European Observatory on Health Systems and Policies


Health Systems in Transition (HiT) profile of Greece

3.4 Out of pocket payments

Greece’s health system has always relied on a large share of private financing, with high OOP payments particularly because of public health sector’s underfunding. OOP payments form the bulk of private health financing and in 2015 amounted to 35% of current health expenditure, increasing from 28% in 2010.

3.4.1 Cost-sharing (user charges)

The largest share of user fees is for co-insurance charges on pharmaceuticals. The increases in co-insurance for medicines treating specific diseases have resulted in increased average monthly household pharmaceutical expenditure, despite price reductions in pharmaceuticals. Cost-sharing for services provided in the public health care sector is considered to be low. In 2011, an increase in user charges from €3 to €5 was imposed on outpatient services provided in public hospitals and health centres; however, the charge was abolished altogether in 2015. In addition, a €25 patient fee for admission to a state hospital was introduced in 2014 together with an extra €1 for each prescription issued under the ESY (both in primary/ambulatory care and inpatient settings; Law 4093/2012). The hospital admission fee was also revoked in 2015 as major concerns regarding the impact on access to care were raised by health professionals and other stakeholders; instead, an extra tax on cigarettes was imposed. In 2016, exemptions were introduced regarding the €1 prescription charge to relieve former welfare beneficiaries, the uninsured on low income and those belonging to vulnerable groups.

The most common cost-sharing arrangements are outlined here and in Table3.4.

Primary/ambulatory care. All visits to physicians in primary care (GPs) are free of charge. Patients may visit the outpatient departments of hospitals or health centres (located mostly in rural areas) or an EOPYY-contracted physician (a GP or a specialist) free of charge. The ceiling imposed on the number of consultations provided by the contracted physicians is 200 consultations per month (50 consultations per week) and not more than 20 visits of insured patients per day. This means that once the ceiling for consultations is reached, patients may need to seek care in private settings. EOPYY allows insured patients to visit a non-contracted physician, pay them the fee for service directly and later receive reimbursement of a fixed amount ranging between €10 and €20, which is below the market price of about €50 on average. Additionally, a minimum time limit of 15 minutes per patient has been set.

Outpatient specialist visits. Since 2002, doctors working in public hospitals are able to run private outpatient clinics in the afternoons, with payments distributed between the hospital (40%) and the physician (60%). The rationale behind the introduction of private clinics in public hospitals was to reduce informal payments and tax evasion as well as to enhance patient choice. This came at the cost, however, of increasing inequalities in access. In 2013, the Ministry of Health established a 20% reduction rate on physicians’ fees, with flat rates moving to €36–72 for professors in university-affiliated hospitals, €24–64 for physicians in Athens and Thessaloniki and €16–44 for the rest of the country, while in arid areas the price is set at €24. Fee reductions were implemented in an effort to make services more affordable for citizens. Demand for afternoon outpatient clinics has fallen substantially since 2009, reflecting the deterioration in household incomes.

Outpatient pharmaceuticals. User charges on pharmaceuticals constitute the highest share of cost-sharing revenue. The rate of co-insurance for an outpatient drug prescription varies bet ween 0% (exemptions) and 25% (typical charge), depending on the health condition and population group. There is no user charge for medications for cancer, psychosis, haemophilia, renal deficiency, multiple sclerosis, paraplegia, quadriplegia, immune system deficiency and some other conditions; an exemption is also applied to individuals or families with low income (below €2400 and €3600 per year, respectively, increasing by €600 for each dependant); for those with low income (below €6000 per year) and suffering from a chronic disease; for children under 18 years hosted in social care; and some other population groups. A co-insurance charge of 10% applies for pensioners on low income and for medication for Alzheimer’s and Parkinson’s diseases, dementia, diabetes, epilepsy, chronic pulmonary heart disease, osteoporosis, tuberculosis, asthma and some other conditions.

Co-insurance rates for some medicines were introduced or increased in 2011 (Economou et al., 2015), increasing the average proportion of patients’ cost-sharing for pharmaceuticals from 13% in 2012 to 18% in 2013. At the same time, the proportion of prescribed medication packages that did not require a patient co-payment fell from 13% to 8% (Siskou et al., 2014b). In addition to the co-insurance charges outlined above, there is an additional user charge for the difference between the retail price and the reference price reimbursed by health insurance, currently set with an upper limit of €20 (Law B64/16-01-2014 & amendment Γ5/41797/3-6-2015), as well as an extra fee of €1 per prescription issued under the ESY. The uninsured, the poor and some other vulnerable groups are exempted from the co-payment.

Inpatient stay. Although there are no user charges for hospital treatment in the public sector for those who are insured (section 3.3.1), there are some OOP payments in public hospitals, which include hospital charges for services not reimbursed by EOPYY (e.g. an extra charge for hospitalization in rooms with advanced hotel facilities, payments for some pharmaceuticals, direct payments and co-payments for some laboratory or diagnostic tests). User charges for hospitalization in contracted private clinics are set at 30% of the cost of the services (except for members of the Agricultural Insurance Organization, whose contribution is set at 50%).

Dental care. A fixed low fee (much lower than the market prices) exists for a limited set of dental services provided by contracted dentists. However, to date, no private sector dentists have actually been assigned contracts. Within the ESY, there is limited capacity to provide dental services in health centres, which are usually understaffed (section 5.12); dental services are also provided in dental outpatient departments of public hospitals. Recently many services (e.g. dental prosthetics) have been removed from the reimbursement list, and OOP payments for dental treatment have increased markedly. The lack of full coverage, either by EOPYY or by private insurance, makes dental care one of the predominant fields for direct payments, with over 15% of total OOP expenditure financing dental treatment in 2014 (OECD, 2018a).

Diagnostic and laboratory tests. These are covered with co-insurance, which ranges from 0% (in public hospitals) to 15% (in contracted centres). No reimbursement is provided to the insured visiting non-contracted diagnostic laboratories.

3.4.2 Direct payments

Direct payments form the highest share of private expenditure on health (more than 90%), with the majority representing OOP payments at the point of use for services not covered by the state. However, existing data do not allow a distinction between cost-shared and entirely OOP expenditure.

A notable increase in OOP payments for hospital services has occurred, doubling from 5.2% of current health expenditure in 2009 to 11.2% in 2015. Possible reasons for this rise include increased user charges, the high number who were uninsured and had to pay for hospitalization costs and direct payments for expensive tests not covered by SHI. Direct payments for medical goods (e.g. pharmaceuticals and devices) also increased, from 6.7% of current health expenditure in 2009 to 13.0% in 2015 through the tightened exemptions and an increase in co-insurance for certain medications. In contrast, payments for ambulatory services decreased from 15.5% of current health expenditure in 2009 to 9.3% in 2015, possibly due to the limited capacity of households to pay for non-emergency consultations and preventive services (Eurostat, 2018c).

3.4.3 Informal payments

Informal payments, which are included in the calculations of private expenditure, represent more than a quarter of OOP payments in Greece, raising serious concerns about access barriers to health care services (section 7.3). One of the main reasons for their scale and existence is the lack of a rational pricing and remuneration policy within the health care system. Studies have shown that almost one in three patients reported making at least one informal payment; these were mainly for the provision of hospital services or payments to physicians, primarily surgeons, so that patients can bypass waiting lists or ensure better quality of service and more attention from doctors (Liaropoulos et al., 2008; Souliotis et al., 2016).

According to the estimations of a recent study, hidden payments in the Greek health sector in 2012 amounted to almost €1.5 billion, representing 28% of private OOP expenditure on health (Souliotis et al., 2016). Additionally, new types of informal payments have emerged recently, as patients seeking medication prescriptions have to pay an additional fee under the table for a service that is supposed to be free of user charges. In a study conducted in 2015, more than 47% of patients reported making informal payment ranging from €10 to €20 to EOPYY-contracted doctors in order to obtain a prescription (Kyriklidis et al., 2016) (Box3.4).