European Observatory on Health Systems and Policies


Health Systems in Transition (HiT) profile of Lithuania

3.4 Out of pocket payments

There are no ceilings for OOP spending in Lithuania. According to household survey data (Statistics Lithuania, 2013a), in 2000–2008 an average of 75% of OOP payments was for pharmaceuticals, while 4% was for optics and 4% for other medical goods. About 10% of the average annual OOP spending was for dental services, whereas other outpatient services took 5%, including 3% for physician services. Payments for inpatient (hospital and sanatoria) services constituted approximately 2% of the total.

3.4.1 Cost-sharing (user charges)

The Law on Health Insurance makes provisions for cost-sharing for services covered by the NHIF (Parliament of the Republic of Lithuania, 1996b). The main legal cost-sharing measure involves co-insurance for outpatient pharmaceuticals and some medical aids for groups of patients who are exempt from direct payments (see sections 3.3.1 and 3.4.2). The amount of co-insurance is a fixed proportion of the reference price of a service, medication or medical aid.

There have been several changes in co-insurance rates and eligibility under the state health insurance scheme. Major changes centred around prescription for outpatient medicines (in addition to 100% and 80% reimbursement rates, rates of 90% and 50% were introduced) and medical rehabilitation and spa treatment, where 80% and 50% reimbursement rates, respectively, replaced 100% for medical rehabilitation and 90% for sanatoria treatment. In 2010, cost-sharing constituted about 32% of the total expenditure for reimbursed medicines (Garuoliene, Alonderis & Marcinkevicius, 2011).

Furthermore, when the pharmaceutical price is higher than the reference price, the patient pays the difference as a co-payment. In 2011, co-payments for reimbursed pharmaceuticals and medical goods constituted €44 million (152 million litas), an 8% decrease compared with 2010 (NHIF, 2012a). The substantial decrease in co-payments was preceded by the introduction of the Plan for the Improvement of Pharmaceutical Accessibility and Price Reductions (approved in July 2009), which included a number of measures on pharmaceutical pricing and reimbursement (see section 2.8.4).

Lastly, a small charge (€0.30) is required to register with a primary health-care physician. If a patient chooses to change physician within six months after registration, there is a further administrative charge of about €3.

Patients have free access to non-emergency outpatient consultation or hospital admission (secondary and tertiary health care) upon referral from a primary health-care physician (there are some exemptions to this rule; for example, no referral is required for a free visit to a dermatologist/venereologist). Without a referral, the patient must pay a fee for the consultation or hospital treatment, as set by the NHIF.

Dental services provided in public facilities or by private dentists contracted with the NHIF are free for children, whereas adults must pay the costs of materials used during treatment.

There are no official statistics on user charges for areas other than pharmaceuticals and medical goods. Some facilities charge patients for treatment, most often for diagnostic tests – a practice that leads to continuing political discussions. The Ministry of Health’s position in 2011 was that certain user charges in public health facilities may contradict constitutional provisions guaranteeing free access to treatment (Ministry of Health, 2011). However some researchers suggest that patient charges in public facilities are broad in scope and should be regulated rather than ignored (Murauskiene, Veniute & Palova, 2010). Moreover, there are legal provisions for charging patients the difference between the basic price of a treatment and the actual cost in case they opt for more expensive treatment components. However, in many cases, there are no clear evidence-based guidelines for formulating treatment protocols; consequently, the difference between standard treatment and voluntary preferences lacks clarity.

3.4.2 Direct payments

Outpatient pharmaceuticals are subject to direct payment for the majority of the population unless they fall into the exception groups specified in section 3.3.1. Spending on pharmaceuticals constitutes the bulk of private expenditure on health care. Total private OOP expenditure on pharmaceuticals and medical goods in 2010 amounted to €370 million (64% of total expenditure on pharmaceuticals and medical goods dispensed in the outpatient setting) (European Commission, 2013). However, this figure also includes medicines partially paid for out of pocket with the rest of the price reimbursed by the NHIF.

Some services in public facilities are subject to direct payments. These are covered in the negative list of health-care services and mainly include ancillary services (acupuncture, occupational health check-ups, abortions, additional care in obstetrics units, substance abuse treatment, cosmetic surgery, dental prostheses and other procedures).

The Health Insurance Law of 1996 stipulated that people without statutory insurance should pay out of pocket for all non-emergency health services.

In private health-care facilities (except services rendered under contracts with the NHIF branches), market pricing and direct payment are applied.

3.4.3 Informal payments

The tradition of making gratitude payments was inherited from the Soviet period. This tendency continued after regaining independence in 1990. A population survey conducted in the Baltic States in 2002 showed that in Lithuania 8% of patients gave unofficial payments while 14% of patients gave gifts in their last contact with health services (Cockcroft et al., 2008). In Estonia and Latvia, the proportion of unofficial payments was lower (0.7% and 3%, respectively), while similar proportions of patients (13% and 14%, respectively) offered gifts. The Transparency International Lithuania report of 2009 showed that 14% of respondents said they gave informal payments in public health-care facilities (Transparency International Lithuania, 2009).

A 2011 survey commissioned by the NHIF showed that 56% of respondents personally paid for health-care services in the past 12 months (45% did it more than once) (NHIF, 2012b). Most frequently, patients paid for a specialist consultation (31% of respondents), GP consultation (24%), surgery (18%) or for a diagnostic examination (14%). Payments for surgery and child birth were the most expensive (€60–145 on average), while specialist consultations, examinations, hospital admissions and anaesthesia required average payments of €15–59. The lowest payments (up to €15) were solicited for paediatrician visits and GP appointments.

A survey conducted in 2010 in Lithuania under the FP7 project ASSPRO CEE 2007 (Assessment of Patient Payment Policies and Projection of their Efficiency, Equity and Quality Effects: The Case of Central and Eastern Europe) demonstrated that 72% of respondents had negative attitudes towards informal payments (Murauskiene et al., 2012). The study also showed that about 40% of outpatients paid for services, but less than half of the payments were informal. For inpatients, the payment rate was higher, about 60%, and a larger portion of these payments (about 70%) was informal.

Although there is some inconsistency in terminology used in different surveys, the results point to a widespread use of informal payments, particularly in inpatient care. In addition, the existing legislation lacks clarity on user charges in health care, and many payments are quasi-formal. Politically, the issue of co-payments set by public providers is considered in the context of corruption. In spring 2012, based on an initiative of the Parliament Anticorruption Commission, a working group in the Ministry of Health proposed to make legal amendments for enforcing a mechanism of penalizing the heads of the public facilities that accept informal payments (Parliament of the Republic of Lithuania Anticorruption Commission, 2011).

According to the early data from the MoH, there has been a decline in patients' co-payments after the new positive list, based on an updated reimbursable pharmaceuticals methodology, came to action earlier this year. In July 2017 average co-payment was 4.7 Eur. This is a decline of around 0.5 Eur in comparison to July 2016, and of around 1 Eur in comparison to June 2017. The average patient's co-payment was 5.7 Eur in June 2017, 5.5 Eur in May and 5.2 Eur in April.

The overall population-wide decline in patients' co-payments was 12%, with patients spending 3.77 mln. Eur in total as co-payments for pharmaceuticals, while in July 2016 the amount was 4.27 mln. Eur.

For cardiac medication, which amounts to 60% of all co-payments, the reduction in co-payments was around 20% (from 2.72 mln. Eur in July 2016, to 2.19 mln. Eur in July 2017).

Source: The Ministry of Health (2017)