Table 4 The description of health policies aiming both OOP healthcare payments’ introduction and at OOP burden reduction

1 Bulgaria

1. Introduction of universal healthcare insurance system 2. Implementation of formal fees

The healthcare insurance act of 1998 converted the Bulgarian health system into a health insurance system. Since 2000 formal co-payments at 1 % of the minimum wage for GP and outpatient visit, 2 % of the minimum wage for the first 10 days of the hospital stay (no fee for a subsequent hospitalization during the year), emergency care without co-pays, full price for specialist care and other services outside the standard patient pathway. User fees apply to all patients with some exceptions: children, pregnant women, unemployed individuals, those with income below a certain threshold, chronically sick patients and some other groups.

There is a Positive Drug List which shortlist full coverage for outpatient, inpatient settings as well as treatment for oncological, rare, infectious diseases as well as AIDS. Drugs outside Positive List have to be fully paid out of pocket.

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2 France

1. Introduction of public complementary health insurance coverage for certain groups introduced

2. Implementation of formal fees

In general, healthcare insurance coverage varies from 100 % for hospital care to 70 % for ambulatory care and 60 % for medical auxiliaries as well as for laboratory tests. Full coverage exists for long-term illnesses, pregnant woman (after 5th month) and others. A system of copayments; since 2004, an extra co-payment for direct access to specialists or other GPs without remission (40 % of the standard SHI tariff). a flat-rate catering fee of €18 per day for accommodation in hospital. Since 2005, €1 on every physician visit, biological test and radiograph up to a ceiling of €4 per day and €50 per year has been introduced. Since 2006, patients have had to pay a flat rate of €18 for care with a statutory tariff over €91. VHI covers cost sharing without flat fees (other exemptions apply as well). The VHI population’s coverage increased from 50 % in 1970 to 88 % in 2006. A free public complementary health insurance (CMU) and a voucher scheme (ACS) for those who cannot afford VHI were established in 2000 and 2004 respectively.

Reimbursement rates varies from 15, 35, 65 or 100 %. On the average rate of reimbursement for drugs is estimated to be 73 %. There is a fee of €0.5 is charged for every drug package up to a ceiling of €50 per year .

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3 Ireland

1. The expansion of GP Visit Card accessibility

2. A decline of 95,000 in the number of Medical Card holders (1997–2005)

For medical card holders (eligibility is set based on income and age) there is a free of charge GP, hospital and dental care, drugs, medical appliances and others. Non-medical card holders pay out of pocket for GP visits (from €50 to €90), consultants’ fees, €66 for hospital stay per day up to €660 per year. Based on a referral for inpatient and outpatient services, no charges are levied for diagnostic tests. Private health insurance covers fully OOPs for inpatient care and outpatient services to some extent. The costs of dental and optical care is reduced for Treatment Benefit Scheme holders (operated by the Department of Social and Family Affairs for those who pays Pay-related social insurance). The number of medical cardholders decreased from 37 % in 80-ties to 30 % in 2007. Since 2005, for those with income up to 50 % (change from 25 %) higher than the ceiling for a Medical Card, a free of charge GP visits’ system (GP Visit Card) was introduced. The evolution of private health insurance from 4 %- 1960 to 35 % -1987

For medical card holders - free of charge, for others - up to €90 per month. For chronic long-Term Illness Scheme, open to individuals with one of a number of predefined chronic conditions - covers the costs of all necessary pharmaceuticals, medicines and appliances Others bears full cost of the drug but they should apply for a Drugs Payment Scheme (DPS) which limits out-of-pocket expenditure for an individual or family to no more than certain ceiling (for example in 2014; €144) per calendar month for prescribed pharmaceuticals, medicines and appliances. DPS replaced Drugs Refund Scheme in July 1999. DRS operated on similar principles as DPS.

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