子模块6.4：家庭自付支出

Module 6:The financing dimension Household out-of-pocket spending6.4:Submodule Content •Out-of-pocket (OOP) health care payment [HF.3]•Boundary setting of out-of-pocket payment•Characteristics of out-of-pocket payment schemes•Main types of out-of-pocket payment schemes•Main modalities of cost sharing•Example of financial flows related to out-of-pocket payment [HF.3]•Revenue and financing agents managing out-of-pocket payment schemes•Frequently used data sources•Accounting notes for out-of-pocket payment schemes•Estimation approaches•Challenges Additional Content: •Questions and Answers•Suggested reading Out-of-pocket (OOP)health care payment[HF.3] OOP expenditure refers to direct payment for health care goods and servicesfrom households’ primary income or savings. It occurswhen no otherarrangement coversthe totality or covers only a part of the health care bill. In some cases, households initially pay for health care but mayreceive full or partial reimbursement from other schemes.Suchreimbursementsmust be deducted from OOP to preventdouble counting and overestimation. This means that OOP isregisterednet of reimbursements. Due to its policy relevance and linkage toUniversal Health Coverage,particularattention is paid toOOP, as it hassignificant implications for access andfinancial protection. In Nepal, some Ministries reimburse their employees’health care payments [these reimbursements are partof government schemes expenditure, see submodule 6.2]. In Health Accounts it is treated as a health carefinancing scheme. It includeshousehold spending throughdirect payments, insuranceco-payments/cost-sharingandunofficial paymentsto providers [gifts and "under the table"payments]. oWhen the payment iswithout any coverageof prepaid schemes, thehousehold pays thefull priceof services or goods.oCost-sharingrefers to the amount households have to pay out-of-pocketfor services that are partially covered by prepaid schemes. Boundary setting of out-of-pocket payment OOPrelies on theSHA 2011 boundaryfor international comparability: the main purpose is health, meaning prevention, treatment, purchase of medicines, and othermedical goods. It excludes It includes Health spending byresidents,even outside the country, which areimports. Payments bynon-residents, which are exports. Non-healthspending, such as education, faith healingor cosmetic surgery (for non-medical reasons). Spending onmedical goods and foodto the inpatient when the healthfacility is not providing or charging the patient for it. Transportationexpenses to the health care facilitywhen these are not inan ambulance. Payments for insurance premiums, contributions, or any other type of health careprepayment. Thailand is known for its well-developed medical tourism industry. Most people who travel abroad for medical care come from high income countries, such as USA,Europe, Australia, and the Middle East.This spending should beexcludedfrom HA in Thailand butincludedin the accounts of the home-countries of the tourists. Characteristics of out-of-pocket payment schemes Mode of participation Benefit entitlement Services are paid eitherfully or partiallyby the household. OOP depends oncapacity and willingness to pay. It is by convention treated asvoluntary, as it involves a householddiscretionary acceptance of the payment to be made. Many schemes request acopaymentas a condition for the beneficiary toreceive the service. Basic method for revenue collection Pooling OOP is funded through householddisposable incomeandsavings,sometimes from other households/relatives. In this scheme, there isno pooling, which increases the vulnerability tocatastrophic spending. However, to reduce financial hardship, specialexemptions for certain population groups might exist, such as limits oncost-sharing. Main types of out-of-pocket payments When thetotal amountof the health service/good is requested from theconsumer. For example, privately paid health services and over the counter (OTC)medicine costs without insurance or reimbursement. Cost-sharingis the amount of spending on health care to be paid by the beneficiary In Mongolia, SHIrequiresco-payments for some services, particularly forsecondary and tertiary inpatient care, exempting certain population groups. Includeprimary/substitutoryandcomplementary/supplementaryinsuranceschemes. In the Bahamas, copayments for patients with private health insurance arehigh, especially for hospitalizations and advanced diagnostics, due to thehigh cost of private medical care. Main modalities of cost-sharing Cost-sharingcan have different forms: Co-payment:Afixed amountpaid by the consumer for each service. When insurance applies, the arrangement specifies thepercentageof the cost the household pays. Deductibles:Amounts paid by the household until a certainthresholdis reached, after which insurance starts to cover. Ceiling:In some countries, OOP payments have a ceiling, limiting thetotal amounthouseholds pay d