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European CommissionThe Second Economic Adjustment Programme for Greece. Fourth Reviewunemployed, children and families, and persons living below the poverty line. A poverty bookletensures full health care access for those living below a EUR 6000 threshold a year. The new primarycare law refers to universal access to services provided in ESY health centres across the country. Theauthorities are currently conducting a detailed analysis of the situation together with the WHO, trying toidentify the number of individuals and services not covered. Following calls for guaranteeing universalaccess to care in Greece, it is crucial that the authorities now identify short term solutions and fundingto ensure a sufficient package of services and goods for the uninsured, while working towards a longtermmore structural solution. Several policies could be considered and as a first step the authorities aresetting aside EUR 20 million to increase coverage of the uninsured. Clarifying and simplifying theadministrative processes to obtain poverty booklets and to qualify for existing EOPYY coverageschemes is an obvious policy. Assessing the plethora of existing coverage mechanisms (booklets,vouchers, special authorisation for urgent treatment), their rules (thresholds, duration, etc) and theirconnection would also be appropriate. Another policy, which the authorities appear to be consideringaccording to media reports, is to allow and/or help individuals pay for current health insurancecontributions if they are long-term unemployed, uninsured senior citizens, professionals who are notworking and are not covered by their fund, and professionals who are active and suffer from chronichealth problems and/or owe money to their fund. In this context, other countries' experiences canprovide examples of how in a social insurance system coverage of the uninsured can be improved.Box 10. Rationalising the social health insurance system and ensuring the financial stability of EOPYYPrior to 2010, individual social health insurance funds provided health care coverage with each fund providing itsown health benefits package with different contribution rules. The health branches of the four main social security funds(IKA, OGA, OAEE and OPAD) covered 95% of the country’s population. Under the economic adjustment programme, Laws3863/2010 and 3918/2011 separated the social health insurance function from pension administration and merged the fourlargest social health insurance branches into a single healthcare insurance fund, EOPYY - the National Organisation for theProvision of Health Services. Subsequent legislation brought the remaining social health insurance branches (the House ofSailor, ETAA, ΕΤΑP – ΜΜΕ and TAYTEKO) into the organisation.EOPYY formally began operation in June 2011 as a single buyer of health care for the insured. The goal was tosimplify the fragmented system, reduce administrative costs, increase bargaining power over providers and increase theequity of access to healthcare by pooling risks and income levels and harmonising rules and benefit packages. More recentlegislation converted EOPYY in a single purchaser of health services and transferred the remaining primary health care unitsto the National Health Service (ESY) under the responsibility of Regional Health Authorities. The population covered byEOPYY are direct insurees and their family members. However, insurees still acquire insurance rights (and the healthinsurance booklet) from their respective social security fund. Despite progress, insurance status still depends on occupationand the contribution rules have not yet been fully harmonised.EOPYY has worked hard to build administrative capacity and improve its financial situation through theimplementation of a number of reforms and by close monitoring of spending and revenues but challenges remain. Onthe spending side, the full application of the two clawback systems – setting an expenditure ceiling and a payback fromsuppliers of all excess expenditure – for pharmaceuticals and for diagnostic tests, physiotherapy and the use of private clinicsand hospitals is crucial to bring the financial situation of EOPYY closer to a balanced budget. On the revenue side, the directtransfer of health-related contributions to EOPYY from the individual social security collection funds remains imperfect.Social security contributions for 2013 were some EUR 450 million lower than originally expected and budgeted. While thesituation has improved significantly, the effective cash transfer may still takes time to materialise and currently about EUR100-200 million in contributions remain to be transferred to EOPYY.EOPYY initially inherited a large stock of arrears from the previous system and delays in payment to suppliers,notably public hospitals, remain. The stock of unpaid arrears remains large though a significant stock of old arrears hasbeen settled. Following a significant clearance process in 2013 (a total of EUR 1.9 billion in arrears in 2012), there are stillsome EUR 737 million of arrears generated prior to 2012 to be paid. EOPYY continues to pay ESY (NHS) hospitals with avery long delay, although the amount budgeted for paying ESY hospitals in 2013 was more realistic than that budgeted in2012. For 2013, only about 7% of the accrued spending with public hospitals has been actually paid. This delay affects theability of ESY hospitals to pay suppliers, potentially leading to further arrears accumulation by hospitals. As a consequence,government transfers are made to ESY hospitals as a compensatory mechanism. On the other hand, ESY hospitals alsocontinue to submit invoices with a significant delay of 3 to 5 months.A substantial increase in the consumption of private interventions and diagnostics was observed in 2013. For example,the consumption of diagnostics doubled compared to 2012, despite the price reductions enacted in November 2012. Providersseem to have increased volumes to attempt to compensate their overall reduction in turnover. A substantial reductionoccurred in public sector diagnostics with the public sector now representing only a very small 3-6% share of overalldiagnostic work. Such increase in demand for private services, coupled with the inability to conduct proper auditing ofclaims, led to potential budget overruns in some categories of EOPYY spending including diagnostic tests, physiotherapy andthe use of private clinics and hospitals. Spending on such categories appeared out of control: if spending with privatehospitals in the first half of 2013 had been continued at the same rate for the rest of the year, EOPYY would have spent42