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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.