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Health systems in transition
Portugal
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In 2006, a reform approved by the government was expected to introduce
further changes to the previous organizational and funding models of primary
care. This reform was based on the idea of FHUs (
Unidades de Saúde Familiar
),
which are multidisciplinary teams, paid partially through incentive mechanisms.
These include, among others: capitations, which are age-adjusted, related
to the dimension of the list of patients, carrying out house-calls, number of
working hours; performance compensations, related to the annual contracting of
specific surveillance activities, with respect to vulnerable or high-risk patients;
and an additional set of services, if contracted (Decree-Law No. 18/2007, of
22 January 2007). Multidisciplinary teamwork and organizational flexibility
were promoted in a bid to provide incentives for the provision of better primary
care service to the population.
The main differences between FHUs and PHCUs include the number of
patients enrolled in an FHU, the voluntary creation of those multidisciplinary
teams, and the incentive mechanisms. FHUs have a level of autonomy and
participative management that PHCUs do not, and the professionals in FHUs
are paid by incentive mechanisms related to their performance, which can
be paid either by bonuses at institutional level and/or the multi-professional
team (but only in FHUs belonging to the B model). There are two models of
FHUs: at its inception, every FHU belongs to the A model, and later, based
on its performance and after approval, becomes a B model, with incentive
mechanisms to personnel. PHCUs are still the most common unit in the NHS
primary care network. They correspond to the old model of primary health
care provision and usually have many patients enrolled, some of them not being
registered with a GP. A recent analysis showed that 99% of the population is
located less than 30 minutes away from an NHS primary care unit, namely
from a PHCU (97.5%). Approximately 74.9% of population is enrolled in an
FHU (ERS, 2016a).
Payment for outpatient care
In NHS hospital outpatient care, patients pay only user charges (if they are not
exempted), whereas in the private sector patients either make direct payments
or use their health subsystems or VHI. The same applies for diagnostic tests:
patients make direct payments, with or without reimbursement or co-payments
by VHI.