Tiago Villanueva: Co-payments in general practice—the Portuguese experience

tiago_villanuevaSince 2011, I’ve worked as a locum GP in Portugal’s national health service, where patients pay five euros for each appointment with a GP. Many people are exempt from paying, for exemple pregnant women, children up to 12 years of age, unemployed people receiving benefits, and patients who have had transplants.

The co-payment to see a GP was 2.25 euros until 2011, but this figure increased the following year to five euros as part of austerity measures implemented by the then Conservative government

As a health professional, I have mixed feelings about people having to pay five euros every time they need to see a GP. Five euros may not seem like a lot, but it is important to realize that salaries are very low in Portugal compared to Western European standards. The minimum wage is currently set at 530 euros per month. Approximately 13% of the Portuguese population earn the minimum wage. Considering that patients also pay co-payments for drugs and even higher co-payments to attend the emergency department (20.6 euros) and hospital outpatient consultations (7.75 euros), out-of-pocket expenses for even non-serious complaints can become considerable for the average citizen using the country’s national health service.

Personally I’ve found that co-payments often cause delays to consultations, as patients have to make a payment to administrative staff before seeing the doctor, and there are often long lines of people waiting their turn to pay, particularly during peak times such as the early morning. This means that I often lose precious time when I could be seeing patients, and may only see the first patient of the day at 08h15 rather than at 08h00, thus creating delays downstream (consultations are booked every 15 to 20 minutes depending on the GP practice) as well as frustrations for both me and my patients.

I also feel that the introduction of higher co-payments drove a lot of people to purchase private health insurance, as co-payments to see private GP’s and private hospital doctors are often less than five euros. This makes private medicine extremely competitive with the public system. Moreover, patients who use the private health system for most of their healthcare needs only resort to state GPs for certain things that only they can do and which are not so clinical, like issuing sick leave. This can generate additional frustrations and a lack of professional satisfaction as challenging clinical problems are being transferred to private doctors, which leaves us with far less interesting tasks. This has implications, for instance, in terms of attracting more doctors to primary care if they perceive it as being mostly about carrying out menial tasks.

From my experience, patients also feel a certain sense of entitlement when they make a co-payment to see the GP. When you pay for a service, you’re more likely to feel you have more negotiating power to demand something, even if the patient’s expectations may seem unreasonable for a GP (e.g. patient requesting expensive tests which the GP may not feel are clinically indicated). Moreover, patients often try to get their money’s worth by using the consultation to sort out multiple rather than a single problems, which can frequently lead to lenghty consultations as I explained above. It is therefore not easy to balance the patient’s expectations with the limitations of a public  system where there’s very limited time and resources.

Co-payments in Portugal are called “moderating fees,” meaning they’re aimed at moderating the use of healthcare services. And even though this may be the case in certain situations, where one will think twice before seeing the doctor for self-limited illness for exemple, it may shift demand for health care towards those that have less need but more ability to pay. In other words, co-payments may foster the inverse care law.

The current liberal (socialist) Government has said it wants to lower these co-payments this year, which would be good news for most Portuguese citizens, who have already withstood very tough austerity measures since 2011. Austerity measures have generated a lot of unemployment and emigration, which has led to an increasingly aged, multi-morbid population staying behind, while a substantial proportion of the working-age population, who fund the national health service through their taxes, has left.

Although deep down I wish co-payments didn’t exist and patients were able to access truly free and high-quality publically funded healthcare, the system has to remain sustainable (it seems increasingly unsustainable to me) and therefore I am aware that is very unlikely to happen anytime soon.

See also: Should patients pay to see the GP?

Tiago Villanueva is assistant editor, The BMJ, and a locum GP in the Portuguese national health service.

  • George Buckland

    In most areas of public life the user pays, unless the user falls into the safety net provided by the State. I can’t see why access to primary and secondary care should be different.

    I’m sure co-payments for the UK NHS would moderate use.

    Moderating use will surely benefit patients and physicians by allowing for more through consultations and less waiting time for appointments and tests.

    As to your point that paying might “shift demand for health care towards those that have less need but more ability to pay” : Do you agree that if there is a State safety net this is not an issue.

    It is very interesting that co-payments made the Portuguese Private Healthcare System more competitive and thus more attractive to many : I think this is an advantage as people choosing to access private services will relieve the burden on the State GP. Do you think this is the case?

  • Tiago

    What do you mean by safety net? The Portuguese National Health Service (which is also tax funded like its UK equivalent) is the safety net for the more deprived segment of the population. But those who have more resources (both financial and in terms of access to other parallel health systems like private care but also others) also use the NHS. In certain areas of the country, accessibility to the GP is a problem (not enough GP’s, long waiting times, etc), so a National Health Service that is “not so free” anymore may give an edge to people with more resources, even though they may not be those who need care the most, which are often the elderly with multiple co-morbidities. This is well described in the literature as the inverse care law, and I’ve felt that an austerity climate fosters that . For example, a lot of slots for GP consultation are taken up by patients who’ve been to private doctors but who are trying to get tests done through the public system because they’re partly covered (there’s always a co-payment), while some people with urgent needs and no alternatives for care may be struggling with accessing an appointment . In other words, some people seem to want the best of both worlds. This also represents an inappropriate use of the health system, “see the specialist first and the GP last”, when it should be the opposite. But of course an austerity climate coupled with problems accessing primary care may encourage this kind of behaviour.

    With the private system competing more with the NHS, the NHS could in theory be “freed up” to serve the needs of those with less resources. But the private system has flourished probably in part to the weakening of the public system due to the crippling austerity experienced in the last 4 years, so I fear that if this trend continues, the less well off may be left with a 2nd rate public health system while those better off will access a well resourced private system. I think the quality of the NHS is still overall good, but it is not clear whether it will be maintained in the near future. This would be heading towards the direction of the US, and would be a shame. It is against the European ideals of welfare and solidarity that some of our predecessors fought so hard for.

  • Tiago

    A good example to illustrate what I have just said is access to colonoscopy, whose out-of-pocket cost is high. A lot of diagnostic tests are done in private clinics which have made agreements with the Government, which covers most of the cost. But these days, few clinics where colonoscopies have these agreements (I think it is because The Government takes a long time to pay back), leaving people with no alternatives or private insurance to line up overnight at clinics to be able to secure a slot for the test. This was the subject of several news reports last year:http://www.tvi24.iol.pt/sociedade/ordem-terceira/centenas-de-pessoas-esperam-para-marcar-uma-colonoscopia

    Of course if you have private insurance or can afford the out-of-pocket cost, you can get it done quickly in many places.