Extended free choice of hospital - follow up

• Abstract
• Characteristics of this policy
• Purpose and process analysis
• Expected outcome
• References

Abstract

The rule of extended free choice of hospital was introduced to reduce waiting time and enhance competition in the hospital sector. The rule provides patients with an option to choose a private hospital if the public system is unable to provide treatment within the guaranteed waiting time. In 2007 the guaranteed waiting time was reduced form two to one month. The waiting time shortening created new incentives for public providers to compete with the private sector and increase activity.

Neue Entwicklungen

The rule of the extended free choice of hospital entitles patients to be treated at private hospitals in Denmark or hospitals abroad if the public health care system is unable to provide treatment within the guaranteed waiting time (see surveys (2) 2003, (3) 2004, (10) 2007). From October 2007 the guaranteed waiting time was reduced from two months to one month. The idea behind reducing the waiting time was to improve the patients' situation and strengthen incentives for effective use of the public hospitals' capacity. So far, there has been no official evaluation of the effects of the policy change. However, one can observe immediate effects with regard to the incentives for better utilisation of the public sector capacity. In response to the reduced waiting time, concrete steps have been taken to increase the activity of the public hospitals sector at the regional level.

More effective use of public capacities: "guarantee clinics" provide extra services

The regional governments, who are responsible for the organisation and financing of health care, responded to the policy change by developing the idea of so-called guarantee clinics. The idea does not involve setting up new clinics in a physical sense. It implies that some public hospitals enter an agreement with the regional governments and take on an obligation to provide extra services in the area of elective surgery, usually outside the normal working hours.

Guarantee clinics as a means to control rise in expenditures associated with new waiting time and expected increase in utilization of private providers

The idea was originated by representatives of the Social Democrats party in the regional governments. The Social Democrats were in opposition to the implementation of the policy of reducing the waiting time (see survey (10) 2007). The guarantee clinics are proposed as a means to increase competitive power of the public hospitals against the private hospitals. More importantly, the idea of guarantee clinics is expected to allow for a control of the rise of health care expenditures resulting from the reduced waiting time. The regional governments are concerned with regard to the rise of health care expenditures since every patient who chooses to be treated in the private hospital is more costly to the region's budget than a patient treated in the public hospital. The reimbursement system implies that the services provided in the private sector within the rule of the extended free choice of hospital are reimbursed with a 100% of the applicable DRG charges. Meanwhile, the mix of reimbursement methods applicable for the public providers implies that the regions reimburse the public hospitals with lower DRG charges - 50% in general, however there are variations between regions. The same consequence for the region's budget appears when the patient is treated in a public hospital in another region.

Financial incentives for public hospitals to become guarantee clinics

There are two types of guarantee clinics: hospitals which agree to treat a concrete additional number of patients and hospitals which agree to perform a so-called back-up function. The latter enter an agreement with the region assuming an obligation that no patient will be referred to the private sector. Since such function involves additional risk it is reimbursed with a special higher rate of DRG charges - e.g. 75% of the DRG charges in the Midtjylland Region. The former type of guarantee clinics is reimbursed for the extra services with the usual rate (around 50%) of the DRG charges. In this case, the incentive to make the agreement with the regional government comes from the extra benefits that the hospitals receive due to the increased activity. The hospitals operate as guarantee clinics within those departments where operational capacity is not fully used.

The process of setting up the guarantee clinics also involves investigations into possibilities of better utilisation of the practices run by specialist physicians who operate in Denmark as private entrepreneurs. This group of physicians was also considered as potential source of staff required for the extra services provided by guarantee clinics. 

The idea of guarantee clinics seems to be most advanced in the second biggest of the Danish regions - the Midtjylland Region - where the decision to establish guarantee clinics was considered already in 2006 and guarantee clinics were put into operation in 2007. At least three out of five Danish regions have been preparing to adopt the guarantee clinics within their territory.

Innovationsgrad	traditionell		innovativ
Kontroversität	unumstritten		kontrovers
Strukturelle Wirkung	marginal		fundamental
Medienpräsenz	sehr gering		sehr hoch
Übertragbarkeit	sehr systemabhängig		systemneutral
current    previous

Purpose and process analysis

Current Process Stages

	Idee	Pilotprojekt	Strategiepapier	Gesetzgebung	Umsetzung	Evaluation	Veränderung/Richtungswechsel
Implemented in this survey?

Initiators of idea/main actors

• Regierung

• Parlament

• Leistungserbringer

• Kostenträger

Stakeholder positions

The public providers reacted positively to the idea of guarantee clinics. It also seems that the hospitals managers perceive the function of guarantee clinic to reflect positively on the image of a hospital. It seems however to be the fact that the physicians have not been involved in the discussion on the planned development right from the beginning. Thus, some dissatisfaction with such state of affairs has been expressed by the members of the Physicians Association. Nevertheless, the different member groups of the Association released official statements supporting the idea, eventually.

Actors and positions

Regierung
Minister of the Interior and Health	sehr unterstützend		stark dagegen
Parlament
Parliament	sehr unterstützend		stark dagegen
Leistungserbringer
Public hospitals	sehr unterstützend		stark dagegen
Private hospitals	sehr unterstützend		stark dagegen
Kostenträger
National government	sehr unterstützend		stark dagegen
Region's local government	sehr unterstützend		stark dagegen
current    previous

Actors and influence

Regierung
Minister of the Interior and Health	sehr groß		kein
Parlament
Parliament	sehr groß		kein
Leistungserbringer
Public hospitals	sehr groß		kein
Private hospitals	sehr groß		kein
Kostenträger
National government	sehr groß		kein
Region's local government	sehr groß		kein
current    previous

Positions and Influences at a glance

Expected outcome

The positive reaction coming from the physicians seems to partly refute arguments that the reduction of the waiting time would result in an radical out-flow of the medical personnel from the public sector to the growing private sector. Physicians express interest in providing additional services in the public hospitals outside their normal working hours.

In addition, the debate on physician dual practice that attracted publicity in connection to the reduced waiting time seems to be based on exaggerated assumptions regarding numbers of physicians involved in dual work i.e. parallel work at a public and a private hospital. In mid 2007 an investigation into the prevalence of dual public-private hospital practice among senior physicians in Denmark was undertaken by the Association of Physicians. The results show that only 7% of the respondents were involved in this type of dual work.

Impact of this policy

Qualität	kaum Einfluss		starker Einfluss
Gerechtigkeit	System weniger gerecht		System gerechter
Kosteneffizienz	sehr gering		sehr hoch
current    previous

References

Sources of Information

• Foreningen af Speciallæge. Garantiklinikker i Region Midtjylland - en kort gennemgang (Guarantee Clinics in the Region Midtjylland - a short introduction). 2006.
• Indenrigs - og Sundhedsministeren. Rapport fra Udvalget om Vilkår for den Udvidede Fritvalgsordning på Sygehusområdet (Report from the Commission on the Conditions for the Extended Free Choice Policy in the Hospital Sector). 2006.
• Jensen Balle, Kurt. Flere Regioner på vej med Garantiklinikker (More Regions on the way to Introduce Guarantee Clinics). Ugeskrift for Læger (169) 24: 2294, 2007. www.ugeskriftet.dk/portal/page/portal/LAEGERDK/UGESKRIFT_FOR_LAEGER/
  TIDLIGERE_NUMRE/2007/UFL_EKCMA_2007_24/UFL_EKCMA_2007_
  24_52394
• Overægeforeningen. Medlemsbrev til Overlægerne Ansat i den Kommende Region Midtjylland Vedrørende Garantiklinikker (A Letter to Members of Specialist Physicians Association in the Region Midjylland concerning Guarantee Clinics). 2006.
• Region Midtjylland. Etablering af garantiklinikker i Region Midtjylland (Establishing of Guarantee Clinics). 2007.
• Socialdemokraten. Etablering af Garantiklinikker i Region Midtjylland (Establishing of Guarantee Clinics in Region Midjylland). Syddjurs (2) II: 9, 2007.
• Overlægeforeningen. Foreløbig Rapport om Overlægers Bibeskæftigelse (Report on Senior Physicians Dual Practite ). 2007.

Reform formerly reported in

Extended free choice of hospital - waiting time Process Stages: Umsetzung

Free choice of hospital extended Process Stages: Evaluation

Extended free choice of hospital Process Stages: Evaluation

Author/s and/or contributors to this survey

Socha, Karolina and Mickael Bech

Karolina Socha, is a Ph.D. student, Mickael Bech is Associate Professor at the  University of Southern Denmark, Institute of Public Health, Health Economics Unit.

Empfohlene Zitierweise für diesen Online-Artikel:

Socha, Karolina and Mickael Bech. "Extended free choice of hospital - follow up". Health Policy Monitor, April 2008. Available at http://www.hpm.org/survey/dk/a11/1