Complexity of Europe

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Economics, Regulations and Framework for a Dialysis

Service Provider

Geographical Europe is composed of more than 40 countries with large economic, demographic and political differences.

The gross domestic product (GDP) per capita ranges from less than USD 5,000 in some eastern European countries to more than USD 40,000 in some wealthier western European ones [11]. The population demographics of the 800 million European inhabitants is also highly diverse from country to country. Average life expectancy is about 71 years for the male and 79 years for the female population in the whole of Europe, but if we look at eastern Europe alone, life expectancy is on average more than 5 years lower [12].

Fig.3. Prevalence of ESRD versus economic welfare in 42 European countries.

1,200 1,000 800 600 400 200 0

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0 5,000 10,000 15,000 20,000 25,000 30,000 35,000 40,000 45,000 50,000 GDP per capita, USD

0 5,000 10,000 15,000 20,000 25,000 30,000 35,000 40,000 45,000 50,000 GDP per capita, USD

Both population demographics and economic strength are factors that highly influence the structure and amount of funding of the countries' healthcare systems. Healthcare expenditure as a percentage of GDP among the European countries varies from less than 4% to around 12% [13]. In the European Union alone, healthcare expenditure as a percentage of GDP varies from around 5% in Estonia to more than 11% in Germany showing the considerable difference in the financial resources dedicated to healthcare within the region (fig. 2).

In the field of renal disease the comparison of the national economic strength (GDP) and the prevalence of end-stage renal disease (ESRD) patients suggests that economic factors may impose restrictions on treatments in European countries where the GDP per capita is below a limiting value (around USD 10,000) [14]. No correlation between economic strength and ESRD prevalence exists when the GDP per capita exceeds the USD 10,000 threshold (fig. 3).

Among European countries, healthcare systems are funded either through taxation (the Beveridge model) or through premium-finance, mandatory social insurance (Bismarck model) [15]. The different structures of funding have certain implications regarding the organization of the provision of healthcare services. In countries in which the system is funded by taxation the presence of private healthcare providers is in general lower than in those countries where the funding system is based on social security payments. This is somehow confirmed in the dialysis field (fig. 4).

With the exception of Portugal, in all countries where the system is funded through taxes the presence of private dialysis providers does not exceed 23% of all treated dialysis patients. In 75% of the countries analyzed above in which the system is funded though social insurance payments, the presence of private providers is between 19% (i.e. Austria) and 78% (i.e. Hungary).

The presence of private dialysis providers is steadily growing in the region. In the year 2000 the percentage of European hemodialysis (HD) patients treated by private providers was around 32%. In the year 2005 this was 39%. Of this 39%, around 37% was being treated by private chains (e.g. Fresenius Medical Care, Gambro, Baxter, B. Braun, Euromedic, Générale de Santé), and the remaining 63% was being treated in private doctor centers.

Despite the average increase in the presence of private dialysis providers in Europe, local regulations in some European countries still limit or do not permit the provision of private dialysis services at all. In countries like Belgium, Denmark, Finland and Luxembourg the dialysis provider system is only public. Private providers have no access to reimbursement for dialysis services. In other countries (e.g. Austria, Greece, Italy, Portugal, Slovenia, Sweden, the Netherlands and Turkey) private dialysis service is limited to some HD modalities while peritoneal dialysis modalities are not offered (fig. 5).

In some European countries (e.g. Spain, Italy) regional authorities can also define additional regional regulations concerning the type of therapies that private dialysis providers may offer and the level of reimbursement. In any case, dialysis services are always regulated and controlled by the healthcare authorities, and the strict regulations on the opening and functioning of a dialysis facility are not homogeneous between the various European countries.







I I Public I I Health Care Organization


Fig. 4. Relation between type of funding and dialysis providers' ownership. Providers presence is measured as the number of patients treated (year 2005). a National taxes (Beveridge system). Reimbursement structure is based mainly on global budgets and fee-for-service. The provider structure is mainly public. b Social Security payments (Bismarck system). Reimbursement structure is based mainly on fee-for-service and a flat rate. Private providers play a significant role.

In Spain and the UK private providers can only operate thanks to multi-year contracts assigned via tender by public hospitals or healthcare authorities which 'outsource' the complete dialysis service. In many other countries collaborations or agreements with public hospitals are necessary to maintain the clinical continuity, thereby ensuring the high level of quality a stand-alone unit cannot, in some cases, ensure.

Reimbursement Variability: Different Structures in

Line with Risk Allocation

The reimbursement system can be defined as the system that establishes who has the right to receive reimbursement for dialysis services (eligibility), how this reimbursement has to be given (reimbursement modality) and the amount of the reimbursement in monetary terms (reimbursement rate). It was explained previously that different regulations exist within Europe concerning who is eligible for dialysis reimbursement, and that access to reimbursement for private dialysis providers is still limited or not permitted at all in many countries.

Public center

Private center

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