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European Observatory on Health Systems and Policies

Poland


Health Systems in Transition (HiT) profile of Poland

3.4 Out of pocket payments

The level of OOP payments made by households has been increasing over the years. Nevertheless, this growth has been less significant than the growth of public spending on health, resulting in a decreasing share of OOP spending in the current spending on health – from 27% in 1999 to 23% in 2016 (GUS, 2019) (see Table3.2). Nearly 60% of this OOP expenditure is spent on medicines. Spending on curative care accounted for 30% of total OOP expenditure in 2016 and was mainly used to pay for dental care, followed by outpatient curative care. Approximately 6% of OOP spending was spent on therapeutic appliances and other medical durable goods (GUS, 2019).

3.4.1 Cost-sharing (user charges)

There is no formal patient cost-sharing in primary care, outpatient specialized care and hospital care provided within the publicly financed system. Hospitals are only allowed to charge a fee (for bed and board) if a family member stays overnight with a hospitalized child, or is present during childbirth. Cost-sharing is also not applied to dental care but most dental services are excluded from the benefits package and there is no possibility of extra billing. For example, it is not possible to pay extra for better dental materials than those that are statutorily covered (see section 5.12).

While inpatient pharmaceuticals are available free of charge as part of hospital treatment, outpatient medicines are subject to direct patient cost-sharing, such as co-payment or co-insurance (Table3.8). Additionally, there is indirect cost-sharing, i.e. patients pay the difference between the reimbursement limit for a given group of medicines (i.e. reference price) and the price of drugs. The prices of reimbursed medicines are uniform (fixed) across the country. Pharmacists are obliged to inform patients about the availability of cheaper generics to avoid indirect cost-sharing (see section 5.6).

Certain medicines with proven efficacy in treating selected health problems are exempted from direct cost-sharing and are only subject to reference pricing. Special reimbursement privileges (mostly exemptions from direct cost-sharing) are granted to certain population groups including war veterans with disabilities and their spouses, repressed individuals9 and their spouses, military veterans, servicemen, blind victims of war, and honorary blood and organ donors. Since September 2016, people aged 75+ can receive a broad range of prescription medicines free of charge (see section 5.6).

Patient cost-sharing also applies to medical devices such as orthopaedic equipment or urine incontinence products, for which reimbursement limits are in place. Co-insurance (payment of a given proportion of the cost) is additionally applied to certain devices. Veterans, blind victims of war, repressed individuals, soldiers or persons in the treatment of injuries or illnesses acquired while on duty outside Poland are exempted from co-insurance. Also, children up to age 18 are largely exempted from co-insurance.

Cost-sharing is also applied in LTC institutions and sanatoria – patients have to contribute towards the cost of room and board (see sections 5.7 and 5.8).

There is generally no cap on patient cost-sharing in the statutory health system, with the exemption of monthly fees in the LTC institutions. However, people with low incomes who are beneficiaries of social assistance might apply for financial support; for example, to cover the cost of purchased medicines.

The Polish population has always been opposed to the idea of obligatory charges for primary care or specialized services and this has never been put forward on the political agenda (Tambor et al., 2015). There have been some discussions about allowing hospitals to charge an additional fee for higher standard of services compared with those offered as part of the statutory benefits basket; for example, for the use of better quality lenses in a cataract surgery. However, there is no consensus about the legality of such extra charges. The NFZ considers them to be illegal and their application is very limited (see section 3.4.3).


9 i.e. victims of war and post-war repressions.

3.4.2 Direct payments

Direct patient payments mainly apply to purchasing non-prescription OTC medicines, of which consumption is very high in Poland. In the 2014 European Health Interview Survey (EHIS), 52% of Polish people aged 15 and over reported having consumed non-prescription medicines during 2 weeks prior to the survey compared with the EU average of 35% (EC, 2017c). Direct payments apply to dental care as it is largely excluded from the statutory benefits basket and there is no possibility of extra billing for better quality dental materials (see section 5.12). Thus, better dental equipment and better dental materials offered in the private sector are the most common reasons for using private dental services (GUS, 2018e). Direct payments are also made for outpatient specialist care as due to long waiting times in the statutory system patients have been increasingly using outpatient specialist services in the private sector (see sections 3.5 and 7.3).

3.4.3 Informal payments

Older reports noted that the scale of informal payments has been decreasing (e.g. Golinowska, 2010) and no more recent data are available. The average value of payments in 2013 was equivalent to €13.5 per outpatient visit, and €28 for hospitalization (Tambor et al., 2013). According to the Special Eurobarometer report on corruption (2017), 7% of respondents in Poland who had visited a public health care practitioner or institution in the previous 12 months reported having to make an extra payment or give a valuable gift to a nurse or doctor, or make a donation to the hospital, compared with an EU28 average of 4% (EC, 2017d). The Polish Social Diagnosis survey (2015) revealed that 2.2% households paid informally for health care, and 2.3% of households gave in-kind presents during the 3 months prior to the survey (Czapiński & Panek, 2015). Informal payments might not be fully reflected in statistics on health expenditure as households might be reluctant to report such payments in household budget surveys.

There are also quasi-formal payments, such as fees charged by some hospitals for additional services or increased standard of care. However, their legality has not been confirmed and they have been prohibited by the NFZ.