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4 Urgences KCE reports vol. 19B 2. DOELSTELLINGEN VAN HET ONDERZOEK Om de beleidsmakers te ondersteunen in dit debat is het KCE gevraagd een onderzoek uit te voeren naar het gebruik van spoedgevallendiensten, de maatschappelijke impact en mogelijke organisatiealternatieven om tegemoet te komen aan medische zorgvragen. Via literatuuronderzoek en kwantitatief en kwalitatief veldonderzoek, wordt onderzocht welke factoren mogelijk een rol spelen in de keuze van de patiënt om de dienst spoedgevallen of de huisartsenwachtdienst te consulteren. Doelstelling van dit onderzoek is een (begin van) antwoord te formuleren op de volgende onderzoeksvragen: Wat is bekend uit de internationale literatuur over impact van het innen van (forfaitaire) bedragen op het gebruik van spoedgevallendiensten voor uiteenlopende maatschappelijke doelgroepen, en wat is relevant voor België? Heeft het innen van een eigen bijdrage van de zorgconsument een impact op de toegankelijkheid en het gebruik van medische dienstverlening in het algemeen? Valt de zorgconsument te responsabiliseren met betrekking tot het gebruik van spoedgevallendiensten door het innen van eigen bijdragen? Voor de Belgische situatie stelt de vraag zich naar de impact van het innen van 12,5 € op de oneigenlijke zorgconsumptie van spoedeisende hulp. Welke motieven of factoren bepalen bij zorgconsumenten de keuze voor het gebruik van de spoeddiensten versus het al dan niet gebruik van andere eerstelijnsvoorzieningen? Hierbij dient uiteraard eerst nagegaan in hoeverre dit forfait gekend is bij de zorgconsument. Welke organisatorische alternatieven bestaan er om de niet doelmatige instroom van patiënten op spoedgevallen (oneigenlijk gebruik), op te vangen via een kwaliteitsvol en drempelverlagend effect (i.h.b. moet de aandacht gaan naar de verhouding spoeddienst-eerste lijn). Heel belangrijk in dit verband is het objectief kunnen aflijnen van oneigenlijk gebruik van een spoedgevallendienst.
KCE reports vol. 19B Urgences 5 3. MEASURES TO CHANGE EMERGENCY DEPARTMENT ATTENDANCE OF HOSPITALS: INSIGHTS FROM THE LITERATURE. 3.1. BACKGROUND: THE ECONOMIC LOGIC OF CO-PAYMENTS IN HEALTH CARE In most developed countries with public health care systems patient cost-sharing b arrangements are imposed. Cost-sharing or user charges refer to a situation where the individual covered is required to pay part of the cost of care received 3, 2, 1 . Cost-sharing can take several forms on a continuum ranging from full thirdparty payment (zero cost-sharing) to full cost-sharing 4 . In this report we focus on direct forms of cost-sharing c (see Table 1), as the 12,5 € measure taken in Belgium for ED consultation falls into the category co-payment. Table 1. Direct forms of cost-sharing Form Definition co-payment the user pays a fixed fee (flat rate) per item or service co-insurance the user pays a fixed proportion of the total cost, the insurer pays the remaining proportion Deductible the user pays a fixed quantity of the costs (up to a certain threshold), the insurer pays the remainder Source: based on WHO (HEN),2004 1 and Thomson, 2003 3 Cost-sharing has different aspects to be considered and is still open for fundamental scientific and political debate: 1- efficiency aspects, related to fighting moral hazard; 2- the potential health effects and 3- equity effects. Cost-sharing can lead to a reduction in overall utilisation of services and drugs, but does not necessarily lead to a reduction in the overall costs of health care, because of possible cost-shifting. Moreover, cost-sharing may inequitably affect vulnerable groups (women, children and the poor). In order to improve the ÿ allocative efficiency it is considered important to have different cost-sharing requirements for different types of health interventions, and (from an equity point of view) to have different cost-sharing requirements for different people 5 . 3.1.1. Efficiency argument: fighting moral hazard The basic economic argument for cost-sharing arrangements on health care markets is to avoid full health insurance patients to consume more health care than they would if they had to pay for the health services themselves. This type of problem is generally referred to as moral hazard . Cost-sharing may stimulate the cost consciousness of patients by restoring the price signal that was negated by insurance. Proponents of costsharing arrangements argue that direct payments at the point of use will discourage the use of services and hence reduce expenditures. The policy measure taken on ED attendance fits into this logic. b In this report we neglect other types of out-of-pocket payments such as informal and direct payments. Informal payments (envelope or under-the-table payments) are different payments to individual and institutional providers in kind or in cash outside official payment channels or for purchases meant to be covered by the health care system 1 . Direct payments are payments for goods and services that are not covered by any form of pre-payment or insurance and that are obtained from the private sector in pure private transactions 2, 1 . c Indirect cost-sharing refers to policies that can result in patient payments even though charges are not directly imposed. Coverage exclusions and certain forms of pharmaceutical regulatory mechanisms are some examples.
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KCE reports 1. Efficacité et renta
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