Optimalisatie van de werkingsprocessen van het Bijzonder ... - KCE

198 Special Solidarity Fund KCE Reports 133
The possibility for the regions to have and to organise additional care provision means,
the regions can include other medical services, treatments, drugs, medical devices,
home care…. in the regional public health system. As a consequence, one can observe
sometime substantial differences in care provision to the citizens depending from the
priorities defined by the regional health authority from the region they live in.
9.16.2.1 Who is covered?
In Spain, one should distinguish between:
The National Health system (public health insurance)
The NHS, through the Regional Health Services, provides universal health care to all of
its citizens. The universal basic health insurance provides a standard benefits package for
all residents. Over 90% of the population uses the National Health System for its
medical needs.
Health care provision in Spain mainly is organised at two levels: The primary care level
and the specialist care level (hospital care). It allows a citizen to choose his primary care
doctor being a part of the NHS system. The general practitioner has a very important
role in the NHS. It’s through the GP the citizens access the rest of the system. Primary
care is mostly concentrated in the primary health care centres that provide the GP
services, paediatrics and nursing care. The primary care centres also provide midwives,
physiotherapists and social workers. In order to consult a specialist, patients must first
be referred by their primary care doctor (except in emergencies). Specialists mostly
work in the hospitals that operate within the NHS system. Most of these hospitals are
owned by the Regional Health Services. Otherwise it can be private hospitals that are
recognised and have an agreement with the Regional Health Service. There are generally
no out-of-pocket expenses for the medical care at primary or secondary care level as
the Regional Health Services pay for all medical care.
Complementary private health insurance:
In Spain the last decade, the private health care sector became more important. About
15% of the population holds private health insurance including most civil servants who
have the choice of coverage by the public or the private systems. The private health
insurance is used either as a supplement or an alternative to public care.
The private insurance companies have their own network of hospitals, clinics and
laboratories. Policyholders usually do not have to wait as long for treatment as patients
using the NHS. At secondary care level, within the NHS, waiting lists are an important
issue. The private insurance companies can direct their members to doctors who are
members of their group. However, most of these private insurers have programs that
refund 80% of the fees charged by physicians outside the group. Adeslas, Asisa and
Sanitas are the largest private health care providers.
9.16.2.2 What is covered?
The 63/1995 Royal Decree for Services Provision 48 drew up a list of medical services
guaranteed by the public health system (maintaining those already in existence and
including those not available to all inhabitants under universal coverage) while trying to
apply security, effectiveness, quality and efficiency criteria to control those newly
introduced services and technologies. 49 It defined benefits as detailed below. Primary
health care includes general medical and pediatric health care provided at health centers
and during home visits, programmes for prevention of disease, health promotion, and
rehabilitation. Specialized health care in the form of outpatient and inpatient care covers
all medical and surgical specialties in acute care.
In 2006 a new Royal decree modified the minimal health care services to be guaranteed
to all citizens. Access to NHS health care provision is regulated in the ‘Cartera de
servicios’. This is a kind of minimum list of common services to be provided and
ensured to all citizens regardless of where in the national territory they live or reside.