JANUARY

DENMARK
portion is small, it makes up regions’ marginal income and presents a strong incentive (Danske Regioner, 2014).
Furthermore, regions are under pressure to deliver good performance, as they can be reformed if they do
not deliver.
At the regional level, hospital cost control includes a combination of global budgets and activity-related
incentives (see above).
Inpatient pharmaceutical expenditure is controlled through national guidelines and clinical monitoring
combined with collective purchasing. Two specific units have been established to evaluate and coordinate the
introduction of expensive pharmaceutical products—the Council for the Use of Expensive Hospital Medicines
(RADS) and the Coordinating Council for the First Use of Hospital Medicines (KRIS).
Policies to control outpatient pharmaceutical expenditure include generic substitution, prescribing guidelines,
and assessment by the regions of deviations in prescribing behavior. Pharmaceutical companies report
a monthly price list to the Danish Health Authority, and pharmacies are obliged to choose the cheapest
alternative with the same active ingredient, unless a specific drug is prescribed. Patients may choose more
expensive drugs, but they have to pay the difference.
Collective agreements with general practitioners and specialists include various types of clauses about rate
reductions if overall expenditures exceed given levels. Regions also monitor the activity level of individual
practices, and may intervene if they deviate significantly from the average.
Health technology assessment and cost-effectiveness information, produced nationally and regionally, is an
integrated part of the decision-making process for new treatments and guidelines for professionals.
Regions may enter into contracts with private providers to deliver diagnostic and curative procedures. Prices
for these services are negotiated between regions and private providers and can be lower than rates in the
public sector.
These measures have been relatively successful in controlling expenditures and driving up activity levels.
General productivity in the hospital sector increased almost 20 percent from 2008 to 2012, while maintaining
high patient satisfaction and also reducing hospital standardized mortality rates (Danske Regioner, 2014b and
2014c).
What major innovations and reforms have been introduced?
A reorganization of the hospital infrastructure is currently under way. All five regions are in the process of closing
or amalgamating small hospitals and building new hospitals, at a total cost of DKK40.0 billion (USD5.3 bilion).
A central part of this process is the reorganization of acute care, with stronger prehospital services and larger
specialized emergency departments with senior medical specialists at the front end.
The third generation of mandatory “health agreements” for coordination between municipalities and regions
came into force in 2014. These agreements cover 2015–2018, and are based on a slightly revised format that
resulted from a formal evaluation published in 2011.
Upscaling of municipal health services with “temporary care units” and various types of health centers is
occurring, with colocation of municipal, private, and regional health providers. At the same time, municipalities
are employing more nursing staff and public health specialists to provide more systematic services for
population health (Rigsrevisionen, 2013).
A plan for reorganization of the central governance structure was decided on by the incoming government
in August 2015, and was implemented in the fall of 2015. The reorganization will split the existing Health and
Medicines Agency into four separate agencies, dealing with health, medicines, patient safety, and IT/data,
to provide more clarity and improve the overall surveillance and accountability structure.
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The Commonwealth Fund