Denmark
In 1996, public and private expenditures on health in Denmark
amounted to DKK60.500 million' or approximately 6.5 percent of the
Gross Domestic Product (GDP). The hospital services are mostly
financed from public funds. In 1 970, all publicly owned hospitals
were transferred to the 1 6 political-administrative authorities, ie,
the 14 county councils and the city councils of Copenhagen and
Frederiksberg.The primary health service is organised on the basis
of automatic insurance with free access for all citizens to the
public health services. The act governing national health insurance
gives all residents the right to free medical treatment by a medical
practitioner or practising specialist. However, access to the public
health service is divided into two groups: Group 1 and Group 2
coverage. Every citizen in Denmark may freely choose between these
two groups regardless of income. Children under the age of 1 6 are
included in the same group as their parents. Approximately 97 per
cent of the population is covered in Group 1.Group 1 members receive
completely free medical care from their general practitioner and
also free specialist care when referred for such treatment by their
general practitioner. They have to choose one particular general
practitioner whom they must contact in order to get their expenses
fully covered. After an initial six- month period, however, they may
change doctor. For some specialties, direct access is permitted. The
general practitioner treats or refers the patient further in the
system, to a specialist or hospital care, free of charge to the
patient.Group 2 members must pay a portion of the cost of their
medical care, both general and specialist care, but have free choice
amongst all general practitioners and are free to change general
practitioner without limit. They also have direct access to all
specialist care and are not obliged to see their general
practitioner first in order to be referred. The amount paid by those
insured in Group 2 constitutes whatever their general practitioner
or specialist charges over and above the amount paid
by a person insured in Group 1.Specialists practising outside
hospital receive their fees from the health insurance scheme on the
basis of a fee for services rendered. Patients receive subsidies to
cover part of the cost of prescribed medicines. These subsidies can
be as much as 75 per cent (more in special cases). The social
security system also pays part of the costs to the patient of dental
care as well as certain other treatments such as physiotherapy.
Dental care for children under the age of 1 6 is provided free of
charge.
Primary
healthcare
Primary healthcare in Denmark covers the services of a wide range
of health personnel. Contact with the primary health services takes
place on the patient's own initiative. The following are included in
those providing primary healthcare:
general practitioners;
specialists in practice outside
hospitals;
dentists;
physiotherapists;
home visitors and nurses;
chiropractors;
chiropodists;
school health and dental service
personnel.
For cost purposes, the expenditures on primary healthcare in Denmark
can be regarded as the total amount spent on public and private
healthcare after expenditures on the hospital system have been
deducted. Within this definition, primary care accounts for 38 per
cent of the total health expenditures; within this total, 55 per
cent of the expenditures are met under the social security system
and 45 per cent privately.
General medical services
The general practitioner is the patient's first contact with the
healthcare system. He or she is the first person to see and treat
the patient and to advise and refer the patient for any further
contact with the remainder of the system when appropriate. This can
take the form of a referral to a practising specialist or to the
hospital system.The range of services provided by the general
practitioner under the general medical services in Denmark is
considerable. As mentioned, the general practitioner is responsible
for referrals of patients further in the system. Each general
practitioner is also responsible for the routine health requirements
of an average of 1,600 patients. Of these, 1,300 will be insured in
Group 1. Care is delivered either by consultations at the surgery or
by home visits and include such areas as maternal and child care,
health examinations, vaccination of children, prescription of
appropriate medicines and ordering treatment at the State Serum
Institute.
The general practitioner also participates in the
appropriate municipal, social, and health organisations. There are
currently 3,300 general practitioners in Denmark. The general
practitioner is in contact with each patient six times per year on
average.As mentioned, the individual patient chooses whether they
wish to be enrolled in Group 1 or 2. At the same time, the
individual Group 1 patient chooses which general practitioner they
wish to be enrolled with. For Group 1 patients, the choice of
general practitioner may be changed at any time. The individual
patient chooses from amongst a certain number of doctors within the
area of the patient's residence. However, in case of disagreement
between patient and doctor, exceptions can be made to this rule and
an alternative doctor can be chosen from outside this broad
framework. Group 2 patients have a free choice of doctor at
any time.The average number of approximately 1,300 Group 1 patients
per general practitioner excludes children under the age of 16. A
practice is unable to increase the number of patients when the total
number exceeds 2,066 other than when no alternative practitioner is
available.
The freedom to set up a new practice is restricted by
general agreement between the social security system and the
Organisation of General Practitioners in Denmark (Praktiserende
Lasgers Organisation), membership of which is obligatory. Under the
terms of this agreement, an area where the overall ratio of Group 1
patients to general practitioners is less than 1,306 will normally be
declared closed to any new practices. However, a general
practitioner may, in principle, practise outside the framework of
the public social security system agreement. In such a case, the
patient would have to pay the entire fee themselves.Fifty-eight per
cent of practices, covering 33 per cent of general practitioners,
are run on a single-handed basis. A further 33 per cent of practices
are partnerships, and the remainder, consisting of some 181
practices, are group practices.The groups share auxiliary staff and
facilities, but not patients unless there is a partnership
agreement.Finally, general practitioners are also responsible for
the out-of-hours services when acute medical assistance is needed.
This has been organised in out-of-hours arrangements in each county.
In 1996, approximately 2.5 million patients contacted the
out-of-hours services throughout the country. Half of these contacts
were dealt with on the telephone, while the other half resulted in
home visits or consultations in out-of-hours clinics.
Remuneration of general practitioners
General practitioners are remunerated partly on a capitation
basis and partly according to the services rendered to the patient.
In 1996, the average gross income was DKK1,225,000 of which
professional expenses would absorb 48 per cent.Out-of-hours service
is covered co-operatively by the entire group of general
practitioners in the county who, in principle, each take an equal
number of duty watches which mostly are divided into eight hour
modules. In an eight hour module, the general practitioner is
responsible for either referral, consultations, or home visits.
Reference
1. US$1 = approximately DKK 6.0 (1996).
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