3.4 Out-of-pocket payments
3.4.1 Cost sharing (user charges)
Patients pay out-of-pocket payments for part of the cost of dental care, physiotherapy, psychological services and other providers outside hospitals, except for GPs. For dental care, the reimbursable amount depends on the procedure performed, but usually only a small part of the total cost is reimbursed, resulting in high co-payments. Inequity in dental status has been attributed to these high co-payments.
Drugs prescribed at hospitals are free at the point of delivery, whereas drugs prescribed by GPs are subject to co-insurance. The degree of co-insurance depends on the individual patient’s drug costs in a year. If the individual patient’s costs do not exceed DKK 865 (€116), the patient does not receive a refund (although patients under 18 years of age will receive a refund of 60% of their drug costs); patients with drug costs of DKK 865–1410 (€116–189) receive a refund of 50% (patients below 18 years of age, 60%); patients with drug costs of DKK 1410–3045 (€189–408) receive a refund of 75% (independently of their age); and patients with drug costs above DKK 3045 (€408) receive a refund of 85%.
Chronically ill patients with permanent or high drug utilization levels can apply for full reimbursement for any expenditure above an annual ceiling of DKK 3555 (€477). The municipalities may pay part of pensioners’ drug costs, the size of the share depending on the pensioner’s capital. Pensioners who find it difficult to pay for pharmaceuticals can apply to their municipality for financial assistance. Patients with very low income can receive partial reimbursement, on a case-by-case basis. In addition, many individuals purchase VHI to spread the risk of high drug costs and level out the cost of drugs prescribed outside hospitals over time.
Pharmacies are required to substitute the least expensive generic drug for the drug prescribed by the GP to reduce drug costs for the public sector as well as for the individual patient.
Out-of-pocket payments are not tax deductible. Limits to costs in drugs but not in other areas (dentistry and other providers outside hospitals) means that user charges in some areas have consequences for individual patients and for equality (see sections 3.7, 7.2 and 7.3.2).
There is no clear pattern behind the utilization of user charges. User charges play a major role in financing dental services, glasses and drugs prescribed outside hospital, as well as some other services provided by independent providers, such as psychologists, physiotherapists and chiropractors, whose services constitute a relatively small share of total health care costs (Table3.4).
User charges have been proposed as a means to reduce the demand for health care services, to promote a more efficient utilization of the health care sector’s resources and to raise revenue. No explicit policy is in place, but decisions on user charges are made by the national government.
Breaking away from the traditional provision of hospital services free at the point of delivery, user charges were introduced for three kinds of hospital care on 1 January 2011: fertilization treatment, 4 sterilization (DKK 8457 (€1134) for men and DKK 12 984 (€1741) for women) and refertilization (DKK 5949 (€798) for men and DKK 33 933 (€4550) for women). According to the bill, the charges for fertilization treatment reflect three considerations:
- how much money the patients, on average, are assumed to be able to afford to pay;
- the need for revenue for the public sector, facing the actual financial crisis; and
- the costs associated with the interventions (the charges may not exceed the actual costs, as approximated by the DRG charges for the intervention).
Some of these user charges introduced in 2011 by the former government have been abolished by the new government in place.
Employers and individual citizens may take out VHI to spread the risk of paying user charges. VHI is tax deductible for employers if all employees are covered. The data on VHI coverage of the Danish population are very poor (see sections 3.3.1 and 3.5).
Central Denmark Region is piloting a system of financial penalties for patients’ non-attendance. Patients will be fined DKK 250 for non-attendance on outpatient visits at the department of orthopedic surgery at Viborg Hospital and at the department of radiology at Silkeborg Hospital. Non-attendance rates in these departments are 4% and 5%, respectively. This initiative aims to evaluate the effectiveness of financial penalties in terms of patient showing up. It has triggered negative reactions from patients’ organizations and the Danish Medical Association. Some regions have highlighted that patients may demand financial compensation for cancelled outpatient visits. More information (in Danish): http://ugeskriftet.dk/nyhed/hospitaler-klar-til-udskrive-pjaekkeboeder-til-patienter
3.4.2 Direct payments
Patients pay directly for glasses, over-the-counter drugs and cosmetic surgery. Prices are set competitively.
3.4.3 Informal payments
In Denmark, patients do not pay informal payments for health care.
The previous centre-right government introduced user charges for in-vitro fertilization, sterilization and re-fertilization effective from 2011. The present centre-left government rolled these user charges back effective from January 1st 2012 as they were considered to create unreasonable barriers for access to health care and thereby reducing utilization of relevant services.
Link to announcement (in Danish): http://www.sum.dk/Aktuelt/Nyheder/Sundhedspolitik/2011/November/FL-sundhedsomraadet.aspx