weniger kommunikativ gibt man sich beim Steuerungskomitee des Cox-Berichts: Zu den Fragen nach dem Einfluss von Pfizer auf die Studie und zu den zukünftigen Schritten war von dieser Stelle keine Stellungnahme erhältlich. Peter Kraft

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Drei Fragen an: Nello Castelli, Délégué aux relations publiques Suisse romande von santésuisse

«Es wurde kaum über Fakten diskutiert»

Fotos: Peter Kraft

Nello Castelli hatte als «Délégué aux relations publiques en Suisse romande» von santésuisse den wohl schwierigsten Job während der Einheitskassen-Abstimmung: Er musste die kassenkritischen Westschweizer davon überzeugen, dass die Initiative nichts als eine Scheinlösung ist. Er hat es geschafft – und kann nun für einen Moment entspannt Rückschau halten. Er betont aber, dass auf santésuisse und die Krankenversicherer auch nach dem klaren Nein eine Menge Arbeit wartet.

«Wir müssen nun erst recht bemüht sein, die Schwächen unseres Systems abzubauen.»

infosantésuisse: Wie haben Sie den Abstimmungskampf in der Romandie erlebt? Nello Castelli: Das Image der Krankenversicherer ist in der Romandie nicht gleich gut wie in der Deutschschweiz. Seit mehreren Jahren verbreiten jene Kreise, die gegen das heutige System sind, Unwahrheiten. Diese Unwahrheiten haben sich auch bei der Bevölkerung festgesetzt: Die Krankenversicherer würden in der Grundversicherung Gewinne machen, hätten millionenteure Verwaltungsräte und würden massenhaft Prämiengelder in der Verwaltung versickern lassen. Die Befürworter der Einheitskassen-Initiative haben sich diese Stimmung zunutze gemacht und insbesondere in der Romandie einen sehr emotionalen Abstimmungskampf geführt. Anders als in der Deutschschweiz wurde kaum über Fakten diskutiert. Für mich war das sehr schwierig, denn santésuisse hat den Abstimmungskampf mit dem Anspruch geführt, sachlich zu bleiben. Ich habe mich also zurückgehalten, wenn die Debatte allzu emotionell wurde. Solche Argumente zu kontern ist das Metier der Politiker und nicht des Branchenverbandes. Kann man das Abstimmungsresultat in der Romandie also als Sieg der Sachlichkeit werten? Das kann ich so nicht sagen, weil die entsprechenden Analysen noch nicht vorliegen. Es wäre wohl vermessen zu glauben, dass nur unsere fachliche Information zum Sieg geführt hat. Gegenüber unseren Zahlen wurde nämlich lautstark und medienwirksam der Manipulationsvorwurf erhoben – obwohl wir unsere Modelle so gut als möglich auf die Aussagen der Initianten abgestützt hatten.

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Überraschungen Sehr überrascht sei er am Nachmittag des 11. März über das positive Resultat in der Romandie gewesen, sagt Nello Castelli. Insbesondere in Genf und im Tessin habe er nicht mit einem Nein gerechnet. Zu oft habe er sich in den öffentlichen Debatten wie in der Höhle des Löwen gefühlt. An den Veranstaltungen zur Einheitskasse, meist von den Befürwortern organisiert, sei die Stimmung äusserst kritisch gegenüber den Krankenversicherern gewesen. Nello Castelli greift ein Beispiel heraus: Am Bahnhof von Lausanne erkannte ihn eine Dame nach einem Fernsehauftritt vom

Wo sehen Sie dann die Gründe für das erfreuliche Resultat in der Westschweiz? Das Hauptargument der Befürworter waren die hohen Prämien – ohne den Stimmbürgern etwas Konkretes anbieten zu können. Die Gegner hingegen konnten Dinge aufzählen, die mit der Initiative sicher verloren gegangen wären – wie etwa die Wahlfreiheit. Eine vage Versprechung stand also einem sicheren Verlust gegenüber. Möglicherweise war, jenseits aller Systemfragen, auch die Zufriedenheit der Leute mit ihrer persönlichen Krankenkasse von

Vorabend. Zuerst sei er erfreut gewesen: Schliesslich sei es nicht alltäglich, wegen eines Fernsehauftritts angesprochen zu werden. Die Überraschung folgte auf dem Fuss und war diesmal eher negativ: Lautstark und mit deutlichen Worten erklärte die Frau Nello Castelli, dass sie seine Meinung überhaupt nicht teile und für die Einheitskasse stimmen würde. Wer weiss, vielleicht konnte Nello Castelli sie mit seinen weiteren Auftritten doch noch überzeugen? Nicht wenigen Romands und Tessinern ist es offenbar so ergangen.

Bedeutung. Eine weitere Erklärung: Viele Stimmbürger halten das System zwar nicht für fehlerfrei, möchten es aber trotzdem nicht komplett verändern. Sie waren sich auch nicht im Klaren darüber, was so ein Systemwechsel für sie persönlich bedeutet hätte. Man darf also die Abstimmung keineswegs so interpretieren, dass kein Handlungsbedarf herrscht: Wir müssen nun erst recht bemüht sein, die Schwächen unseres Systems abzubauen. Weiter ist es wichtig, die Menschen vor allem in der Romandie da-

von zu überzeugen, dass die Probleme des Systems nicht bei den Verwaltungsausgaben oder den vielen Kassen liegen, sondern bei den Kosten. In der Deutschschweiz ist das Bewusstsein dafür stärker, dass die Prämien ein Abbild der Kosten sind. In der Romandie hingegen ist die Auffassung verbreitet, mit den Prämien würden zur Hauptsache Reserven oder gar Gewinne angehäuft, Werbung gemacht und eine unnötige Verwaltung unterhalten. Dieses schiefe Bild müssen wir korrigieren. Interview: Peter Kraft

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KRANKENVERSICHERUNG

infosantésuisse Nr. 4, April 2007

Im Gespräch: Claude Longchamp, Leiter des Forschungsinstituts gfs.bern

«Gesundheitspolitische Volksinitiativen sind schlechte Ratgeber für die Politik» Claude Longchamp stellt nach der Abstimmung zur Einheitskasse fest: Die gesundheitspolitischen Anliegen der Linken polarisieren zu stark, als dass sie in der Mitte viele Anhänger gewinnen könnten. Der Politik und den Akteuren rät er, den Reformpfad ungeachtet radikaler Forderungen weiter zu gehen – gemäss den Wünschen der Bevölkerung in Richtung mehr Wettbewerb.

Die Monopolkasse oder die einkommensabhängigen Prämien – welches Element ist bei der Bevölkerung auf grössere Skepsis gestossen? Definitives werden wir dazu erst mit den VOX-Analysen wissen. Aufgrund der Vorbefragungen scheint aber die Ablehnung wegen der Vereinheitlichung der Kassen stärker gewesen zu sein. Für die Änderung des Prämiensystems gibt es mehr Zustimmung. Hätte die Initiative wesentlich besser abgeschnitten, wenn sie klarer formuliert gewesen wäre? Nein, das Ergebnis war nicht eine Folge des Initiativtextes. In der Dynamik der Meinungsbildung spielte aber eine Rolle, dass die Finanzierungsseite der Initiative konzeptionell nicht ausgestaltet war. Das erlaubte es den Krankenversicherern, dieses für die Bevölkerung relevante Feld als Erste selber zu besetzen.

Ist das wuchtige Nein «nur» aus der Ablehnung gegenüber der Initiative zu verstehen – oder auch als Votum für das bestehende System? Die ersten Analysen legen einen eindeutigen Zusammenhang offen: Die Höhe der Prämien, die eine Familie in der Grundversicherung bezahlt, ist der beste Prädiktor für die Zustimmung. Je höher die Prämien im interkantonalen Vergleich sind, desto stärker fällt auch die Ja-Tendenz aus. In der deutschsprachigen Schweiz wird dieser Effekt aber durch das Mass aufgefangen, in dem die Bevölkerung Prämienvergünstigungen bezieht. Je höher hier der Prozentsatz ist, desto geringer fiel die Zustimmung zur Initiative aus. Einen solchen Effekt können wir für die Romandie nicht nachweisen. Da steigt der Unmut mit der mittleren Prämienhöhe. Der oft beschwörte «Röstigraben» ist nicht so deutlich zutage getreten wie befürchtet. Was hat insbesondere die lateinische Foto: ZVG

infosantésuisse: Die Initiative für eine soziale Einheitskrankenkasse ist mit über 70 Prozent Nein-Stimmen doch überraschend deutlich abgelehnt worden. Wie erklären Sie sich das klare Verdikt? Claude Longchamp: Nimmt man die Fakten, erreichte diese Initiative von den drei gesundheitspolitischen Volksbegehren der Linken das beste Resultat, vor allem wegen der Romandie. Ein Durchbruch in der Gesundheitspolitik ist damit aber weder der SP noch den Grünen gelungen. Die Polarisierung, die ihre Anliegen auslösen, ist zu stark. Sie trennt erfahrungsgemäss nicht nur die Linke und die Rechte. Die bürgerliche Mitte stimmt meist klar mit der ablehnenden Position.

«Die Höhe der Prämien ist der beste Prädiktor für die Zustimmung.»

Schweiz dazu bewogen, die Initiative mehrheitlich abzulehnen? Die Trends verweisen in die umgekehrte Richtung. Kein Romandiekanton hatte bis jetzt eine so hohe Zustimmungsrate zu einer linken Gesundheitsinitiative wie jetzt. Das gilt auch für das Tessin. Die Regionen mit der höchsten Prämienbelastung – Genf und Basel-Stadt – haben die Initiative abgelehnt. Hat sich die Erkenntnis durchgesetzt, dass eine Einheitskasse keine tieferen Krankenversicherungsbeiträge gebracht hätte? In Basel, wie auch in Zürich, gibt es Hinweise für eine solche Trendwende, nicht aber in Bern und Genf. Welchen Weg soll die Politik nach diesem Abstimmungsergebnis einschlagen? Gesundheitspolitische Volksinitiativen sind ein schlechter Ratgeber für die Politik. Egal, ob sie von links oder rechts kamen: Sie wurden seit Bestehen des KVG alle samt und sonders abgelehnt. Der wichtigste Rat an die Behörden dürfte deshalb lauten: Sich in den Reformvorhaben von den meist radikalen Umkehrforderungen aller Initiativen nicht blockieren zu lassen. Welche Konsequenzen müssen die Akteure des Gesundheitswesens ziehen? Die grossen Trends in der Bevölkerung treten seit drei Jahren recht deutlich zu Tage: Gleichbleibende Qualität und Quantität in der medizinischen Versorgung, wenn auch bei gestärkter Eigenverantwortung für die Kosten, verbunden mit generell mehr, nicht weniger Wettbewerb unter den Leistungserbringern, um die Kostensteigerungen in den Griff zu bekommen. Interview: Peter Kraft

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KRANKENVERSICHERUNG

infosantésuisse Nr. 4, April 2007

RVK und santésuisse spannen zusammen für ein zentrales Vertragsregister

Das ZVR erleichtert Rechnungskontrolle und Verhandlungen Wegen des zunehmenden Einsatzes der elektronischen Kommunikationsmittel hat santésuisse für seine Mitglieder und die internen Stellen im Jahre 2001 die Vertragsdatenbank (VDB) realisiert: Dort werden alle allgemein gültigen Verträge aus dem Bereich der obligatorischen Krankenpflegeversicherung abgebildet. Daneben erstellte der RVK vorab für die ihm angeschlossenen Krankenversicherer unter der Bezeichnung «Vertrags- und Tarifdatenbank (VTDB)» eine ähnliche Anwendung. Jetzt werden die beiden Datenbanken zusammengeführt.

eide Anwendungen gewährleisten die elektronische Verteilung der schriftlichen Vertragsinformationen an ihre Mitglieder. Sie unterstützen dabei hauptsächlich die manuelle Rechnungskontrolle und die mit Vertragsverhandlungen betrauten Personen. Die zwei Datenbanken bestehen seit Jahren parallel und haben sich unterschiedlich entwickelt, obwohl sie inhaltlich die gleichen Verträge und die gleichen Vertragsinhalte abbilden. Jede Applikation verfügt über zusätzliche Informationen und Funktionen, damit die Kunden im Bereich der Leistungsinformationen ein aussagekräftiges Nachschlagewerk benutzen können.

Neue Anforderungen – gemeinsame Lösung Aus gemeinsamen Diskussionen zwischen santésuisse und dem RVK entstand im November 2005 die Idee einer gemeinsamen Lösung. Eine Bestandesaufnahme ergab, dass beide Applikationen bei den Kunden stark verankert sind und über unterschiedliche Ausprägungen verfügen. Beide bisherigen Datenbanken müssen nun aber neuen Anforderungen gerecht werden: Insbesondere müssen sie die wachsende Vertragsvielfalt überschaubar darstellen, Vorbereitungen auf die mögliche Auflösung des Vertragszwangs unterstützen und die elektronische Rechnungsprüfung einbeziehen. Deshalb wurde gemeinsam ein Projekt beschlossen, welches die Schwachstellen in den bisherigen Applikationen sowie die aufwändigen und doppelt geführten Bewirtschaftungsaufgaben eliminiert. Nach eingehenden Verhandlungen wurden am 20. Dezember 2006 die Zusammanarbeitsverträge zwischen dem

RVK und santésuisse unterzeichnet. Ziel ist ein Zentrales Vertragsregister (ZVR) mit • Web-Applikation • Standard-Schnittstelle (analog ZSR) mit allen Verknüpfungen • EDI-Schnittstelle als elektronisches Vertragsverzeichnis • Mandantenfähigkeit für eigene Verträge. Für die Kunden wird damit auf verschiedenen Ebenen ein bedeutender Mehrnutzen entstehen.

Das ZVR-Team an der Arbeit. V.l.n.r.: Matthias Wechsler, Franz Wolfisberg, Ruedi Bucher.

Die konkreten Pläne Das ZVR wird dem Ressort Zahlstellenregister (ZSR) in Luzern angegliedert und von dort aus bewirtschaftet und betrieben. Die Aufgabenstellung des ZVR ist derjenigen des ZSR sehr ähnlich. Damit können die Erfahrungen aus dem Projekt «ZSR-Revision 2004» einfliessen. Ebenso kommen gleichartige Tools und Methoden wie beim ZSR zur Anwendung. Zudem sind für das ZVR identische Verteil- und Produktionsvorgänge wie beim ZSR vorgesehen. In einer ersten Phase sind die Versicherer kontaktiert und eingeladen worden, den Lizenzvertrag für das neue Zentrale Vertragsregister zu unterzeichnen. Dieser Prozess beansprucht noch einige Zeit, weil sich jeder Versicherer intern mit den verschiedenen Lösungsansätzen befassen und entsprechende strategische Entscheide fällen muss. Zurzeit werden zusätzliche Wün-

sche und Anliegen der Versicherer entgegengenommen und so weit wie möglich in das Projekt integriert. In einer weiteren Phase wird die neue Applikation zur Bewirtschaftung und Verteilung realisiert. Dann beginnt auch der Pilotbetrieb. Nach einer ersten Bereinigung werden dann die Daten in die neue Applikation übernommen. Dieser Prozess wird sehr zeitintensiv sein, da jeder Vertrag durchgearbeitet und gemäss den neuen Strukturen bereinigt werden muss. In jedem Fall ist die Bewirtschaftung der Vertragsdaten ein zentraler Erfolgsfaktor für das Projekt. Dementsprechend wird diesem Punkt besondere Beachtung geschenkt. Die Einführung des Zentralen Vertragsregisters ist auf den 1. Januar 2008 ge plant. Franz Wolfisberg

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GESUNDHEITSWESEN

infosantésuisse Nr. 4, April 2007

Grafik des Monats

Pflegekosten und restliche Ausgaben driften ab 80 auseinander Ab dieser Ausgabe präsentieren wir im infosantésuisse regelmässig die «Grafik des Monats». Den Anfang macht ein aufschlussreicher Vergleich zwischen Pflegekosten und übrigen Ausgaben nach Altersgruppen.

• Noch vor dem 90. Lebensjahr werden die Kosten für die Pflege pro Versicherten höher als für alle restlichen Gesundheitsleistungen zusammengenommen. • Die stark steigenden Pflegekosten ab dem 80. Lebensjahr sind vor allem auf die Pflegeheime zurückzuführen. • Die Spitex spielt eine deutlich kleinere Rolle. Deren Kosten pro Versicherten sind erstens im Vergleich zu den Pflegeheimen niedrig. Zweitens steigen sie mit dem Älterwerden deutlich weniger stark an.

• Die stark steigenden Kosten im höheren Lebensalter, verbunden mit der demografischen Alterung, werden die Krankenversicherung in Zukunft vor grosse Herausforderungen stellen. Unsere Grafik des Monats April bestätigt zweierlei: Zum einen sind die Pflegekosten ein Gebiet, auf dem Handlungsbedarf herrscht. Zum anderen ist die häusliche gegenüber der stationären Pflege zu fördern – nicht nur aus Kostengründen, sondern auch für eine höhere Selbstbestimmung und eine bessere Lebensqualität der Betroffenen. Matthias Schenker

K o s t e n p r o Ve r s i c h e r t e n nach Pflegeheim und Spitex 2005 Bruttoleistungen pro Versicherten in Fr.

Quelle: santésuisse-Datenpool, Jahresdaten 2005

ie Grafik des Monats April zeigt auf, wie sich die Kosten für Spitex, Pflegeheime und übrige KVGLeistungen in den verschiedenen Altersgruppen verteilen. Aufgrund der Zahlen des santésuisse-Datenpools lassen sich einige sehr interessante Aussagen machen: • Erst ab einem Alter von etwa 70 Jahren fallen bei den Versicherten nennenswerte Pflegekosten an. • Ab etwa 80 Jahren beginnen die Pflegekosten stark zu steigen. • Ebenfalls ab etwa 80 Jahren sinken die restlichen Gesundheitskosten pro Versicherten.

25000

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Spitex / Versicherte Pflegeheim / Versicherte Übriges / Versicherte

15000

10000

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0 5J 0-

. . . . . . . . . . . . . . . . . . . . J. 5J 8J 0J 5J 0J 5J 0J 5J 0J 5J 5J 0J 0J 5J 0J 5J 0J 5J 0J 5J 10 -1 -1 -2 -2 -3 -3 -4 -4 -5 -5 -6 -6 -7 -7 -8 -8 -9 -9 10 10 61 6 9 1 6 1 6 1 6 1 1 6 6 1 6 1 6 1 1 1 1 2 2 3 3 4 4 5 6 5 6 7 7 8 8 9 1 96 10

Altersgruppen

Ab etwa 80 Jahren beginnen die Pflegekosten stark zu steigen, während die restlichen Gesundheitsausgaben sinken.

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GESUNDHEITSWESEN

infosantésuisse Nr. 4, April 2007

Die Schleudertrauma-Diskussion dreht sich seit Jahrzehnten im Kreis

Von der Eisenbahnkrankheit zum Schleudertrauma Wie häufig führen Schleudertraumas zwingend in die Invalidität? Was sind die wahren Ursachen für die Beschwerden, die vor allem nach Auffahrunfällen auftreten? Wann sind Renten oder Entschädigungszahlungen der beste Weg, um den Opfern zu helfen? Diese Fragen sind hochaktuell – und gleichzeitig so alt wie die ältesten Exponate in der Eisenbahnabteilung des Luzerner Verkehrshauses.

er englische Chirurg John Eric Erichsen stellte 1866 eine These auf, die seiner Meinung nach die unerklärlich starken Folgen auch von leichteren Eisenbahnunfällen erklärte. Durch die Erschütterungen, die bei einer plötzlichen Geschwindigkeitsänderung auf das Rückenmark einwirken, komme es zu Strukturveränderungen, die Sinnesstörungen, Kopf- und Gliederschmerzen und Konzentrationsschwierigkeiten hervorrufen. Zwanzig Jahre später konterte der deutsche Arzt Hermann Oppenheim mit der Theorie, die auffällig starken Beschwerden nach Zugsunfällen hätten «traumatische Neurosen» als Ursache. Nicht eine Veränderung im Rückenmark, sondern ein Schockerlebnis, noch dazu in Verbindung mit einer neuen, «geheimnisvollen» Technologie, lösten die Beschwerden aus.

der Romandie haben sich die Kosten seit 1990 verdoppelt – in der Deutschschweiz versechsfacht. Das wirft die Frage auf: Sind Schleudertraumas hauptsächlich die Folge von Auffahrunfällen – oder spielen auch kulturelle Faktoren oder der Bekanntheitsgrad des Themas eine Rolle? Die Versicherungsgesellschaften sprechen von einer «Hypersensibilisierung» insbesondere in der Deutschschweiz, während Opferverbände klagen, in der Romandie werde die Krankheit oft nicht erkannt – auch, weil die Bevölkerung zuwenig darüber informiert sei. Laut dem deutschen Psychiater Andreas Stevens erwarten viele Opfer nach einem Verkehrsunbfall geradezu ein Schleudertrauma. Das sei ein «kulturbezogenes und erlerntes Ritual», bei dem auch die Erwartung einer Entschädigung eine wichtige Rolle spiele.

Ein kulturelles Phänomen?

Ändert Bundesgericht Praxis?

Weil sich zu jener Zeit die ersten Versicherungssysteme etablierten, wurde die Diskussion um die Ursache der «Eisenbahnkrankheit» bereits im 19. Jahrhundert intensiv geführt: Führen Zugsunfälle wirklich häufig zu bleibenden Schäden, oder verursachen sie «nur» Traumas, die überwindbar sind? Zwei Jahrhunderte später läuft die gleiche Debatte immer noch – inzwischen unter dem Stichwort Schleudertrauma. In den letzten Jahren hat das Thema in der Schweiz zusätzliche Brisanz erhalten, weil die Versicherungskosten (vor allem in der Invaliden-, Unfall- und Haftpflichtversicherung) exorbitant gestiegen sind. 33 Prozent aller Zahlungen für Körperschäden entfallen in der Schweiz auf das Schleudertrauma – in Frankreich sind es nur drei Prozent. Rund eine halbe Milliarde Franken gehen hierzulande jährlich an die Opfer von Schleudertraumas. In

Wie dem auch sei: Augenfällig ist, dass der starke Anstieg der Schleudertrauma-Kosten mit einem Bundesgerichts-Entscheid von 1991 begann: Es anerkannte den Anspruch eines Patienten auf IV-Rente – obwohl es für seine Beschwerden keine medizinische Erklärung gab. Dieses Leiturteil war der Grundstein der kommenden grosszügigen Rentenvergabe. Der Freiburger Sozialversicherungsrechtler Erwin Murer rechnet jedoch mit einer Kehrtwende: Die grossen finanziellen Aufwendungen für Versicherungsfälle ohne bekannte Ursache hätten dazu geführt, dass die Bundesrichter bereits jetzt die Fälle vorsichtiger beurteilen. Das Schleudertrauma werde damit seinen Status als juristisch gefördertes Leiden verlieren. Stattdessen, so Murer, könnten wieder die wahren Ursachen vieler Schleudertraumas in den Vordergrund treten: Berufliche Überfor-

derung, familiäre Spannungen oder andere persönliche Schwierigkeiten. Mehrere Studien, unter anderem von den Professoren Bogdan Radanov und Thomas Ettlin, empfehlen denn auch den stärkeren Einbezug der Psychotherapie in die Schleudertrauma-Behandlung. Aber auch die Versicherungen sind gefordert: Der schweizerische Versicherungsverband empfiehlt seinen Mitgliedern, bei Schleudertrauma-Patienten so schnell wie möglich das «Chronifizierungsrisiko» abzuklären. Nur so könnten rechtzeitig die richtigen Schritte eingeleitet und damit das Auftreten einer Dauerinvalidität verhindert werden. Peter Kraft

Vor vier Jahren haben die Versicherer zusammen mit den Leistungserbringern einen Fragebogen erarbeitet, welcher nun nach Auftreten eines Schleudertraumas ausgefüllt werden soll. Der Dokumentationsbogen erfasst den Unfallhergang und ermöglicht die medizinischen Befunde halbstrukturiert festzuhalten, so wie sie sich bei der ersten Kontaktaufnahme auf der Notfallstation oder in der erstversorgenden Praxis präsentieren. Der Fragebogen kann mitsamt Anleitung auf der Webseite des medizinischen Dienstes des SVV (www.med.svv.ch) heruntergelanden und nach TARMED abgerechnet werden. Damit werden wichtige Daten gesichert, welche für das Verstehen des späteren Verlaufes wertvoll sein können. Die Unfall- und Krankenversicherer haben pro Jahr etwa gleich viele Fälle zu bearbeiten und fordern alle erstversorgenden Ärztinnen und Ärzte auf, den Dokumentationsbogen zu verwenden.

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GESUNDHEITSWESEN

infosantésuisse Nr. 4, April 2007

Buchtipp: Gesundheitsdaten verstehen

Auch Gesundheitsdaten müssen verlässlich sein «Die Statistik lügt» – ein Ausspruch, der oft zu hören ist, der aber in dieser absoluten Form sicher nicht zutrifft. Statistiken können durchaus einen Aussagewert haben, sofern sie nach wissenschaftlichen Methoden erstellt worden sind – doch sind sie nicht immer frei von Tücken. Das zeigt das Buch «Gesundheitsdaten verstehen» anhand konkreter Beispiele auf.

Interpretationsbedürftig... Viele Daten sind interpretationsbedürftig. Ein Beispiel: Warum sterben so viele Menschen an Herz-Kreislauf-Erkrankungen? Weil es «typische Alterskrankheiten» sind. Dass diese Erkrankungen bei den Todesursachen dominieren, ist vor allem darauf zurückzuführen, dass die Menschen heute älter werden und weniger an anderen Krankheiten sterben. Mit anderen Worten: Im Verhältnis zur steigenden Lebenserwartung nimmt die Sterblichkeit bei Herz-Kreislauf-Erkrankungen ab, während die Erkrankungen und damit auch die Krankenhausfälle zunehmen.

Ein wichtiger Punkt: Verlässlichkeit

Josef Kuhn Manfred Wildner «Gesundheitsdaten verstehen», 100 Seiten. Verlag Hans Huber, Bern

er Fokus des Buches ist auf das deutsche Gesundheitswesen gerichtet, wobei die von den Autoren Joseph Kuhn und Manfred Wildner vorgebrachten Analysen und Folgerungen von allgemeiner Gültigkeit sind. Gesundheitsdaten begegnen uns täglich, sei es in Form von Kosten und von Krankheitshäufigkeiten oder in Form von Kennziffern über die Wirksamkeit von medizinischen Behandlungen. Dabei kann man den Daten nicht immer ohne weiteres ansehen, was sie bedeuten: Sie müssen interpretiert werden, wenn man sie verstehen will. Um den Umgang mit Gesundheitsdaten zu erleichtern, werden im Buch einleitend Begriffe erklärt, die in der Epidemiologie* wichtig sind, so Begriffe wie Sterblichkeit, Prävalenz, oder relatives Risiko.

Unfallstatistiken, soweit überhaupt vorhanden, sind nicht unbedingt verlässlich. So erfasst die in Deutschland jährlich erstellte Statistik der Verkehrsunfälle lediglich die von der Polizei aufgenommenen Unfälle. Unfälle von Fussgängern ohne Beteiligung von anderen Verkehrsteilnehmern gelten nicht als Strassenverkehrsunfälle. Über die Zahl derer, die im Winter auf vereisten Strassen und Bürgersteigen ausrutschen und sich verletzen, ist aus der Statistik nichts zu erfahren. Ebenfalls nicht als Strassenverkehrsunfälle gelten Unfälle auf Privatgrund. Während schwere Unfälle und inbesondere solche mit tödlichem Ausgang recht zuverlässig erfasst werden, ist dies bei leichteren Unfällen nicht der Fall. Die Frage der Verlässlichkeit stellt sich insbesondere auch bei statistischen Ergebnissen, die einen Zusammenhang zwischen Ursache und Wirkung belegen sollen. So ist es keineswegs erwiesen, dass ein statistisch höheres Unfallrisiko der Jugendlichen auf jeden Fall etwas mit dem Merkmal «Jugend» zu tun hat. Als berühmtes

Beispiel erwähnt das Buch den Rückgang der Storchenpopulation und den Rückgang der Geburten.

Durchschnittswerte hinterfragen Kritisch hinterfragen die Autoren auch den häufigen Gebrauch von Durchschnittswerten. Indem eine grosse Datenmenge auf eine einzige Kennziffer verdichtet werde, lasse sich die Darstellung eines Sachverhaltes zwar vereinfachen, was aber die Gefahr einschliesse, dass wichtige Differenzierungen verdeckt werden. Wie etwa bei einer Durchschnittsnote allein die guten und die schlechten Leistungen nicht erkennbar sind, verschwinden auch bei einem generellen Krankenstand die Unterschiede nach Alter, Geschlecht, beruflichem Status oder Betriebsgrösse. Nicht umsonst heisst es bei Statistikern: «Beim Durchschnitt ist die Kuh ersoffen»: Auch wenn ein Fluss im Durchschnitt nur 50cm tief ist, kann er doch Stellen mit einer viel grösseren Tiefe haben, an denen auch eine Kuh ertrinken kann. Das vorliegende Buch ist ein wichtiger Beitrag zum besseren Verstehen von statistischen Zahlen. Es nimmt Daten und Datenquellen kritisch unter die Lupe und es zeigt auch Möglichkeiten auf, Daten manipulativ darzustellen. Das 100 Seiten kleine Buch ist kein akademisches Lehrmittel, wohl aber ein leicht verständlicher Ratgeber in der Flut von Gesundheitsinfos. Wünschbar wäre, dass in der nächsten Auflage des Buches auch Schweizer Daten berücksichtigt werden. Josef Ziegler

* Lehre von der Häufigkeit und Verteilung von Risikofaktoren, Erkrankungen und Befindlichkeitsstörungen in der Bevölkerung

infosantésuisse : Dossier Die europäischen Gesundheitssysteme im Vergleich (Teil 4) 1/2010 1359

service Migros-Kulturprozent mit neuer Initiative

Kurs für übergewichtige Kinder und ihre Familien

Ab nach Deutschland: Die Universitätsklinik Schleswig-Holstein hat einen Kooperationsvertrag mit den sechs grössten dänischen Spitälern abgeschlossen. Ziel ist es, jährlich etwa 150 dänische Krebspatienten im deutschen Grenzgebiet behandeln zu lassen. Der Hintergrund: Wegen der langen Wartezeiten im dänischen Gesundheitssystem ist nicht für alle Krebspatienten eine Behandlung innert vernünftiger Frist möglich.

Im kommenden Mai startet das Migros-Kulturprozent einen neuen Kurs des club minu, dem Verhaltenstraining für übergewichtige Kinder und Jugendliche. Das Programm bezieht die ganze Familie mit ein und motiviert übergewichtige Elf- bis Sechzehnjährige zu einer gesunden Ernährung und mehr

Bewegung. Der Kurs dauert neun Monate und umfasst 13 für Kinder und Eltern separat durchgeführte Gruppentreffen sowie zwei Familiengespräche. Im Sommer findet ein zweiwöchiges Sommerlager für die Kinder statt. Im Herbst folgt ein Familientag. Vorgängig zur definitiven Anmeldung wird mit

jeder Familie ein Aufnahmegespräch durchgeführt. Geleitet wird der club minu von einem Fachteam, bestehend aus einem Ernährungspsychologen, einer Ernährungsberaterin, einer Hauswirtschaftslehrerin und einem Sportlehrer. Interessierte können sich anmelden unter www.minuweb.ch.

Foto: Prisma

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Druck auf die Preise: Die britische Wettbewerbsbehörde will das Preisbildungsverfahren für Medikamente radikal ändern – trotz Wegzugsdrohungen der Industrie. Das Sparpotenzial liege bei 1,5 Milliarden Franken. Aktuell steht es den Pharmafirmen frei, wie sie ihre Preise gestalten. Es gibt lediglich Obergrenzen für den Unternehmensgewinn. USA I: Laut Polizeiberichten aus Los Angeles kommt es immer wieder vor, dass Kliniken obdachlose oder demente Patienten vor dem Ende der Behandlung auf der Strasse absetzen. Der Grund: Diese Patienten sind nicht in der Lage, ihre Spitalrechnungen zu bezahlen. USA II: Alle drei demokratischen Präsidentschafts-BewerberInnen steigen deshalb mit dem erklärten Ziel in den Wahlkampf, eine obligatorische Krankenversicherung einzuführen. Eine Kandidatin, Hillary Clinton, hatte dies während der Präsidentschaft ihres Ehemannes bereits einmal vergeblich versucht.

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Testen Sie Ihr Wissen zur Krankenversicherung Auf www.santesuisse.ch haben Sie die Möglichkeit, Ihr Wissen zu Fragen der Krankenversicherung zu testen. Sie beantworten 20 Fragen mit unterschiedlichem Schwierigkeitsgrad und erhalten am Schluss eine Auswertung. Der Test wird Ihr Wis-

sen erweitern und Sie vielleicht auch auf weitere Fragen aufmerksam machen, deren Antworten Ihnen bisher nicht bekannt sind. Denn Hand aufs Herz: Wissen Sie aus dem Stegreif, ob Medikamente von der OPK auch bezahlt werden, wenn sie vom Zahnarzt ver-

schrieben sind? Oder innert wie vielen Tagen Sie rekurrieren müssen, wenn Sie mit einem Entscheid Ihres Versicherers nicht einverstanden sind? Den Test finden Sie unter: www.santesuisse.ch – Ausbildung – E-Learning

SANTÉSUISSE – SERVICE

infosantésuisse Nr. 4, April 2007

Foto: Prisma

infosantésuisse : Dossier Die europäischen Gesundheitssysteme im Vergleich (Teil 4) 1/2010 1360

Krebsliga lanciert zwei Kampagnen

Prävention von Hautund Darmkrebs Die Krebsliga Schweiz führt zurzeit Kampagnen zur Verhinderung von zwei der häufigsten – und damit gefährlichsten – Krebsarten. Am 7. Mai organisiert die Krebsliga in Zusammenarbeit mit der Schweizerischen Gesellschaft für Dermatologie, dem Bundesamt für Gesundheit und dem Apothekerverband pharmasuisse den nationalen Hautkrebstag. Hautärzte in der ganzen Schweiz bieten an diesem Tag die kostenlose Untersuchung von auffälligen Hautveränderungen an. Vor einem Jahr wurde bereits eine ähnliche Aktion durchgeführt – mit dem Resultat, dass dank der kostenlosen Untersuchungen 177 Melanome (bösartiger Hautkrebs) entdeckt wurden. Früherkennung ist bei Hautkrebs für die Heilungschancen entscheidend. Zur Prävention empfiehlt die Krebsliga neben regelmässigen Selbstuntersuchungen das Vermeiden von Sonnenbränden und von Solariumbesuchen. Vor allem Menschen mit heller Haut sollten diese Vorsichtsmassnahmen strikte beachten. Die Schweiz steht bei der Häufigkeit von

Hautkrebs hinter Norwegen an zweiter Stelle in Europa. Die Häufigkeit der Erkrankungen hat in unserem Land in den letzten zwanzig Jahren stark zugenommen (siehe Grafik). Die Kampagne «Darmkrebs nie» erfährt eine Neuauflage. Die Krebsliga stellt eine Broschüre mit grundlegenden Informationen zur Krankheit bereit: Was ist Darmkrebs, welches sind die Risikofaktoren, wie sehen die Symptome aus und wie wird er behandelt? Natürlich wird auch erklärt, was jeder zur Minderung des persönlichen Risikos unternehmen kann. Die wichtigsten Vorsichtsmassnahmen sind eine ausgewogene Ernährung, genügend Bewegung, massvoller Alkoholgenuss und der Verzicht aufs Rauchen. Ein spezieller Ratgeber ist der gesunden Ernährung gewidmet – welche nicht «nur» das Krebsrisiko senkt. Darüber hinaus organisiert die Krebsliga am 13. September eine Fachtagung zum Thema Darmkrebs-Screening. Unterlagen zu beiden Kampagnen können kostenlos unter shop@swisscancer.ch oder 0844 85 00 00 bestellt werden

NEUERKRANKUNGEN / 100000

HAUTKREBS: NEUERKRANKUNGEN VON 1985 – 2003 22 20 18 16 14 12 10 1985–88

1989–92 MÄNNER

1993–96

1997–00

2001–03

FRAUEN

Die Häufigkeit von Hautkrebs ist in den letzten Jahren stark gestiegen.

Weitgehend privat finanziert

Schweizer Lehrstuhl für Chiropraktik ab 2008 Weil es im deutschsprachigen Raum keinen Lehrstuhl gibt, müssen angehende Chiropraktoren ihr Studium in Kanada oder den USA absolvieren. Das ist mit hohen Kosten verbunden und schliesst deshalb viele begabte Personen von der Ausbildung aus. Ab Herbst 2008 hat dies ein Ende: Dann wird an der Universität Zürich ein Lehrstuhl für Chiropraktik sei-

nen Betrieb einnehmen. Finanziert wird die Professur von der Fachgesellschaft Chirosuisse und durch die Privatinitiative von Schweizer Chiropraktoren. Diese hatten beispielsweise 2005 auf ein Tageshonorar verzichtet, um Geld für den Lehrstuhl aufzutreiben. Chirosuisse gründete ausserdem die private «Stiftung für die Ausbildung von Chiropraktoren.»

infosantésuisse : Dossier Die europäischen Gesundheitssysteme im Vergleich (Teil 4) 1/2010 1361

SANTÉSUISSE – SERVICE

infosantésuisse Nr. 4, April 2007

Veranstaltungen Veranstalter

Besonderes

Datum/Ort

Weitere Informationen

Abschlusspräsentation

12. April 2007 Bern

www.snf.ch

U.a. mit Peter Indra, Vizedirektor des BAG

3. Mai 2007 Hotel Bern, Bern

www.sggp.ch

Thema: Die Zukunft der Telemedizin

8. Mai 2007 Hotel Hilton, Basel

www.medgate.ch

77 Parallelveranstaltungen und Fachausstellung

9.-11. Mai 2007 Music & Convention Centre, Montreux

www.sbk.ch

10. Mai 2007 Kongresshaus Zürich

www.rvk.ch.ch

NFP 49 Antibiotikaresistenz Nationalfonds

Komplementärmedizin – Grundbedürfnis oder Luxus? SGGP

4. Medgate-Symposium Medgate

Pflegekongress 07 Schweizer Berufsverband der Pflegefachfrauen und Pflegefachmänner SBK

RVK

Der Patient im Mittelpunkt – Referate u.a. von Thierry Carrel und Peter Indra

Zeichnung: Marc Roulin

9. Schweizerisches Forum der sozialen Krankenversicherung

infosantésuisse : Dossier Die europäischen Gesundheitssysteme im Vergleich (Teil 4) 1/2010 1362 9. Schweizerisches Forum der sozialen Krankenversicherung: Donnerstag, 10. Mai 2007, 9.30 bis 16.00 Uhr im Kongresshaus Zürich

Der Patient im Mittelpunkt Der Patient als Mittel. Punkt Es sind viele Parteien, die im schweizerischen Gesundheitswesen mitspielen: Ärzte, Spitäler, Krankenkassen, Versicherte, Patienten, Politiker. Und es sind ebenso viele, die mit einem Stück des 50 Milliarden grossen Kuchen liebäugeln. Manchmal so intensiv, dass Ziel und Zweck aus den Augen verloren gehen. Das diesjährige Schweizerische Forum der sozialen Krankenversicherung lässt alle Parteien zu Wort kommen. Damit der Patient und seine Gesundheit wieder in den Mittelpunkt rücken. Informationen und Anmeldung: www.rvk.ch

Daniela Lager Moderatorin «10 vor 10», SF DRS

Ben L. Pfeifer Aeskulap-Klinik

Volker Amelung Medizinische Hochschule Hannover

Antoine Chaix Médecins Sans Frontières Schweiz

Weitere Informationen und Online-Anmeldung im Internet: www.rvk.ch

Frank Mathwig Schweiz. Evang. Kirchenbund

Peter R. Müller Krebsliga Schweiz

RVK Haldenstrasse 25, 6006 Luzern Telefon +41 (0) 41 417 05 00

Peter Indra Bundesamt für Gesundheit

Thierry Carrel Inselspital Bern

Charles Giroud Präsident RVK

RVK – Verband der kleinen und mittleren Krankenversicherer

Handbuch der Schweizerischen Krankenversicherung 2007 Das Handbuch der Schweizerischen Krankenversicherung 2007 wird voraussichtlich im April/Mai erscheinen. Mit diesem aktualisierten und unentbehrlichen Nachschlagewerk sind Sie vollumfänglich auf dem neusten Stand bei der Durchführung der Kranken- und Unfallversicherung. Das Handbuch ist in deutscher und französischer Sprache erhältlich und kostet je Fr. 35.– zuzüglich MwSt, Porto- und Verpackungskosten.

Bestellung _____ Exemplar(e) Handbuch der Schweizerischen Krankenversicherung 2007, deutsch _____ exemplaire(s) de l’Annuaire de l’assurance-maladie suisse 2007, édition française

Vorname / Name • Fax: 032 625 41 51 • shop@santesuisse.ch • www.santesuisse.ch

Strasse / Nr. PLZ / Ort

Infosantesuisse 91x270 C

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18:17 Uhr

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Jetzt gilt’s ernst! Verpassen Sie nicht, Ihr Wissen unter Beweis zu stellen – melden Sie sich rechtzeitig zu den alljährlich durch die Prüfungskommission SVS durchgeführten Prüfungen an:

Berufsprüfung Sozialversicherungs-Fachausweis 2007 Prüfungsdatum- und Ort: 9./10./11. Oktober 2007, mündlich nach Aufgebot, in Aarau, Bern, Chur, Lausanne*, Luzern, St. Gallen, Winterthur und Zürich. Prüfungsgebühr: Fr. 2’000.- + BBT-Urkunde Anmeldung: Bis 31. Mai 2007.

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Für beide Prüfungen melden Sie sich mittels besonderem Anmeldeformular bei der Prüfungskommission Deutschschweiz an. Die Lehrgangsteilnehmer erhalten die Anmeldeunterlagen direkt zugestellt. *Anmeldung bei: FEAS, Commission romande des examens, c/o Jean-Paul Coquoz, président, Wasserschöpfi 24, 8055 Zürich.

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Prüfungskommission Deutschschweiz Sekretariat: Postfach 273 . 8353 Elgg . Tel. 052 368 61 50 Fax 052 368 61 51 . info@ svs-edu.ch . www.svs-edu.ch

infosantĂŠsuisse : Dossier Die europĂ¤ischen Gesundheitssysteme im Vergleich (Teil 4) 1/2010 1364

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info santésuisse

Die verschiedenen Gesundheitssysteme in Europa

Das Magazin der Schweizer Krankenversicherer

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Seite 4

Seite 10

Seite 11

Die europäischen Gesundheitssysteme im Vergleich

Welches ist das «beste» Gesundheitssystem?

Drei Fragen an Dr. Willy Oggier, Gesundheitsökonom

Inhalt Im Fokus 4 Ein Dreieck beschreibt die Gesundheitssysteme: Die europäischen Gesundheitssysteme im Vergleich 5 Das Bismarck- und das Beveridge-Modell: In Europa dominieren zwei Gesundheitssysteme 6 Finanzierung der Gesundheitssysteme: Reformen in Richtung regulierten Wettbewerbs 8 Ein Reformtrend und seine Auswirkungen: Dezentralisierung der Gesundheitssysteme 10 Welches ist das «beste» Gesundheitssystem? Gute Platzierung der Schweiz 11 Drei Fragen an Dr. Willy Oggier, Gesundheitsökonom: «Die Einheitskasse wäre ein Schritt in die falsche Richtung» 12 Europäische Gesundheitssysteme gleichen sich an: Ein dauernder Reformprozess Gesundheitswesen 14 Das Chronic-Care-Modell: Für eine bessere Behandlung chronisch Kranker 15 Grafik des Monats: Gesundheitskosten im internationalen Vergleich 16 Buchtipp: Zunehmender Mangel an Pflegepersonen: Konkrete Gegenmassnahmen gefordert 17 Neuerungen im Zahlstellenregister von santésuisse: Weshalb das ZSR wichtig und unverzichtbar bleibt 18 Start geglückt: Die neue Versichertenkarte ist im Spital angekommen Service 19 Bild des Monats: Hanami: Albtraum für Allergiker? 20 Physiotherapie in der freien Praxis: Zwei Stellungnahmen der Paritätischen Vertrauenskommission physioswiss–santésuisse/UV/MV/IV 20 Aus aller Welt 21 Veranstaltungen 21 Mr Raoul

Nr. 3, april 2010. Erscheint zehnmal jährlich Abonnementspreis Fr. 69.− pro Jahr, Einzelnummer Fr. 10.− Herausgeber und Administration santésuisse, Die Schweizer Krankenversicherer, Römerstrasse 20, Postfach, 4502 Solothurn Verantwortliche Redaktion Maud Hilaire Schenker, Abteilung Politik und Kommunikation, Postfach, 4502 Solothurn, Tel. 032 625 41 27, Fax 032 625 41 51, E-Mail: redaktion@santesuisse.ch Herstellung: Rub Graf-Lehmann, Murtenstrasse 40, 3001 Bern Gestaltungskonzept: Pomcany’s Layout: Henriette Lux Anzeigenverwaltung: Alle Inserate − auch Stelleninserate − sind zu richten an: «infosantésuisse», Römerstrasse 20, Postfach, 4502 Solothurn E-Mail: redaktion@santesuisse.ch Abonnementsverwaltung Tel. 032 625 42 74, Fax 032 625 41 51 Homepage: www.santesuisse.ch Titelbild: Keystone, Zürich ISSN 1660-7228

infosantésuisse : Dossier Die europäischen Gesundheitssysteme im Vergleich (Teil 4) 1/2010 1367

Auf Stärken aufbauen, statt Experimente wagen Die vorliegende Ausgabe widmet sich dem Vergleich der verschiedenen europäischen Gesundheitssysteme. In der Schweiz ist das Thema Gesundheitswesen seit der Ankündigung der überdurchschnittlichen Prämienerhöhungen für 2010 wieder vermehrt im Fokus der Politik. Das Parlament ist aber offensichtlich nicht willens, pragmatischen Reformen zum Durchbruch zu verhelfen und verheddert sich stattdessen in kosmetischer Symptombekämpfung. Das sogenannte Massnahmenpaket zur Eindämmung der Kostenentwicklung lässt grüssen. Gleichzeitig gewinnt die Idee der Einheitskasse wieder mehr Befürworter. Auch dieser Vorschlag ist reine Symptombekämpfung und setzt den Hebel nicht da an, wo der Schuh tatsächlich drückt – bei den Leistungskosten. Zugegeben, die steigenden Prämien sind ein Ärgernis, insbesondere für Haushalte in bescheidenen wirtschaftlichen Verhältnissen. Wir dürfen aber die Vorzüge des schweizerischen Gesundheitswesens nicht vergessen. Andere Länder beneiden uns um die wichtigsten Prinzipien des 1996 eingeführten KVG, wie das Versicherungsobligatorium, die Einheitsprämie mit (allerdings ungenügendem) Risikoausgleich und Prämienverbilligung sowie den umfassenden Leistungskatalog. Die Einführung eines Versicherungsobligatoriums in den USA oder die geplante Reform der deutschen Koalitionsregierung, die Gesundheits- von den Arbeitskosten zu entkoppeln, zeigen deutlich, dass die Schweiz diesen Ländern einiges voraus hat. Weit weg sind wir auch von der Rationierungsdiskussion in Grossbritannien im Zusammenhang mit dessen zentralistischem, staatlichem National Health Service. Tragen wir darum Sorge zu unseren unbestreitbaren Errungenschaften und lösen die anstehenden Probleme, indem wir auf den Stärken aufbauen und die nötigen Reformen umsetzen. Anstatt mit der Einführung einer Einheitskasse einen Schritt in Richtung britischer Verhältnisse – sprich Staatsmedizin – zu machen, müssen wir eine weitere Verbesserung des Risikoausgleichs prüfen. Der regulierte Wettbewerb in der schweizerischen Ausgestaltung ist – bezogen auf den Zugang der Bevölkerung zu einer hochstehenden medizinischen Versorgung – sowohl dem liberalen amerikanischen Ansatz als auch dem britischen Planungsmodell überlegen. Zudem zeigt der Vergleich, dass diese Systeme nicht günstiger sind als das unsrige. Bei der gegenwärtig diskutierten Managed Care-Vorlage darf das vorhandene Sparpotenzial nicht durch eine Überregulierung gefährdet werden. Leistungserbringer und Krankenversicherer brauchen Gestaltungsspielraum, damit Managed Care tatsächlich zur Steigerung der Wertschöpfung beitragen kann. Viel besser wäre es, endlich die Vertragsfreiheit einzuführen. Dass sich weder Ärzte noch Patienten vor dieser zu fürchten brauchen, zeigt der Blick auf die Niederlande. Vermeiden wir also die Fehler unserer Nachbarn und lernen stattdessen von deren bewährten Modellen.

3 | Editorial 3/10

Peter Fischer Verwaltungsrat santésuisse

infosantésuisse : Dossier Die europäischen Gesundheitssysteme im Vergleich (Teil 4) 1/2010 1368 Ein Dreieck beschreibt die Gesundheitssysteme

Die europäischen Gesundheitssysteme im Vergleich Die Gesundheitssysteme sind komplexe und vielgestaltige Gebilde. Anhand welcher Kriterien können diese Systeme beschrieben werden? Welches sind dabei die zentralen Fragen?

Professor Reinhard Busse* verwendet zur vereinfachenden Beschreibung der Gesundheitssysteme ein Dreieck. Auf der Unterseite des Dreiecks befinden sich die beiden Hauptakteure: die Bevölkerung (links ) und die Leistungserbringer (rechts). An seiner Spitze stehen die «Tiers payants», das heisst die Organisationen, welche die Prämien und Beiträge einziehen und die Leistungen bezahlen (vor allem die Krankenversicherer oder der Staat). In der Mitte des Dreiecks stehen die Regulatoren des Gesundheitssystems (die öffentliche Hand). Um dieses Dreieck platziert Professor Busse die wichtigen Fragen und Kriterien zur Definition und Klassifizierung der Gesundheitssysteme. Wer ist wie versichert?

Auf der Unterseite des Dreiecks stehen Fragen zum Versicherungsschutz, zum Zugang und zur Versorgung: Wer ist versichert? Gibt es wie in der Schweiz ein Obligatorium für alle Einwohner oder sind nur Teile der Bevölkerung versichert? Wie sieht der Leistungsumfang aus? Gibt es einen Leistungskatalog (Schweiz, Niederlande)? Wie ist der Zugang zur Pflege geregelt? Wie ist die Qualität der Gesundheitsversorgung? Gibt es regionale Unterschiede? Gibt es Wartelisten (Grossbritannien)? Hat die Bevölkerung direkten Zugang zu Spezialisten (Schweiz) oder gibt es sogenannte Gatekeepers (Frankreich, Niederlande)?

Werden die Pflegeleistungen durch Prämien (Schweiz) oder über die Steuern (Grossbritannien) finanziert? Werden sie auf dem Einkommen erhoben (Frankreich)? Handelt es sich um Pro-Kopf-Prämien (Schweiz) oder um eine proportional zum Einkommen berechnete Beteiligung (Frankreich)? Handelt es sich um ein solidarisches System, basierend auf einem gemeinsamen, von der ganzen Bevölkerung finanzierten Fonds wie in Grossbritannien? Oder handelt es sich um ein ganz auf die Eigenverantwortung ausgerichtetes System wie in Singapur, wo jeder Bürger über sein eigenes Gesundheitssparkonto verfügt? Wie werden die Ressourcen zugeteilt?

An der Spitze des Dreiecks, wo die Leistungszahler angeordnet sind, geht es um folgende Fragen: Wie werden die Ressourcen an die Leistungszahler (z.B. die Versicherer) zugeteilt? Gibt es einen Risikoausgleich und wie ist er gestaltet? Werden die Ausgleichszahlungen im Voraus berechnet oder erfolgt der Ausgleich nachträglich? Werden beim Risikoausgleich neben allgemeinen demografischen Variablen (wie Alter und Geschlecht) auch Krankheitsindikatoren wie Hospitalisierung (Schweiz) oder Indikatoren zur Sterblichkeit (Niederlande) berücksichtigt? Anzumerken ist hier, dass sich Fragen zum Risikoausgleich nicht nur in wettbewerbsorientierten Systemen stellen, sondern auch in solchen mit einem nationalen Pool, aus dem die Verteilung der Finanzmittel an die Regionen erfolgt. Wie werden die Leistungen vergütet?

LEISTUNGSERBRINGER

BEVÖLKERUNG VERSICHERUNG WER? WAS (LEISTUNGSKATALOG)?

ZUGANG UND VERSORGUNG

QUELLE: DIE VOLKSWIRTSCHAFT

Auf der rechten Seite des Dreiecks geht es um Fragen zum Leistungseinkauf, zur Leistungsvergütung und zur Vertragspolitik. Wer kauft die Leistungen ein und wer bezahlt sie? Gibt es Tarifverträge? Gibt es zwischen Versicherern und Leistungserbringern einen Vertragszwang (Schweiz) oder sind die Verträge Woher kommen die finanziellen Ressourcen? selektiv (Niederlande)? Schreibt der Staat die Tarife und Preise Auf der linken Seite des Dreiecks stehen Fragen rund um die vor oder spielt der Wettbewerb? Wird das Gesundheitssystem Finanzierung des Gesundheitssystems: Wie werden die Finan- weitgehend durch den Staat reguliert (Frankreich) oder bestezen aufgebracht? Welcher Art sind sie? Woher stammen sie? hen im Sinne eines regulierten Wettbewerbs Spielräume für die Akteure, wie etwa in den Niederlanden, wo der Staat nur eingreift, um die Qualität einer ausreichenden Gesundheitsversorgung zu gewährleisten? Wie RESSOURCENPOOLING & (RE-)ALLOKATION steht es mit den Kosten und der Qualität der Leistungen? Entscheidend ist letztBEITRAGSEINNEHMER ZAHLER («THIRD PARTY PAYER») lich, inwieweit das Ziel eines optimalen Gesundheitssystems erreicht wird: Das Ziel nämlich, der ganzen Bevölkerung LEISTUNGSEINKAUF / RESSOURCENMOBILISIERUNG / VERTRÄGE / VERGÜTUNG AUFBRINGUNG Zugang zu einer qualitativ hochstehen«STEWARD» REGULIERER den medizinischen Versorgung zu tragREGULIERUNG baren Kosten zu gewährleisten.

Gemäss Prof. Dr. med. Reinhard Busse lassen sich Gesundheitssysteme vereinfacht als Dreieck darstellen.

4 | Im Fokus 3/10

maud hilaire schenker

* Reinhard Busse, «Europäische Gesundheitssysteme: Grundfragen und Vergleich», erschienen in «Die Volkswirtschaft – Das Magazin für Wirtschaftspolitik», 12–2006, S. 10–13

infosantésuisse : Dossier Die europäischen Gesundheitssysteme im Vergleich (Teil 4) 1/2010 1369 Foto: Keystone

Das Bismarck- und das Beveridge-Modell

In Europa dominieren zwei Gesundheitssysteme In Europa lassen sich im Wesentlichen zwei Arten von Gesundheitssystemen unterscheiden: das Bismarck- und das Beveridge-Modell. Das erste beruht auf Abgaben vom Arbeitseinkommen, das zweite wird durch Steuern finanziert. Die Grenzen zwischen beiden Systemen sind allerdings fliessend.

Das Beveridge-Modell, ein staatliches Gesundheitssystem, das hauptsächlich durch Steuern finanziert wird, ist in den nordeuropäischen Ländern sowie in Irland und in Grossbritannien anzutreffen. In den Achtzigerjahren wurde es aber auch in Spanien, Portugal und Griechenland eingeführt. Das Bismarck-Modell beruht auf der obligatorischen Krankenversicherung. Es ist in nahezu allen Ländern Mitteleuropas verbreitet, seit rund zehn Jahren auch in den osteuropäischen Staaten.

In Europa sind hauptsächlich zwei Systeme anzutreffen: das Bismarck-Modell und das Beveridge-Modell.

Das Bismarck-Modell

Das Beveridge-Modell

Der Grundstein für den Aufbau der Sozialversicherungen wurde Ende des 19. Jahrhunderts, zur Zeit des Reichskanzlers Otto von Bismarck, in Deutschland gelegt. Bismarcks Politik war vom Kampf gegen die Gewerkschaften sowie die aufkommende sozialdemokratische Partei geprägt. Er löste die beiden Organisationen schliesslich auf. Im Gegenzug erklärte sich der Staat für den sozialen Schutz der Bevölkerung und die Einrichtung entsprechender Institutionen verantwortllich. Zuvor waren dafür zahlreiche «Hilfskassen» zuständig gewesen. Ab 1883 entstanden in Deutschland die ersten obligatorischen Sozialversicherungen. Das Bismarck-System wird durch vier grundlegende Prinzipien definiert: • Der soziale Schutz basiert ausschliesslich auf der Arbeitstätigkeit, d.h., er beschränkt sich auf Arbeitnehmerinnen und Arbeitnehmer, die durch ihr Einkommen versichert sind. • Nur Arbeitnehmende, deren Lohn unterhalb eines bestimmten Betrages liegt, sind obligatorisch versichert. Es sind jene, die nicht in der Lage sind, private Vorsorge zu treffen. • Massgebend für den Umfang und die Höhe des sozialen Schutzes ist die Versicherungstechnik. Sprich: Die Höhe der Beiträge richtet sich nach der Höhe der Löhne, und die Leistungen richten sich nach der Höhe der Beiträge. • Die Sozialversicherungen werden von den Arbeitgebern und den Arbeitnehmern selbst verwaltet. Die Versicherung unterscheidet sich damit deutlich von der Sozialhilfe. Sie ist als Gegenleistung zu einer beruflichen Tätigkeit konzipiert. Dem Staat – als Garant der Wohlfahrt der Bürgerinnen und Bürger – bleibt im Bereich der Krankenversicherung die Aufgabe, den Tätigkeitsrahmen der Krankenkassen festzulegen und ein eventuelles finanzielles Ungleichgewicht wieder auszugleichen. Seit den Siebzigerjahren hat ein Grossteil der Länder (Frankreich, Luxemburg, Niederlande, Österreich), deren Krankenversicherungen durch das Bismarck-Modell inspiriert sind, Massnahmen ergriffen, um die Leistungen des Gesundheitswesens der ganzen Bevölkerung zugänglich zu machen.

Das Beveridge-Modell eines staatlichen Gesundheitssystems ist in Grossbritannien entstanden. Seine Grundsätze wurden 1942 durch Lord William Beveridge formuliert und dem britischen Parlament vorgelegt. Zuvor hatte Lord Beveridge das britische System der obligatorischen Krankenversicherung stark kritisiert. Er bezeichnete es wegen der Begrenzung der Versicherungspflicht als viel zu eingeschränkt, wegen seines Systems als zu komplex und wegen seiner Vielzahl an Kassen als schlecht koordiniert. Er schlug eine Reform vor, die auf der Übernahme der Kosten durch den Staat basiert. Dieses System beruht auf folgenden Grundsätzen: • Universalität: Alle Bürgerinnen und Bürger sind vor den sozialen Risiken geschützt, unabhängig von ihrer beruflichen Stellung. • Gleiche Leistungen für alle: Jede Person kann unabhängig von ihrem Einkommen Leistungen gemäss ihren Bedürfnissen beziehen. • Finanzierung durch Steuern. • Einheitlichkeit: Der Staat verwaltet alle Systeme der sozialen Sicherheit. Entwicklung dieser Modelle

Es ist nicht immer einfach, ein steuerfinanziertes System und ein System bismarckscher Prägung voneinander zu unterscheiden. So ist die Finanzierung via Steuern in Belgien und in der Schweiz ein wichtiger Teil des Systems, doch mit ihren Krankenkassen gehören diese Gesundheitssysteme doch eher in die Kategorie der Bismarck-Modelle. Tendenziell ist aber festzustellen, dass sich in der Praxis die Unterschiede zwischen den Systemen abzuflachen beginnen. Alle Staaten sind nämlich heute denselben Zwängen unterworfen und zwar in sozialer (genereller Zugang zu den Leistungen), in organisatorischer (Verbesserung der Effizienz der Systeme) und in wirtschaftlicher (Begrenzung der Gesundheitsausgaben) Hinsicht. maud hilaire schenker

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Reformen in Richtung regulierten Wettbewerbs Ein wichtiger Unterschied zwischen den Gesundheitssystemen, die nach dem Bismarck- oder dem BeveridgeModell organisiert sind, ist die Art der Finanzierung. Das Bismarck-System wird durch Sozialabgaben, Beiträge des Staates aber teilweise auch durch private Quellen finanziert. Das Beveridge-System ist hingegen zum grössten Teil steuerfinanziert. Gemeinsam ist beiden Systemen das Ziel der jüngsten Reformen, nämlich die Verstärkung der Wettbewerbselemente.

Die Gesundheitsausgaben werden sowohl in Ländern mit dem Beveridge-System als auch in solchen mit dem Bismarck-System weitgehend mit öffentlichen Geldern finanziert. Im Jahr 2007 lag die durchschnittliche Beteiligung der öffentlichen Hand an den Gesundheitsausgaben in allen OECD-Ländern (mit Ausnahme von Mexiko und den USA) bei 73 Prozent. In den nordeuropäischen Ländern (mit Ausnahme von Finnland), in Grossbritannien und in Irland – alles Länder, die nach dem Beveridge-Modell organisiert sind – wurden sogar über 80 Prozent der Gesundheitsausgaben öffentlich finanziert. Unterschiedlich sind allerdings je nach System die Finanzierungsquellen. Wo die Zentralregierung und/oder die lokalen Verwaltungen (Spanien, Norwegen) für das Gesundheitswesen und seine Finanzierung zuständig sind, werden dafür praktisch ausschliesslich öffentliche Gelder eingesetzt. In Ländern, in denen die Finanzierung auf einem Sozialversicherungssystem beruht (Frankreich, Deutschland), spielen neben öffentlichen Geldern auch die Sozialabgaben eine wichtige Rolle. In vielen Ländern tragen auch private Quellen zur Finanzierung des Gesundheitswesens bei. Dazu gehören Direktzahlungen der privaten Haushalte, Prämien für die private Krankenversicherung und direkt vom Arbeitgeber finanzierte Gesundheitsleistungen (Arbeitsmedizin). Ausmass und Zusammensetzung der privaten Finanzierung unterscheiden sich stark von einem Land zum anderen, unabhängig vom jeweiligen Referenzmodell1. Festzuhalten ist, dass die Art der Finanzierung die Struktur des Gesundheitssystems prägt. Die staatlichen Gesundheitssysteme

Das Beveridge-Modell beruht auf dem Prinzip der Unentgeltlichkeit der Behandlung und Pflege, so dass eine universelle Versorgung der Bevölkerung mit Gesundheitsleistungen gewährleistet werden kann. Diesem universellen Schutz entspricht eine Finanzierung durch Steuern und die Dominanz des staatlichen Sektors im Gesundheitswesen. Die Spitäler gehören den öffentlichen Gemeinwesen und die Spitalärzte haben den Status von Angestellten. Die Ärzte für Allgemeinmedizin sind entweder wie in Grossbritannien beim National Health Service unter Vertrag oder wie in Schweden und Finnland direkt von den lokalen Gesundheitszentren angestellt. In Ländern mit staatlichen Gesundheitssystemen ist es teilweise gelungen, die Gesundheitsausgaben mit Hilfe von

Globalbudgets einzuschränken. Die Folgen waren aber Leistungsbegrenzungen (quantitative Rationierung) und lange Wartelisten wegen fehlender Investitionen und Schwerfälligkeiten des Systems. Um diese Probleme in den Griff zu bekommen, wurden in den Neunzigerjahren mehrere Marktmechanismen eingeführt: Schaffung von Wettbewerb zwischen den Akteuren des Gesundheitssystems, Zurückgreifen auf Anreizsysteme bei der Honorierung der Ärzte oder Übertragung von Verantwortung an die Leiter von Gesundheitszentren. Das Beispiel Schweden

In Schweden sind zwanzig Generalräte (in einigen Fällen auch die Gemeinden) für die Versorgung der Bevölkerung mit Gesundheitsleistungen verantwortlich. Schwachstellen des Systems sind die regionalen Unterschiede bei der Versorgung und die langen Wartelisten in den Spitälern. Positiv ist zu erwähnen, dass der Anteil der Gesundheitsausgaben am BIP (rund neun Prozent) seit Beginn der Achtzigerjahre relativ stabil geblieben ist. Die Ausgaben für die vom Staat garantierten Gesundheitsleistungen, eingeschlossen die Beiträge an die Arzneimittel, verursachten 2005 Kosten in Höhe von 175 Milliarden Schwedische Kronen SEK (25,7 Milliarden CHF). Diese Ausgaben werden zu 71 Prozent durch regionale Einkommenssteuern finanziert. Den Steuersatz, der durchschnittlich 11 Prozent beträgt, legen die Generalräte fest. 16 Prozent der Ausgaben decken die Beiträge des Staates. Nur drei Prozent der Kosten werden von den Patienten selber bezahlt. Sie entrichten im Spital eine Tagespauschale von 80 SEK (11,70 CHF) und für die spitalexterne Pflege einen Beitrag, den die Generalräte bestimmen. Hinzu kommen eine Gebühr von 100 bis 150 SEK (14,70 CHF bis 22 CHF) pro Konsultation beim Allgemeinpraktiker, eine etwas höhere für die Konsultation eines Spezialisten sowie die Kostenbeteiligung für Medikamente. Diese Abgaben sind allerdings plafoniert (auf 900 SEK [132 CHF] pro Jahr für Arzt kosten und auf 1800 SEK [264 CHF] für Arzneimittel).

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Verschiedene Gesundheitssysteme, aber mit gleicher Zielrichtung: hin zum regulierten Wettbewerb.

Die Systeme mit obligatorischer Krankenversicherung

In Ländern mit gesetzlichen Sozialversicherungssystemen (Bismarck-Modell) war das Versicherungsverhältnis vorerst an das Arbeitsverhältnis geknüpft und hat erst später einen universellen Charakter erhalten. Heute ist die Krankenversicherung in einer Reihe von Ländern (so in Deutschland) regional organisiert, in andern (wie in Frankreich) zentralisiert. Die Beiträge werden manchmal in einen nationalen Topf einbezahlt, manchmal von den einzelnen Krankenversicherern eingezogen. Die Gesundheitsleistungen werden teils von staatlichen Institutionen und ihren Angestellten erbracht, teils von privaten Betrieben und selbstständigen Leistungserbringern. Alle Länder mit einer gesetzlichen Krankenversicherung haben Probleme, die wachsenden Gesundheitskosten in den Griff zu bekommen. Beitragserhöhungen und Beteiligung der Versicherten an ihren Krankheitskosten reichen nicht mehr aus, um die chronischen Defizite zu decken. Es sind deshalb überall Reformen eingeleitet oder schon abgeschlossen worden. Wichtigste Inhalte der Reformen sind: Vereinfachung der Strukturen, Einschränkung des Leistungsangebots, Erschliessen neuer Finanzquellen oder auch Einführung der Vertragsfreiheit (wie in den Niederlanden). Das Beispiel Deutschland

In der gesetzlichen Krankenversicherung sind in Deutschland rund 85 Prozent der Bevölkerung versichert (Personen mit einem Einkommen über einer bestimmten Grenze können sich privat versichern lassen). Die noch rund 170 in sieben Verbänden organisierten Krankenkassen konnten sich bis 2009 einer relativ grossen Autonomie erfreuen. Dann verloren sie mit der Schaffung eines gemeinsamen Gesundheitsfonds ihre finanzielle Selbstständigkeit weitgehend. Beibehalten haben sie hingegen ihre Autonomie bei den Vertragsverhandlungen mit den Leistungserbringern. Heute finanzieren sich die Kassen aus den Zuweisungen des nationalen Fonds. Dieser wird hauptsächlich durch Beiträge der versicherten Arbeitnehmer und ihrer Arbeitgeber gespeist. Der Beitragssatz beträgt landesweit 14,3

Lohnprozente (14,9 inklusive Krankengeld) und wird bis zu einer bestimmten Einkommensgrenze (2010: 45 000 Euro) erhoben. Rentner bezahlen die Hälfte des Beitragssatzes auf ihre Rente. Die Kassen können zudem von ihren Mitgliedern einen Zusatzbeitrag von maximal einem Prozent des beitragspflichtigen Einkommens erheben. Weiter steuert der Staat einen Zuschuss aus Steuergeldern (für sog. versicherungsfremde Leistungen) zur Finanzierung bei. An immer mehr Leistungen müssen schliesslich Patienten einen Kostenbeitrag leisten. In Deutschland beliefen sich die gesamthaften Gesundheitsausgaben im Jahr 2007 auf 10,4 Prozent des BIP, d.h. sie lagen 1,5 Prozent über dem Durchschnitt der OECD-Länder, und sie steigen weiter rasch an. Es erstaunt daher nicht, dass die neue Bundesregierung schon wieder eine Gesundheitsreform vorbereitet. Zur Diskussion steht ein System, das zu je einem Drittel durch die Unternehmen, durch Steuern und mit Beiträgen der Bürgerinnen und Bürger finanziert wird. Zudem soll der Wettbewerb wieder mehr zum Zug kommen. Die Reform der staatlichen Systeme

In den letzten Jahren sind, wie der Experte für Management im Gesundheitswesen Reinhard Busse darlegt2, die steuer finanzierten Systeme (Beveridge-Modell) deutlich vielfältiger geworden. In diesen Systemen hatte es der Bürger noch vor 15 Jahren mit nur einer Organisation zu tun: Dem Staat, dem er seine Steuern bezahlte und der ihm im Gegenzug einen (oftmals beschränkten) Zugang zu Gesundheitsleistungen gab. Die erste wichtige Reformentwicklung in den Beveridge-Ländern war der sogenannte Purchaser Provider Split, d.h. die Trennung von Leistungserbringern und Leistungsvergüter. Während die Kontrolle über das System in den Händen des Staates blieb, wurden Teile der Leistungserbringer (Spitäler, Rettungsdienste usw.) autonom. Sie blieben zwar in staatlicher Hand, wurden aber finanziell unabhängig und erhielten ein eigenständiges Management. Die zweite Reformentwicklung ist eng mit der ersten verknüpft. Sie räumte der Bevölkerung eine grössere Wahlfreiheit ein. Die dritte Reformentwicklung brachte die Dezentralisierung, die vierte schliesslich machte es möglich, nicht nur staatliche, sondern auch private Leistungserbringer zu kontrahieren. Es scheint also, dass sowohl das Bismarck- als auch das Beveridge-System in Richtung mehr Wettbewerb tendieren. Nur in der Schweiz diskutiert man über eine Verstaatlichung der Krankenversicherung. Dabei ist sie, betrachtet man die Entwicklungen in Europa, mit ihrem teilweise wettbewerblich geprägten System trotzdem auf der richtigen Schiene, auch wenn gewiss noch Einiges zu verbessern ist. maud hilaire schenker

OECD, Health at a Glance 2009, Paris, 2009, S. 170 [verfügbar in Englisch und Französisch] 2 Europäische Gesundheitssysteme – Grundfragen und Vergleich, Die Volkswirtschaft 12-2006 1

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Dezentralisierung der Gesundheitssysteme In den Neunzigerjahren entwickelten sich die Gesundheitssysteme vieler Länder in Richtung Denzentralisierung. In einigen Ländern wurde die Verwaltung und die Finanzierung des Gesundheitssystems Regionalregierungen übertragen, in andern übernahmen lokale Institu tionen oder Fachgremien einen Teil der Verantwortung. Wie hat sich diese Entwicklung auf die Gesundheits systeme ausgewirkt?

Unter Dezentralisierung versteht man in den Sozialwissenschaften eine Stärkung der Verantwortung und der Autonomie der peripheren Akteure gegenüber der zentralen Ebene. Es gibt vier Formen von Dezentralisierung1: • Dekonzentration: Übertragung von Verantwortung von der Zentralregierung auf tiefere territoriale Ebenen. • Delegation: Übertragung von Verantwortung für bestimmte Bereiche und für spezifische Funktionen an Organisationen am Rande oder ausserhalb der zentralen Verwaltungsstruktur (parastaatliche Institutionen). • Devolution: Übertragung von Befugnissen an autonome Gebietsregierungen. • Privatisierung: Übertragung von bisher staatlichen Funktionen an private (Profit- oder Nonprofit-)Organisationen. Im Gesundheitswesen sind je nach Land verschiedene Formen der Dezentralisierung anzutreffen. Regionalisierung in Skandinavien

Die skandinavischen Gesundheitssysteme sind nationale Dienste, die vom Grundsatz ausgehen, dass die Leistungen des Gesundheitswesens der ganzen Bevölkerung zugute kommen und unentgeltlich sind. Es gibt fast ausschliesslich öffentliche Leistungserbringer. Finanzierung und Verwaltung sind jedoch weitgehend regional oder lokal (Finnland) organisiert. So besitzen und verwalten in Dänemark die fünf Regionen die Spitäler sowie die Zentren für die medizinische Grundversorgung, und sie bezahlen die Gesundheitsfachleute, die nicht selbstständig sind oder unter Vertrag arbeiten. Die 160 Grossgemeinden kümmern sich um die Prävention und die Gesundheitsförderung aber auch um die Langzeitpflege und die Hilfsdienste zu Hause für betagte Personen, Behinderte und geistig Kranke. Die Rolle des Staates ist begrenzt: Er gibt die Hauptziele des Gesundheitswesens vor und legt die Rahmenbedingungen fest. Zudem verteilt er die Finanzmittel auf die Regionen und auf die für spezielle Aufgaben geschaffenen Fonds.

Schrittweise Dezentralisierung in Spanien

In Spanien verlief der Dezentralisierungsprozess schrittweise. 1978, nach dem Tod Francos, wurden mit der neuen Verfassung die Grundlagen für den Aufbau regionaler Verwaltungen, aber auch für ein nationales Gesundheitssystem geschaffen. Das bisher vorwiegend zentral verwaltete Sozialversicherungssystem wurde in der Folge regionalisiert. Zwischen 1981 und 1994 wurde die Verwaltung des Gesundheitsdienstes zuerst in Katalonien und dann in sechs weiteren Regionen regionalen Gremien übertragen. Finanziert wurden die Leistungen aber weiterhin zum grossen Teil zentral, und zwar durch Beiträge aus einem nationalen Budget. Spanien sah sich in der Folge mit drei Problemen konfrontiert: erstens einen Konsens über die Regeln des Finanzausgleichs zu finden, zweitens die Regionen zu koordinieren und drittens die Verwaltung und die Finanzierung des Systems zu entkoppeln. In den zehn anderen Regionen wurden die Gesundheitsdienste bis 2002 zentral durch das staatliche Gesundheitssystem (Systema Nacional de Salúd – SNS) verwaltet. Ab 2002 erhielten dann alle Regionen weitgehende Befugnisse für die Planung und Umsetzung der Gesundheitspolitik. Dezentralisierung oder kollektive Akteure: Die Modelle Grossbritanniens und Deutschlands

Im Nationalen Gesundheitsdienst Grossbritanniens NHS (National Health Service) erhielten zu Beginn der Neunzigerjahre unter der Regierung Thatcher die lokalen Akteure (Gesundheitsbehörden, Hausärzte, Spitäler) mehr Autonomie, Gestaltungsspielraum und Verantwortung. In einer zweiten Reform wurde 1997 den primary care trusts mehr berufliche und wirtschaftliche Autonomie übertragen. Diese Netzwerke, die jeweils für eine Zone mit rund 150 000 Einwohnern verantwortlich sind, umfassen die Akutspitäler, die Hausärzte und die Teams für medizinische Grundversorgung. Zu den Aufgaben der Trusts gehören auch die Verwaltung der Finanzen und das Qualitätsmanagement. In ihrer Funktion als Leistungseinkäufer verfügen sie über ein vom NHS zugeteiltes Globalbudget. Damit garantieren sie die ambulante, medizinische und pflegerische Grundversorgung der ganzen Bevölkerung. In Deutschland ist neben stark regionalisierten Versorgungsstrukturen eine weitere Form der Dezentralisierung festzustellen, nämlich die dezentralisierten Tarifverhandlungen. Die Tarife werden auf der Basis kollektivvertraglicher Verhandlungen zwischen den lokalen Krankenkassenverbänden und den Vereinigungen der Leistungserbringer festgesetzt. Vor- und Nachteile der Dezentralisierung

Der Dezentralisierung schreibt man häufig eine Steigerung der Effizienz und der Flexibilität des Systems zu. Man geht davon aus, dass damit die Bevölkerung besser in die Entscheidungen miteinbezogen wird, und bei der Verteilung der Finanzmittel lokale Besonderheiten und Bedürfnisse angemessen berücksichtigt werden können. Zudem fördere der Vergleich mit anderen Regionen den Wettbewerbsgedanken und damit die Leistungs- und Innovationsfähigkeit des Systems.

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Allerdings gibt es auch eine Kehrseite der Medaille: Was positiv als Anpassung an die lokalen Bedürfnisse bezeichnet wird, wandelt sich dann im negativen Sinne zur ungerechten Bevorzugung von bestimmten Bevölkerungsgruppen. Der Wettbewerb zwischen den Regionen stimuliert dann nicht mehr die Effizienz, sondern ein Überangebot an Leistungen und verursacht Defizite. Befürchtet werden zudem der Einfluss von Interessengruppen, Informationsdefizite und eine Blockierung von Reformen. Auswirkungen der Dezentralisierung

Zu den Auswirkungen der Dezentralisierung auf die Gesundheitssysteme liegen nur wenige wissenschaftliche Arbeiten vor. Was die Entwicklung der Gesundheitsausgaben betrifft, stehen zwar Grossbritannien und die skandinavischen Länder gut da, aber andere Länder wie Spanien haben bedeutend mehr Mühe, die Kosten in den Griff zu bekommen. Schwer zu bewerten sind auch die Auswirkungen der Dezentralisierung auf die Effizienz. Die meisten Länder haben in den Neunzigerjahren wettbewerbs- und managementorientierte Ansätze zur Steigerung der Effizienz ihres Gesundheitswesens gewählt, unabhängig davon, ob ihr Gesundheitssystem eher zentralisiert funktioniert wie in Grossbritannien oder dezentralisiert wie in den skandinavischen Ländern und in Spanien. Bei den Auswirkungen auf die Finanzierung ist festzuhalten, dass die Dezentralisierung zu unterschiedlichen regionalen Beitrags- oder Steuersätzen und oft auch zu Problemen beim Finanzausgleich führt. Regionale Ungleichheiten bei der Gesundheitsversorgung kommen in dezentralisierten und zentralisierten Ländern vor. In den skandinavischen Ländern beispielsweise bestehen bei den spezialärztlichen Leistungen grosse Unterschiede zwischen den Regionen. In Dänemark z.B. variieren die Konsultationen bei Spezialisten in einem Verhältnis von 1 zu 2,2. Doch dieselben Ungleichheiten gibt es auch in Frankreich – im zentralisierten Land «par excellence». Hier variieren die Ausgaben für Spezialärzte zwischen den Departementen im Verhältnis von 1 bis 2,3. Der Grad der Zentralisierung oder Dezentralisierung ist nur ein Aspekt der Gesundheitssysteme. Andere ebenso wichtige Fragen bleiben damit offen: Soll das Leistungsangebot staatlich oder vertraglich geplant und geregelt werden? Sollen Leistungen durch Plan oder Wettbewerb zugeteilt werden? Wie sollen die Leistungserbringer abgegolten werden? Und wie wird das Gesundheitswesen finanziert?2 maud hilaire schenker

Rondinelli D. A., Nellis J. R., Cheema S. (1983), Decentralization in developing countries: a review of recent experiences, World Bank Staff working paper, n° 581, World Bank. 2 Polton Dominique, «Décentralisation des systèmes de santé: un éclairage international», in Revue française des affaires sociales, Nr. 4–2004, S. 267–299 1

Ein Gesundheitssystem und lokale Organisationen: Die Dezentralisierung verwandelt Gesundheitssysteme in farbige Mosaike.

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Gute Platzierung der Schweiz Welches Gesundheitssystem ist weltweit das «beste» und weshalb? Die politischen Entscheidungsträger möchten wissen, wo der Schlüssel zum Erfolg liegt. Ländervergleiche der OECD1, der WHO2 oder der «Euro Health Consumer Index» (EHCI)3 versuchen, der Sache auf den Grund zu gehen.

Wodurch zeichnen sich gute Gesundheitssysteme aus? Um diese Frage zu beantworten, gilt es zunächst einmal, Ziele und Kriterien zu analysieren, die ein gutes Gesundheitssystem ausmachen. Am häufigsten werden dabei auf internationaler Ebene genannt: Qualität, Zugang zur medizinischen Versorgung, gleiche Behandlung für alle, Kostenbegrenzung und ein optimales Kosten-Nutzen-Verhältnis. Die Schwierigkeit von Ländervergleichen

Es ist indessen nicht einfach, eine Rangliste aufzustellen, da jedes Land bei der Datenerhebung ganz unterschiedliche Methoden anwendet. Die WHO hat dies erkannt und ihre Ländervergleiche rasch eingestellt. Die OECD hingegen hält an ihren regelmässigen Vergleichen fest. Diesen liegen folgende Kriterien zugrunde: Gesundheit, Zugang zu bedarfsgerechten Technologien und zu einer angemessenen Versorgung, Rücksicht auf die Bedürfnisse der Bevölkerung und der Patienten sowie eine faire und nachhaltige Finanzierung. Der EHCI nimmt die Patientenzufriedenheit in 33 Ländern als Untersuchungsbasis. Massgebend sind dabei folgende Merkmale: Patientenrechte und -information, E-Health, Wartefristen, Ergebnisse, Umfang und Tragweite der medizinischen Leistungen und der pharmazeutischen Produkte.

Top 10 Euro Health Consumer Index 2009 Rang

Land

Entwicklung

Niederlande

Dänemark

Island

Österreich

-1

Schweiz

1. Beteiligung

Deutschland

Frankreich

Schweden

-3

Luxemburg

-5

Norwegen

-2

Quelle : health consumer powerhouse ab, 2009

Wahlfreiheiten steigern die Zufriedenheit der Patienten

Am höchsten in der Gunst der Patienten stehen wettbewerbsorientierte Systeme mit einem grossen privaten Sektor. Am besten schneiden dabei laut EHCI die Niederlanden ab. Dort können die Versicherten frei zwischen den im Wettbewerb stehenden Versicherern wählen. Zudem wurde eine spezielle Institution geschaffen, um die Patienten in die Entscheide zur Weiterentwicklung des Gesundheitssystems einzubinden. Politiker und Beamte hingegen sind davon ausgeschlossen. Federführend bei Reformen sind Gesundheitsfachleute, die aufgrund von Absprachen mit den Hauptbetroffenen, den Versicherten, handeln. An zweiter Stelle in der Patientengunst steht Dänemark. Versicherte haben hier die freie Wahl des Leistungserbringers. Bei der Wahl behilflich ist ihnen eine Liste mit den qualitativ besten Spitälern des Landes, die im Internet veröffentlicht wird. Es besteht also ein Wettbewerb unter den Leistungserbringern im Interesse der Patienten. In beiden Ländern liegen allerdings die (öffentlichen und privaten) Gesundheitskosten pro Einwohner deutlich über dem OECD-Durchschnitt von 2894 Dollar4. In den Niederlanden betragen sie 3837 und in Dänemark 3362 Dollar. Schweiz: Hohe Kosten – guter Gesundheitsstand

Die Schweiz gehört zu den Ländern mit den höchsten Gesundheitskosten (öffentliche und private). Bei den ProKopf-Ausgaben belegt sie mit 4417 Dollar hinter den USA (7290 Dollar) und Norwegen (4763 Dollar) den dritten Platz5. Einen Spitzenrang nimmt sie aber auch bei der Gesundheit der Bevölkerung und der Vorsorgequalität ein. Bei der Lebenserwartung liegt die Schweiz mit 81,9 Jahren hinter Japan an zweiter Stelle6. Von grosser Bedeutung für die Qualität eines Gesundheitssystems ist die Zahl der vermeidbaren Todesursachen. Aber auch hier verzeichnet die Schweiz gute Ergebnisse, besonders bei Atemwegserkrankungen, bei Herzschwäche und bei Bluthochdruck. Im EHCI 2009 liegt die Schweiz an fünfter Stelle. Positiv ins Gewicht fallen für die Schweiz die Wartefristen, der Zugang zu Arzneimitteln und die Behandlungsresultate. Schwachpunkte sind die Statistiken und die Patienteninformation. Insgesamt steht das Schweizer System trotz Verbesserungsbedarf in einigen Bereichen sehr gut da. maud hilaire schenker

Organisation für wirtschaftliche Zusammenarbeit und Entwicklung Weltgesundheitsorganisation Der Europäische Gesundheitskonsumenten-Index basiert auf öffentlichen Statistiken, Befragungen und Recherchen des Forschungsbüros Health Consumer Powerhouse in Brüssel. 4 OECD, Panorama de la Santé 2009. Zahlen 2007 5 OECD, Panorama de la Santé 2009. Zahlen 2007 6 OECD, Panorama de la Santé 2009. Zahlen 2007 1 2 3

In den Niederlanden können Versicherte frei zwischen den im Wettbewerb stehenden Krankenversicherern wählen.

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infosantésuisse : Dossier Die europäischen Gesundheitssysteme im Vergleich (Teil 4) 1/2010 1375 Drei Fragen an Dr. Willy Oggier, Gesundheitsökonom

«Die Einheitskasse wäre ein Schritt in die falsche Richtung» Foto: ZVG

nes Systems z.B. beim Aufkommen neuer Krankheitsbilder sind wichtige weitere Kriterien. Hier schliessen Staatssysteme, die oft ein knallhartes System von Rationierungen haben, oft schlechter ab. Was könnte die Schweiz aus diesem Vergleich lernen? Welche Ideen könnten übernommen werden?

Dr. Willy Oggier: «Die Gefahr ist gross, dass bei einer Einheitskasse jenen Menschen Leistungen vorenthalten werden, die es besonders nötig haben.»

Für den Gesundheitsökonomen Willy Oggier sind im internationalen Vergleich drei Elemente für ein gutes Gesundheitswesen zentral: Ein besserer Risikoausgleich unter den Versicherern, die Spitalfinanzierung aus einer Hand und mehr Wahlmöglichkeiten durch mehr Vertragsmöglichkeiten. Die zurzeit von diversen politischen Kreisen stark gepushte Einheitskrankenkasse löst hingegen keine Probleme, weil sie dieses Konzept des regulierten Wettbewerbs unterläuft.

Welches ist aus wissenschaftlicher Sicht das beste Gesundheitssystem in Europa und warum?

Aus gesundheitsökonomischer Sicht ist diese Frage erst dann eindeutig beantwortbar, wenn die Kriterien für das Prädikat «bestes Gesundheitswesen» definiert sind. Aus reiner Kostenoptik beispielsweise schneiden in der Regel staatliche Systeme besser ab. Doch im Gesundheitswesen kann es nie nur um Kostendämpfung gehen. Bedarfsgerechtigkeit, Zugang zum System für sozial Schwächere, für ältere Menschen und für kostenintensive Patienten oder die Leistungsfähigkeit ei-

International lässt sich eine verstärkte Orientierung am Konzept des regulierten Wettbewerbs feststellen, das mit dem Motto «So viel Staat wie nötig, so viel Wettbewerb wie möglich» umschrieben werden kann. Um diesem Konzept Beachtung zu verschaffen, sind folgende Elemente zentral: Es besteht ein Risikoausgleich unter den Krankenversicherern, welcher den Gesundheitszustand der Versicherten berücksichtigt (also morbiditätsorientiert ist). Damit soll die Kassenseite ein stärkeres Interesse an guten Versorgungskonzepten erhalten als an der Jagd nach guten Risiken. Es besteht zweitens eine monistische Spitalfinanzierung, damit zwischen ambulanten und stationären Bereichen keine Verzerrungen finanzieller Art entstehen und Substitutionspotenziale vermehrt ausgeschöpft werden, weil der eine Finanzierer nicht mehr auf Kosten eines anderen profitiert. Und drittens braucht es mehr Wahlmöglichkeiten durch mehr Vertragsmöglichkeiten, d.h. Versicherte müssen ihre Versicherer wählen und Krankenversicherer und Leistungserbringer müssen neben dem ordentlichen Modell der Krankenversicherung auch andere innovative Vertragsformen anbieten können. Insbesondere für das erste und das dritte Element lassen sich sowohl in Deutschland als auch in den Niederlanden positive Entwicklungen feststellen. Legt man diesen europäischen Vergleich der Systeme zugrunde: Was ist dann von der bei uns in letzter Zeit in gewissen Kreisen verstärkt propagierten «Wunderlösung» Einheitskasse zu halten?

Die Aufzählung der wesentlichen Elemente eines regulierten Wettbewerbs macht deutlich, dass die Einheitskasse einen Schritt in die falsche Richtung darstellt. Denn diese ändert nichts an den falschen vorherrschenden finanziellen Anreizen. Und in einem Monopol haben die Versicherten nicht mehr das Recht, die Kasse zu wechseln, wenn sie nicht mehr zufrieden sind. Dies gilt auch für kranke Menschen. Daher ist die Gefahr gross, dass bei einer Einheitskasse – ähnlich wie bei rein staatlichen Systemen – insbesondere jenen Menschen Leistungen vorenthalten werden, die es besonders nötig haben. Denn sie sind auf Gedeih und Verderb der Einheitskasse ausgeliefert und können sich in der Regel nicht leisten, diese Leistungen auf dem freien Markt privat zu finanzieren. Daher erstaunt es auch nicht, dass Gesundheitsexperten aus politisch linksstehenden Parteien in anderen Staaten sich klar gegen eine Einheitskasse aussprechen. Dazu gehört beispielsweise der deutsche Epidemiologe, Gesundheitsökonom und sozialdemokratische Bundestagsabgeordnete Prof. Dr. Karl W. Lauterbach. Interview: Gregor Patorski

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Foto: Prisma

infosantésuisse : Dossier Die europäischen Gesundheitssysteme im Vergleich (Teil 4) 1/2010 1376

Europaweit unterliegen die Gesundheitssysteme seit mehreren Jahren grundlegenden Reformen. Kommt es zu einer Harmonisierung der europäischen Gesundheitspolitik?

Europäische Gesundheitssysteme gleichen sich an

Ein dauernder Reformprozess Die Krankenversicherungssysteme der EU-Staaten, die sich bis vor kurzem stark voneinander abgegrenzt haben, nähern sich nach und nach an. Sie stehen angesichts der knappen Finanzen und der steigenden Anforderungen an die Gesundheitsversorgung vor ähnlichen Problemen. Die Reformen zielen denn auch in die gleiche Richtung.

Die Krankenversicherung ist fest in den nationalen Traditionen verankert. Innerhalb der Europäischen Union gibt es zahlreiche unterschiedliche Systeme. Die einen haben das Beveridge-, die andern das Bismarck-Modell als Grundlage, wobei das sozialpolitische Konzept nach Bismarck die neuen Mitgliedstaaten stark geprägt hat. Beide Modelle haben ihre Schwachstellen: Entweder werden die Kosten zulasten der Qualität in Grenzen gehalten oder eine gute Versorgungsqualität für die ganze Bevölkerung hat Vorrang vor einem ausgeglichenen Budget. Indes stehen alle Länder vor den gleichen Herausforderungen. Denn die Kosten im Gesundheitswesen steigen überall aufgrund des medizinischen Fortschritts, wachsender Ansprüche an die Qualität der Versorgung und der Alterung der Bevölkerung. Zudem fällt es fast allen Ländern schwer, die Sozialausgaben oder den Finanzierungsanteil der öffentlichen Hand auf einem Niveau zu halten, das für die Wirtschaft, die im internationalen Wettbewerb steht, verkraftbar ist. Heute gehen die Reformen aller EU-Staaten in die gleiche Richtung: mehr Wettbewerb, Druck auf die Medikamentenpreise und Eigenverantwortung der Akteure. Die Europäische Union begrüsst, dass sich die Mitgliedländer ähnliche Reformziele setzen. Drei Reformgruppen

Europaweit lassen sich die Reformen in drei Gruppen einteilen: Für die erste mit den Schwerpunkten Leistungsbe-

grenzungen und Eigenverantwortung steht die deutsche Reform, für die zweite mit den Schwerpunkten Dezentralisierung und Einführung von Wettbewerbselementen steht die britische und für die dritte mit dem Schwerpunkt Aufbau eines neuen Versicherungssystems die polnische. Die deutsche Gesundheitsreform Hauptziel der deutschen Gesundheitsreform ist die Stabilisierung des Beitragssatzes. Das soll vor allem mit Leistungseinschränkungen und Erhöhung der Zuzahlungen erreicht werden. So wurden bei der Reform von 2004 die Leistungen für Medikamente, Brillen und Kontaktlinsen sowie Transporte gekürzt. Es wurden eine Praxisgebühr (10 Euro pro Quartal) und ein Beitrag für den Spitalaufenthalt (10 Euro pro Tag) sowie Zuzahlungen für Arzneimittel eingeführt. Im Weiteren wurden neue Finanzierungsquellen erschlossen (Solidaritätsbeitrag der Pharmabranche, erhöhte Beiträge für Pensionierte). Zudem wurde durch die Einführung der freien Kassenwahl der Wettbewerb verstärkt. Die Reform von 2007 brachte den einheitlichen Beitragssatz und (ab 1.1.2009) die Einführung eines gemeinsamen Gesundheitsfonds, aus dem die bisher finanziell selbstständigen Krankenkassen nun die notwendigen Mittel erhalten. Sofern die Einnahmen aus dem Fonds nicht reichen, können die Kassen einen Zusatzbeitrag von maximal einem Prozent des beitragspflichtigen Einkommens erheben. Andererseits können gut wirtschaftende Kassen auch Prämienrückzahlungen vornehmen. Die Reform hat den Vertragspartnern zudem mehr Freiheiten in der Vertragsgestaltung eingeräumt und schliesslich eine Kosten-Nutzen-Bewertung für Arzneimittel eingeführt. Zurzeit wird eine neue Reform diskutiert. Die neue Bundesregierung will den Wettbewerb wieder verstärken. Sehr umstritten ist der vom Gesundheitsminister geplante schrittweise Übergang zu einkommensunabhängigen Prämien.

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infosantésuisse : Dossier Die europäischen Gesundheitssysteme im Vergleich (Teil 4) 1/2010 1377

Die britische Reform Die Reform der britischen Krankenversicherung von 1991 brachte eine dezentrale Verwaltung und mehr Wettbewerb zwischen den Gesundheitsakteuren. Sie führte Marktmechanismen in den bürokratischen Nationalen Gesundheitsdienst (NHS) ein, um die Gesundheitsausgaben besser zu regulieren. Die Spitäler wurden zu finanziell unabhängigen, selbstverwalteten Einrichtungen («NHS trusts»), die untereinander im Wettbewerb stehen. Die Labour Party führte diese Reform weiter. Als neue Ebene des Nationalen Gesundheitsdienstes entstanden Gesundheitsnetzwerke und Zentren für die medizinische Grundversorgung (Primary Care Trusts, PCT), die Regionen mit bis zu 150 000 Einwohnern abdecken. Daran beteiligt sind Hausärzte, Pflegefachleute, Sozialdienste und Patienten. Der NHS bzw. die regionalen Gesundheitsbehörden legen für die einzelnen PTC-Zentren ein Globalbudget fest, das als Grundlage für die Leistungsverträge mit den Spitälern dient. Im Rahmen der Spitalreform von 2003 erhielten effizient arbeitende Krankenhäuser den Status eines «NHS-KrankenhausTrusts». Diese Spitäler werden entweder von der öffentlichen Hand oder von privaten Unternehmen geführt und können ihr Vermögen in Eigenregie investieren und verwalten, Darlehen aufnehmen und die Löhne der Angestellten selber festlegen. Der NHS und der Privatsektor arbeiten zudem in öffentlich-privaten Partnerschaften (PPP) zusammen. So können NHS-Krankenhäuser und PCT-Zentren mit Kliniken und privaten Gesundheitszentren Verträge abschliessen, um die Wartefristen der Patienten zu verringern. Um zu verhindern, dass die Öffentlichkeit die Marktöffnung als Verschlechterung des öffentlichen Gesundheitswesens empfindet, wurden 572 lokale Foren ins Leben gerufen. Diese unabhängigen lokalen Kommissionen vertreten die Patienten und die Bevölkerung. Sie können eigenständig Befragungen und Prüfungen vor Ort durchführen. Eine unabhängige nationale Kommission leitet ihre Empfehlungen an das Gesundheitsministerium weiter.

Pflichtversichert sind alle erwerbstätigen Polen (Familien sind mitversichert). Der Beitragssatz liegt heute bei neun Prozent. Hinzu kommen jedoch Zuzahlungen der Patienten für viele Leistungen. Patienten können den Familienarzt aus einem Netz von Vertragsärzten auswählen und zweimal im Jahr kostenlos wechseln. Es hat aber viel zu wenige Familienärzte, so dass auch Spezialisten die Aufgabe eines Primärarztes übernehmen. Die Warteschlangen vor den staatlichen Ärztezimmern sind deshalb oft lang. Eine grosse Rolle spielen im polnischen Gesundheitssystem die öffentlichen Gesundheitsbetriebe (stationäre Einrichtungen, Ambulanzen und Kinderkrippen). Da der nationale Gesundheitsfonds aber viel zu wenig Geld hat, haben diese Betriebe sehr hohe Schulden angehäuft, und sie können nicht immer eine ausreichende Versorgung garantieren. Private Einrichtungen sind jedoch für viele Polen zu teuer. Eine dritte Reform wäre deshalb dringend nötig. Sie ist schon lange angekündigt, aber noch immer nicht in Angriff genommen worden. Eine europäische Gesundheitspolitik

Die Lissabon-Strategie des Europarates ist ein erster Schritt in Richtung sozialer Erneuerung in Europa. Sie bildete den Auftakt für eine engere Zusammenarbeit zwischen den Mitgliedstaaten bei der Reform der EU-weiten Sozialschutzsysteme. So beschloss man, dass sich EU-Staatsangehörige in anderen Mitgliedsländern medizinisch behandeln lassen können und die nationalen Gesundheitssysteme aufeinander abgestimmt werden. Die Freizügigkeit wurde somit auf Personen (Patienten, Fachleute) wie auch auf Gesundheitsdienstleistungen ausgeweitet. Zudem wurde rechtlich verbindlich die Einführung der europäischen Krankenversicherungskarte entschieden. Die Europäische Kommission macht sich im Weiteren für eine gemeinschaftliche Medikamentenpolitik stark. Im Zentrum stehen dabei der vermehrte Einsatz von Generika und Parallelimporten innerhalb der Europäischen Union. Keine Harmonisierung der Systeme

Die Reform in Polen Die Reform in Polen ist ein Beispiel für die Entwicklung der Gesundheitssysteme in Osteuropa nach dem Zusammenbruch des Kommunismus. 1999 schuf die Regierung eine umlagefinanzierte gesetzliche Krankenversicherung nach Bismarckschem Vorbild mit unabhängigen regionalen Krankenkassen, finanziert durch Arbeitnehmerbeiträge (einen Arbeitgeberbeitrag gibt es in Polen nicht). Das Modell wies jedoch grosse Mängel auf. Deshalb kam es 2003 zur zweiten Reform. Das Gesundheitswesen wurde wieder vereinheitlicht und der Nationale Gesundheitsfonds (NFZ) übernahm die Aufgaben der Krankenkassen. Er gliedert sich in 16 regionale Einheiten, die einer Zentrale untergeordnet sind. Der NFZ selbst untersteht dem Gesundheitsministerium, das über grosse Kompetenzen verfügt. Es entscheidet über das Budget und das Leistungsangebot des NFZ.

Das französische Zentrum für strategische Analysen stellt fest, dass die Gesundheitsreformen der EU-Staaten, die alle vor ähnlichen Herausforderungen stehen, in die gleiche Richtung zielen. Es sieht zwei Reformschwerpunkte: Erstens werden die vom Einkommen abhängigen Versicherungsbeiträge durch eine steuerbasierte Finanzierung ersetzt und zweitens wird die Eigenverantwortung der verschiedenen Akteure im Gesundheitswesen gefördert. Mit einer Harmonisierung der Gesundheitssysteme, die stark von der Kultur der einzelnen Staaten geprägt sind, rechnet das Zentrum aber auch mittelfristig nicht*. maud hilaire schenker

* Philippe Garabiol, «L’assurance-maladie en Europe», in Questions d’Europe Nr. 37, Fondation Robert Schuman, 4. September 2006

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infosantésuisse : Dossier Die europäischen Gesundheitssysteme im Vergleich (Teil 4) 1/2010 1378 Das Chronic-Care-Modell

Foto: Keystone

Für eine bessere Behandlung chronisch Kranker

Chronische Erkrankungen sind die häufigste Todesursache weltweit. Die effiziente gesundheitliche Versorgung von chronisch kranken Menschen ist deshalb eine vorrangige Aufgabe eines Gesundheitssystems. Eine britische Studie* schlägt eine Reihe von Massnahmen für eine optimale Gesundheitsversorgung dieser Patienten vor.

Das sogenannte Chronic-Care-Modell zielt auf eine qualitativ hochwertige Gesundheitsversorgung für chronisch kranke Menschen. Kernstück des Systems bilden der Einbezug der Patienten in die Behandlung, das medizinische Informationssystem, die Patientensicherheit, die Koordinierung der Betreuung und das Case Management. Das System fusst auf der evidenzbasierten Medizin und stellt den Patienten in den Mittelpunkt. Das System kennt keinen eigentlichen Behandlungsschwerpunkt, sondern ist durch das Zusammenspiel aller Komponenten effizient. Die WHO und der britische Gesundheitsdienst (National Health Service) arbeiten bereits mit solchen Modellen. Enorme Unterschiede

2006 untersuchte der Commonwealth Fund die Gesundheitsversorgung chronisch kranker Menschen in sechs Ländern. Dabei kamen grossen Unterschiede ans Licht, vor allem, was die Folgebehandlungen und die Kontrolle der Medikation durch die Ärzte anbelangt. Die Patienten werden nicht überall systematisch in die Behandlung einbezogen. Sehr unterschiedlich fällt auch die Rolle des Pflegepersonals aus: In

Australien gaben 16 Prozent der chronisch Kranken an, bei der Behandlung von einer Pflegeperson unterstützt zu werden, in Grossbritannien waren es 52 Prozent der Befragten. Die Kommunikation zwischen Patient und Arzt, die Koordination der Betreuung und der Zugang zur Versorgung über eine bestimmte Zeit sind weitere Probleme, die immer wieder auftauchen. Generell gilt, dass vermehrt in die medizinische Grundbetreuung investiert werden sollte, statt in Akutspitäler. Zu fördern ist vor allem die Mitwirkung der Patienten. Die zehn Eckpfeiler einer effizienten Behandlung und Betreuung

Folgende zehn Merkmale zeichnen eine effiziente medizinische Versorgung für chronisch kranke Menschen aus: 1 Eine gute allgemeine Gesundheitsversorgung bildet das Fundament. 2 Die Finanzierungsmodelle dürfen ärmere Bevölkerungskreise nicht benachteiligen (Keine Bevorschussung der Pflegekosten wie z.B. beim Tiers-payant). 3 Prävention und Gesundheitsförderung haben Priorität. 4 Der Patient muss in die Behandlung einbezogen werden und ist in der Rolle eines Gestalters seiner Krankheit (Selbstmanagement) zu unterstützen. Die Interaktion zwischen Patienten, Angehörigen und Pflegenden muss verbessert werden. 5 Die Grundversorgung und die Zusammenarbeit in interdisziplinären Behandlungsteams müssen speziell gefördert werden. 6 Chronisch kranke Patienten sind in Risikogruppen einzuteilen und die Versorgung muss sich nach den speziellen Risiken ausrichten. 7 Mit Hilfe von Managed Care sind die Schnittstellen zwischen den Versorgungsstufen genau zu definieren und die Versorgungsabläufe besser zu koordinieren. Die Versorgung ist auf die speziellen Bedürfnisse der einzelnen Patienten auszurichten. 8 Die Informationstechnologien, insbesondere die klinischen Informationssysteme (Patientenregister, Pa-

tientenpässe, Therapiepläne usw.), müssen verbessert werden, nicht zuletzt, um die Patienten aktiv einzubinden. 9 Besser zu koordinieren ist auch die medizinische Betreuung (Zusammenarbeit zwischen Ärzten, Krankenhäusern, Rehabilitationszentren). 10 Die neun genannten Merkmale sind im Rahmen einer kohärenten Gesamtstrategie zusammenzuführen. Strategien für die Praxis

Damit die Eckpfeiler der Gesundheitsversorgung für chronisch Kranke in die Praxis umgesetzt werden können, muss auf verschiedenen Ebenen angesetzt werden: • Die Ärzteschaft muss ihre zentrale Rolle bei der Neuausrichtung der Gesundheitsdienste auf die Behandlung der chronischen Krankheiten wahrnehmen. • Die Ergebnisse sind regelmässig zu evaluieren, damit die Programme kontinuierlich verbessert werden können. • Es müssen Anreize zur Förderung der verschiedenen Elemente von Chronical Care geschaffen werden, z.B. durch eine ergebnisorientierte Finanzierung, oder den Ausbau der Grundversorgung. • Auch Organisationen ausserhalb des medizinischen Systems wie Selbsthilfegruppen und Patientenverbände sollten ihren Beitrag leisten. Mit dem Chronic-Care-Modell werden die Gesundheitssysteme besser auf die chronisch kranken Menschen ausgerichtet. Doch es gibt noch viel zu tun, bis die Strukturen geschaffen, die Abläufe verbessert sowie Behandlung und Betreuung optimal koordiniert sind, d.h. bis ein qualitativ hochstehendes und effizientes System der gesundheitlichen Versorgung chronisch Kranker tatsächlich erreicht ist. maud hilaire schenker

* Chris Ham, «The ten characteristics of the high-performing chronic care system», in Health Economics, Policy and Law (2010), Cambridge University Press 2009, S.71–90

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infosantésuisse : Dossier Die europäischen Gesundheitssysteme im Vergleich (Teil 4) 1/2010 1379

Grafik des Monats: Gesundheitskosten im internationalen Vergleich

Günstiger als sein Ruf: Das Schweizer Gesundheitssystem Das Schweizer Gesundheitswesen ist als eines der teuersten weltweit verschrien. Doch analysiert man die Zahlen der OECD eingehender, kommt man zu einem erstaunlichen Ergebnis: Die Schweiz liegt im internationalen Vergleich im Mittelfeld, wenn man die öffentlichen Gesundheitsausgaben als Mass nimmt und die privaten Kosten aussen vor lässt.

Mit 7290 USD pro Kopf und Jahr ist das US-amerikanische Gesundheitssystem das mit Abstand teuerste der Welt. Die Schweiz folgt auf Rang 3 mit 4417 USD. Auch wenn man den Anteil der Gesundheitsausgaben am BIP misst, ergibt sich ein ähnliches Bild: Obenaus schwingen die USA mit 16 Prozent, die Schweiz folgt auf Rang 3 mit 10,8 Prozent (OECD-Schnitt: 2984 USD bzw. 8,9 Prozent). Öffentlicher Teil nicht teurer als anderswo

Ganz anders sieht es aus, wenn nur die öffentlichen Gesundheitsausgaben berücksichtigt werden (d.h. alle Gesundheitsdienstleistungen, die durch Sozial versicherungen bezahlt werden) und man die privaten Ausgaben separat ausweist: Ohne die freiwilligen, privaten Auslagen (d.h. Out-of-the-Pocket-Kosten, Zusatzversicherungen, andere nicht

von der Grundversicherung gedeckte Kosten) befindet sich die Schweiz nämlich im Schnitt der OECD-Länder: Gemessen am BIP erreicht sie genau den OECD-Schnitt von 6,4 Prozent. Auch in absoluten Zahlen liegt die Schweiz mit 2618 USD pro Kopf und Jahr nur knapp über dem OECD-Wert von 2193 USD. Das Gesundheitssystem ist also nur teuer, weil der Durchschnittsschweizer sich seine eigene Gesundheit privat viel kosten lässt. Obwohl die Grundversicherung viele Leistungen abdeckt, verlangen Herr und Frau Schweizer mehr: 40,7 Prozent (1799 USD) vom Gesamtkosten-Kuchen zahlen sie aus der eigenen Tasche. Das öffentliche Schweizer Gesundheitssystem hingegen ist weitaus günstiger als sein Ruf. Gregor Patorski

GESAMTE GESUNDHEITSKOSTEN PRO KOPF 2007 (ÖFFENTLICH UND PRIVAT) ÖFFENTLICHE GESUNDHEITSAUSGABEN 7290

7000

PRIVATE GESUNDHEITSAUSGABEN

823 MEXIKO

TÜRKEI (2005)

POLEN

KOREA

UNGARN

PORTUGAL (2006)

NEUSEELAND

FINNLAND

AUSTRALIEN (2006/07)

BELGIEN

SCHWEIZ

KANADA

SCHWEDEN

ISLAND

IRLAND

DEUTSCHLAND

FRANKREICH

DÄNEMARK

ÖSTERREICH

USA

NIEDERLANDE

NORWEGEN

LUXEMBURG (2006)

Betrachtet man nur die öffentlichen Gesundheitsausgaben, liegt die Schweiz nur knapp über dem OECDDurchschnitt.

15 | Gesundheitswesen 3/10

QUELLE: ECO-SANTÉ OECD 2009

1000

618

1688 1035

1388

1626

1555 SLOWAKEI

2000

TSCHECHIEN

2727

2150

2671 SPANIEN

GRIECHENLAND

2686 ITALIEN

2510

2581 JAPAN (2006)

3137

2840

2984 OECD

4417 2992

3000

GROSSBRITANNIEN

3595 2618

3895

3323

3588

3319

3424

3763

3601

4000

3512

3837

4162

5000

4763

6000

infosantésuisse : Dossier Die europäischen Gesundheitssysteme im Vergleich (Teil 4) 1/2010 1380 Foto: Keystone

Buchtipp: Zunehmender Mangel an Pflegepersonen

Konkrete Gegenmassnahmen gefordert

Die in der SGGP-Schriftenreihe erschienene Studie von Barbara Brühwiler-Müller über die «Laufbahnplanung für Pflegefachpersonen ab 40» ist zwar bereits drei Jahre alt, aber die Feststellungen der Autorin sind nach wie vor höchst aktuell. Von Interesse sind vor allem die zur Diskussion gestellten Massnahmen, welche es auch älteren MitarbeiterInnen im Pflegedienst gestatten sollen, bis zur Pensionierung arbeiten zu können. Die Probleme müssen angesichts des sich abzeichnenden Mangels an Pflegepersonal rasch gelöst werden.

Das Gesundheitswesen ist stark herausgefordert: Auf der Nachfrageseite mit dem qualitativ und quantitativ steigenden Bedarf an Behandlungs-, Pflege- und Betreuungsleistungen, auf der Angebotsseite durch die Verschiebungen in der Altersstruktur des noch berufstätigen Personals. Dazu kommen die Folgen der während vieler Jahre rückläufigen Geburtenzahlen für die Rekrutierung von Berufsnachwuchs. Anregungen und Vorschläge

Als Grundlage für die Laufbahnplanung für ältere Pflegefachkräfte postuliert die Autorin ein Führungsgespräch mit allen Mitarbeitenden zwischen 40 und 45 über deren berufliche Zukunft. Angestrebt werden eine individuelle Schichtdienstleistung ab 55 Jahren, sowie besonders altersgerechte Aufgabenbereiche oder Rollen im Pflegeteam. Ältere Mitarbeitende sind im kontinuierlichen Fort- und Weiterbildungsprozess zu halten. Im Bereich Gesundheit und Fitness können die vorhandenen betrieblichen Angebote besser bekannt gemacht, sowie noch weitere altersspezifische Angebote geschaffen werden. Von grosser Bedeutung ist im Weiteren die individuelle Gestaltung der Arbeitsplätze, wel-

che auf die Bedürfnisse des Unternehmens und die Fähigkeiten und Bedürfnisse älterer Arbeitskräfte abzustimmen ist. Zur Entlastung älterer Arbeitskräfte sollten auch Dauer und Verteilung der Arbeitszeit möglichst optimal gestaltet werden. Ein weiteres, wenn auch noch wenig diskutiertes Element, wäre die Abkehr vom so genannten Senioritätsprinzip. Hier stellt sich die Frage: Warum sollen 58-Jährige deutlich mehr verdienen als 35-Jährige? Es ist nicht zu übersehen, dass heute Angestellte über 50 kaum mehr Jobs erhalten, was oft auch mit den überhöhten Lohn- und Einkommenserwartungen zusammenhängt. Das ist denn auch ein Grund dafür, dass zahlreiche Unternehmen das Senioritätsprinzip korrigiert oder gar gänzlich abgeschafft haben. Dass in diesem Punkt faire und verträgliche Regelungen für die Mitarbeitenden getroffen werden müssten, ist selbstverständlich. Jedenfalls sind langjährige treue Dienste nicht zu unterschätzen. Individuelle Schichteinsätze

Zentral für die Studie von Barbara Brühwiler sind die von ihr vorgeschlagenen Schichtdienstmodelle für ältere Mitarbeitende. Denn offensichtlich nimmt die Bereitschaft, über längere Zeit unregelmässig Schichtarbeit zu leisten, bei den jüngeren Menschen eher ab und bei den älteren ist sie ohnehin nicht gefragt. Diesem Trend könnte gegengesteuert werden, wenn die Spitäler die Schichtarbeit attraktiver vergüten würden, was aber eine Kostensteigerung zur Folge hätte. Probleme könnten sich auch ergeben, wenn vakante Stellen nicht lückenlos wieder besetzt werden und in altersdurchmischten Teams zu wenig Mitarbeitende alle Schichten übernehmen wollen. Was oft Unbehagen bereitet, so die Autorin, sei nicht so sehr die Bedingung, Schichtarbeit leisten zu müssen, sondern vielmehr die Häufigkeit, sowie die Unregelmässigkeit und vor al-

lem die Nachtschichten. Lösungsansätze wie die Möglichkeit, als ältere Mitarbeitende in regelmässigen Schichten arbeiten zu können oder bevorzugt einzelne Schichten zu übernehmen, seien sicher eine Überlegung wert. So könne man sich gut vorstellen, Mitarbeitenden ab 55 die Möglichkeit zu bieten, in einer Art von degressivem Modell vom reinen Schichtdienst mit fixen Wechseln wegzukommen. Ab 60 könnte ein solches Modell auch bedeuten, dass Mitarbeitende von einer Schicht, beispielsweise einer Nachtschicht, gänzlich befreit werden oder fast ausschliesslich Nachtdienst übernehmen. Dass die Dienstplanung schon heute sehr hohe Ansprüche an die Vorgesetzten stelle, stehe ausser Zweifel, gelte es doch, nebst den vielen anderen professionellen Verpflichtungen nach Möglichkeit die Wünsche der Mitarbeitenden zu berücksichtigen, so jene von berufstätigen Müttern, die noch Kinder zu betreuen und weitere familiäre Aufgaben zu erledigen haben. Der Autorin ist jedenfalls beizupflichten, wenn sie am Schluss ihrer in mancher Hinsicht wegleitenden Studie schreibt: «Dass Betriebe Rahmenbedingungen schaffen, welche es älteren Mitarbeitenden ermöglichen, Gesundheit und Leistungsfähigkeit so gut wie nur möglich zu erhalten und mit aktualisiertem Wissen länger im Arbeitsprozess zu bleiben, ist von grosser sozialpolitischer und gesellschaftlicher Relevanz.» Die Schaffung solcher Rahmenbedingungen werde in den nächsten Jahren für die Betriebe ein wichtiger Wettbewerbsvorteil und deshalb von hoher Dringlichkeit sein. Josef Ziegler

Babara Brühwiler-Müller: Erfahrung ist Gold wert. Laufbahnplanung für Pflegefachpersonen ab 40. Schriftenreihe der Gesellschaft für Gesundheitspolitik (SGGP) Nr. 94, 2007.

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infosantésuisse : Dossier Die europäischen Gesundheitssysteme im Vergleich (Teil 4) 1/2010 1381 Neuerungen im Zahlstellenregister von santésuisse

Weshalb das ZSR wichtig und unverzichtbar bleibt

Das Zahlstellenregister ist seit vielen Jahren eine zentrale Dienstleistung von santésuisse für die einzelnen Krankenversicherer. Es verwaltet die Stammdaten aller Leistungserbringer, welche medizinische Leistungen für die Grundversicherung – aber auch für die Zusatzversicherung – in Rechnung stellen. Die ZSR-Nummer ist ein Gütezeichen, das sicherstellt, ob ein Leistungserbringer auch zu Recht Leistungen erbringt. Denn das dürfen nur Leistungserbringer, die die Zulassungskriterien des KVG erfüllen und den Tarifverträgen beigetreten sind. Drei Nutzungsbereiche

Das ZSR umfasst insgesamt drei Nutzungsbereiche: Erstens den Kreditorenstamm und Zahlungsverkehr, zweitens die Rechnungsprüfung und Berufszulassung und drittens die Statistik samt Wirtschaftlichkeitsprüfung bei Ärzten. Diese zentralen Daten werden von den Versicherern laufend übernommen und bei Bedarf durch interne Angaben ergänzt. Die SASIS AG, ein Tochterunternehmen von santésuisse, betreibt das Register seit dem 1. Januar 2009. Diese Dienstleistung nimmt den einzelnen Versicherern die Aufgabe ab, diese Angaben bei jedem Leistungserbringer beschaffen und prüfen zu müssen. Auch den Leistungserbringern wird das Leben erleichtert: Sie müssen nicht jeden Versiche-

rer einzeln für jeden Leistungsfall mit den entsprechenden Informationen wie z.B. Adressen, Berufsausübungsbewilligung, Kontoangaben usw. versorgen. Darüber hinaus bildet das ZSR eine wichtige Grundlage für die Erarbeitung von Statistiken und für die Wirtschaftlichkeitsprüfungen. Mittels ZSR werden die Bruttoleistungen pro Leistungserbringer der einzelnen Krankenversicherer im Datenpool und im Tarifpool von santésuisse konsolidiert. Diese nach Leistungserbringer-Gruppen zusammengefassten Zahlen erlauben dann einen Gesamtüberblick über die Gesundheitskosten. Was ist neu im Zahlstellenregister?

Das Register ist seit seiner Einführung für alle Beteiligten zu einem wichtigen und unverzichtbaren Arbeitsinstrument geworden. Sein Informationsgehalt für die Versicherer wird ständig ausgebaut. Seit diesem Jahr sind neu folgende ergänzende Angaben abrufbar: • Im Spitalbereich wird neu die Art des Laboratoriums (Typ O: Spital ohne Labor; Typ A: Analysen der Grundversorgung; Typ B: auf Standortspital ausgerichtet, Fremdaufträge nur gemäss Grundversorgung; oder Typ C: gesamtes Analysespektrum mit Fremdaufträgen) hinterlegt, um eine Rechnungsprüfung von Seiten der Versicherer zu gewährleisten. • Eine zweijährige praktische Tätigkeit für Pflegefachpersonen in der Psychiatrie wird gemäss der Bestimmung in Art. 7, Abs. 2bis KLV seit Juli 2007 für Bedarfsabklärungen für die gerontologische bzw. psychiatrische Pflege vorausgesetzt. Der vom Berufsverband SBK ausgestellte Weiterbildungsnachweis ist nun ebenfalls im Register verzeichnet. • Nach dem BundesgerichtsUrteil vom 20. April 2009

müssen ZSR-Nummern auch an Einrichtungen nach Art. 36a KVG erteilt werden, die der ambulanten Krankenpflege durch Ärzte dienen. Im ZSR ist nun ersichtlich, ob es sich um eine derartige Einrichtung handelt. • Neu sind gemäss Art. 52, lit.a KVV Organisationen der Physiotherapie zugelassen. Analog dem ErgotherapieBereich wurde im ZSR neu je eine Untergruppe für selbstständig tätige Physiotherapeuten (UG 00) sowie für Organisationen der Physiotherapie (UG 01) definiert. • Bereits vorbereitet ist, dass der Beitritt von Apotheken zum Vertrag LOA IV im ZSR abgebildet wird, sobald dieser in Kraft tritt. Franz Wolfisberg/Gregor Patorski

Foto: ZVG

Damit ein Spital, ein Arzt oder sonst ein Leistungserbringer im Gesundheitswesen seine Arbeit auch korrekt verrechnen kann, braucht er einen Eintrag im Zahlstellenregister (ZSR) von santésuisse. Das ZSR stellt aber nicht nur die Zahlungswege sicher, sondern dient auch zur Bestätigung der Zulassung und um Statistiken zu erarbeiten. Seit dem 1. Januar 2009 wird das ZSR von der SASIS AG betrieben. Auch dieses Jahr wurden ergänzende Informationen neu ins Register aufgenommen.

Trotz des Computerzeitalters bleibt die Arbeit im ZSR in Luzern eine papierlastige Angelegenheit.

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infosantésuisse : Dossier Die europäischen Gesundheitssysteme im Vergleich (Teil 4) 1/2010 1382 Start geglückt

Die neue Versichertenkarte ist im Spital angekommen Trotz öffentlicher Kontroversen über die neue Versichertenkarte gemäss Art. 42a KVG und der Verordnung Versichertenkarte (VVK) läuft die Produktion und die Verteilung an die Versicherten auf Hochtouren. Im Inselspital Bern sind in den ersten Wochen seit dem produktiven Start bereits 928 Chipkarten eingelesen worden.

Jetzt ist das Inselspital Bern für die neue elektronische Versichertenkarte bereit – 77 Chiplesegeräte stehen zur Verfügung. Die Karte stellt für jeden Versicherten den organisatorisch einheitlichen Zugang zum Gesundheitswesen sicher. Die Karte trägt Namen und AHV-Nummer des Versicherten – aufgedruckt und auf einem Chip gespeichert – und erleichtert so die Identifikation des Versicherten beim Leistungserbringer. Weitere medizinische Daten können auf Wunsch ebenfalls elektronisch eingetragen werden. Sechs Millionen Versichertenkarten bis Ende Mai

Seit dem 4. Januar 2010 läuft die Kartenproduktion der neuen Chipkarte. Aufgrund der vielen Versicherer-Wechsler aus dem Jahresübergang 2009/2010 kam es zu Verspätungen bei der Auslieferung. Bis Ende Mai 2010 werden nun über sechs Millionen Exemplare der neuen Versichertenkarte bei den Versicherten angekommen sein. Die neue Karte wird weiterhin ausschliesslich für administrative Zwecke zur Optimierung der Prozesse zwischen Spital, Apotheke, Arzt usw. auf der einen Seite und den Krankenversicherern auf der anderen Seite (Per sonendaten des Patienten, Versicherungsdeckung und Rechnung für die medizinischen Leistungen) eingesetzt. Ab Mitte Jahr ist mit den ersten Anwendungen für die medizinischen Notfalldaten zu rechnen.

Das Inselspital hat den Nutzen früh erkannt

Für einmal sind die Berner schneller als die ganze Schweiz. In Zusammenarbeit mit der Spital-Software von der SAP AG wurde eine zweckmässige Lösung vorbereitet, welche Ende Februar produktiv gestartet werden konnte. Es stehen schon 77 Chiplese geräte im Einsatz. 928 Chipkarten wurden damit bereits eingelesen. Die Aktualisierung der gespeicherten administrativen Daten erfolgt über eine elektronische Online-Abfrage beim VeKa-Center. Das Inselspital sieht in dieser Lösung einen grossen Nutzen, da bereits bei der Patientenaufnahme verbindliche Informationen bestehen und damit falsche Rechnungsstellungen verhindert werden können. Zudem können auch ausserhalb der ordentlichen Bürozeiten der Krankenversicherer verbindliche Informationen zu den Deckungen und Aufenthalts-Kategorien eingeholt werden. In den dezentralen Behandlungsstellen können die Angaben auf dem Eintrittsformular bereits bei der Ausstellung durch die Online-Abfrage verifiziert werden. Damit ist es dem Inselspital gelungen, die Chipkarte als erstes Spital der Schweiz integriert und nutzbringend einzusetzen. Anfang März hat auch das Basler Universitätsspital den produktiven Start geschafft. Die Universitätsspitäler von Zürich und St. Gallen werden bis Anfang April auch zur Spitzengruppe vorstossen. H.-P. Schönenberger, Projektleiter VeKa-Center der SASIS AG

Die neue Versichertenkarte ist da. Das Inselspital ist bereit.

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Hanami: Albtraum für Allergiker? Der Frühling lässt die Natur zu neuem Leben erwachen. Wir geniessen die ersten warmen Sonnenstrahlen und freuen uns über die blühenden Landschaften. Die Japaner feiern den Frühling auf ihre Art. Hanami ist die japanische Tradition, im Frühjahr mit Kirschblütenfesten die Schönheit der blühenden Kirschbäume (Sakura) zu feiern. Ende März, anfangs April ist ganz Japan voll von blühenden Kirschbäumen. Diese Frühlings tradition hat ihre Entsprechung auch im Herbst. Sie heisst Momijigari und besteht darin, Landschaften mit herbstlicher Laubfärbung zu besuchen und zu geniessen. Im Frühling, wenn die Kirschbäume blühen, picknicken die Japaner gerne mit der ganzen Familie und Freunden unter der Kirschblütenpracht. Die Krönung für alle, vor allem für Fotografen, ist jeweils die erste Blüte und der Zeitpunkt der vollen Blüte. Für Allergiker ist diese Zeit ein Albtraum. Der Frühlingsbeginn und die milden Temperaturen läuten die Pollensaison ein. Erle, Zypresse, Pappel und Esche machen den Anfang. Heuschnupfen, Bindehautentzündung und Asthma sind nur einige der Folgen. Allergien sind Überreaktionen unseres Körpers auf äusserliche Einflüsse, die normalerweise harmlos sind (Pollen, Katzenhaare, Erdbeeren, usw.). Damit eine allergische Reaktion auftritt, muss der Organismus über die Atemwege, übers Essen oder über die Haut ein erstes Mal mit dem Allergieauslöser in Kontakt kommen. Danach entwickelt der Körper spezifische Antikörper gegen die Allergie. Es handelt sich um die sogenannte Sensibilisierungsphase, die mehrere Jahre dauern kann. Man weiss bis heute nicht genau, aus welchen Gründen der Körper gegen die eine oder andere Allergie Antikörper bildet.

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Bild

Monats

Foto : Prisma

infosantésuisse : Dossier Die europäischen Gesundheitssysteme im Vergleich (Teil 4) 1/2010 1383

infosantésuisse : Dossier Die europäischen Gesundheitssysteme im Vergleich (Teil 4) 1/2010 1384

Zwei Stellungnahmen der Paritätischen Vertrauenskommission physioswiss – santésuisse/UV/MV/IV Rechnungen der Physiotherapeuten

Die Rollen der Physiotherapeuten und der Versicherer bei der Rechnungsstellung sind im Krankenversicherungsgesetz (Art. 42) definiert. Der Leistungserbringer (in diesem Fall der Physiotherapeut) muss dem Versicherer eine detaillierte und verständliche Rechnung zustellen. Der Versicherer kann zusätzlich eine genaue Diagnose oder zusätzliche Auskünfte medizinischer Natur verlangen (Art. 42 KVG). Weiter muss der Physiotherapeut dem Versicherer alle Angaben machen, welche der Versicherer benötigt, um die Berechnung der Vergütung und die Wirtschaftlichkeit der Leistung überprüfen zu können. Der Tarifvertrag von September 1997 (Art. 7 Abs. 4) präzisiert: In fraglichen Fällen hat der Physiotherapeut auf Verlangen der Versicherer die vorgesehenen Therapiemassnahmen und/oder die Verrechnung von entsprechenden Tarifpositionen zu begründen. Der Versicherer ist berechtigt, dem verordnenden Arzt Fragen medizinischer Natur zu stellen. Für Auskünfte tarifspezifischer Art ist der entsprechende Vertragspartner der kompetente Ansprechpartner. Rundschreiben Nr. 67/2004 von santésuisse

Foto: Keystone

Vielleicht haben Sie vom Rundschreiben Nr. 67/2004 von santésuisse Kenntnis? Dieses Rundschreiben bezieht sich auf einen Tarifvertrag zwischen der FMH und santésuisse über Physiotherapie und weitere paramedizinische Leistungen in der Arztpraxis, was im besagten Dokument auch klar festgehalten wird. Die Empfehlungen, welche im Rundschreiben Nr. 67/2004 enthalten sind, wurden somit nicht für selbstständige Physiotherapeuten in eigener Praxis erarbeitet. Im Interesse aller Parteien sind die jeweiligen Verträge für Physiotherapeuten in eigener Praxis bzw. für angestellte Physiotherapeuten in der Arztpraxis als eigenständig wahrzunehmen.

Aus aller Welt

Service

Physiotherapie in der freien Praxis:

Barack Obama unterzeichnet historisches Reformgesetz: Der amerikanische Präsident Barack Obama hat am 23. März 2010 ein Krankenversicherungsgesetz verabschiedet, mit dem über 32 Millionen Amerikanerinnen und Amerikaner endlich über eine Gesundheitsversorgung verfügen werden. Nachdem das Projekt, welches im Kongress sehr umstritten war, beinahe gescheitert wäre, muss der Präsident nun die US-Bürgerinnen und Bürger davon überzeugen. Sie haben in erster Linie Angst vor den Kosten der Reform und sehen das Projekt als Einmischung der Regierung in das Gesundheitswesen. London eröffnet ein Zentrum für Computersüchtige: Ein Spital in London behandelt Patienten, die ohne soziale Online-Netzwerke und Videospiele nicht mehr leben können. Die Behandlung dauert 28 Tage. Das Ziel ist es nicht, den Patienten den Computer abzugewöhnen, sondern ihnen zu helfen, kontrolliert damit umzugehen. Glasgow mit hoher Sterblichkeitsrate: In der schottischen Stadt Glasgow ist die Sterblichkeitsrate höher als in vergleichbaren Städten mit gleich hoher Armut. In Glasgow sterben durchschnittlich 900 Personen mehr als in Liverpool oder Manchester und zwar unabhängig vom Alter und von der sozialen Schicht. Hauptursache sind Krebs und Herzinfarkte. Die Experten können sich den «GlasgowEffekt» nicht erklären.

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infosantésuisse : Dossier Die europäischen Gesundheitssysteme im Vergleich (Teil 4) 1/2010 1385

Veranstaltungen Veranstalter

Besonderes

Datum/Ort

Weitere Informationen

Die Basler Arzthaftpflichttage asim Academy of Swiss Insurance Medicine

Thema: «Arzt – Patient – Versicherung: wer 22. bis 23. April 2010 www. asim.unibas.ch schadet wem?» Uni Basel, Grosser Hörsaal, Basel

SwissDRG Forum 2010 SwissDRG SA

Thema: Erfahrungen mit Fallpauschalen und Vorbereitungen auf 2010

30. April 2010 Congress Center, Basel

www.swissdrg.org

12. Schweizerisches Forum der sozialen Krankenversicherung RVK

Thema: Leistungskatalog im Kreuzfeuer: Grundversorger oder Wunschversorgung?

www.rvk.ch 19. Mai 2010 Kongresshaus, Zurich

Zeichnung: Marc Roulin

Melden Sie uns Ihre Veranstaltungen an: redaktion@santesuisse.ch! Weitere Veranstaltungen unter www.santesuisse.ch

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infosantésuisse : Dossier Die europäischen Gesundheitssysteme im Vergleich (Teil 4) 1/2010 1386

spital interlaken Die Akutspitäler Frutigen und Interlaken sowie das Gesundheitszentrum Meiringen bilden unter dem Namen spitäler fmi ag das Regionale Spitalzentrum für das östliche Berner Oberland Für die Patientenadministration des fmi Spitals Interlaken suchen wir per sofort oder nach Vereinbarung eine/einen



Sachbearbeiter/in ambulantes Controlling (80-100%)

Ihr Aufgabengebiet: 



 

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Kontrolle und Bearbeitung der erfassten Spitalleistungen anhand der Krankengeschichte zusammen mit den Leistungserbringern Vorbereiten und Durchführen von Abrechnungen Ambulante Tarifverantwortung TARMED Bearbeitung von Rechnungsanfragen Mithilfe bei der Schulung für Leistungserfassung Kontakte zu internen/externen Stellen

Wir erwarten von Ihnen Medizinische Ausbildung mit Berufserfahrung (Notfall, Pflege)  Kaufmännische Weiterbildung  Tarifkenntnisse TARMED  Durchsetzungsvermögen und Belastbarkeit  Verantwortungsbewusstsein und Selbständigkeit 

Wir bieten Ihnen Interessante und abwechslungsreiche Tätigkeit  Lebhaftes und teamorientiertes Umfeld  Zeitgemässe Arbeitsmittel 

Weitere Informationen erteilt Ihnen gerne Frau Elsbeth Zurbrügg, Leiterin Patientenadministration Tel. 033 826 25 52. Ihre schriftliche Bewerbung mit den üblichen Unterlagen richten Sie bitte an: spitäler frutigen meiringen interlaken ag, spital interlaken personaldienst, weissenaustrasse 27, 3800 unterseen oder i.personaldienst@spitalfmi.ch www.spitalfmi.ch

Neue Spital- und Pflegefinanzierung ante portas: Praktische Herausforderungen bei der Umsetzung des revidierten Krankenversicherungsgesetzes (KVG) Donnerstag, 26. August 2010, Grand Casino Luzern

Themen/Referierende • Einführung Dr. oec. HSG Willy Oggier, Gesundheitsökonomische Beratungen AG, Küsnacht

Die Umsetzung der neuen Spitalfinanzierung: Stand der Dinge • Sicht des zuständigen Bundesamtes lic. iur., RA, Sandra Schneider, Leiterin der Abteilung Leistungen, Bundesamt für Gesundheit, Bern • Sicht der Eidgenössischen Preisüberwachung lic. rer. pol. Manuel Jung, Leiter Fachbereich Gesundheit, Eidgenössische Preisüberwachung, Bern • Sicht eines Universitätsspitals Dr. med. Werner Kübler, MBA, Vorsitzender der Spitaldirektion, Universitätsspital Basel, Basel • Sicht einer Privatspital-Gruppe Peter Kappert, Direktor Klinik Sonnenhof und Präsident der Swiss Leading Hospitals, Bern • Sicht eines Krankenversicherers lic. iur. Peter Fischer, Exec. MBA, CEO Visana-Gruppe, Bern

Die neue Pflegefinanzierung • Was wollte der Bundesgesetzgeber? Ständerätin Christine Egerszegi, Mellingen

Die Umsetzung der neuen Pflegefinanzierung: Stand der Dinge • Sicht des Kantons Solothurn Regierungsrat lic. iur. Peter Gomm, Vorsteher des Departements des Innern des Kantons Solothurn, Solothurn • Sicht von santésuisse lic. rer. pol. Stefan Kaufmann, Direktor santésuisse, Solothurn • Sicht des Spitex Verbands Schweiz lic. rer. soc. Silvia Marti Lavanchy, Wissenschaftliche Mitarbeiterin Politik und Grundlagen, Spitex Verband Schweiz, Bern

Tagungsleitung Prof. Dr. Dr. h.c. René Schaffhauser, Universitäten St. Gallen und Banská Bystrica/Slowakei, St. Gallen Dr. oec. HSG Willy Oggier, Küsnacht Monika Merki Frey, Beraterin im Gesundheitswesen, TROVACON AG, Zürich

Programme/Anmeldung Institut für Rechtswissenschaft und Rechtspraxis (IRP-HSG), Bodanstrasse 4, 9000 St. Gallen Tel. 071 224 24 24, Fax 071 224 28 83, e-mail: irp@unisg.ch/www.irp.unisg.ch

infosantésuisse : Dossier Die europäischen Gesundheitssysteme im Vergleich (Teil 4) 1/2010 1387

Nationale Tagung für betriebliche Gesundheitsförderung 2010 Donnerstag, 2. September 2010, Universität Freiburg

BGM – was sichert den Erfolg? Ziele der Tagung Das Betriebliche Gesundheitsmanagement (BGM) ist erfolgreich, wenn es gelingt, in der Gesamtorganisation eines Unternehmens Wurzeln zu schlagen und dort fruchtbar zu werden. Im Zentrum der Tagung steht deshalb die Frage: Welche Faktoren sind entscheidend für die Integration des BGM in die zentralen Abläufe und Strukturen eines Unternehmens? Wichtige Punkte sind zum Beispiel eine partizipative Planung, Kennzahlen für das Evaluieren des Erfolgs, aber auch schnell erlebbare Erfolge. Kurz gesagt – der Erfolg wird gesichert durch eine bewusste und aktive Prozessgestaltung. Die Tagung will Denkanstösse vermitteln und im Einzelnen folgende Themen ausleuchten: Motivation zur Gesundheitsförderung: Welche Möglichkeiten haben die verschiedenen Akteure im Betrieb, einen BGF-Prozess zu initiieren und zu steuern? Projekte sicher umsetzen: Wie kann die BGF in Management- und andere Systeme eingebettet werden (ASA-System, Balanced Score Card, Management-Systeme, …)? Externe Unterstützung nutzen: Welche Rolle spielen externe Experten in diesem Prozess? Welchen Mehrwert bringt welche berufliche Qualifikation? Prozess richtig planen: Wie lässt sich die Unterstützung von oben, von unten und «von der Seite» bis zur Phase der Evaluation sicherstellen? Betriebsgrösse berücksichtigen: Welchen speziellen Bedingungen ist in einem Kleinbetrieb, einem mittelgrossen oder grossen Betrieb Rechnung zu tragen? Standards etablieren: Welche Qualitätskriterien sind Schweizer Standard?

Return on Investment: Welche Bedeutung haben Kennzahlen für die Evaluation? Wie lässt sich der Nutzen aufzeigen? Zielpublikum – Führungskräfte und Personalfachleute – Gesundheitsbeauftragte in Unternehmen, Spezialistinnen und Spezialisten der Arbeitssicherheit – Vertreterinnen und Vertreter von öffentlichen Institutionen – Entscheidungsträger/-innen in Politik, Wirtschaft und Verwaltung Veranstalter Gesundheitsförderung Schweiz in Kooperation mit dem Staatssekretariat für Wirtschaft SECO Tagungsgebühr CHF 300.–/EUR 200.– inkl. Mittagessen, Pausenverpflegung und Tagungsmappe Tagungspartner Schweizerischer Verband für Betriebliche Gesundheitsförderung SVBGF | Schweizerische Gesellschaft für Arbeits- und Organisationspsychologie SGAOP | Suva | EKAS – Eidg. Koordinationskommission für Arbeitssicherheit | Schweizerischer Versicherungsverband SVV | santésuisse | Swiss Re | Helsana Versicherungen AG | Trust Sympany | Vivit Gesundheits AG | Bundesamt für Gesundheit BAG | Dachverband der Fachgesellschaften für Sicherheit und Gesundheit am Arbeitsplatz suissepro Detailprogramm und Anmeldung: www.gesundheitsfoerderung.ch/tagung

infosantésuisse : Dossier Die europäischen Gesundheitssysteme im Vergleich (Teil 4) 1/2010 1388

Weiterbildungskurs Erwerb Fähigkeitsausweis Vertrauensarzt Die Schweizerische Gesellschaft der Vertrauens- und Versicherungsärzte führt in Zusammenarbeit mit dem Winterthurer Institut für Gesundheitsökonomie WIG den Kurs zum Erwerb des Fähigkeitsausweises Vertrauensarzt durch.

Développez votre carrière dans le domaine de la santé

Formation postgrade

Master of Advanced studies en économie et management de la santé * Formation à temps partiel sur 2 ans

Teilnehmerkreis:

Ärzte/innen aus allen Sozial- und Personenversicherungen sowie weitere interessierte Ärzte/innen

Kurssprache:

Deutsch. Zweisprachige Modulbegleitung unterstützt Kursteilnehmende mit französischer Muttersprache im Bedarfsfall

Kursdaten:

Modul Modul Modul Modul Modul

* S’adresse aux professionnels de la santé : médecins, gestionnaires, assurance maladie, administration, industrie pharmaceutique...

26. 23. 14. 11. 16.

28.08.2010 25.09.2010 16.10.2010 13.11.2010 18.12.2010

Fähigkeitsausweis: Wird nach Kursabsolvierung und Schlussprüfung erteilt Kosten: Für Vertrauensärzte/innen mit KVG-Mandat: Fr. 1'250.Für Ärzte/innen ohne KVG-Mandat, (FMH-Mitglieder): Fr. 5’625.übrige: Fr. 7’500.-

* Délai d’inscription : 15 juin 2010 Contact : mashem@unil.ch Tél. : +41 21 692 34 68

1: 2: 3: 4: 5:

Informations : www.hec.unil.ch/mashem

Auskünfte und Anmeldung: Sekretariat SGV, Tel. 052 226 06 03, Fax 052 226 06 04, E-Mail: info@vertrauensaerzte.ch Ausschreibung Online: www.vertrauensaerzte.ch und www.medecins-conseils Anmeldeschluss:

31. 07. 2010

12. Schweizerisches Forum der sozialen Krankenversicherung Mittwoch, 19. Mai 2010, 09.30 – 16.00 Uhr im Kongresshaus Zürich

Fachleute diskutieren über Massnahmen im Gesundheitswesen

Leistungskatalog im Kreuzfeuer: Grundversorgung oder Wunschversorgung ?

Charles Giroud Dr. rer. pol., Präsident RVK

Erika Ziltener Kantonsrätin SP Zürich, Präsidentin Schweizer Patientenstelle

Werner Widmer Dr. rer. pol., Direktor Stiftung Diakoniewerk Neumünster

Niklaus Brantschen lic. phil. und lic. theol. Jesuit, Gründer und Projektleiter Lasalle-Institut

Urs P. Gasche lic. sc. pol., Gesundheitsökonom, freier Publizist

Beat Kappeler Dr. h.c., Kommentator NZZ am Sonntag

«ForumTALK » Tagungsmoderation: Markus Gilli

Tilman Slembeck Prof. Dr. oec. HSG, Zürcher Hochschule für Angewandte Wissenschaften

Sarah Kleijnen M. Sc., Fachberaterin des Niederländischen Krankenversicherungsgremiums (College voor Zorgverzekeringen)

Warum? Wie? Wann? Fachleute und Meinungsführer diskutieren, hinterfragen und vertiefen auf dem Podium die Thesen der Referenten.

Informationen und Anmeldung: www.rvk.ch Verband der kleinen und mittleren Krankenversicherer – Haldenstrasse 25 – CH-6006 Luzern – Telefon +41 (0) 41 417 05 00

Pascal Strupler lic. iur., Direktor Bundesamt für Gesundheit

infosantésuisse : Dossier Die europäischen Gesundheitssysteme im Vergleich (Teil 4) 1/2010 1389

Dossier infosantésuisse Liens utiles Organisations internationales OCDE www.oecd.org/ Euro HealthConsumer Index http://www.healthpowerhouse.com/ OMS http://www.who.int/fr/ Ministères et services nationaux : Ministère de la santé allemand : http://www.bmg.bund.de/ National Health Service britannique : www.nhs.uk/ Ministère de la santé français : http://www.sante-sports.gouv.fr/ Haute autorité de la santé française : www.has-sante.fr Services de santé aux Pays-Bas : Ministère de la Santé, du Bien-être social, la Jeunesse et les Sports: www.minvws.nl Institut National pour la Santé (RIVM): www.rivm.nl Conseil de la Santé: www.gr.nl Autorité pour la Sécurité des Aliments: www.vwa.nl Services de santé en Suède : Services du gouvernement suédois www.sweden.gov.se Direction nationale de la santé et des affaires sociales www.sos.se Association suédoise des autorités locales et régionales www.skl.se Conseil national pour l’évaluation des technologies médicales M:\02\11\03\36\

infosantésuisse : Dossier Die europäischen Gesundheitssysteme im Vergleich (Teil 4) 1/2010 1390

www.sbu.se Institut national de la santé publique www.fhi.se Institut suédois de prévention des maladies infectieuses www.smittskyddsinstitutet.se Conseil des prestations pharmaceutiques www.lfn.se Agence suédoise du médicament www.lakemedelsverket.se

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