Health Systems in Transition

Health systems in transition

Portugal

The RHA budget for primary care is set on the basis of a combination of

historical expense and capitation. This approach was introduced in 1998 and the

budget computation has been progressively skewed towards a relative increase

of the capitation component. In order to provide an adjustment for health

care needs, the capitation component was adjusted by demography (age and

gender) and also by a disease burden index computed according to the regional

prevalence of selected health problems, namely four chronic conditions:

hypertension, diabetes, stress and arthritis. Weights, based on pharmaceutical

expenditure for each disease and region, were computed to create a disease

burden index. The demographic index was based on the intensity of primary

care visits per cell of age and gender.

3.3.4 Purchasing and purchaser–provider relations

Reform proposals initiated in 1996 intended to increase the purchasing role of

the RHAs to move the system gradually from an integrated model towards a

contract model of health care (see section 3.7.1,

Payment of hospitals

Payment

of primary care centres

). The core instruments of this contracting culture would

be the regional contracting agencies at each RHA. Their role is to identify the

health needs of geographically defined populations and prospectively negotiate

activity programmes and budgets with the provider institutions, with a view to

integrating primary and hospital care to meet those needs.

Since 2002, the hospital payment system has evolved to a contract-based

approach (see section 3.7.1,

Payment of hospitals

). In that year, roughly half

of the hospital sector was given corporate-like status, which has now been

extended to more hospitals. The contract approach is currently applied also to

purely public hospitals. Contracts are set for 1 year and stipulate the overall

payment and expected production level of the hospital (by broad lines of activity).

3.4 Out-of-pocket payments

OOP payments (including cost sharing and direct payments for private

sector services) accounted for approximately 26.8% of total health

expenditure in 2014 (see Table 3.1), and provisional data for 2015 indicate

that OOP payments have increased to 27.6% of total health expenditure.

Pharmacies (dispensing chemists), outpatient care centres and offices of

physicians, hospitals, and nursing and residential care facilities represent