The Greek Healthcare System

Today we look at Greece as referred to in the CATO institute report. The Grass Is Not Always Greener: A Look at National Health Care Systems Around the World Michael D. Tanner Cato Institute: Policy Analysis

Greece

Although ostensibly an employer-based system, the Greek system operates more like a single- payer system in that it is highly centralized and regulated. Virtually every aspect of health care financing and provision is strictly controlled by the Ministry of Social Health and Cohesion.(189) Some attempts have been made to decentralize decision making, with 17 regional organizations having some responsibility for implementing policy and managing the delivery of health care, but most power remains with the central government.

Greek employers must enroll their workers in one of 35 “social insurance funds,” funded in part through a payroll tax and in part through general tax revenues. Unlike Germany, where employers have a choice among competing sickness funds, Greek social insurance funds are specific to industry sectors. The range of benefits offered by each fund, the contribution rates, and the types of providers that the insured can access are all determined by the Ministry of Social Health and Cohesion. (190)

Certain funds known as “noble funds,” primarily used by government workers, the banking sector, and public utility workers, offer more extensive benefits and require smaller worker contributions. The powerful unions representing workers from these sectors have consistently blocked attempts to merge these funds with other social insurance funds or to allow buy-ins from other industry sectors. (191)

Social insurance funds reimburse doctors in two ways. Some providers are employed directly by the funds at fund-operated clinics and are effectively salaried employees. Others practice privately but contract with funds to provide care. Contract physicians are reimbursed on a fee-for-service basis, but reimbursement rates are extremely low. Balance-billing is prohibited.

In theory, funds provide first-dollar coverage, with no deductibles and low co-payments for only a few services. However, as discussed below, most physicians demand “informal” payments in exchange for treatment.

In addition to the social insurance funds, the National Health Service employs physicians and operates hospitals. The NHS operates parallel to the social insurance funds, acting essentially as a back-up mechanism, although it may be the principal provider of health services in some rural areas. It also provides health care for the uninsured and the elderly.

In addition to NHS hospitals, other public hospitals contract with the social insurance funds. In both cases, the Ministry of Social Health and Cohesion determines not only the hospital’s budget, but the number of personnel, the specialties of the personnel, salary levels, number of beds, and the purchase of technology. Budgets are rigidly monitored and hospital administrators have little leeway. (192) Hospitals are reimbursed on a per diem payment system, a type of a fixed charge. (193)

NHS hospitals in particular are considered substandard. Most suffer from severe staffing shortages caused by low pay and poor living conditions in rural areas. It has been estimated that less than half of authorized medical positions are actually filled. (194) Low salaries have also led to personnel shortages in public hospitals associated with social insurance funds. (195)

A series of reforms implemented in 2005 imposed a referral requirement for hospital admissions. Patients seeking free treatment in a public NHS hospital must have a referral from a general practitioner, who acts as a gatekeeper. Private practice physicians may not make referrals to public or NHS hospitals. (196) Unfortunately, general practitioners are in severely short supply. Greece needs an estimated 5,000 general practitioners to meet demand. In actuality it has only around 600. (197)

Despite overlapping health plans, the Greek system falls short of universal coverage. About 83 percent of the population is covered for primary care (on par with the United States), and about 97 percent for hospital care. (198) In theory, the uninsured can always receive treatment by walking into an NHS clinic or hospital. Only about 8 percent of Greeks have private supplemental health insurance, although this percentage has risen substantially in the past few years and further growth is predicted. (199)

Accurate information on waiting lists is difficult to come by. According to the WHO, “although ‘patient registries’ at the hospital level do exist, there is no systematic data processing available at any level of care,” to provide adequate analysis.(200) However, most observers agree that waiting lists are a severe problem at almost every level of care, and particularly bad at both NHS and public hospitals. An examination of waiting lists at Athens hospitals by the Ta Nea newspaper found the wait for surgery was as long as six months; for an outpatient appointment with either the hypertension or neurology departments, 150 days. Even simple blood tests required a month-long wait. (201)

The Greek system has developed a level of endemic corruption as patients have sought ways around the system’s rationing, bureaucracy, and inefficiencies. For example, Greeks routinely provide physicians with “informal” payments for seeing a patient from a sickness fund that has not contracted with the doctor, for moving a patient up in the queue, or for providing treatment outside government guidelines. In addition, physicians actively attempt to persuade patients to move from a doctor’s sickness fund contract to the doctor’s private practice. Patients who switch pay out of pocket but receive faster and better care. Even NHS physicians see private patients on the side. (This practice was illegal until 2002 but went on despite the prohibition). (202) Physicians also receive payments for referrals to private hospitals or diagnostic centers. Such informal out of- pocket payments made up 42 percent of total health expenditures in 2002, fully 4.5 percent of GDP.(203) Essentially, the Greek health care system is funded through payroll taxes, general tax revenue, and bribery.

In addition, the health care bureaucracy has become highly politicized. Every staff appointment in the public health sector must be approved at the ministry level. All hospital administrators and other health officials are appointed on the basis of political affiliation with the governing party, often with little regard for relevant training or other qualifications. (204)
Not surprisingly, Greece has far less modern health care technology than the United States. The United States has more than twice as many MRI units per million people and 20 percent more CT scanners. (205) Much of the state-of-the-art equipment that does exist is clustered in the country’s small number of private clinics and hospitals. Indeed, the vast majority of high technology biomedical tests are performed by the private sector. (206)

One study summed up the problems with the Greek health care system this way:

The Greek health system does not yet offer universal coverage and has fragmented funding and delivery. Funding is regressive, with a reliance on informal payments, and there are inequities in access, supply and quality of services. Inefficiencies arise from an over reliance on relatively expensive inputs, as evidenced by the oversupply of specialists and undersupply of nurses. Resource allocation mechanisms are historical and political with no relation to performance or output; therefore providers have little incentive to improve productivity. (207)

That would appear to be a fairly accurate summary.