Introduction of freedom of choice for hospital outpatient care in Portugal: Implications and results of the 2016 reform

Abstract

In Portugal, the National Health Service (NHS) assures universal access to medical treatment and care that is free at the point of delivery - except for relatively small user charges. Freedom of choice is limited and competition between the public and the private sectors is almost non-existent. In May 2016, the Ministry of Health introduced a new law that facilitates the referral of NHS users from primary healthcare units to outpatient consultations in NHS hospitals outside of the referral area. However, for inpatient care, patients are still bound to receive treatment within their referral area, which is determined by place of residence. The aim of the reform was to provide a timelier response to citizens' health needs and to increase efficiency. According to preliminary data from June 2016 to May 2017, 10.6% of all outpatient referrals from NHS primary health care units were made to an NHS hospital out of the referral area, with the highest proportion in the Lisbon (15.8%) region. In general, median waiting time for first outpatient consultation increased after the introduction of choice in the five specialties with the highest proportions of out-of-area referrals - but it reduced in two departments with the longest waiting times prior to the reform. The reform constitutes a major change to the relationship between NHS hospitals, with foreseeable consequences in hospital funding and the patients' perception of hospital quality.

Financial Crisis in Portugal: Effects in the Health Care Sector

“…Moreover, past experiences may dictate future demand: a dissatisfied patient is unlikely to demand future care from the same provider. Therefore, citizens are now free to choose where they want to be treated, 40 according to a referral system. Given the current financing system, the citizens’ free choice is likely to induce quality enhancements of delivered care.…”

Patients’ experiences and preferences for primary care delivery: a focus group analysis

“…Individuals are legally entitled to choose the PC unit and FD. In reality, individuals have limited choice because there is a shortage of doctors (Simões et al, 2017). In addition, individuals do not have easy access to information about the choices available to them or, until December 2017, information about the performance of FDs or the PC units in which they are based.…”

“…These are autonomous units of self-selected GPs, nurses, managers and other professionals within a flexible organisational structure that has autonomy. FHUs' remuneration is based on a combination of salaries, capitation and pay for performance (Simões et al, 2017). Virtually all patients in an FHU are assigned to an FD.…”

Economic Analysis of Portuguese Public Hospitals Through the Construction of Quality, Efficiency, Access, and Financial Related Composite Indicators

“…However, there are also out-of-pocket payments (co-payments and direct payments by the patient, such as moderating fees) and a private financing component associated with voluntary insurance and health subsystems (Nunes and Ferreira 2018b). Regarding public funding, the Finance Ministry annually sets the NHS budget based on the historical expenses and plans presented by the Health Ministry (Nunes et al 2019;Simões et al 2017b). In 2017, hospital care represented nearly 53% of the budget, while primary care received 42% of resources.…”