The development of voluntary private health insurance in the Nordic countries

68 No dic Jou nal o Heal h Economics, Vol. 4 (2016), No. 1, pp. 68-83 * Co espondence o: Odd a Kaa boe, HELED, UIO. P.O. BOX 1089, Blinde n, 0317 Oslo. E-mail: odd a .kaa b[email p o ec ed].no dx.doi.o g/10.5617/njhe.2718 The de elopmen o olun a y p i a e heal h insu ance in he No dic coun ies NINA ALEXANDERSEN 1 ANDERS ANELL 2 ODDVAR KAARBOE 1, * JUHANI S. LEHTO 3 LIINA-KAISA TYNKKYNEN 4 KARSTEN VRANGBÆK 5 1 Depa men o Heal h Managemen and Heal h Economics, Uni e si y o Oslo, No way 2 Depa men o Business Adminis a ion, Lund Uni e si y, Sweden 3 School o Heal h Sciences, Uni e si y o Tampe e, Finland 4 Ins i u e o Ad anced Social Resea ch, Uni e si y o Tampe e, Na ional Ins i u e o Heal h and Wel a e, Finland 5 Depa men o Poli ical Science and Depa men o Public Heal h, Uni e si y o Copenhagen, Denma k Abs ac : The No dic coun ies ep esen an ins i u ional se ing wi h ax-based heal h ca e inancing and uni e sal access o heal h ca e se ices. Ve y ew heal h ca e se ices a e excluded om wha a e o e ed wi hin he publically inanced heal h ca e sys em. Use ees a e o en non-exis ing o low and capped. Ne e heless, he ma ke s o olun a y p i a e heal h insu ance (VPHI) ha e been apidly expanding. In his pape we desc ibe he de elopmen o he ma ke o VPHI in he No dic coun ies. We ou line simila i ies and di e ences and p o ide discussion o he a ionale o he exis ence o di e en ypes o VPHI. Da a is collec ed on he popula ion co e ed by VPHI, ype and scope o co e age, supplie s o VPHI and hei ela ions wi h heal h p o ide s. I seems ha he main oles o VPHI a e o co e ou -o -pocke paymen s o se ices ha a e only pa ly inanced by he public heal h ca e sys em (complemen a y), and o p o ide p e e en ial access o ea men s ha a e also a ailable ee o cha ge wi hin he public heal h ca e sys em, bu o en wi h some wai ing ime (duplica e). JEL classi ica ion: I11, I13 Key wo ds: olun a y p i a e heal h insu ance, complemen a y p i a e heal h insu ance, duplica e p i a e heal h insu ance, ax-policies 1 In oduc ion The No dic coun ies a e well known o hei wel a e s a es. An impo an ea u e o he wel a e s a e e hos is easy and equal access o adequa e heal hca e o he whole popula ion. Ve y ew se ices a e de ined ou side he public heal h ca e sys em, he use co-paymen s a e ela i ely low and complemen ed wi h an annual high-cos ceiling. Ins ead o using N. Alexande sen e al. / No dic Jou nal o Heal h Economics, Vol. 4 (2016), No. 1, pp. 68-83 69 inancial incen i es o educe demand he heal h ca e sys ems ha e been cha ac e ized by a ioning by wai ing ime and ga e-keeping o specialized ca e. In spi e o he appa en simila i ies o he No dic heal h ca e sys ems, he e a e di e ences be ween he coun ies in e ms o go e nance/o ganiza ion and inancing o he heal h se ices. 1 The Finnish public heal h sys em is buil on h ee pa s: The i s pa is a ax unded sys em un by he municipali ies wi h public and some ou sou ced p i a e p o ide s. Specialis ca e is p o ided by 20 egional p o ide s, hospi al dis ic s. The second pa is an obliga o y public heal h insu ance (PHI) based sys em eimbu sing he use o p i a ely p o ided heal h se ices. I co e s all pe manen esiden s in Finland. The PHI unded sys em mainly p o ides se ices ha a e duplica e o he ax unded se ices. Wai ing imes a e ei he non-exis en o much sho e han in he ax unded sys em, bu co-paymen s a e signi ican ly highe . The hi d pa is ha employe s a e obliged o o ganize p e en i e occupa ional heal h ca e se ices o hei employees. Many employe s also pu chase medical ou pa ien se ices o hei s a . These se ices a e eimbu sed pa ly by Na ional Heal h Insu ance. Occupa ional heal h ca e se ices, unlike o he i s con ac se ices in Finland, a e ee o cha ge o he use s. No way is cha ac e ized by a semi-decen alized heal h ca e sys em. The municipali ies hold esponsibili y o p ima y ca e while he cen al go e nmen , ep esen ed by ou egional heal h au ho i ies, go e ns specialis ca e. Bo h p ima y and specialized ca e a e ax unded. Denma k also has a semi-cen alized heal h ca e sys em. Since 2007 specialized ca e is mainly p o ided by hospi als owned and un by i e egions. Gene al p ac i ione s and p ac icing specialis s a e p i a ely owned, bu ope a e unde gene al con ac s wi h he egions and ecei e mos o hei income om public sou ces gene a ed by axa ion a he s a e and municipal le els. Bo h gene al and p ac icing specialis s a e subjec o egional planning in e ms o he numbe and loca ion o p ac ices. In Sweden he esponsibili y o inancing and p o ision o heal h se ices lies a he coun y councils/ egions, while municipali ies a e equi ed o p o ide ca e o he aged and disabled. Mos heal h ca e is inanced h ough local axa ion, and con a y o Denma k and No way, coun y councils ha e he igh o collec hei own axes. Access o specialis ca e in Denma k and No way is con olled by ga ekeeping. Tha is, by gene al p ac i ione s ha e e pa ien s o he specialis s. In Sweden, he majo i y o coun y councils do no o mally equi e e e als o en e specialized ca e, al hough pa ien s a e encou aged o seek p ima y ca e i s . In Finland e e als a e no equi ed i a pe son isi s he p i a e sec o specialis s (PHI sys em). As he popula ions in he No dic coun ies ha e become olde and iche , demand o , and expendi u e o , heal h ca e has g own mo e han he inc ease in esou ces. Go e nmen s in he No dic coun ies ha e in oduced e o ms on bo h he demand side and he supply side o he heal h ca e sec o o cope wi h limi ed capaci y and long wai ing imes. On he supply side, inc eased unding o heal h ca e, wai ing- ime gua an ees and p ospec i e eimbu semen , such as ac i i y-based inancing using diagnoses- ela ed g oups, a e some o he policies ha ha e been in oduced. Howe e , hese policies ha e gene ally been unsuccess ul in b inging down wai ing imes. E en policies o ac i i y-based inancing do no necessa ily dec ease wai ing imes, al hough hospi al p oduc i i y 1 We use he e m No dic coun ies, e en hough we only include Denma k, Finland, No way and Sweden in he o e iew ha ollows. The eason ha Iceland is no included is ha olun a y p i a e heal h insu ance is ha dly exis ing on Iceland. Acco ding o he OECD Heal h S a is ics (2015), 0,2% o he popula ion on Iceland we e co e ed by p i a e heal h insu ance. 70 N. Alexande sen e al. / No dic Jou nal o Heal h Economics, Vol. 4 (2016), No. 1, pp. 68-83 gene ally inc eases (Siciliani e al, 2013). In oduc ion o ac i i y-based inancing is howe e a key componen in in oducing choice and compe i ion, which may in i sel educe wai ing imes. In addi ion choice and compe i ion will inc ease he inhabi an s’ op ion o p o ide s, and may u ilize capaci y a ailable in he p i a e sec o . The demand side e o ms ypically imply inc eased ou -o -pocke paymen s and inc eased cos -sha ing o se ices ha a e pa ly co e ed by he public sys em. The main a ionale, in addi ion o con ain public expendi u e expansion, has been o make people mo e awa e o he cos o medical se ices hus p e en ing o e u iliza ion. In addi ion, inc eased ou -o -pocke paymen s o (p ice-inelas ic) se ices will also inc ease he inancial esou ces a ailable o he heal h ca e sec o . The o he demand side policy app oach has been o shi demand o he p i a e sec o . One example o such a policy is o s imula e he g ow h o olun a y p i a e heal h insu ances (VPHI) by in oducing ax incen i es o employees and employe s. The VPHI schemes ha a e in oduced in he No dic coun ies a e mainly complemen a y o duplica e in ela ion o he public heal h ca e sys em. Tha is, he VPHI schemes co e ou -o -pocke paymen s o se ices ha a e only pa ly inanced by he public heal h ca e sys em (complemen a y), o hey p o ide p e e en ial access o ea men s ha a e also a ailable ee o cha ge wi hin he public heal h ca e sys em, bu o en wi h some wai ing ime (duplica e). In addi ion some o he VPHI schemes also o e supplemen a y heal h se ices. Tha is, se ices no co e ed by he public heal h ca e sys em (OECD, 2004). The pu pose o his pape is o desc ibe he de elopmen o he VPHI in he No dic coun ies. We will highligh simila i ies and di e ences ela ed o popula ion co e age, he ype and scope o co e age, he supplie s o VPHI and hei ela ionship wi h heal h ca e p o ide s. Fu he mo e we will ou line whe he ax-policies ha e been in oduced o p omo e VPHI. We p o ide discussion o he a ionale o he exis ence o di e en ypes o he VPHI. Finally we indica e possible a enues o u u e esea ch ela ed o VPHI in he No dic coun ies. 2 Po en ial bene i s and d awbacks o VPHI One o he main bene i s o VPHI is ha i may shi demand om he public heal h ca e sec o o he p i a e sec o . In his case VPHI migh inc ease a ailable capaci y, educing wai ing imes and eleasing inancial p essu e om he public sys em since hose wi h p i a e insu ance will co e some o he medical expenses hemsel es. In addi ion, VPHI may demons a e mo e lexibili y and esponsi eness o popula ion needs and p e e ences by p o iding pa ien s wi h as e access and inc eased choice o p o ide s. VPHI may also p o ide access o se ices excluded om he public co e age. P i a e insu e s can p o ide pa ien s wi h e ec i e guidance ough complica ed heal h ca e sys em and p omo e mo e e icien u iliza ion o a ailable capaci y in he public and p i a e sec o s. Finally, i can lead o mo e dynamic and compe i i e ma ke wi h a highe deg ee o inno a ion; imp o e e iciency, quali y and sus ainabili y o he public sys em and enhance access (Colombo and Tapay, 2004). In spi e o he numbe o po en ial posi i e consequences, hese e ec s ha e no ye been consis en ly demons a ed (Sagan and Thomson 2015). Mo eo e , he e a e conce ns and challenges associa ed wi h he expansion o p i a e sec o heal h se ices ha need o be add essed. VPHI may educe capaci y by c owding ou esou ces om he public sys em. I may lead o dis o ion in esou ce alloca ion and p io i ies, and esul in o e u iliza ion o se ices. These conce ns a e pa icula ly ele an when he e is a limi ed supply o N. Alexande sen e al. / No dic Jou nal o Heal h Economics, Vol. 4 (2016), No. 1, pp. 68-83 71 physicians and bo de s be ween public and p i a e sys ems a e no clea ly de ined (Mossialos and Thomson, 2004). Compe i i e ma ke en i onmen s may u he inc ease p essu e on he public sys em i VPHI gi es insu e s and p i a e p o ide s oppo uni ies o isk selec ion hus lea ing he public sec o wi h pa ien s ha equi e mo e cos ly ea men s. VPHI may also wo k agains he policy goal o making pa ien s/physicians mo e conscious o he use o se ices hus po en ially esul ing in excessi e u iliza ion o se ices. The expansion o VPHI in he No dic coun ies, as well as in o he coun ies wi h na ional heal h ca e sys ems, has been subjec o deba e as VPHI is o en bough by indi iduals o highe socioeconomic s a us (see e.g. Kiil (2012)). In his espec , VPHI can lead o medical ca e di ided by social class (Mani es , 2009) and p io i ies de e mined by he indi iduals’ inancial/insu ance s a us. I is also a gued ha highe income g oups ( ha pu chase VPHI and pay axes) migh be less mo i a ed o con ibu e o he public sys em in he u u e. Despi e ha expansion o VPHI has a po en ial o add essing he cu en challenges in he No dic heal h ca e sys ems and in heo y sounds p omising, i is impo an o be awa e o i s po en ial nega i e e ec s and moni o i s de elopmen o ensu e ha i does no iola e impo an socie al goals such as equi y and solida i y and does no ad e sely a ec e iciency, coo dina ion and sus ainabili y o he public sys em. 3 The ins i u ional amewo k o VPHI In he ollowing we will p esen da a on he popula ion co e ed, ype and scope o co e age, supplie s o VPHI and hei ela ionship wi h heal h ca e p o ide s o Finland, Denma k, No way and Sweden. 3.1 Popula ion co e ed wi h VPHI The ma ke o VPHI has g own signi ican ly in he No dic coun ies. Cu en ly abou 20 % o he popula ion in Finland is co e ed by VPHI. The co esponding numbe s o Denma k, No way and Sweden a e espec i ely 51 %, 9 % and 7 %. Acco ding o he Finnish Fede a ion o Financial Se ices 438 421 child en had p i a e insu ance o heal h ca e cos s, 363 382 adul s had p i a e insu ance and 171 007 had p i a e insu ance h ough an employe in 2013 (FFFS 2013). 2 The g ow h has been signi ican he la e yea s. 3 In No way, he ma ke o VPHI was almos non-exis en un il he beginning o he millennium. Since hen he ma ke has apidly expanded. In 2015, 472 000 indi iduals we e co e ed (Finans No ge, 2015a). Collec i e/g oup policies cons i u e a ound 90 %, while 10 % a e indi idual policies. In Sweden, 626 000 people had VPHI a he end o 2015. This is an inc ease om 218 000 in 2006. 72 % o insu ance policies we e paid by he employe . The emaining policies we e di ided be ween indi idually pu chased, 5 %, and g oup policies, 23 % (S ensk Fö säk ing, 2015). G oup policies, which con ibu es o he mos o he ma ke expansion in ecen yea s, a e signed by employe s, unions o o he membe o ganiza ions, bu paid by indi iduals. 2 In he i s su ey o heal h insu ance in Finland i is es ima ed ha 22.7 % o Finnish adul s and 52 % o he child en had p i a e heal h insu ance. O he insu ed adul s, 74.8 % had sel -pu chased heal h insu ance, 16.2 % employe -pu chased heal h insu ance and 9 % bo h, Val onen e al. (2014). 3 In 2005, 375 000 child en and 237 000 adul s had olun a y p i a e heal h insu ance, Vuo enkoski (2008). 72 N. Alexande sen e al. / No dic Jou nal o Heal h Economics, Vol. 4 (2016), No. 1, pp. 68-83 In Denma k, complemen a y VPHI has played a signi ican ole since he ea ly 1970s while duplica e VPHI is a mo e ecen phenomenon. 4 Complimen a y insu ance was held by 2.3 million Danes in 2014 (Heal h insu ance ‘danma k’, Annual epo 2014). The numbe o inhabi an s wi h duplica e ea men insu ance has inc eased om 230 000 in 2003 o 2 million in 2014. In mos cases (abou 75 %) duplica e insu ance is pa o an employmen con ac . The numbe o pe sons co e ed by indi idual policies is low and dec easing ( om 4 % in 2003 o 1.8 % in 2013). The emaining (23.5%) a e co e ed by ea men insu ance con ac s whe e pa ne s and child en a e co-insu ed (Fo sik ing & Pension, 2014a). Abou 37 % o hose wi h complemen a y VPHI also had medical ea men insu ance. I is he e o e es ima ed ha 2.9 million inhabi an s we e co e ed by p i a e heal h insu ance, CEPOS (2014). 3.2 Type and scope o co e age 3.2.1 Complemen a y VPHI Complemen a y VPHI plays a signi ican ole in Finland and Denma k, while in No way and Sweden his ype o co e age is almos non-exis en . Complemen a y heal h insu ance is de ined as p i a e heal h insu ance ha complemen s co e age o he public sec o se ices by co e ing all o pa o he esidual cos s no o he wise eimbu sed (OECD, 2015). A dis inc ea u e o he complemen a y insu ance in Finland is ha i can p o ide a as e access o p ima y 5 and seconda y ca e le el ambula o y se ices and di ec access o a specialis wi hou a e e al om GP 6 . In o he No dic coun ies p ima y ca e is usually excluded om he co e age. In Finland, VPHI is la gely complemen a y o he use o p i a ely p o ided heal h se ices eimbu sed by he obliga o y PHI based sys em h ough which he isi s, diagnos ic and ea men se ices, and p esc ip ion d ugs a e eimbu sed o a small ex en . Howe e , while VPHI is mos ly used o co e he high co-copaymen s in he PHI eimbu sed sys em i usually co e s also co-paymen s in he municipal p ima y ca e cen e s and public hospi als. The complemen a y insu ance in Denma k co e s co-paymen s o pha maceu icals, and se ices such as adul den al se ices, glasses and con ac lenses, and physio he apy (Pede sen, 2005). The o al compensa ions ela ed o complemen a y co-paymen insu ance in Denma k amoun ed o 2 649 million Danish k one (€355 mill.) in 2014, compa ed o a ound 25 000 million Danish K one in o al p i a e use paymen s. 3.2.2 Duplica e VPHI Duplica e p i a e co e age exis s in all No dic coun ies. I plays a majo ole in No way and Sweden. Duplica e VPHI o e s co e age o heal h se ices al eady included unde go e nmen heal h insu ance, while also o e ing access o di e en p o ide s (e.g., p i a e hospi als) o le els o se ice (e.g., as e access o ca e). I does no exemp indi iduals om con ibu ing o go e nmen heal h co e age p og ams, OECD (2015). 4 Duplica e insu ance is called supplemen a y in Denma k and includes bo h duplica e and supplemen a y se ices. The in o ma ion and numbe s below a e o ea men insu ance ha co e s bo h ypes o se ices. 5 Wi h VPHI pa ien s can access p i a e sec o in which he e a e doc o s ha can be seen as pa allel o GPs in a sense ha hey a e ei he no specialis s o hey a e specialis s in gene al p ac ice. Mos o he doc o s wo king in he p i a e sec o a e howe e specialis s in o he han gene al p ac ice. The access in u n esembles he p ima y ca e in a sense ha i is he place o i s -con ac -ca e. The physicians in he p i a e sec o can also e e pa ien s o public hospi als which also ea u es p ima y ca e. 6 The di ec access applies only o hose specialis s wo king in he p i a e sec o . N. Alexande sen e al. / No dic Jou nal o Heal h Economics, Vol. 4 (2016), No. 1, pp. 68-83 73 As al eady desc ibed, in Finland, use o p i a e heal h se ices is pa ly eimbu sed by he obliga o y public heal h insu ance. This sys em is o en duplica e o he municipal sys em bu i o e s be e access o ca e and o en also a di ec access o a specialis . In addi ion, he use o he p i a e se ices pa ly eimbu sed om he PHI allows he choice o a doc o and p o ide o ganiza ion in he p i a e sec o . Howe e , he co-paymen s a e ela i ely high since PHI is co e ing only a ound 20-30% o he cos s. Hence, by pu chasing a VPHI he indi idual can ha e mo e a o dable se ices compa ed o PHI bu also be e access compa ed o he municipal sys em. Howe e , no all se ices a e included in VPHI. Se ices ha a e o en excluded include p ena al examina ions, e mina ions, deli e y, e ili y ea men , con acep ion, isual examina ions and ea men o e ac i e e o , accina ions, i amins o o he heal h oods and nu ien s, es he ic su ge y, ea men o i ili y and ‘al e na i e’ ea men s. The insu ance companies may exclude ea men o speci ic diseases on he basis o indi idual exclusion c i e ia. This is usually based on he case his o y o he insu ed pe son, i.e. exis ing medical condi ions be o e pu chase o VPHI a e usually excluded. Typical condi ions ha a e excluded a pu chase a e ype one diabe es and o he ch onic diseases. Fo child en, condi ions such as congeni al medical condi ions and disabili ies may be excluded. In Denma k he e a e se e al ypes o VPHI. The majo i y o policies p o ide as e access o specialis diagnosis and ea men se ices ha a e also a ailable in he public sys em. They co e expenses o examina ions and ea men s (including su ge y and medicines) a p i a e hospi als, p e en i e se ices by physio he apis s and chi op ac o s, and gene al heal h examina ions. A ound 33% o all policies a e less comp ehensi e, and only co e diagnos ic and p e en i e se ices. Mos policies do no co e ongoing medica ion o ch onic condi ions, bu do co e medica ion ela ed o acu e ea men episodes and some ollow up (In e iew wi h “Fo sik ing og Pension”, 7 Janua y 27, 2016). Policies on exclusion o p oduc s a y be ween companies, bu gene ally all ea men s ha a e co e ed in he public sec o and can lead o sus ained heal h bene i s a e co e ed (in e iew wi h “Fo sik ing og Pension”, Janua y 27 2016). Mos collec i e policies exclude medica ion o ch onic condi ions and/o de ine a speci ic pe iod (12-24 mon hs) be o e co e age s a s o p eexis ing condi ions. Cosme ic su ge y is ypically excluded as in he public sys em, and in e ili y ea men is excluded o subjec o limi a ions. VPHI in Denma k inc eases he choice o p o ide , bu he choice can be limi ed o he p o ide ne wo k ha is associa ed wi h a pa icula insu e . As a ule a e e al is equi ed o access specialis ca e in Denma k. Howe e , some p i a e insu ance policies do no equi e e e als. In Denma k he e is also an op ion in he public sys em o selec a co e age scheme ha p o ides di ec access o p i a ely p ac icing specialis s. Pa ien s wi hin his scheme ecei e eimbu semen up o he le el o public ees, bu mus pay an addi ional ee. In No way, VPHI p o ides he insu ed gua an eed access o medical examina ion o ea men by a specialis physician/elec i e su ge y wi hin a speci ied ime ame. VPHI ypically co e s diagnos ics, examina ions, specialis consul a ions and ea men s, hospi aliza ions and elec i e su ge ies as well as ehabili a ion. In addi ion, physio he apy and psychological ea men can be included. VPHI will ypically no include eme gency ea men s, ea men s a public acili ies like hospi als and p ima y ca e cen e s, psychia ic ea men , den al ea men , addic ions ela ed o alcohol, d ugs, sleep agen s o na co ic subs ances, p egnancy- ela ed ea men s, deli e ies, abo ion and s e iliza ion, in e ili y ea men s, sleep- ela ed ea men , obesi y, cosme ic ea men s, examina ion and ea men ela ed o ision as well as ision and hea ing aids, accina ion and p e en i e examina ion. 7 “Fo sik ing og Pension” is he business associa ion o p i a e insu ance and pension p o ide s in Denma k. 74 N. Alexande sen e al. / No dic Jou nal o Heal h Economics, Vol. 4 (2016), No. 1, pp. 68-83 In addi ion, VPHI will ypically no co e se ices ha a e excluded om he public co e age. Mos insu e s exclude p eexis ing condi ions and de ine a speci ic pe iod be ween he pu chase o VPHI and he ime om which co e age s a s o apply. This is pa icula ly he case o indi idual policies and small g oups policies. In No way VPHI inc eases he choice o p o ide s in specialis ca e. Howe e , he choice o p o ide is usually es ic ed o he p o ide ne wo k ha a pa icula insu ance company has es ablished a collabo a ion wi h. Insu ance companies usually ha e a se ice uni ha looks o a ailable capaci y and coo dina e all pa ien s’ ea men ac i i ies. In cases when he e is a lack o capaci y o compe ence, p o ide ne wo ks can be expanded. As a ule insu ance companies in No way also equi e e e al om a p ima y ca e physician o access seconda y/specialis ca e. In some cases, he insu ed will ha e an oppo uni y o ecei e a ‘second opinion’, pa icula ly in case o li e- h ea ening condi ions o a isky ea men . One company in No way ‘Ve ikal Helse’ o e s a special media ion se ice ha is included in he heal h insu ance package hey o e . This se ice is unique since i p o ides assis ance wi hin a wide ange o se ices, including hose no co e ed by he insu ance, o ind he mos app op ia e and compe en heal h ca e p o ide . The sea ch will include bo h public and p i a e p o ide s in No way as well as p o ide s in he No dic coun ies and Eu ope. Those who buy his ype o se ice can ge discoun ed p ices o medical se ices wi hin he insu e s’ p o ide ne wo k. In Sweden, VPHI ypically co e s heal h ca e ad ice, ca e planning and coo dina ion and specialis ca e wi h a ocus on elec i e su ge ies and ehabili a ion (S ensk Fö säk ing, 2013). Many insu ance companies a e also o e ing p e en i e ca e o inc ease heal h and wellbeing among employees and o p e en sickness absen s. Examples o such se ices include p og ams o educe s ess and suppo changes owa ds a heal hy li es yle, and counseling om beha io al he apis s o psychologis s. P i a e insu e s in Sweden ollow simila p ac ices on exclusion o ea men s as No wegian insu e s. The main se ices ha a e excluded ela e o acu e ea men and highly specialized se ices. Insu e s in Sweden may exclude p eexis ing condi ions. The choice o a heal h ca e p o ide is usually limi ed o p i a e p o ide s wi hin he insu e ’s ne wo k and can be also es ic ed o he p o ide s ha ope a e in Sweden. VPHI in Sweden (in con as o No way) does no equi e a e e al om a GP o access specialis ca e, hus po en ially emo ing ba ie s o di ec access o a specialis ca e. Ins ead, ca e planning is o en ca ied ou h ough a iage unc ion o e he phone. Co-paymen s o se ices p o ided h ough VPHI a y bo h wi hin and be ween he coun ies. In Finland he e a e di e en a angemen s o co-paymen s. The mos common a e: i) pe iodical co-paymen ha has o be co e ed ou -o -pocke each policy pe iod (usually a yea ); ii) disease ela ed co-paymen ha is cha ged once pe ea ed disease/condi ion; iii) co-paymen ha is cha ged e e y ime eimbu semen is claimed om an insu ance company; i ) no-copaymen s. (The Finnish Financial Ombudsman Bu eu 2014.). In No way, co-paymen s in he p i a e sec o may depend on he heal h insu ance ag eemen /policy, bu many insu e s do no equi e copaymen s. Only a ew policies in Denma k equi e co-paymen s. The insu ance companies ha e a emp ed o in oduce a deduc ible, bu wi h limi ed success and compe i ion has la gely elimina ed his (In e iew wi h “Fo sik ing and Pension, Janua y 27 2016). In Sweden indi iduals a e o en equi ed o pay co-paymen o use o se ices. The le el o co-paymen s a ies bu has gene ally inc eased in ecen yea s (Skoglund, 2012). A common p ac ice is ha indi iduals pay 500 SEK o mo e in copaymen s o he i s isi in a heal hca e episode. N. Alexande sen e al. / No dic Jou nal o Heal h Economics, Vol. 4 (2016), No. 1, pp. 68-83 75 3.2.3 Supplemen a y VPHI The ole o supplemen a y insu ance is ela i e small in he No dic coun ies. I p o ides co e age o addi ional heal h se ices no a all co e ed by he go e nmen /social scheme, OECD (2015). In Finland VPHI has a e y small supplemen a y elemen as some policies include se ices no co e ed by he publicly unded sys em. These include a ele s’ a el cos s om ou side Finland and policies conce ning some luxu y p oduc s. A pa o VPHI policies only co e se ices needed due o spo s acciden s – hese a e ma ke ed in coope a ion wi h spo s associa ions. Fo a numbe o spo ac i i ies, ac i e pa icipa ion is e en condi ional o ha ing his kind o VPHI. A slowly g owing numbe o VPHIs in Finland a e o e ed o employe s o co e o employees o “key” employees se ices ha a e no accep ed medical se ices co e ed by he PHI unds acco ding o he occupa ional heal h law. Ano he g oup o people a ge ed by VPHI is people a he “ hi d age”, lea ing he co e age o e ed by occupa ional heal h. The e a e also ce ain sickness speci ic insu ance p oduc s such as cance insu ances. In Denma k supplemen a y heal h insu ance is an in eg a ed pa o many comme cial and non-comme cial policies, bu o a ying deg ees. I ypically co e s se ices in si ua ions whe e he public sec o does no co e , such as some ypes o physio he apy, psychological he apy e.g. o s ess ela ed condi ions and heal h check-ups. In No way supplemen a y VPHI ha dly exis s. I i is p o ided i is ela ed o den al ea men o collec i e policies, gambling, d ug and alcohol addic ion, and some addi ional ypes o al e na i e ea men s (e.g. acupunc u e) p o ided by au ho ized pe sonnel. In Sweden supplemen a y se ices exis mainly o adul den al se ices. In exchange o a mon hly isk-adjus ed ee, indi iduals a e o e ed den al ca e se ices ee o cha ge. This supplemen a y se ice is usually o e ed a public den al clinics (Folk and å den) and a e less common among p i a e den al p ac ices. The insu ance co e s gene al examina ions, acu e se ices and ea men o ca ies and oo h loss. Se ices such as oo h eplacemen s, o hodon ics and oo h whi ening a e no included. Abou 200.000 indi iduals had his insu ance in 2011 and i is mo e common among young adul s (Fö säk ingskassan 2012). 3.3 Supplie s o VPHI 8 The majo ac o s ope a ing in he Finnish VPHI ma ke a e OP-Pohjola-g oup (31.7 %), LähiTapiola-g oup (24.9 %), I (24.7 %), and Fennia (9.8%). All a e o -p o i companies. In addi ion a ew smalle companies a e ac i e (The Fede a ion o Finnish Financial Se ices 2015). In Denma k, complemen a y VPHI is o e ed by he non-p o i heal h insu e ‘danma k’. This company had a ound 2.3 million membe s in 2014 (Syge o sik ing ‘danma k’ annual epo 2014). Duplica e VPHI is mainly p o ided by comme cial s ock– based insu ance companies. In addi ion, he non-p o i insu e ‘danma k’ o e s some policies wi h eimbu semen o some expenses o elec i e su ge ies a p i a e hospi als. The companies ha p o ide p i a e heal h insu ance in Denma k include PFA Pension (incl. Mølholm Insu ance) (33.2 %), T yg (13.4 %), Danica (12.1 %), Skandia (10.1 %), Codan (9.8 %), I (7.4 %), PensionDanma k (7.3 %), Topdanma k (6.6 %), Fo sik ing & Pension (2014b). The p o ide s ha o e VPHI in No way a e mainly o -p o i insu ance companies. The majo ac o s ope a ing in No wegian ma ke a e: Codan Fo sik ing/Ve ikal 8 The pe cen ages in his sec ion indica e ma ke sha es in 2014. 76 N. Alexande sen e al. / No dic Jou nal o Heal h Economics, Vol. 4 (2016), No. 1, pp. 68-83 Helseassis anse (32.6 %), S o eb and Helse o sik ing (18 %), I NUF (16.7 %), Gjensidige Fo sik ing (13.6 %) T yg Fo sik ing (11%) and Spa eBank 1 (7.7 %) (Finans No ge, 2014). Abou 15 insu ance companies a e p esen ly o e ing VPHI in Sweden. The numbe o VPHI p oduc s on he ma ke is highe , howe e , as insu ance companies usually o e mo e han one policy wi h di e ences in se ices co e ed, es ic ions and deduc ibles. The ou main ac o s in Sweden 9 a e T ygg-Hansa (38%), Läns ö säk inga (19%), Folksam (20%) and I (11%). Läns ö säk inga and Folksam a e cus ome -owned companies, while T ygg-Hansa and I a e o -p o i companies. 3.4 The ela ionship be ween supplie s o VPHI and heal h ca e p o ide s 3.4.1 Paymen o p i a e heal h p o ide s In Finland, policy holde s usually disbu se he expendi u es and a e eimbu sed by insu e s a e wa ds. In cases o expensi e ea men s he insu e s usually pay di ec ly o he p i a e p o ide . In hese cases he insu ance company ypically equi es a p elimina y app o al o he ea men s. Some insu ance companies – such as LähiTapiola – ha e signed con ac s wi h di ec paymen o p i a e p o ide s so he insu ed do no ha e o pay ou -o -pocke . In No way p i a ely insu ed pa ien s usually pay o specialis consul a ions/se ices ecei ed h ough he insu e s’ p o ide ne wo k. They a e la e eimbu sed by insu e s. In some cases he insu e s pay di ec ly o he p i a e p o ide s. ‘S o eb and Helse o sik ing’ o example pays di ec ly o p i a e p o ide s (i.e. hospi al o ehabili a ion ins i u ion) in case o hospi aliza ion (wi h and wi hou su ge y) as well as o cance ea men . In Denma k mos policies do no equi e pa ien s o pay ou o pocke . This has changed o e ime in esponse o consume p e e ences (in e iew wi h “Fo sik ing og Pension”, Janua y 27, 2016). Insu e s do no p o ide access o de ailed in o ma ion abou hei con ac s wi h p o ide s as his is subjec o compe i ion. In Sweden p o ide s a e usually paid di ec ly om insu ance companies, excluding deduc ibles ha may be paid di ec ly by indi iduals a he poin o se ice. Insu ance companies ypically equi e app o al o expensi e diagnos ic se ices and ea men s. 3.4.2 Con ac ing wi h p i a e heal h p o ide s Con ac ing be ween insu ance companies and p i a e p o ide s is no common in Finland. The basic o ien a ion is eimbu semen . This is pa icula ly ue when i comes o eimbu semen o p i a e ou pa ien se ices. Howe e , he e seems o be a mo emen owa ds s ic e cos con ol o p ices o su ge ies and expensi e diagnos ic p ocedu es. Some policies equi e ha a pa ien only uses p o ide s accep ed by he insu ance company. Should he pa ien use ano he p o ide (s)he has o co e he addi ional cos s ou -o -pocke . OP-Pohjola has es ablished i s own hospi al (Omasai aala), and is u he expanding by es ablishing a hospi al chain in which hei insu ed pa ien s will be ea ed. The aim is o ea especially he high cos VPHI pa ien s (e.g. su ge y) in hese hospi als. In his way OP-Pohjola is p obably aiming a a be e con ol o e he cos s o (inpa ien ) ca e. In No way, p i a e heal h insu e s usually selec i ely con ac p i a e heal h p o ide s in No way and he o he No dic coun ies. The choice o p o ide s is based on hei expe ise, quali y, a ailable capaci y and p ices. Howe e , he selec i e con ac ing migh be limi ed as o -p o i hospi als do no p o ide all kinds o ea men . When he e is 9 The ma ke sha es wi hin b acke s e e s o “sjuk å d och olycks all” (heal h and acciden insu ance) i.e. a b oade ca ego y o insu ance including VPHI. Howe e , hese ou ac o s is esponsible o mos o he ma ke , and hey a e o en e e ed o in compa isons be ween VPHI p oduc s. N. Alexande sen e al. / No dic Jou nal o Heal h Economics, Vol. 4 (2016), No. 1, pp. 68-83 83 Tynkkynen L-K., Chydenius M., Salo an a A., Keskimäki I. (2016). Expanding choice o p ima y ca e in Finland: much deba e bu li le change so a . Heal h Policy, Jan 19. Val onen H., Kempe s J. and Ka unen A. (2014). Supplemen a y heal h insu ance in Finland. Consume p e e ences and beha iou . Helsinki, KELA Wo king pape no. 65/2014, 5-55 Van Doo slae E.C., Masse ia C., he OECD Heal h Equi y Resea ch G oup Membe s (2004). Income- ela ed Inequali y in he Use o Medical Ca e in 21 OECD Coun ies. Towa ds High- Pe o ming Heal h Sys ems: Policy S udies om he OECD Heal h P ojec . Pa is: OECD, 3-88 Vuo enkoski, L. (2008). Finland. Heal h Sys em Re iew. In Heal h Sys ems in T ansi ion 10(4), eds. Mlado sky and Mossialos. © 2016 by he au ho (s). This a icle is an open access a icle dis ibu ed unde he e ms and cond- i ions o he C ea i e Commons A ibu ion license (h p://c ea i ecommons.o g/licenses/by/4.0/).