3.4 Out of pocket payments
OOP payments in the Czech Republic mainly consist of (1) direct payments for over-the-counter pharmaceuticals and some dental procedures; (2) co-payments on medical aids and prescription pharmaceuticals, the actual price of which exceeds the reference price in a particular pharmaceutical group, and – between 2012 and 2013 – on above-standard care (see section 3.3.1); and (3) user fees for prescription pharmaceuticals and various health services. These three categories accounted for virtually 100% of all private sources of health expenditure and for 15.7% of total health expenditure in 2011 (Czech Statistical Office, 2014a). OOP payments as a percentage of final household expenditure in the Czech Republic remain among the lowest in OECD countries (OECD, 2014a).
3.4.1 Cost-sharing (user charges)
Until the end of 2007 inpatient and outpatient health services were free of charge at the point of use, with the exception of some prescription pharmaceuticals and medical aids. Starting in 2008, flat user fees of CZK 30 (€1.20) per doctor visit, CZK 60 (€2.40) per hospital day and CZK 90 (€3.60) per use of ambulatory services outside standard office hours were introduced as a method of containing costs by reducing inappropriate demand. A flat user fee of CZK 30 (€1.20) was also introduced for each prescribed pharmaceutical (thus, a patient would pay CZK 60 for one prescription with two prescribed pharmaceuticals on it). This was changed to a flat fee of CZK 30 (€1.20) per prescription in 2012 (thus, the patient pays only one fee even if there is more than one pharmaceutical on the prescription). Since 2009, for pharmaceuticals for which the actual price exceeds the reference price in a particular pharmaceutical group, patients additionally must either pay the difference in price or pay CZK 30 (€1.20), whichever is greater. In 2011 the user fee per hospital day was increased from CZK 60 to CZK 100 (€4.00).
Some groups were (and are) exempt from the fees, including people living below the poverty line, neonates, chronically ill children, pregnant women, patients with infectious diseases, organ and tissue donors, and individuals receiving preventive services. Moreover, an annual ceiling of CZK 5000 (€200) per insured individual was established for selected user fees (user fees for hospital stays and the use of ambulatory services outside standard office hours were (and are) not included in the individual calculation of ceilings), as well as for co-payments on prescription pharmaceuticals the actual price of which exceeds the reference price in a particular pharmaceutical group. Due to popular and political opposition to the user fees, the annual ceiling was lowered to CZK 2500 (€100) in 2009 for persons under 18 and over 65 years. Patients who exceed this limit are reimbursed for the additional user fees and prescription pharmaceutical co-payments by their health insurance fund. Moreover, children up to the age of 18 years were exempted from user fees for doctor visits. In 2013 the CZK 2500 (€100) ceiling was reached by 228 000 people (approximately 2.2% of the population) (Ministry of Health, 2014a). In July 2013 the Czech Constitutional Court abolished the user fees for hospital days as of January 2015. The main argument behind this decision was that CZK 100 (€4) per day was unfair to certain vulnerable groups. User fees have been politically divisive and controversial as well as unpopular among the population since their introduction (Van Ginneken et al., 2010). Any future developments will heavily depend on who is in power. Before the early elections in October 2013 most political parties (including the Social Democratic Party, ČSSD) declared they wanted to maintain user fees per hospital day at CZK 60 (€2.40) and fees for the use of ambulatory services outside standard GP office hours. The new coalition (ČSSD, ANO, KDU-ČSL) abolished user fees per doctor visit and for prescription pharmaceuticals in January 2015, therefore only the user fee for the use of ambulatory services outside standard office hours remains in force, at CZK 90 (€ 3.60).
Table3.6 summarizes changes in user fees between 2008 and 2015 in the Czech Republic.
3.4.2 Direct payments
Direct payments consist of payments for over-the counter pharmaceuticals and medicinal products and non-SHI services and are limited in scope given the broad SHI benefit package. Direct payments are, for instance, payments for treatment by selected senior physicians or more luxurious hotel-related services in inpatient settings.
Approximately 42% of total expenditure on dental care is funded privately through OOP payments, as the range of dental treatments covered by SHI is limited and restricted to the least expensive options. Most insured individuals choose to pay in full for higher-quality dental materials (although the treatment itself is usually covered by SHI). OOP payments on dental care accounted for 15.6% of total OOP expenditure on health care in the Czech Republic in 2012 (OECD, 2014a).
3.4.3 Informal payments
There is little official evidence on informal payments in the Czech health system. According to the Transparency International Global Corruption Barometer 2013, 15% of the population make informal payments in the health system. A European Commission study on corruption in the health care sector (European Commission, 2013) found that informal payments by patients are relevant only in relatively limited areas of Czech health care. For example, more timely treatment of non-life-threatening but highly painful conditions (such as hip replacement) are said to be susceptible to informal payments. Equally, informal payments occur in gynaecology and obstetrics. Additionally, the study suggests that corruption in public procurement is a serious issue (see also Chapter 7).
As of January 1, 2020, people with moderate and severe disability have been newly assigned to the lowest copayment limit of CZK 500 (EUR 18.7). People with moderate and severe disability are defined as those with the 2nd and 3rd disability level according to the Act on Social Services. Defined copayments on prescribed pharmaceuticals will be reimbursed after reaching the annual limit. This measure further extends financial protection for socially vulnerable groups (see log from 29/4/2017), and broadens previous limit definition which was based only on age.
Act 282/2018 Coll. amending Act 48/1997 Coll. on Social Health Insurance
In January 2017, the government approved the MoH’s proposal to reduce the annual ceiling on copayments for prescribed pharmaceuticals for a) children up to 18 years of age and b) for the elderly above 65 years of age within an amendment to the Law on Public Health Insurance. The ceiling reduces significantly from CZK 2,500 (EUR 93) to CZK 1,000 (EUR 37). In addition, the limit for 70+ further reduces to CZK 500 (EUR 18.7). The proponents argue by social vulnerability of these groups.
The State Institute for Drug Control sets about 6,000 pharmaceuticals that count into the limit. However, only a share of copayments for these drugs that equals the copayment on the cheapest pharmaceutical in each ATC group counts into the copayment limit. Once the ceiling has been exceeded and a patient applies, health insurance fund reimburses the excess amounts. On February 22, 2017, the proposal was approved by the one Chamber of the Parliament already. Once approved by Senate, the new ceiling on copayments for pharmaceuticals should come into effect from January 2018 onwards.