Private for – profit health

sector in Greece. Development characteristics (1980

– 2002)

Kondilis Elias Thessaloniki, May 2005

National Health System’s foundation act (L. 1397/83)

Article 6, §1

“All hospitals are founded as Legal Entities of Public Law (LEPL) … the foundation of hospitals with a different Legal Entity is prohibited”

Article 6, §2

“all hospitals owned by sickness funds or function as Legal Entities of Private Law (LEPrL) and receiving public subsides must be

converted into LEPL, within a year after the law has being issued”

source: L. 1397/83. National Health System. Government’s Newspaper A’ n.143. Athens. 7/10/1983

Number of hospitals by legal status, Greece 1980 - 2004

0

50

100

150

200

250

300

350

400

450

500

1980 1985 1990 1995 2000 2004

PUBLIC

LEPrL

PRIVATE

sources: (a) National Statistical Service of Greece. Statistical Yearbook of Greece. Athens. 1981 – 2003 (b) Ministry of Health & Social Solidarity. Department of private clinics. 2004

Number of hospital beds by legal status,

Greece 1980 - 2004

sources: (a) National Statistical Service of Greece. Statistical Yearbook of Greece. Athens. 1981 – 2003 (b) Ministry of Health & Social Solidarity. Department of private clinics. 2004

0

5000

10000

15000

20000

25000

30000

35000

40000

1980 1985 1990 1995 2000 2004

PUBLIC

LEPrL

PRIVATE

COMMUNALHEALTHCENTERS

Number of hospital beds by legal status, % total hospital beds, Greece

1980 - 2000

44,40%

61,30%70,10% 70,30% 69,40%

41,70%32,60% 29,60% 29,20% 29,40%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

1980 1985 1990 1995 2000

PRIVATELEPrLPUBLIC

sources: National Statistical Service of Greece. Statistical Yearbook of Greece. Athens. 1981 – 2003

Movement of hospitals by legal status,

Greece 1980 - 1996Patient discharged by hospital's legal status, % total patient discharged

48,0%

67,0%

80,8% 80,2% 80,0%

15,9%

35,9%24,8%

19,2% 19,3% 19,5%

0%10%20%30%40%50%60%70%80%90%

100%

1980 1985 1990 1995 1996

PRIVATELEPrLHealth CentersPUBLIC

sources: National Statistical Service of Greece. Social welfare and health statistics 1980-1996. Athens 1981 - 2000

Post – NHS development period of private for – profit health sector in

Greece (1983 - 2002)

Main features: high investment rate of private enterprises in

biomedical technology

selective development of private enterprises on the most profitable health care sectors

absence of governmental control on the quality, the quantity and the type of services provided by the PFP health sector

Private Diagnostic Centers’ foundation act

(P.D. 3/11/1934)

Article 1, §1“the permission of Microbiological and Biological Diagnostic

function Laboratories can be granted only to medical doctors”

Article 7, §1-2“Microbiological and Biological Diagnostic Laboratories can also be

set up within private clinics on the grounds that the clinic’s

proprietor leaves the laboratory’s supervision to a certified medical doctor”

source: Presidential Decree. Institution and inspection of Microbiological and Biological Diagnostic Laboratories. Government’s Newspaper A’ no 384. Athens. 3/11/1934

Private Diagnostic Centers, Greece 1980 - 2002

33

192

421 403 401

0

50

100

150

200

250

300

350

400

450

n. P

riva

te D

iagn

ostic

Cen

ters

1985 1991 1994 1996 2002

sources: (a) Besis N. Private Health Services. Institute of Economic and Industrial Research. Athens. 1993(b) ICAP. Private Health Services. ICAP AE. Athens. 1995 - 1997(c) Ministry of Health & Welfare. Health Map. Athens 2002 www.healthgis.ariadne-t.gr/healthmap/

Biomedical Technology in Public and Private Health Sector, Greece 1980 -

2002

0

20

40

60

80

100

120

140

160

180

1980 1985 1990 1992 1997 2002

n. C

ompu

ted

Tom

ogra

phy

Scan

ners

PUBLIC*

PRIVATE**

0

10

20

30

40

50

60

70

80

1985 1990 1992 2002

n. M

agne

tic R

eson

ance

Im

agin

g U

nits

PUBLIC*

PRIVATE**

* PUBLIC: included NHS, LEPrL, military hospitals**PRIVATE: included private clinics and diagnostics centers

Sources: (a) Besis N. Private Health Services. Institute of Economic and Industrial Research. Athens. 1993(b) Kyriopoulos G. Niakas D. Issues of Economics and Health Policy. Center of Social Health Studies. Athens. 1994(c) ICAP. Private Health Services. ICAP AE. Athens. 2001 – 2003(d) OECD. Health Data. A comparative analysis of 30 countries. 3rd edition. OECD. Paris. 2004(e) Ministry of Health & Welfare. Study of high technology equipment installation in NHS hospitals. EKEVYL AE. Athens. 2003

Biomedical Technology, Greece 2002

6,95

20

16,5

0

2

4

6

8

10

12

14

16

18

20

CT Scanners per millionpopulation, 2002

Public CTGreeceTotal CTGreeceCT EU-15

0,22

3,32

7,2

0

1

2

3

4

5

6

7

8

MRI Units per millionpopulation, 2002

Public MRIGreece

Total MRIGreece

MRI EU-15

Sources: (a) OECD. Health Data. A comparative analysis of 30 countries. 3rd edition. OECD. Paris. 2004(b) Ministry of Health & Welfare. Study of high technology equipment installation in NHS hospitals. EKEVYL AE. Athens. 2003

IKA’s Payments for medical examinations held in Private for – profit Diagnostic Centers, Greece

1998

Number of Patients

Payments

Athens 219.817 10.855.476 €

Province 363.823 24.973.666 €

Total 583.640 35.829.143 €

source: Fyntanidou E. IKA gives trillions to private health sector. ΤΟ ΒΗΜΑ, 9-7-2000, p.50

Private for profit Hospital Beds by geographic region, % total PFP hospital

beds, Greece 1980 - 2004

47% 50% 53% 53% 52% 56%

23% 25% 24% 24% 26% 24%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

1980 1985 1990 1995 2000 2004

Kriti

Aegean Islands

Thraki

Macedonia

Thessalia

Ipiros

Ionian Islands

Peloponnissos

Rest of Central Greece & Evia

Greater Athens

sources: (a) National Statistical Service of Greece. Statistical Yearbook of Greece. Athens. 1981 – 2003 (b) Ministry of Health & Social Solidarity. Department of private clinics. 2004

Private for – profit Hospital Beds by specialty of clinics, % total (Public & Private) Hospital Beds, Greece 1996 All specialties 29.07%

Obstetrical - Gynecological 52.81%

Neuro - Psychiatric 38.31%

Otorhinolaryngological 33.47%

Nephrological 29.73%

Surgical 28.83%

Pathological 23.69%

Neonatology 12.54%

Paediatrics 8.73%

Heart Infract Units 6.33%

Oncological – Chemotherapy 5.04%

Radiotherapeutic

source: National Statistical Service of Greece. Social welfare and health statistics 1996. Athens. 2000

Movement & surgical procedures by legal status of hospitals, Greece 1995 -

1996

80,2

15,2

62,470

19,3

84,8

37,429,6

0%10%20%30%40%50%60%70%80%90%

100%

Total PatientDischarged*

ObstreticalGynecological

PatientDischarged*

NeuroPsychiatricPatient

Discharged*

SurgicalProcedures**

PRIVATELEPrLPUBLIC

source: National Statistical Service of Greece. Social welfare and health statistics 1995 - 1996. Athens. 1999 - 2000

* 1995** 1996

Legislation on Private for – profit clinics, Greece (1925 – 2004)

1925 Legislative Decree 18/7/25 (a) Allows the foundation of private Infectious Diseases and Tubercular

Clinics

1961

1963

Royal Decree 451/62(b)

Royal Decree 521/63(c)

Sets the technical and constructural specification frames of the operation of

private clinics

1983 Law 1397/83(d) Forbids the foundation, merger or relocation of private clinics

1991 Presidential Decree 247/91(e)

Presidential Decree 517/91(f)

Allows the foundation of private clinics.

Updates the private clinics’ operational requirements

2000 Presidential Decree 235/00(g) Sets the technical and constructural specification frames of the operation of

private clinics

sources: (a) Continual Legislation Code 1925 – 1994. Vol. 34 Sanitary Legislation. Subject: Private Clinics and Laboratories (b) Government’s Newspaper A’ 108. 21/7/1962 (c) Government’s Newspaper A’ 145. 17/9/1963 (d) Government’s Newspaper A’ 143. 7/10/1983

(e) Government’s Newspaper A’ 93. 21/6/1991 (f) Government’s Newspaper A’ 202. 24/12/1991 (g) Government’s Newspaper A’ 199. 14/9/2000

Legislation on Private for – profit clinics, Greece

95%

29%

66%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

2002 2004

n. c

linic

s, %

tot

al c

linic

s

P.D. 235/ 00P.D. 247/ 91 & 517/ 91R.D. 451/ 62 & 521/ 63

source: Ministry of Health and Social Solidarity. Department of Private Clinics. Athens. 21/12/2004

Contemporary development characteristics of PFP health sector in

GreeceMain features:

High rate of revenue increase

Increase of private hospitals’ mergers and acquisitions

creation of oligopoly in PFP health sector

Creation of vertically integrated health systems - HMOs

Revenues of Private for – profit health sector, Greece 1993 – 2002

0 250.000.000 500.000.000 750.000.000 1.000.000.000

1993

1995

1997

1999

2001 General &NeuroPsychiatricClinics

Obstetrical -GynecologicalClinics

DiagnosticCenters

Sources: ICAP. Private Health Services. ICAP AE. Athens. 1995 – 2003

All amounts in €Private Medical Consultants’ Revenues not included

Median Bed Capacity of PFP hospitals, Greece 1980 - 2004

50

55

60

65

70

75

80

85

1985 1990 1995 2000 2004

n. in

patien

t ca

re b

eds pe

r pr

ivat

e cl

inic

sources: (a) National Statistical Service of Greece. Statistical Yearbook of Greece. Athens. 1981 – 2003 (b) Ministry of Health & Social Solidarity. Department of private clinics. 2004

Creation of oligopoly in PFP health sector,

Greece 2002

Revenues, % total revenues per sector

8 General Private Clinics 70.2%

3 Obstetrical Clinics 79%

12 Diagnostic Centers 45,4%

Sources: ICAP. Private Health Services. ICAP AE. Athens. 2003

PHP health sector’s development characteristics, Greece 1980–2002

The impact of NHS foundation on PHP health sector

private hospitals decreased by 60%

private inpatient care beds decreased by 40%

patient discharged from PFP hospitals decreased by 28% Post – NHS development period of PFP health sector

high investment rate in biomedical technology

selective development on the most profitable health care sectors

absence of governmental control Contemporary development characteristics of PFP Health Sector

high rate of revenue increase

increase of private hospitals’ mergers and acquisitions

creation of oligopoly