Table 3.
Outpatient benefit catalogues or substitutes
| Country | Name of taxonomy | Applied geographical area | Taxonomy (and grouping criteria) | Actors involved in decision making | Criteria for in-/exclusion of benefits | Benefits, procedures explicitly excluded |
|---|---|---|---|---|---|---|
| Denmark | Health Care Reimbursement Scheme Fee Schedule | National | Services are grouped according to medical specialty and for GPs additionally in basic, supplementary, laboratory and miscellaneous services. Each service has an item number. It is referred to the respective legislation decree specifying the benefit, certain goods, procedures or in rare cases indications | National level (law, general framework) | Need | Alternative care |
| Ministry for the Interior and Health (approval) | ||||||
| Counties (budgeting, health plan) | ||||||
| Health care Reimbursement Negotiating Committee and health professional associations (negotiate catalogue) | ||||||
| France | Common Classification of Medical Procedures (CCAM) | National | Lists all medical procedures reimbursable and excluded. Grouping criteria: anatomic classification, medical specialties | National level (law, general framework) | Effectiveness, safety | Spa treatments; cosmetic surgery |
| Ministry of Health (approval) | ||||||
| National Union of Health Insurance Funds (in- and exclusion of services) | ||||||
| High Health Authority (advisory body on in- and exclusion of services) | ||||||
| Germany | SHI-EBM, SHI-BEMA, SHI-BEL-II | National | Services are grouped according to the medical specialty allowed to provide the service. Each service is assigned a numeric code in accordance with the subjection of the catalogue | National level (law, general framework) | Diagnostic and therapeutic expedience, medical necessity and cost-effectiveness | Orthopedic services after the age of 18 years |
| Federal Joint Committee (approval of new benefits) | ||||||
| Valuation Committee (negotiates EBM) | ||||||
| Dental Valuation Committee (negotiates BEMA, BEL-II) | ||||||
| Hungary | Governmental decrees and reimbursement catalogues | National | Similar services are listed in groups. Governmental decrees relate to different areas of care (e.g., dental care, specialist services). Items in reimbursement catalogues are listed with the respective ICPM code and a point value | Legislation at the national level (law, general framework, budgeting) | Costs, effectiveness | – |
| Ministry of Welfare (decrees, approval) | ||||||
| National Health Insurance Fund | ||||||
| Administration, especially (prepares decisions) | ||||||
| Payment Codes Updating Committee (reimbursement catalogues) | ||||||
| Italy | National contract for primary care; decree on specialist outpatient services | National benefit package, regions include additional services | Contract for primary care describes obligations of GP. Individual services are not further itemized. Decree on specialist outpatient services lists services in three sections: available, availability restricted to specific indications, excluded | Government at national level (sets decree, negotiates contract) | Effectiveness, costs | Nonconventional treatments (e.g., acupuncture, phytotherapy); vaccination for traveling purposes |
| Representatives of GPs (negotiate contract) | ||||||
| Ministry of Health (transfers contract into law) | ||||||
| Government at regional level (negotiates additional contracts) | ||||||
| The Netherlands | Health Insurance (Treatment and Services) Decree; Diagnose Behandeling Combinaties (DBC; DRG-like system); Jan. 2005 | National | GP services are regulated in generic terms only by decree, DBC catalogue (111,527 DBCs) combine information on diagnosis and treatment for medical specialists. DBCs are on three different lists determining the status for tariff negotiations or excluding DBCs from the benefit package. Grouping criteria: medical specialty, product group | Legislation at the national level (law, general framework) | Costs, effectiveness | – |
| Ministry of Health (decrees) | ||||||
| DBC-Maintenance Organization (DBC-System) | ||||||
| Physicians (priority setting) | ||||||
| Poland | Governmental decrees and catalogue of benefits | National | Catalogue lists all services covered under social health insurance scheme. Services are linked to the respective regulation/law. Grouping criteria: area of care, medical specialty | Legislation at the national level (law, general framework) | – | Vaccination; acupuncture, unless part of chronic pain management |
| Ministry of Health (regulations) | ||||||
| National Health Fund (catalogue) | ||||||
| Spain | Royal Decree 63/1995 | National with regional differences | Services are listed explicitly in decree. In some cases, services are restricted to specific patient groups. Decree lists services in 5 areas of care (e.g., primary care, specialized care, pharmaceutical care) which are further subdivided. | Legislation at the national level (law, general framework) | Safety, efficacy, efficiency | Cosmetic surgery (transplantation of hair and nails); sex change |
| Federal Government (decree) | ||||||
| Inter-territorial Council and Council of the State (inclusion of new benefits) | ||||||
| Clinicians (provision of services relating to entitlements defined by decree) | ||||||
| England | National Service Framework | National | Health Resource Groups are linked to procedures. Currently only 48 HRGs are in use. Guidelines recommend services to be used on certain indications | Legislator at national level (law, general framework) | Need, effectiveness | Cosmetic dental treatments |
| General Medical Services Contract | National, with possible variation at PCT-level | NHS Confederation and General Practitioners Committee (negotiate contract) | Need, costs | |||
| Clinical Guidelines | National | Primary Care Trusts (PCT) (negotiate additional contracts) | Need, costs, effectiveness | |||
| NICE (clinical guidelines) |