{"id":12822,"date":"2011-11-22T15:01:48","date_gmt":"2011-11-22T14:01:48","guid":{"rendered":"https:\/\/blogs.bmj.com\/bmj\/?p=12822"},"modified":"2011-11-22T15:01:48","modified_gmt":"2011-11-22T14:01:48","slug":"aser-garcia-rada-co-payments-and-privatisation-in-spain","status":"publish","type":"post","link":"https:\/\/blogs.bmj.com\/bmj\/2011\/11\/22\/aser-garcia-rada-co-payments-and-privatisation-in-spain\/","title":{"rendered":"Aser Garcia Rada: Co-payments and privatisation in Spain"},"content":{"rendered":"<p><img loading=\"lazy\" decoding=\"async\" src=\"http:\/\/www.bmj.com\/site\/blog\/icons\/aser.jpg\" alt=\"Aser Garcia Rada\" width=\"160\" height=\"160\" align=\"left\" \/>Some time ago I wrote a letter to the Spanish daily <em>El Mundo,<\/em> saying that co-payments \u2013an extra charge for accessing medical services in the public healthcare system, should be considered as a measure to help the public system. Co-payments have traditionally been\u00a0a forbidden issue among politicians as\u00a0they amount to paying twice for something we already fund with general taxes \u2013some people call it repayment. But I argued that we should debate the issue.<\/p>\n<p>Currently, access to public healthcare is free, and the only extra thing we have to pay for is that people under 65 years old pay 40% of the cost of prescribed drugs. Against the backdrop of the 20 November general elections, all political parties rejected co-payments, but the <a href=\"http:\/\/www.abc.es\/20111105\/sociedad\/abcp-cama-junto-enfermo-euros-20111105.html\">debate is growing<\/a> together with healthcare debt, and <a href=\"http:\/\/www.lavozdegalicia.es\/galicia\/2011\/11\/09\/0003_201111G9P16994.htm\">different kinds of co-payment are beginning to be implemented<\/a>.<!--more--><\/p>\n<p><a href=\"http:\/\/www.semergen.es\/semergen\/contentFiles\/14123\/es\/libro.pdf\">In a poll<\/a> of the Spanish Society of Primary Care Physicians (SEMERGEN) 86% of responding doctors thought that some kind of co-payment was necessary,\u00a0owing to their\u00a0perception that a lot of\u00a0people abuse the system by visiting their doctors\u00a0despite not having\u00a0any problems. At the time that I wrote the letter I agreed with this widespread perception, but now I have realised that this view is very limited.<\/p>\n<p>Firstly, and most importantly, we don\u00b4t know how many patients are not \u201cabusing the system\u201d because we don\u2019t see them. Secondly, patients may misinterpret or ignore the significance of their symptoms. If we have doubts sometimes, how can we expect patients not to have them? Thirdly, indiscriminate co-payments would primarily limit access\u00a0for the poorest while the establishment of a means tested co-payment \u2014as commonly suggested\u2014 is difficult, and if achieved, would not take into account the real incomes of those defrauding the treasury \u2013<a href=\"http:\/\/www.elpais.com\/articulo\/economia\/Funcas\/afirma\/economia\/sumergida\/Espana\/asciende\/24\/PIB\/elpepueco\/20110601elpepueco_8\/Tes\">the underground economy may account for 23.7% of Spanish GDP<\/a>. And finally: it will not serve its purpose.<\/p>\n<p>According to Jose Ram\u00f3n Repullo, an expert in health economics from the National School of Health, although a \u201cdevastating effect on mortality\u201d is unlikely in developed countries, co-payments will \u201csurely\u201d affect morbidity.<\/p>\n<p>Repullo refers to two articles. <a href=\"http:\/\/www.nejm.org\/doi\/pdf\/10.1056\/NEJMsa0904533\">The first one<\/a> is a US study stating that \u201cthe rising cost sharing for ambulatory care among elderly patients may have adverse health consequences.These effects would be magnified among those with lower incomes,less education, and those with chronic diseases such as hypertension, diabetes, or a previous myocardial infarction. It may increase total spending on health care.\u201d <a href=\"http:\/\/www.springerlink.com\/content\/ut5121252871u291\/\">The second article<\/a> concludes that a low co-payment for\u00a0outpatient care established in Germany \u201cfailed to reduce the demand for physician visits.\u201d Furthermore, <a href=\"http:\/\/www.oecd.org\/dataoecd\/46\/7\/38980294.pdf\">costs of healthcare in Spain are lower than those of other countries applying co-payments<\/a>.<\/p>\n<p>Beside, concurrent circumstances occurring in Spain suggest that <a href=\"http:\/\/www.bmj.com\/content\/343\/bmj.d7297\">co-payments are being used as a smokescreen<\/a> to promote growing public private partnerships (PPP).<\/p>\n<p>Interested parties have been spreading\u00a0 continuous and distorted messages about the unsustainability of the public system which is driving citizens to swallow the co-payment pill. According to a survey by the General Nursing Council, 63.5% of the population would accept a co-payment based on income.<\/p>\n<p>Surely media positioning is contributing to population\u2019s distorted view, strikingly so that of the two most important Spanish newspapers. The\u00a0 centre-left <a href=\"http:\/\/www.elpais.com\/articulo\/opinion\/Recorte\/sanitario\/elpepuopi\/20101031elpepiopi_2\/Tes\"><em>El Pa\u00eds<\/em> has asked for co-payments<\/a> in some editorials, and the conservative <a href=\"http:\/\/www.elmundo.es\/elecciones\/elecciones-generales\/2011\/propuestas\/propuesta75.html\"><em>El Mundo<\/em> has done so repeatedly<\/a>. The editor of <em>El Mundo<\/em> didn\u00b4t answer my question via Twitter asking whether their position had something to do with the fact that their <a href=\"http:\/\/www.elmundo.es\/elmundosalud\/2010\/07\/30\/videoblogs\/1280506566.html\">editorial group signed an agreement last year with a company of private hospitals<\/a>.\u00a0<\/p>\n<p>Meanwhile, the Institute for Development and Integration of Health (IDIS), a lobby involving most private health sector operators that has <a href=\"http:\/\/www.diariomedico.com\/2011\/03\/15\/area-profesional\/sanidad\/sanidad-privada-se-puede-defender-sin-erosionar-publica-y-sin-falacias\">already been accused of lying<\/a> with\u00a0its unreal arguments, insists that to avoid unfair measures like \u201cco-payment or benefit cuts,\u201d PPP must be promoted, though evidence of its efficiency is lacking.<\/p>\n<p>And the Madrid Business Confederation (CEIM) <a href=\"http:\/\/www.ceim.es\/upload\/file\/publicaciones\/PropuestasEmpresariosNacional\/\">just called for co-payments<\/a>. Are they worried about the population\u2019s health or about the sustainability of public healthcare? They could be. But notably in Madrid, nine public hospitals \u2014and two more next year\u2014 are already managed by a private company, receiving a fixed annual amount to provide care independently of the number of patients who attend. Do they think that co-payments may reduce demand and make their business more profitable? If that was the case, the more PPP, the more likely it is that employers will demand co-payment in a spiral of unknown consequences that contradicts IDIS&#8217;s arguments.<\/p>\n<p>These events may be causal, but if linked\u00a0they seem to lead to a\u00a0rather vicious circle.<\/p>\n<p><em><strong>Aser Garc\u00eda Rada<\/strong> is a paediatrician at the Hospital Infantil Universitario Ni\u00f1o Jes\u00fas in Madrid, Spain, and a freelance journalist.<\/em><\/p>\n","protected":false},"excerpt":{"rendered":"<p>Some time ago I wrote a letter to the Spanish daily El Mundo, saying that co-payments \u2013an extra charge for accessing medical services in the public healthcare system, should be [&#8230;]<\/p>\n<p><a class=\"btn btn-secondary understrap-read-more-link\" href=\"https:\/\/blogs.bmj.com\/bmj\/2011\/11\/22\/aser-garcia-rada-co-payments-and-privatisation-in-spain\/\">More&#8230;<\/a><\/p>\n","protected":false},"author":1,"featured_media":0,"comment_status":"open","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[223],"tags":[2677,2678,566],"class_list":["post-12822","post","type-post","status-publish","format-standard","hentry","category-guest-bloggers","tag-debt-crisis","tag-eurozone-crisis","tag-spain"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v27.6 - 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