Basque Country

The Basque Country is an autonomous community of northern Spain. It includes the Basque provinces of Álava, Biscay and Gipuzkoa. It has a universal health insurance system (Spanish General Healthcare Act: 1986), which is financed through general taxes. There is a capitation payment system, based on a payment per person, rather than a payment per service. This addresses both equity (how society resources are distributed) and efficiency (allocation of resources). Co-payment can occur with medication for outpatient care. Besides public insurance, access to private health centres is possible with supplementary private insurance. The central Spanish government takes care to provide basic legislation, general health policy, finance and a minimum healthcare coverage package. The Basque Country acts as an autonomous health care region for its organisational structure. Some of its many other roles include accreditation, purchasing and service provision.

The Basque public healthcare provider is Servicio Vasco de Salud-Osakidetza (OSAKIDETZA). All public hospitals and primary care centres of the Basque Region are under this governmental organisation. The Basque Health System includes 320 primary care centres, 14 acute hospitals (4,278 beds), four sub-acute hospitals (524 beds), four psychiatric hospitals (777 beds) and two contracted long-term mental hospitals. Osakidetza has a target population of more than two million inhabitants. Currently, ageing and chronic conditions account for 80% of the medical consultation in the Basque Country. which take 75% of the total health budget. More than 19% (>400,000 inhabitants) of the total population is older than 65 years.

Catalonia

Catalonia has a universal health insurance system (Spanish General Healthcare Act: 1986), which is financed through general taxes. There is a capitation payment system, based on a payment per person, rather than a payment per service. This addresses both equity (how society resources are distributed) and efficiency (allocation of resources).

Co-payment can occur with medication for outpatient care. Besides public insurance, access to private health centres is possible with supplementary private insurance. The central Spanish government takes care to provide basic legislation, general health policy, finance and a minimum healthcare coverage package. Catalonia acts as an autonomous health care region for its organisational structure. Some of its many other roles include accreditation, purchasing and service provision.

The Catalan Health System includes 400 primary care centres, 63 public in-patient acute hospitals with outpatient clinics and 56 emergency rooms (13,167 beds). Catalonia has a target population of 7,503,118 inhabitants, with a total functional health care budget of about 11.4 billion euro (in 2011, about 30% of total Catalonia Government budget), which amounts to about 1500 euro per capita public expenditure. As shown in Figure 5, Catalonia consists of seven districts. The distribution of the Catalan population varies across districts.

Lombardy

Lombardy is one of 20 regions in Italy. In 2007, the population of Lombardy was 9,545,441 million people. At that time, about 19.7% of its population were above 65 years of age. About 27.5% had been diagnosed with a chronic condition. Lombardy is divided into 12 administrative provinces (see Figure 7). In 1997, Lombardy was the first Italian region with a quasi-market form of local health care delivery;. iIt has introduced competition to improve quality and control expenditures. As a consequence, the four main principles of the Lombardy health care system are universal coverage (solidarity), separation between health care purchasers and providers, competition between public and private accredited providers in the presence of a third part payer, and liberation of choices for patients between providers.

The Lombardy Region raises and manages funds for health care, plans activities in cooperation with Local Health Authorities (LHA or ASL; see Figure 5), and monitors the delivery of minimum levels as defined by the central Italian Government. LHAs (15 in total) manage health care in a geographic region within Lombardy. This is done through smaller units called Districts (86 in total), contracts volume and services are with providers. LHAs are the purchasers of care. Each District manages the care of 40,000 to 100,000 people. Providers – either public, not for profit, or private accredited - compete on production following the same rules. LHAs are paid by Lombardy through weighted capitation using previous expenses, demographics and geographical criteria. Providers are financed by LHAs on a fee for service basis: prospective DRG (Diagnosis Related Group) payment for hospital discharges, and tariffs for outpatient services. Revenues for Lombard health care fund raising are collected through Governmental (VAT) and regional taxations. Any deficit is covered by copayment. Lombardy is able to control its balance (21.177 million euro in 2008) to break even. In short, Lombardy act as an autonomous region, with insurance and funding functions. The LHA has programming and purchasing power. While production is performed by providers. Lombardy has implemented a DRG (Diagnosis Related Group) prospective payment for hospital activities as reimbursement model. In 2007, Lombardy has 29 public hospital firms, each managing several local hospitals (97), 73 private accredited hospitals and 23 academic hospitals (IRCCS - Istituto di Ricovero e Cura a Carattere Scientifico). A total of 220 hospitals. The bed count is 33.7 per 10,000 inhabitants for acute cases, and 6.4 for long stay. The total amount of GPs is 8,120.

West Lothian

The district in Scotland that participated in ACT is West Lothian. One of 32 local government council areas of Scotland, West Lothian borders Edinburgh, Falkirk, North Lanarkshire, the Scottish Borders and South Lanarkshire. The population of Scotland is 5,295,000 (March 2011), and has 4,859 GPs. The 225 publicly owned hospitals offer 24,380 beds.

The health and social care system in Scotland is overseen directly by the Scottish Government’s Health and Social Care Directorate. WhoThey are responsible for overseeing NHS Scotland, and deliver the Healthier Strategic Objective. This helps people to sustain and improve their health, especially in disadvantaged communities, with better, local, and faster access to healthcare.

The Directorate allocates resources, and sets the strategic direction for NHS Scotland. It is also responsible for the development and implementation of health and social care policy. Finding the best way to develop, support and mobilise the health and social care system in Scotland is primary responsibility. This includes delivering the highest quality of health and social care services to people in Scotland. At the same time, working towards a shared vision of a world-leading, safe, effective and person-centred healthcare provider. ;

Northern Netherlands

Groningen, Friesland and Drenthe are the northern three regions (provinces) in the Netherlands. Groningen is the smallest and most sparsely populated Dutch province. It contains 23 municipalities, located in Northern Netherlands. There are 582,161 inhabitants (2012), a third of which live in the eponymous capital Groningen. Dutch provinces form the governance structure between the government—located in The Hague— and local municipalities.

The Netherlands has a partially publicly funded (dual), multi-payer, universal health care system. The Dutch government acts only as a regulator for quality and universality of care. A basic and essential insurance package is compulsory for every individual, and is provided by private insurance companies. The government sets down the package, and ensures universality of care by extra risk-adjusted finance schemes. It is paid for with a flat-rate premium (nominal premium) for the basic package to the selected insurer, and salary deductions collected by the Health Insurance Fund (CVZ)—which organises the finance for risk adjustment. There is an option for every individual to buy supplementary cover for procedures outside the basic package.

There is a compensation (zorgtoeslag) for those with a low income. However, the care for patients with long-term conditions is completely under governmental control. It is regulated by the Exceptional Medical Expenses Act (AWBZ). It is paid for with salary deductions, and supplemented by a government revenue grant. Reimbursement is on a case-by-case basis using DBCs/DOTs, but still has a fixed budget component. DBC stands for Diagnose Behandel Combinatie (Diagnosis Treatment Combination). To create the DBC, the Ministry of Health, Welfare and Sport (VWS) partnered with the hospitals to map the cost of every conceivable need for care, diagnosis, and treatment options. Then set an average rate. This includes the cost of specialists and nurses, for example, and indirect costs to the hospital. Each DBC has its own price tag.

DBC has recently been simplified by DOT (DBC Op weg naar Transparantie/DBC On its way to Transparency). Since its reform in 2006, the Dutch reimbursement model underwent, and is still undergoing, changes to stimulate price competition. Its efficiency and fraud-sensitivity are currently under public debate.

More than 90% of Dutch hospitals are owned and managed on a private not-for-profit basis. With about 70% of the specialists working on a self-employed basis (working together in private corporations without legal personality: maatschappen). Specialists at university hospitals are often on the payroll. The most important hospital in the Groningen region is the University Medical Center Groningen (UMCG). It has an annual budget of €950 million, with roughly 32,000 admissions and 500,000 outpatient visits per year. As one of the eight university Dutch hospitals, it provides the highly specialised medical treatments for the whole of the Northern Netherlands (see Figure 9). Together with the twelve general hospitals, it offers 5,295 beds to the Northern Netherland’s population.

General practitioners (GP) play a coordinating role within the Dutch healthcare system. Every citizen is obliged to register with a GP of their own choice. Visiting a specialist is only possible after referral from a GP (or post-referral from another specialist). There are 915 GPs in the Groningen region.