Treatment Cost Reimbursement from the Healthcare Systems


BISMARCK MODEL

Almost universal healthcare system based on mandatory social insurances. There are several funding sources such as social contributions and taxes to cover healthcare services/ treatments. To leave the social healthcare system, citizens could buy a private healthcare insurance.

Country

Funding characteristics

Austria: Bismarck

Social insurances (social contribution).

Belgium: Bismarck

Social insurances (social contribution). There are various types of social insurances and citizens have the right to choose health insurance.

East Europe: Bismarck

Single social insurance managed by the State.

France: impure Bismarck

Mandatory social insurances: public or private health insurance funds.

Germany: Bismarck

Solidaristic System. Social protection and insurance circuit covers 86.9%, an additional 2.4 % receives state coverage, 11% of the population opt for a form of private insurance coverage.

Netherlands: atypical Bismarck

Mandatory health insurance. Citizens have the right to choose health insurance and they are free to change insurance company once a year.

BEVERIDGE MODEL

Establishment of a national health service based on universal coverage and mainly, if not exclusively, financed by general taxation (national or local). Private insurances overlap the public coverage, offering additional guarantees such as freedom of choice and time of access to the benefits or to the services not covered by NHS (National Health System).

Country

Funding characteristics

Denmark/Sweden/ Finland: Beveridge

NHS – Decentralized system: the commitment to provide services is mainly Beveridge in the hands of local authorities.

Greece: Beveridge

NHS – ESY “Ethniko Systima Ygeias” — with the presence of a complex network of social insurance of illness (ASM).

Ireland: Beveridge

NHS – The right to healthcare benefits is recognized only based on resident status and not on the payment of contributions. The 1st category is “absolutely entitled” (Medical Card); the 2nd category does not enjoy some free services but it has the right to treatment and to stay in public hospitals at no charge.

Italy: Beveridge

NHS – The level of resources is determined annually at a central level by Regional general taxation. Citizens have to contribute by co-payment (ticket), patients with chronic diseases or with social hardship are relieved.

Portugal: Beveridge

The NHS is managed, regulated and planned at a central level; although health service delivery is structured on a regional level. Universal coverage is mostly cost-free at the point of care.

Spain: Beveridge

The NHS has an open access and predominant role as a public service. Free level, central, local and Autonomous Communities.

United Kingdom: hybrid Beveridge

NHS – The funding sources are mainly public (83%) through taxation and VHI (Voluntary Health Insurance) covers 3%, out-of-pocket payment (14%).

United States: neither Beveridge, nor Bismarck

Private insurances (companies, individuals) 78%; large public programs (Medicaid, Medicare, SCHIP) 21%; sum of both the sources 1%.




Table 20.2
Providers’ reimbursement systems











































































Budget

A total constraint is established on the amount of resources available for the single provider. It is mainly used by the “Beveridge systems”, sometimes it is weighted per capita share. In the “Bismarck systems”, hospital financing consists of global budgets negotiated between the associations representing the various insurance funds and those of hospitals.

DRG

System of hospital financing based on hospital admissions, valued for a price list defined on the allocation of each admission to one single DRG (Diagnosis-Related Group).

Country

DRG state and features

Austria: DRGs

Developed, LFK-PCS.

East Europe: DRGs

Adapted, HBCS based on CMS-DRG (Hungary); adapted,
 
JPG based on HRG (Poland).

Finland: DRGs

Adapted, Nord-DRG based on CMS-DRG.

Germany: DRGs

Adapted, G-DRG based on AN-DRG (“Institute for the Hospital Remuneration System” INek). 80% of hospital revenues are based on DRGs; high-cost drugs, devices and procedures are covered by additional funding.

Greece: DRGs

Adopted, G-DRG, trail – MoU with Germany.

Italy: DRGs

Adopted, CMS-DRG (Ministry of Health). Some functions
 
(DEA, File F) have a separate reimbursement.

Netherlands: DRGs

Developed, DBCs system (Diagnosis Treatments Combinations), pricing system similar to DRGs but based on the combination of therapeutic areas. The calculation of DBCs consists of two elements: Segment A, a fixed share is determined at national level, it is estimated on a prospective budget and negotiated with the associations of providers and of insurances; Segment B: directly negotiated between private insurances and hospitals, today this segment weighs 35% in the price-related calculation.

Spain: DRGs

Adopted, AP-DRG based on CMS-DRG in Catalonia.

United States: DRGs

Developed, MS-DRG also AP-DRG and APR-DRG. There are two types of coverage plans to provide services: Fee For Service and Managed Care Organizations.

Hybrid system DRG/Budget
 

Country

DRG state and features

Belgium: DRGs

Adopted, APR-DRG; budget.

Denmark/Sweden:

Adapted, Nord-DRG based on CMS-DRG; global budget.

East Europe: DRGs

Adapted, SL-DRG based on G-DRG; budget (Slovakia). Adopted, IR-DRG; budget (Czech Republic).

France: DRGs, global budget

Developed, HRG, first version based on CMS-DRG. Public and non-profit hospitals negotiate a general budget at regional level and they are paid on a monthly basis; those for profit are reimbursed through negotiated rates with the Government. 56% of hospital revenues are based on DRGs; organ transplants, high-cost drugs, devices, research and emergency care are covered by additional funding.

Ireland: DRGs

Adopted, AR-DRG; global budget.

Portugal: DRGs

Adopted, AP-DRG; global budget.

United Kingdom: DRGs (previously budget)

Developed, HRG (“Health and Social Care Information Centre-National Casemix Office”). The system of “Payment by results” was introduced for the reimbursement of hospital care that determines variability of the refunded fee and of the use of the Health Resource Group pricing system (a variation of the DRGs). 60% of hospital revenues are based on DRGs; high-cost drugs, devices and procedures are covered by additional funding.


Since the existing reimbursement mechanism in Italy is based on the diagnostic-related groups (DRGs) system [13], we have focused our evaluation on this logic/categorization of reimbursement.

Our analysis is based on DRG 161–163 which include inguinal hernia surgery that are among the group of abdominal wall surgery procedures DRG 159–163. DRG 161–163 include procedures for inguinal/femoral hernia with or without complications in childhood and adulthood, while DRG 159–160 include the remaining abdominal wall surgeries: umbilical hernia, incisional hernia, diastasis recti. More specifically, as regards inguinal hernia surgery, Table 20.3 shows the Italian distribution of the cases reimbursed with regard to the four abovementioned DRG, for each region in the first half of 2015.


Table 20.3
Discharges for abdominal wall surgery DRGs 159, 160, 161, 162, 163 in the first half of 2015 in Italy




























































Region

DRG 159

DRG 160

DRG 161

DRG 162

DRG 163

Total

Piemonte

120

1182

168

4100

95

5665

Lombardia

215

2167

283

4063

256

6984

Valle d’Aosta

4

12

25

60

1

102

P.A. Bolzano

9

53

21

81

22

186

P.A. Trento

4

59

16

74

1

154

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Nov 28, 2017 | Posted by in Uncategorized | Comments Off on Treatment Cost Reimbursement from the Healthcare Systems
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