Evaluación del compromiso en materia de precios sugerido por la Secretaría

94. Fee-for-service is the predominant mode of payments for primary care doctors in Australia, Belgium, Canada, France, Germany, Ireland, Japan, Korea, Luxembourg and Switzerland. Primary care physicians are predominantly remunerated by salary in Greece, Iceland, Mexico, Portugal, and Sweden and by capitation in Hungary, Italy, Poland and the Slovak Republic. The other 10 countries use a mix of these modes of payment.

95. In Austria, “contracted” primary care doctors working in private practice are paid by a capitation, for “basic services”, and by fee-for-service. Capitation accounts for almost 70% of their income (Hofmarcher and Rack, 2006). In Czech Republic, 91% of primary care doctors are self-employed. They are paid through a mix of capitation (adjusted by age) and fee-for-service. Capitation rates are adjusted by age and decline beyond a certain limit in the number of registered patients. Some services, such as preventive examinations and home visits are paid by fee-for-service, which accounted for 30% of physicians’ income in 2008 (Bryndová et al., 2009). In Denmark, GPs are paid through a mix of capitation (30% of their income) and fee-for-service (Strandberg-Larsen et al., 2007). In the Netherlands, since 2006, general practitioners have been paid through a mix of capitation (€52 per patient) and fee-for-service for each additional contact (€9 for a consultation, lower fees for e-mail contacts) (Knotterus and ten Velden, 2007). In Norway, generalists receive a capitation fee (30% of their income) as well as fees for individual services paid by patients and National Insurance (Grytten J. and R.J. Sørensen, 2009). In the United Kingdom, 87% of GPs are independent contractors grouped in primary practices paid through a mixture of capitation payments and fee-for-service payments for the provision of enhanced services and bonuses. 96. In Finland, most doctors working in municipal services are salaried employees. In some centres, patients are assigned to a specific doctor (“personal doctor system”). In those cases, doctors are paid through a mix of salary (60%), capitation (20%), fee-for-service (15%) and other allowances (5%), in order to encourage the provision of timely care to patients (Järvelin, 2002).

97. Australia, Austria, Belgium, Canada, France, Germany, Iceland, Japan, Luxembourg, and Switzerland employ a fee-for-services system as the predominant mode of payment for out-patient

and the UK use salary and another 7 countries use a combination of these two modes of payments. In Poland, where out-patient services are provided equally by the public and private sector, doctors working in public settings are paid on a salary basis, while doctors in private practices are paid by fee-for-service. In the Czech Republic, outpatient services are provided in public hospitals or in private settings and are paid on a fee-for-service basis. However, physicians delivering these services may be employed by the hospital and salaried.

Table 15. Predominant modes of physician payment

Country

Prim ary care physicians paym ent Out-patient specialists payment In-patient specialists paym ent Australia FFS FFS Salary

Austria FFS/Cap FFS Salary

Belgium FFS FFS

Canada FFS FFS FFS

Czech Republic FFS/Cap FFS/Salary Salary

Denmark FFS/Cap Salary Salary

Finland Salary/Cap/FFS Salary Salary

France FFS FFS Salary

Germany FFS FFS Salary

Greece Salary FFS/Salary Salary

Hungary Cap Salary

Iceland Salary FFS Salary

Ireland FFS Salary Salary

Italy Cap Salary Salary

Japan FFS FFS FFS

Korea FFS FFS/Salary FFS/Salary

Luxembourg FFS FFS

Mexico Salary Salary Salary

Netherlands FFS/Cap FFS

New Zealand FFS/Salary FFS/Salary FFS/Salary

Norw ay FFS/Cap FFS/Salary Salary

Poland(*) _{Cap FFS/Salary Salary}

Portugal Salary Salary

Slovak Republic Cap Salary

Spain Salary/Cap Salary Salary

Sw eden Salary Salary

Sw itzerland FFS FFS

Turkey FFS/Salary FFS/Salary FFS/Salary

United Kingdom Salary/Cap/FFS Salary Salary

Note: Cap means capitation, FFS fee-for-service.(*) In Poland, around half of physicians who work in hospitals receive salary; second half is self-employed and is remunerated according to contracts.

Source: OECD Survey on health system characteristics 2008-2009 and OECD estimates.

98. Canada, Japan, and the Netherlands have a fee-for-services system as the predominant mode of payment for specialists providing inpatient services. Salary is the predominant mode of payment in Australia, Austria, the Czech Republic, Denmark, Finland, France, Germany, Greece, Iceland, Ireland, Italy, Mexico, Norway, Poland10_{, the Slovak Republic, Spain and the United Kingdom. Korea, New}

Zealand, and Turkey use a combination of these two modes of payments.

99. In fact, in several countries, specialists can be employed by public or private hospitals, be self- employed or have a dual practice. Generally, doctors receive salaries from the establishment which employs them and fee-for-service when they are self-employed. In France, for example, 49% of specialists are exclusively salaried while 51% work as full-time or part-time self-employed. Most salaried specialists work in public hospitals. Typically, private-for-profit hospitals do not employ physicians, who rather intervene as self-employed. The proportion of exclusively-salaried doctors varies according to the specialty and is higher for specialists providing mainly inpatient services. In 2009, 75% of neurosurgeons were exclusively salaried while only 14% of ophthalmologists were (Eco-santé France, 2009).

100. In Australia and the United Kingdom –and France to a lesser extent-, where patients can be treated privately in public hospitals, specialists are paid by salary for treating public patients in public hospitals and by fee-for-service for treating private patients in either public and private hospitals.