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264 Economic crisis, health systems and health in Europe: country experience
medical specialist care provided in hospitals is currently not included in these
negotiations because of this budget cap. From 2015 onwards, 70% of hospital
care will be subject to price negotiations, including medical specialist care. 9 The
Health Care Authority will continue to set the remaining 30% of tariffs.
Health care budgets were also reduced in the area of primary care: in 2010, the
budget for capitation fees for GPs was reduced by €60 million and GPs were
allowed to earn it back by prescribing medicines more efficiently (e.g. prescribe
cheaper generic drugs; Table 8.5) and thus reducing the expenditure on
pharmaceutical care. In 2012, the Ministry of Health concluded an agreement
(implemented in 2013) with the National Association of General Practitioners:
no tariff reduction would be imposed by the Ministry for the amount overspent
in 2011 (€99 million), while at the same time the National Association agreed
to realize a saving of €50 million through prescribing cheaper generic drugs
in 2012. It was also agreed that the central role of GPs as gatekeepers would
be strengthened and GPs would have a more central role in the provision of
care in the community. Therefore, expenditure on GP care was allowed to
grow by 2.5% per year between 2014 and 2017. In addition, expenditure on
the coordination of community care (including GPs and other providers) was
allowed to grow by an additional 0.5% per year in 2012 and 2013 (National
Association of General Practitioners & Ministry of Health, 2012).
In an agreement signed in 2013 between health care providers (in both primary
and specialized care), insurers, patient associations and the Ministry of Health, all
stakeholders agreed to a further decrease in the growth in health care expenditure
to 1.5% in 2014 and to 1% per year between 2015 and 2017. This decrease was
mainly to be achieved through the substitution of secondary care with primary care
and by continuing the efforts to prescribe medicines more efficiently. Moreover,
public health expenditure would be monitored closely and reimbursement of
treatments, medication and medical devices could be put on hold if the agreed
growth in expenditure was exceeded. For GP care, a higher percentage of 2.5%
per annum between 2014 and 2017 was maintained, provided that GPs managed
to decrease the number of referrals to hospital care (no absolute target was
prescribed but GP practices would receive information about referral rates of
other practices – practices with relatively high referral rates should reduce the
number of referrals). If GPs do not achieve a decrease in the number of referrals,
the Ministry of Health could impose new (tariff) measures (National Association
of General Practitioners & Ministry of Health, 2013).
9 Diagnosis and treatment combination prices are negotiated by hospitals; prices cover the normative working times of
medical specialists. These working times are set by scientific associations of medical specialists and cannot be negotiated;
however, their price can be. Currently, because of the budget cap for medical specialists, hospitals can no longer negotiate
on the price of these working times. This will change in 2015: hospitals will again be able to negotiate on DBC prices,
including the price of working times of medical specialists, with the insurers and will then negotiate on the payments
with their medical specialists.