3.4 Out of pocket payments
OOP payments (including cost sharing and direct payments for private sector services) accounted for approximately 26.8% of total health expenditure in 2014 (see Table3.1), and provisional data for 2015 indicate that OOP payments have increased to 27.6% of total health expenditure. Pharmacies (dispensing chemists), outpatient care centres and offices of physicians, hospitals, and nursing and residential care facilities represent approximately 90% of a household’s OOP payments on health care. Most dental care is paid out of pocket, as are many specialist consultations in private ambulatory care.
3.4.1 Cost sharing (user charges)
Cost sharing is part of both the NHS and private financing arrangements. All three forms of cost sharing are present in the NHS; the most common are co-payments (or user charges), defined as a fixed amount charged for a service; these exist in most public health care services (see Table3.4).
The values set for co-payments are typically small, when compared to the cost of the service. For example, the co-payment for an emergency visit currently ranges from €14 (in primary health care units) to €18 (in hospitals), while the average cost of an episode ranges from €36 (for a basic emergency at a primary health care unit) to €112 (in a general emergency service in a hospital), according to the values published by the government (Ordinance (Portaria) No. 234/2015, of 7 August 2015). There is no annual ceiling on co-payments.
Also in 2016, the values for user charges in the NHS were reduced for the first time (Table3.5) and the overall cap per episode of care was redefined to €40 (previously €50) (Ordinance No. 64-C/2016, of 31 March 2016).
In March 2016, the existing exemptions for user charges were revised. Firemen, blood donors and donors of live cells and tissues became totally exempted from user charges in the NHS. Examinations performed in day hospitals and emergency services (if referred by primary units, the INEM or Saúde 24 call centre) also became exempted. Finally, first outpatient consultations referred by primary care units; emergency service visits referred by primary care units, INEM or Saúde 24; and primary care visits referred by Saúde 24 were also exempted for user charges (ACSS, 2016a).
Currently, users in a situation of financial hardship (i.e. with an average household monthly income ≤ 1.5 times the Index of Social Support; for more details on household income definition, see corresponding legislation in Ordinance No. 311-D/2011, of 27 December 2011), unemployed people, pregnant and parturient women, blood donors, live donors of cells and tissues, refugees and asylum seekers, firemen, people aged 18 years or under, and those belonging to certain patient groups are exempted from user charges in all NHS institutions. In April 2016, 6.1 million NHS users (roughly 60% of the population) were exempted from any user charges, with 2.7 million (44%) being exempted due to financial hardship.
Coinsurance, in which the user pays a fraction of the cost of the service, is in place for pharmaceutical products covered by the NHS and for other health insurance arrangements (subsystems and VHI). The coinsurance on pharmaceuticals varies depending on the therapeutic value of the drug. Pensioners pay a reduced rate and chronically ill patients are exempt from the cost of some courses of medication (see section 5.6). Indirect methods of cost sharing are also present, namely reference pricing for pharmaceutical products. Finally, deductibles are present in some commercial health insurance contracts.
Cost sharing is a highly debated issue in Portugal. The different cost-sharing instruments have different objectives. The (stated) objective for co-payments is to contain and regulate demand for public services (the standard argument of moral hazard control). This is visible, for example, in the smaller value paid by patients if they choose to go to primary care centres instead of going to hospital emergency departments for care. On the other hand, the role of coinsurance in pharmaceutical products is not only to influence demand but also to shift the financial burden to the users, given its relatively high value (see section 5.6).
The total value of co-payments in NHS hospitals accounted for 1.7% of the total NHS expenditure in 2012, which represents a significant increase from previous years: 0.74% in 2010 and 0.95% in 2011 (ERS, 2013a). The above cost-sharing arrangements are accompanied by mechanisms designed to protect vulnerable groups of the population. Exemptions from co-payments are generous and include pregnant women, those aged 18 years or younger, pensioners with low income, persons responsible for disabled young people, socially and economically disadvantaged people, and patients with some chronic conditions. In August 2016, there were 6 159 324 users exempted from paying user charges (roughly 60% of the population).2
The New Health Basic Law of 2019 established the waiving of user charges for primary health care and other care whose referral has taken place within the NHS.
With the aim of achieving an increasingly fair and inclusive NHS, the government provided for the phasing out of the payment of user charges for primary health care (March 2020), for the complementary diagnostic and therapeutic examinations prescribed at primary health care and carried out in NHS institutions and services (September 2020) and for all diagnostic and therapeutic examinations prescribed at the primary health care level (January 2021).
More information (in Portuguese):
Decree-Law n.º 96/2020 of 4 november (https://dre.pt/web/guest/pesquisa/-/search/147533138/details/maximized)
Law 95/2019 of 4 september (https://dre.pt/web/guest/pesquisa/-/search/124417108/details/normal?l=1)
3.4.2 Direct payments
Direct payments take place for those services not covered by statuary prepayment, including dental care and specialist consultations in private ambulatory care. The patient pays transportation costs, except in special circumstances, such as long-distance travel, or specific health conditions (e.g. patients on dialysis), in which case costs are subsidized. Emergency care transportation, on the other hand, is provided free of charge by INEM (see section 5.5).
3.4.3 Informal payments
There is no detailed information on the role and magnitude of informal payments. The general perception is that they play at most a minor role.