|Waiting List Reduction: Activity- Based Grant|
|Free Choice of Hospital|
|Free choice of hospital extended|
|Implemented in this survey?|
The rule of extended free choice of hospital was introduced in 2002 to reduce waiting times, enhance competition among public hospitals and give a larger role to private providers. So far, the rule has entitled patients to treatment at a private hospital in Denmark or a hospital abroad if the public health care system is unable to provide treatment within two months. As of 1 October 2007 the extended free choice of hospital will come into effect if the waiting time exceeds one month.
Legislation on free hospital choice in 2002
The hitherto existing regulations concerning patients' access to extended free choice of hospital have a basis in the law introduced by the 2002 reform (See surveys (2) 2003, (3) 2004). The 2002 reform program called "Welfare and Choice" aimed at enhancing competition and quality of public services through allowing citizens to choose between different solutions. In the health care field the reform extended the existing right to free choice of hospital from 1993 by allowing patients to choose not only between different public hospitals but also to receive treatment free of charge at a private hospital in Denmark or a hospital abroad if the waiting time for treatment in the public health care sector exceeded two months. By the same means the maximum waiting time was reduced by one third - from three to two months. Waiting time was defined as the time span from the point of referral to the beginning of treatment.
The extended free choice of hospital comes into effect on the condition that the chosen private or foreign hospital has entered an agreement with the regional authorities regarding the treatment in question (as a result of the Danish Structural Reform, the 14 counties were re-aligned as of January 2007 to form 5 new regions).
New developments since 2005
In 2005 the Danish government announced intentions to further alter the regulations for extended free choice of hospital introduced by the 2002 reform. The commitment was announced in the so-called 2005 "New Goals" programme, which stated that from 2007 the rule of the extended free choice of hospital will come into effect if the public health care system is unable to provide treatment within a waiting time of one month.
In December 2006 a new amendment act to the Health Law thus shortened the waiting time from two months to one month, with effect from 1 October 2007. The amendment is limited to a shortening of the waiting time, leaving unchanged the other provisions of the regulations on the free choice of hospital.
In summary, from 1 October 2007 Danish patients in need of hospital treatment will first have free choice, within certain limits, of the public hospital they wish to be treated at across regional borders, and thereafter can choose a private hospital in Denmark or a hospital abroad if the waiting time for the treatment exceeds one month.
|Medienpräsenz||sehr gering||sehr hoch|
|Implemented in this survey?|
There has been little change in the political background behind the amendment to the rule of the extended free choice of hospitals since the inception of the idea in 2002. Stakeholders' positions towards the policy are unchanged and there have been no serious conflicts between stakeholders or appearances of new alliances.
The leadership role in bringing forward the amendment has been handled by the Liberal-Conservative government, in power since autumn 2001. Outside the governmental coalition, the idea of a shorter waiting time gained support from the Danish People's Party (the third biggest party in the parliament) and the proposal was adopted with 59 votes of support against 49 votes against. Opponents to the proposal did not explicitly object to the shorter waiting time, but rather questioned the proposed financial and organisational arrangements for achieving the goal. The major argument was set by the Social Democrats (the second biggest party in the parliament), who criticised the proposal for its market-oriented character and opposed the idea of enhancing the role of private health care providers.
The regional governments, who are responsible for the organisation and financing of the health care sector, supported the general idea of shorter waiting times, but also had some reservations due to the financial and organisational aspects of the amendment. As mentioned above, the regions are responsible for entering into and financing agreements with private hospitals or hospitals abroad in order to facilitate the functioning of the extended free choice of hospital. Due to differences in the reimbursement rates applicable to public and private or foreign hospitals, it is conceivable that the costs of treatments performed at the private or foreign hospitals are higher than those at public hospitals. Since the number of patients treated in the private hospitals will rise as a consequence of waiting time reduction and the limited capacity of the public health care sector, the regional governments have feared for their budgets.
Public providers, represented most often by hospital managers, have been sceptical about the possibilities for a successful implementation of the one-month waiting time, claiming that this new waiting time is too short. At the same time, however, there have been signals from some public hospitals that their operational capacity can be improved. Numerous hospitals have also positively welcomed the regional governments' initiatives that aim at enhancing public sector capacity through the establishment of so-called "guarantee clinics". The assumption is that such clinics will allow the public hospitals to operate over-time or to increase capacity in selected areas. The proposal has been strengthened by strong financial incentives, in that the hospitals interested in being a "guarantee clinic" are offered higher reimbursement rates for their over-time services than for their standard services. The costs borne by the regional budgets are expected to be lower, however, than the reimbursement rates applicable to services performed by private or foreign providers.
Furthermore, a number of regional politicians and public hospital physicians have voiced concerns regarding potential staffing problems in the public sector due to the growth of private hospitals, which compete for physicians by offering better earning conditions.
In the same context, the issue of physicians' dual clinical practice has also become a major concern. The notion of dual practice as raised in the public debate refers to physicians' simultaneous public-private clinical practice. The predominant assumption is that dual practice harms the productivity and quality of public health care due to a concentration of the physician's time and effort in the private sector, which offers more attractive financial rewards. It is also argued that dual practitioners with a substantial private practice income tend to restrict their total labour supply, thus reducing overall health care provision. Moreover, in the context of the one-month waiting time and a subsequent possibility to refer public patients to private hospitals, dual practice is often described as an invitation to manipulate the public sector in favour of the private sector. As a result, there are frequent calls for a ban on dual practice. The concerns raised and the calls for a ban on dual practice have, however, not been addressed by legislative policy proposals.
|Minister of the Interior and Health||sehr unterstützend||stark dagegen|
|Parliament||sehr unterstützend||stark dagegen|
|Publlic hospitals||sehr unterstützend||stark dagegen|
|Private hospitals||sehr unterstützend||stark dagegen|
|National Government||sehr unterstützend||stark dagegen|
|Regions' local governments||sehr unterstützend||stark dagegen|
The proposal to enhance the hitherto existing rules for the extended free choice of hospital by shortening the waiting time from two months to one month was met with support from different parliamentary parties, but the financial and organisational arrangements proposed for achieving the goal gave rise to disputes. Despite this, the proposal for the amendment was adopted without any major change to the orginal content as submitted by the Minister of the Interior and Health.
|Minister of the Interior and Health||sehr groß||kein|
|Publlic hospitals||sehr groß||kein|
|Private hospitals||sehr groß||kein|
|National Government||sehr groß||kein|
|Regions' local governments||sehr groß||kein|
The groups directly affected by the new regulations are the patients and the regions, along with their public hospitals.
Indirectly, the new legislation will have a positive effect on the private health care sector, since it is likely that the demand for privately offered health care services will grow and then stabilise at a much higher level than currently.
Patients in need of a planned operation will be the winners in the new situation due to considerably shorter waiting times.
The regions, who are responsible for entering into and financing agreements with private or foreign providers, will probably experience an increased workload in this area as a result of an expected increase in cooperation with private or foreign health care providers.
Indirect beneficiaries may also be members of the medical labour force, as the demand for their services will definitely rise and there may be greater employment opportunities in the private sector.
As the new waiting time regulations have only recently come into force, it is too early to evaluate the course of the implementation process.
The policy initiative providing for the extended free choice of hospital and the two-month waiting time guarantee has been evaluated by various governmental agencies and the Association of Counties (see previous survey no (3) 2004). The evaluation reports indicate a general satisfaction among the stakeholders (patients, counties and their hospitals, private hospitals) and high patient satisfaction with the treatment in the private hospitals. However, the private hospitals indicated some dissatisfaction with the level of information that the public hospitals and/or counties provide to patients regarding the rule of the extended free choice of hospital.
The number of patients actually using the extended free choice of hospital seems to be limited in comparison with the expectations. The available reports do not, however, allow an explicit determination of the reasons for this. It seems that most of the activity affected by the patients' right to extended free choice of hospital is related to hospitals located close to county borders with historical and geographical links to patient groups in other counties. Several surveys indicate that patients tend to prefer treatment close to their homes and that preferences are not exclusively tied to waiting times. Intra-county choices have been more difficult to trace, but limited evidence also indicates a preference for proximity.
In spring 2007 the Danish Institute of Health published a report analysing data on hospital activity in 22 Diagnosis Related Groups (DRG) in order to test the hypothesis of the so-called "cream-skimming" exercised by private health care providers. The hypothesis assumes that the use of private providers to facilitate the extended free choice scheme causes inequality in access to treatment among patients with different severity as the private providers, operating under strong economic incentives, select less severe patients in order to avoid costly treatments. The findings of the report have not confirmed the "cream-skimming" hypothesis.
The policy amendment will be another step in the direction of competition in the health care system. This fact raises numerous traditional questions about the advantages and disadvantages of the private provision of health care.
The introduction of private hospitals, which operate under strong economic incentives, to publicly financed health care has given rise to concerns about the quality of health care, and especially the equality of patient access to health care. In the light of the above-mentioned assessments, however, these concerns seem to be rebuttable and the reduction of the maximum waiting time from October 2007 will not change the situation. In general, the policy seems to serve well in achieving the postulated goals of improved access and responsiveness, and its net impact on the functioning of the overall health care system seems to be advantageous.
Nevertheless, it is conceivable that the private health care sector will play a larger role after October 2007, for example through employment of a much higher number of physicians. The issue of supply of physicians' labour in a market with more private providers and extended opportunities for dual clinical practice would appear to require an investigation.
|Qualität||kaum Einfluss||starker Einfluss|
|Gerechtigkeit||System weniger gerecht||System gerechter|
|Kosteneffizienz||sehr gering||sehr hoch|
|Waiting List Reduction: Activity- Based Grant|
Process Stages: Umsetzung, Evaluation, Gesetzgebung
|Free Choice of Hospital|
Process Stages: Umsetzung
|Free choice of hospital extended|
Process Stages: Evaluation
Socha, Karolina and Mickael Bech
Karolina Socha, Ph.D. Research Fellow, Institute of Public Health - Health Economics Department and Mickael Bech, Associate Professor, Institute of Public Health - Health Economics Department