The Impact of the Financial and Economic Crisis on Health Law THE PAINFUL EFFECTS OF THE FINANCIAL CRISIS ON SPANISH HEALTH CARE Xavier Bosch, Pedro Moreno, and Alfonso López-Soto

Spain has an advanced, integrated health care system that has achieved remarkable results, including substantially improved health outcomes, over a relatively short time. Measures introduced by central and regional governments to combat the financial crisis may be severely affecting the health sector, with proposed changes potentially threatening the principles of equity and social cohesion underlying the welfare state. This article examines recent developments in Spanish health care, focusing on the austerity measures introduced since 2010. In Spain, as in other countries, evaluation of health care changes is difficult due to the paucity of data and because the effects of measures often lag well behind their introduction, meaning the full effects of changes on access to care or health outcomes only become apparent years later. However, some effects are already clear. With exceptions, Spain has not used the crisis as an opportunity to increase efficiency and quality, rationalize and reorganize health services, increase productivity, and regain public trust. We argue that immediate health care cuts may not be the best long-term answer and suggest evidence-driven interventions that involve the portfolio of free services and the private sector, while ensuring that the most vulnerable are protected.

FROM PLENTY TO CRISIS The ongoing economic recession has had severe consequences for Spain. Although gross domestic product (GDP) rose more than 5 percent annually at the beginning of this century, the 2007 collapse of the construction-led and debt-financed boom saw the stock market fall from 125 percent of GDP in International Journal of Health Services, Volume 44, Number 1, Pages 25–51, 2014 © 2014, Baywood Publishing Co., Inc. doi: http://dx.doi.org/10.2190/HS.44.1.c http://baywood.com

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November 2007 to 54 percent one year later, and government deficits soared (in 2012, the deficit was 10.6% of GDP, the worst in Europe and above the 10% Greek deficit) (1–3). With public debt (69.3% of GDP in 2011, 84.2% in 2012, and 87% in February 2013) and private debt at record levels, unemployment has jumped from 8 percent in 2007 to 27.16 percent (6,202,700 people) in March 2013, the highest in Europe (4, 5). DEVELOPMENT OF A HEALTH SYSTEM Spaniards are proud of their health system. In a March 2010 national survey, 21.7 percent of 2,593 subjects surveyed stated the Spanish system was working well and 49.5 percent said it worked fairly well, although changes were needed (6). Historic changes in 1986 introduced universal taxpayer-financed, free-at-thepoint-of-delivery public health care and recognized the right of all Spaniards and resident foreigners to health care. Today, Spain has very low infant mortality and one of the world’s highest life expectancies, and it is a world leader in organ donation and transplantation (7, 8). The Spanish system, listed as the seventh-best worldwide by the World Health Organization in 2000, includes tertiary and district hospitals and primary health care centers (PHCs) that provide acute and chronic medical care, preventive care, health promotion, home-based care, and rehabilitation. Devolution of all responsibilities for health care to the 17 Autonomous Communities (ACs), which are accountable only to their regional parliaments, between 1981 and 2002 resulted in different management models and health care priorities, with 30 percent to 40 percent of regional budgets allocated to health (7, 9, 10). The ACs administer 90 percent of public health care funding (11). The national health ministry retains some financial and legal oversight. It is responsible for international health and pharmaceutical policies and provides the secretariat for the coordinating Spanish National Health Service (SNS) Interterritorial Council (9–13). CHRONIC AND EMERGING PROBLEMS The system’s main shortcoming is unrestrained growth outstripping GDP increases, with annual increases of 4 percent during 2000–2010. Previously, Spain’s health care was comparable to, but cheaper than, other European countries; however, a new allocation system, introduced in 2002, saw costs rise to 7.3 percent of GDP in 2002, 8.1 percent in 2003, and 9.6 percent in 2010 (14), similar to the Organisation for Economic Co-operation and Development average, although health spending per capita remained below the average. This rise is largely explained by a 20 percent increase in public health care workers between 2000 and 2010, accompanied by salary rises of more than 21 percent. Likewise,

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spending per capita on publicly funded drugs increased by 25 percent between 1999 and 2009, although this was mitigated by reductions in the mean price per prescription (4, 15). Free access has resulted in an overused system responding to patient demand rather than need (7, 10). Physician excess, exemplified by the mean increase in drug prescriptions from 17.3 per head in 2005 to 20.4 per head in 2010, is second only to the United States (16). Chronic, structural budget problems have led to commitments being made with insufficient financing and transfers of services to ACs without adequate funding. Health care management has suffered various problems, including a dearth of strategic reorganization; a focus on short-term goals to the detriment of long-term policies; a culture of complacency that focused on much-heralded technological advances while ignoring results-led care; and competition between ACs that had an inflationary effect on spending (17). Although in Spain, as in other countries, increasing health care costs and dissatisfaction with care are endemic, the economic crisis revealed the system’s failings. In the good times, central and regional governments happily countenanced rising health spending. The new situation, with pressure from Europe and the financial markets from above and pressure from the public and regional governments from below, has resulted in services being cut, sometimes severely (17). CHANGING COURSE Austerity measures adopted include significant reductions in public employees’ salaries since 2010, freezing of pensions, and tax increases in January and July 2012 (4), although major national and regional cuts in health spending were not proposed until late 2010 (10). Total per capita health care expenditure rose from US$1,961.2 in 2003 to US$3,008 in 2009, but fell to US$2,978.6 in 2010 (Figure 1) (14). Public expenditure followed similar trends (Figure 2) (14). Figure 3 shows the health budgets of each AC between 2007 and 2012 and the annual change, respectively, and Figure 4 shows the evolution of the total national health budget. More recent data show total health spending fell by 10.6 percent between 2010 and 2013, equivalent to €6,700 million, or €150 per capita (18). The reduction may be even greater when the Basque Country and Catalonia approve their 2013 budgets: in Catalonia, a 10 percent cut in spending on public hospitals and their workers has been announced (19). Catalonia, which has been at the forefront of budget control measures (Box 1), had already introduced a 9 percent reduction in health spending (about €1 billion) for 2011 and a further 9 percent reduction in 2012 (Figure 5) (20, 21). In 2012, Catalonia also imposed a €1 tax on each drug prescription (10), a policy followed by the Madrid AC (22), although both taxes have been suspended by the Constitutional Court (23).

Figure 1. Total expenditure on health care (individual and collective), per capita, in U.S. Dollars, purchasing power parity. General government (excluding Social Security) = territorial government. Source: Organisation for Economic Co-operation and Development StatExtracts, 2012 (latest available year: 2010).

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Figure 2. Public expenditure on health care, per capita, in U.S. Dollars, purchasing power parity. Source: Organisation for Economic Co-operation and Development StatExtracts, 2012 (latest available year: 2010).

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Figure 3. Initial health budgets of the Autonomous Communities 2007-2012 (million €). Note: The 2012 Castile-La Mancha budget has not been published; the 2011 budget is shown. Source: Regional health ministries, National Statistics Institute (INE). 2007-2011 data: Health, Social Services and Equality Ministry’s General Secretary. 2012 data: Other.

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Figure 4. Evolution of the total national health budget (million €) from 2007 to 2012, resulting from the sum of the health budgets of the Autonomous Communities. Source: Analysis and assessment of Autonomous Communities’ health budgets foreseen for 2012. Health Federation and Social Health Sectors, CCOO (FSS-CCOO) [data from regional health ministries and National Statistics Institute (INE)]. 2011 data: Health, Social Services and Equality Ministry’s General Secretary. 2012 data: Other.

There is concern that the changes, often characterized as incoherent (24), may threaten the principles of equity and social cohesion and the welfare state itself. Spending on staff and drugs, which accounted for 62.4 percent of public health expenditure in 2009, has been cut (4). Staff costs have been reduced by freezing promotions, reducing substitutions, increasing the working day of interim staff, closing hospital wards, reducing on-call hours, and leaving posts unfilled after retirements, with a consequent drop in recruitment in all ACs (4). In primary care, figures from June 2012 show that at least eight ACs have closed continuing care centers (56 in Catalonia) (25). More recently, some ACs decided to close scores of rural primary care night emergency services (26). Professional advancement has been halted in 15 of the 17 ACs, and seven have reduced training days for family physicians. Delays in diagnostic testing have been rising throughout Spain (25).

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/ Bosch et al. Box 1 Cost-Containment Measures Implemented by Catalan Government in 2011

• Average 8.5 percent reduction in the budget of public hospitals • Reduction of interim health workers from 46,000 to 42,000 by the Catalan Health Service (CatSalut) • Reductions in the number of working hours of public-sector physicians or, alternatively, increases in working hours without a parallel wage increase • Closure of departments and hospital beds in both public hospitals and contracted providers (nearly one in four hospital beds were closed during the summer of 2011) • Closure of at least 40 primary health care centers (10% of total) in summer • Delay or halting of construction of seven new hospitals and at least 44 primary health care centers and termination of investments in new health care infrastructure • Closure or reduction in opening hours of 100 outpatient centers • Ending of non-urgent evening operations (a measure adopted until 2010 to reduce waiting lists) • Closure of primary care centers’ nocturnal emergency services in rural areas in favor of telephone assistance and hospital emergency services

Despite pharmaceutical industry opposition, generic drug prices have been reduced by 30 percent since 2010, while a 2012 law promoted the use of generics, controlled the number of prescriptions per head, and ended public funding for almost 500 drugs of dubious therapeutic value, with annual savings estimated at €7.2 billion (4). In April 2012, a law changing health coverage from universal to employment-based was introduced without approval from parliament. This regulated prescription drug cost sharing according to income, with pensioners and the permanently disabled, who previously received medications free of charge, paying 10 percent of costs (27). Although drugs are now free for unemployed people not receiving benefits (formerly, all unemployed people paid 40% of costs, like employees) and for people suffering occupational accidents or diseases, undocumented immigrants (about 460,000) have had access only to emergency, maternity, and pediatric care since September 2012 (27). CONSEQUENCES In Spain, as in other countries, evaluation of health care changes is difficult due to the paucity of data and because the effects of measures often lag well behind their introduction (23, 24), with the full effects of changes on access to care or health outcomes only becoming apparent years later (28). However, some effects are already clear.

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Figure 5. Evolution of the health budget and real spending per capita of Catalonia (€). Source: Catalan Health Service (CatSalut) and Catalan Health Institute (ICS).

Consequences for the System and Health Care Quality Some measures adopted to reduce health spending, such as encouraging generic prescribing, may be justified. Public drug expenditure grew by 6.9 percent in 2008 but fell by 8.8 percent in 2011, due to a tripling in generic use between 2003 and 2010, active ingredient prescription policies in family physician payment programs, and a reduction in the increase in prescriptions dispensed from 4.9 percent in 2009 to 1.6 percent in 2011 (4). Public spending on medicaments fell by 21.69 percent between March 2012 and March 2013. Total savings between December 2011 and March 2013 were €1846.1 million. The number of prescriptions written fell by 6.12 percent in 2012 with respect to 2011, and the mean cost per prescription fell by 6.54 percent. The number of prescriptions emitted fell by 19.71 percent between March 2012 and March 2013 (29, 30). Delayed payments to suppliers have increased dramatically. Hospitals owed €6.4 billion to pharmaceutical suppliers by the end of 2011, 36 percent more than in 2010 and 92 percent more than 2009. The mean delay in payment for

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hospital drugs was 525 days at the end of 2011, 35 percent more than in 2010 and 80 percent more than in 2009 (15, 31). Delayed regional payments to medical technology companies were at least €5.2 billion by the end of 2011, a 35 percent increase compared with 2010, with a mean payment delay of 473 days, 126 more than in 2010 (15). Health care quality is suffering. In 10 ACs, surgical waiting lists increased by 125 percent between December 2010 and June 2012, with the mean delay rising from 32 to 72 days. Patients waiting for more than the established 180 days for cardiac surgery, knee and hip prostheses, and cataracts increased by 178 percent during this period to 27,662 (32). Undocumented immigrants are among the hardest hit by the crisis. Recent legal changes mean that, after September 2012, between 2,700 and 4,600 HIV-infected undocumented immigrants have no access to antiretroviral therapies: this could result in increased morbidity and mortality and greater medium- and long-term health expenditure (33). The substantial salary reductions for public physicians might, in some cases, further impair health care quality by reducing motivation. Spanish physicians in general are among the worst-paid in the European Union (14, 34). Consequences for Health Attention has been focused on the potential economic effects of the health care changes, but there are little or no current data on the possible effects on morbidity and mortality (28). The prevalence of mental health disorders, especially major depression, increased significantly between 2006 and 2010, and 50 percent or more of the increase could be attributed to the risk of unemployment and inability to fulfill mortgage commitments (35). Initial data suggest the suicide rate increased from 5.16 per 100,000 in 2007 to 5.56 per 100,000 in 2008, reversing previous downward trends (28, 35). The number of road accidents is falling because of the economic downturn, leading to shortages of organ donations and transplantations (36). Reductions in chronic care and preventive medicine, including vaccination and primary cancer prevention, may also occur (10, 37). In Greece, cuts in preventive medicine have contributed substantially to increases in HIV transmission and disruption of preventive measures such as needle exchanges (28). A recent study in Catalonia found that uptake of the conjugate pneumococcal vaccine, which is only publicly financed for high-risk or immunocompromised children, fell between 2007 and 2011, after a rapid increase in preceding years, possibly due to the high vaccine cost (38). A Barcelona city council survey found that 1.7 percent (n = 2,865) of schoolchildren in the city’s 500 public and subsidized private schools were receiving deficient nutrition (e.g., no breakfast or dinner or insufficient dinner) (39), leading

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the Spanish ombudsperson to start a nationwide investigation to determine how the crisis is affecting infant nutrition (40). REACTIONS TO CHANGE The considerable opposition to health cuts, shown by demonstrations by health workers and statements by health bodies, has, with exceptions, not produced concrete results (41). Sustained staff and patient pressure, with mass media coverage, led the Balearic Islands AC to negotiate with staff on alternatives to the closure of two small public hospitals, announced in April 2012 (42). Strikes by pharmacists from Castile-La Mancha and Valencia ACs took place in response to their governments’ failure to compensate them for medicines dispensed (23). Measures to exclude illegal immigrants from most types of health care have been challenged by some physicians who propose to continue treating them (43). General opposition has led the government to offer care for a fee ranging from €710.40 to €1,864.80 per year, according to age. However, as drug costs are excluded, undocumented immigrants with HIV would have to pay out-of-pocket costs of €10,000 or more for treatment (22). Furthermore, some ACs have rejected the exclusion of undocumented immigrants, contending that it is inequitable, hazardous, and possibly unconstitutional (23). Legido-Quigley and colleagues recently explored the consequences of Spanish austerity on health policy in depth and argued that incoherent reforms as a response to austerity, could, without remedial actions, break down large areas of the health system and potentially harm health (23). Interviews conducted with 30 Catalan physicians and four nurses produced examples of the adverse effects on patients and a general feeling of a lack of clarity on future directions. One general practitioner was told to resume attending patients after two decades in a technical position, and remarked, “I think these decisions are crazy. They have done this with me to save six months on a substitution. . . . I am not competent to treat my patients properly” (23). A recent Delphi panel of health managers, physicians, and ex-politicians was asked to score a list of priority, cost-saving measures that had been identified (Box 2). They recommended a national health pact on the structural reforms necessary to significantly improve the internal sustainability of the SNS and the creation of a national, executive SNS agency that would include health authorities, health professionals, and users (44). PRIVATE INTERESTS In 2010, private health care accounted for 25.2 percent of total health expenditure (14), and one-third of hospital beds were private (15). Figure 6 shows private health insurance expenditure per capita between 2003 and 2010. Revenues grew

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/ Bosch et al. Box 2 Top Ten Cost-Saving Measures for Spanish National Health Service (SNS)* 1. Introduction of centralized purchasing of drugs, health products, and health technology using homogenized criteria approved by the Interterritorial Council of the SNS 2. Harmonization of responsibilities between health administrations and elimination of duplicated and overlapping processes 3. A single, national agency to oversee quality, inspections, and accreditations (elimination of regional agencies) 4. Elimination of overtime for afternoon and evening work 5. Charging for health provision to foreigners and third-persons 6. Positive encouragement of the use of generic medicaments 7. Adjustment of drug doses to the treatment prescribed 8. Guaranteed continuous care: coordination between health care levels within a single organization 9. Single, electronic prescription in the SNS

10. Development and encouragement of medium- and long-stay facilities to reduce stays in acute hospitals *According to expert scores: 1 (highest score) to 10 (lowest score). Source: (44).

by about 10 percent annually before 2007 and continued to increase by 4.2 percent in 2010 and by 3.1 percent in 2011 (to €6.6 billion). The number of people with private insurance increased by 5.6 percent in 2010 and by 1.6 percent in 2011, reaching about 10.5 million. Typical monthly payments range between €35 and €70 (45, 46). Traditionally, 85 percent of Spanish civil servants are covered free of charge by private insurers reimbursed by the government, although workers choose between private insurance and public coverage (15). Private health providers and insurance companies are increasing efforts to access the public system, with plans for public-private partnerships (PPP) to manage auxiliary and health care services and to construct new hospitals, which, they say, will result in savings. Many ACs now contract out some services, such as waiting list management, to private providers, but only a few, most notably Valencia, have introduced full-service provision through PPPs (47). In Valencia AC, about 20 percent of public health care is managed by private companies, which are licensed to manage health care at hospitals and health centers in exchange for a fixed annual payment for each user in the catchment area (€639 in 2012) (47, 48).

Figure 6. Evolution of the private health care insurance expenditure from 2003 to 2010, per capita, in U.S. Dollars, purchasing power parity. Source: Organisation for Economic Co-operation and Development StatExtracts, 2012 (latest available year: 2010).

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The conservative regional government in Valencia AC was the first to implement the 1997 law that enabled the use of PPPs, stating that this would save money (49). Alzira, a small city without a hospital, was the chosen pilot project. The new, privately managed Alzira hospital asked health professionals to choose between existing tenured positions or new private contracts (50). Currently, 80 percent of employees are employed privately, while 20 percent remain as civil servants (51). The integrated private system has been reported to provide high-quality services 25 percent cheaper than public facilities (52). This apparent success has led to implementation of the model in other ACs such as Madrid, whose conservative government had already privatized non-clinical, auxiliary services in six small public hospitals. Recently, full privatization under the Alzira PPP model has been announced, as has the privatization of 10 percent of primary health care auxiliary services and all auxiliary services of existing public hospitals (53). Two months of mass protest, with even specialists striking for 17 days (22, 53), and four days of generalized strikes that resulted in 50,000 outpatient appointments and 6,500 operations being cancelled, ensued (54). A million-signature petition protested against privatization; medical and academic leaders objected; and more than 300 leading health professionals representing more than half of the 270 PHCs sent resignation letters. Although the Madrid AC claimed privatization would save €200 million, rigorous evidence was lacking, further fueling public outrage (54). Moves to privatize some regional hospitals and ancillary services are also proposed by other ACs governed by the conservative Popular Party. The Madrid AC has guaranteed participating centers will maintain all 5,200 staff, including 3,000 workers without fixed contracts, although workers will have to work more hours for the same or similar salary (55). REFORMING TO SURVIVE The prognosis for Spain is intensified recession, further economic contraction, and unemployment rising above 27 percent in 2013 (56). After the partial European bailout of up to €100 billion in 2012, a full bailout, resulting in more austerity, might be inevitable (57). In Portugal, which received a full bailout, major health cuts have been imposed by the Troika consisting of the International Monetary Fund, European Commission, and European Central Bank (24). Results from an online international survey of 12,001 adult patients from 15 mainly high-income countries in January 2013 to determine whether patients have seen improvements in health care during the last five years showed that 53 percent of 1,000 Spanish responders felt overall access to health care (to physicians, specialists, hospitals, diagnostic tests, and drugs) was worse in 2013 than in 2008, while only 16 percent felt it was better. Spanish patients rated their health care system as having the least improvement (58). The current situation of the SNS may be unsustainable. Spain cannot continue to accumulate deficits while making cuts that may affect the quality of care and

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health outcomes. In addition to economic woes, the system is threatened by other factors, including accumulated structural debts; an aging population; increasing chronic disease; insufficiently evaluated, high-cost new technologies; and excessive medicalization (44). Although reform is necessary, some suggest that measures to date have lacked evidence-based analysis (as exemplified by the privatization controversy). With exceptions, Spain has not used the crisis as an opportunity to increase efficiency and quality, rationalize and reorganize health services, increase productivity, or regain public trust. Box 3 shows some suggested reforms. One way of introducing reform would be to follow the example of evidence-based medicine: fund what works and cut what does not. When evidence is strong, act; when it is weak, search for increased knowledge to inform decision making. Spanish health care has not changed significantly since the 1980s (10). The model remains slanted toward acute care, but health costs are overwhelmingly due to increasingly prevalent chronic diseases such as dementia and diabetes, whose management is rapidly becoming an EU priority (59). There is agreement that the focus should shift to improving the management of chronic disease, even at the cost of acute beds and hospitalizations (60). Some suggest that Spain should follow other countries by taxing trans fats and sugar to change consumer habits and, combined with higher duties on alcohol and tobacco, dedicate the revenue obtained to job-creating disease prevention and social welfare programs (37, 59). Experts have recommended that national, regional, and local health authorities prioritize existing preventive and health promotion programs to counter the risk of a population-wide reduction in the health status (28, 37).

Box 3 Summary of Previous Recommendations • Rationalize services: elimination of duplication of services by neighboring hospitals, especially emergency services and specialties (e.g., cardiac surgery) • Prioritize less costly alternatives to hospital admission and emergency department referrals • Fight corruption and politicization of health management through transparency, accountability, and improved governance • Reduce the responsibilities of specialist care in favor of primary care • Increase patient choice: encourage patients to take responsibility for their health, especially chronic conditions, and ensure correct use of health services Source: (10, 60).

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Protecting the Most Vulnerable According to the 2008 Tallinn Charter (61), a building block for Health 2020 (62)—the World Health Organization’s ambitious European strategy— economic crises require reinforcement of equity, solidarity, and financial protection, ensuring protection of the health and social sectors, especially for the most vulnerable. Equity is an increasing concern in Spain. March 2013 data show that, of the 17,391,500 households, all members are unemployed in 1,906,100 and 4,474,400 have no active workers, while 3.5 million unemployed people have no right to unemployment pay or other social benefits (5, 63). Unemployment is a risk factor for malnutrition, mental disorders, and lower self-protection of health. Other groups at risk of exclusion include the elderly, especially those living alone, immigrants, and single mothers with dependent children (64). Reducing the numbers at risk for poverty or social exclusion in the European Union is a key target of the Europe 2020 strategy (65). According to the strategy’s risk criteria of poverty or social exclusion, in 2011 in Spain, 12.4 million people (27%) were at risk, compared to 23.1 percent in 2007, and 28.2 percent of people aged 16 to 64 years were at risk in 2012 compared with 21 percent in 2007 (65, 66). An estimated 3 million people now live in extreme poverty (annual income < €3,650) (67). Measures to save on dependency payments (increased copayment, reductions in dependency payments, and elimination of social security for caregivers) have resulted in government savings of €599 million in 2012, an estimated €1,108 million in 2013, and €571 million in 2014 (68). However, about 25 percent of people eligible for dependency benefits have not yet received them (69). Evictions due to non-payment of mortgages or rent are another serious problem. Official figures show 30,012 evictions due to non-payment of mortgages for the primary home in 2012 (14% more than 2011) (70) and 198,116 mortgage foreclosures underway in the courts at the end of 2012. Mortgage foreclosures underway have risen by 482.9 percent (annual increase of 96.6%) in the five years after the crisis (2008–2012) compared with five years before (2003–2007) (71). Press coverage led the government to introduce a two-year moratorium on evictions for some vulnerable groups and allow judges to suspend evictions when mortgage terms are abusive (72). Spaniards are increasingly dependent on nongovernment organizations for aid in food, housing, jobs, legal help, and psychological counseling (28, 73), suggesting interventions targeting support for the poorest should be a leading social priority. In addition, health authorities should prioritize disease incidence and access to care in the most vulnerable, with targeted health interventions for people disproportionally affected by the crisis. Revisiting the Portfolio of Free Services User Charges. Adjusting health care to need rather than demand may be a way to go. Some free services could be reduced by implementing user charges (Box 4).

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Box 4 Examples of Free Health Care Services and Publicly Funded Prescription Drugs Included in National and/or Regional Portfolies for Which Income-, Age-, and Health Status-Based User Charges Might be Introduced* • • • • • •

• • • •

Bariatric surgery Induced abortion** Hormonal and surgical sex reassignment for transgender persons Emergency contraceptives Assisted reproductive technologies, including in vitro fertilization Contraception, including oral and injectable contraceptives, contraceptive implants (containing etonogestrel), intrauterine devices, tubal sterilization for women, and vasectomy for men Surgical treatment of palmar hyperhidrosis Dental health prevention and treatment for the whole population Physical therapy*** Podiatry

*Basic services and publicly funded drugs do not apply equally to all of the Spanish National Health System, with some differences between Autonomous Communities. For example, while Andalusia Autonomous Community provides free coverage for surgical sex reassignment for transgender persons, the Basque Country does not. **Induced abortion due to rape, serious risk to the pregnant woman’s health, and fetal malformations should remain free of charge. ***For some conditions, such as femoral fracture in the elderly, this service should remain free of charge.

Cost sharing, although common to almost all EU countries, may result in poorer outcomes for prevalent disorders, with patients delaying or forgoing health care due to difficulties in meeting cost-sharing obligations, even in wealthier EU states (74, 75). However, studies suggest it might work in some circumstances. Japan, like Spain, provides universal hospital and outpatient care through national health insurance. By 2007, 81.9 percent of total health costs were publicly financed by tax transfers and social health insurance. Since 2001, two cost-sharing tariffs have been operative: 30 percent for adults younger than age 70 and 10 percent (formerly 30%) for relatively low-income people age 70 or older. The reduction from 30 percent to 10 percent resulted in improvements in physical health, significant reductions in out-of-pocket costs, and significant improvements in mental health (76). Rapidly increasing health expenditure in the United States has led to discussion of raising cost sharing for the Children’s Health Insurance Program and Medicaid.

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Recent reports suggest families on low incomes would be subject to high and rising health spending burdens if even minimal cost sharing was introduced for publicly insured children, but that the adverse effects could be reduced by introducing income-based caps on family spending, which would not greatly affect the projected savings in the health budget (77). Cost sharing could incentivize the use of good-value health services. U.S. health insurers frequently reduce cost-sharing tariffs if preferred providers (e.g., those providing better-quality care or cost-effective prescription drugs) are used (78). Cost sharing and copayment are seen as increasingly attractive options and an opportunity to generate additional resources while avoiding widespread restructuring, despite the weight of evidence underlining their negative effects (28). This type of charge may reduce the use of both high- and low-value care, above all by the poor and frequent users of health services (79). User charges for basic services such as primary or outpatient care could worsen the overall health status and, paradoxically, lead to greater use of resource-intensive free services like the emergency department (ED), thus increasing rather than reducing costs (28). However, if finally adopted, cost-sharing models mainly based on income, age, and health status might be applied, for instance, to some unnecessary and avoidable free diagnostic tests and illogically-free therapeutic interventions. For example, some countries no longer fund specific services (e.g., in vitro fertilization and physiotherapy in the Netherlands) (80). If implemented, exemptions from charges could be granted to low-income groups, chronic patients, people with significant disability, and children and pregnant women, as occurs in Portugal (81). Exemptions for the vulnerable are recognized internationally and would preserve access to health care, while risking increased misuse of (free-to-some) services (81). However, unlike Portugal, given the level of public health coverage in Spain, users should not be charged for services such as primary care appointments, outpatient specialist care visits, or ED visits. In the last decade, ED demand in Spain has risen by more than 4 percent annually, often surpassing the growth in ED capacity, and double the 2 percent population increase (82). The ED is often used as a time-saving alternative to specialist or diagnostic referrals and 30 percent of referrals are unnecessary (60, 82). Delays in referral processes and reductions in health care spending have led to alternatives being sought, including hospital-based quick diagnosis units for patients with suspected serious disease such as anemia or cancer (83). This model avoids hospitalizations and ED referrals and has equal efficacy, lower costs, and greater patient satisfaction than conventional admissions (60, 83, 84). Specific medical conditions granting exemptions should also include certain public services such as family planning and vaccination programs. Disinvestment. Rigorous evaluation of the value of health interventions, specifically with respect to disinvestment and decisions on resource allocation, may be

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preferable to implementing user charges. Disinvestment means withdrawing funding from health interventions with no or low added-value and allocating the funds to safe, cost-effective interventions. The Spanish Health Technologies Evaluation Agency decides the inclusion/ exclusion of all free health technologies and procedures, but provides considerable leeway for ACs to decide, not always based on scientific evidence, what they do or do not need (15). Likewise, economic evaluation is not always used effectively in SNS decision making (85). García-Armesto and colleagues reviewed the instruments necessary and the barriers to implementing a value-for-money approach in the SNS (9). They identified the factors required as a regulatory framework, identification of lowvalue interventions, best practice guidance, and monitoring of enforced guidance. They suggested that, although the enabling elements of a disinvestment strategy have been in place in the SNS for years, it remains absent from the political agenda. They also suggested identifying low-value procedures and effective alternatives to encourage local disinvestment by increasing the knowledge base, which might improve the global efficiency and capacity of the SNS over time (9). Considering Private Initiatives Public-Private Partnerships. Arguably, to guarantee successful PPPs, regional governments should safeguard and recognize public interests and help design innovation-based business models that enable private providers to contribute substantially to public services at reasonable cost, which might require new regulatory frameworks to ensure transparency (15). Is this realistic? Their proponents see PPPs as a way for governments and health care organizations to solve underfunding due to budgetary limitations and to ensure efficient, qualitybased delivery based on pay-for-performance and meeting quality targets (86). However, although advocates claim PPPs provide better value for money than public options, solid comparative studies are lacking. Assertions that privatesector provision is superior are not supported by various studies in low-, middle-, and high-income countries, including systematic reviews (87, 88). Practical reasons to use nonclinical, accommodation-only PPP models (e.g., UK private finance initiatives [PFI]) include the ability to build and equip hospitals when funds are lacking (89). However, more than half of the larger UK PFI hospitals were in financial difficulties by 2006, compared with only 25 percent of non-PFI hospitals (90). There is a lack of evidence that the PPP capitation model (e.g., Alzira) results in savings while providing equal or better quality (89). Publicly available information on financing is often limited and opaque, and transparency is further hindered by claims of commercial confidentiality (50, 91). Initial evidence on outcomes in the Alzira model shows improvements in a range of indicators, including reductions in waiting times for surgery and imaging studies, mean

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hospital stays, and readmission rates and productivity gains in surgery (52, 86). However, after 14 years, and despite the model being extended to cover more than 1 million Valencians, the efficiency and efficacy of the Alzira model have still not been independently evaluated (50). Likewise, there is little information comparing private and public care in other ACs. Although patient surveys purport to show that users are more satisfied with private hospitals, the lack of clearness in presenting essential data, such as penalties or reduced payments due to failures in service provision, impedes thorough analysis (89). Barlow and colleagues have recently argued that worries about PPPs center on the alignment between incentives against complexity and cost against quality (86). Major differences exist between direct (e.g., the UK PFI) and indirect (e.g., Alzira) capitation models. A major risk is that, due to bureaucratic inefficiency, the payer ends up locked-in to a contract weighted heavily in favor of private interests. PPP models seem to be most successful when applied to utilities, where quality and outcomes can be clearly measured. This may be harder in health care, argue Barlow and colleagues (86). In-House Private Care. Pioneering experiences in some Spanish public hospitals, such as in-house private care, with profits being reinvested in the hospital, show that revenue-sharing alternatives to the PPP model are feasible, although separation of public and private activities is essential. In Catalonia, this type of initiative is not possible in hospitals administered directly by the health service, but it is increasing, and providing valuable revenue, in state-subsidized hospitals (92, 93). The prime example is Barnaclínic, which provides private medical care, without waiting lists, using the resources (only outside the regular timetable of the public system) of the internationally recognized Hospital Clínic of Barcelona. There is no conflict with public provision, and private patients have no preferential treatment. Barnaclínic provides a wide range of high-technology medical services, including some not covered by the public system. Crucially, all profits are reinvested in the public Hospital Clínic (92). Other state-subsidized Catalan hospitals that are implementing this type of model all have codes of conduct to ensure private care does not impinge on private provision with respect to waiting lists and resource use. Hospitals using this model guarantee not to use private services to enable patients to jump waiting lists. All profits are reinvested in public health care, waiting list management is transparent, private and public access is clearly differentiated, and the price of private services includes the corresponding write-down of the public installations. If necessary, written withdrawal from a waiting list is obtained and, if the patient decides to join the waiting list again, they do so at the end of the queue (93). The in-house private models being implemented in Catalonian state-subsidized hospitals are based on a 2006 report that suggested this model does not necessarily violate the principle of equity if it does not affect access to health care for patients with severe disease, that all could benefit if waiting lists did not increase,

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that potential loss of quality or increased discrimination should be monitored, and that the whole process should be clear and transparent (94). Associative-Based Entities. Primary health care in Spain suffers from long waits, excessive hospital referrals, and lack of cost control, especially for drugs. In the 1990s, interest grew in the possibility of health professionals themselves assuming the running of PHCs, an idea to which the Catalan government was receptive (95). A 1995 Catalan law legalized associative-based entities (EBAs), with at least 75 percent of shares held by health professionals and the rest by nongovernment private interests (96). EBAs are profit-making, but all profits are reinvested to improve services and provide incentives. Between 30 percent and 50 percent of total salary is pay-for-performance. EBAs are supervised by Catalonia’s CatSalut (the regional public health care provider); contracts, which allow for quality evaluation of the services provided, are renewed annually. However, due to lack of political will from all sides, only nine EBAs, 3 percent of all PHCs, currently exist in Catalonia. Despite high user satisfaction, EBAs have not been extended to other ACs (97, 98). The greatest advantage of EBAs may be that they allow greater direct decision making and involvement by health workers at a time of decreasing salaries and demotivation and, like purely private companies, permit a wide range of management possibilities in human resources, drug prescriptions, diagnostic tests, maintenance, and negotiations with providers. Likewise, the mean annual cost per patient is 30 percent lower than at traditional PHCs, while the health outcomes obtained are at least as good as traditional models (95, 97). The Role of Health Professionals Changes in the professional mindset have been slow. However, managerial conservatism, which has blocked previous transforming initiatives, is being swept away by the tide of change forced by the current crisis (17). To improve transparency, accountability, and good governance, health professionals could be given leading roles in official health bodies to manage new investment and disinvestment and to evaluate health care institutions, results, and processes, with publicly available accounting. It is increasingly recognized that the involvement of front-line physicians, many disinterested in leadership, is essential for the success of health care organizations and, ultimately, health care reform (99). The same is true for nurses and other groups. CONCLUSIONS We have examined the general inconsistency of performing severe health changes in the present economic conditions in Spain. While some reforms, such as

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encouraging generic drug prescription and ceasing public support for dozens of medicines of uncertain value, are well-founded and may improve efficiency and reduce costs, large cuts to health care services and salaries, together with the introduction or increase in charges, especially for low-income users, worsen the use, performance, and excellence of the system and may cause unfavorable health consequences (100). Although data are lacking for a broad appraisal of the burden of austerity, added detrimental repercussions can be envisaged given the recognized influence of social factors on health (100). The exclusion of undocumented immigrants is especially unjust and has been challenged by some ACs, which prioritize health over finances (23). While ensuring the most vulnerable are protected (effective social protection schemes can safeguard against the enduring health effects of the economic crisis [100]), we have suggested some interventions that involve good governance and require that health needs and health system performance are rigorously evaluated to guarantee efficient investing and access to quality care. In addition, there is room to boost feasible private alternatives to controversial PPPs. Individual health professionals, professional societies, and learned bodies in Spain will have to decide how to make their voices heard on decisions affecting the quality of health care and to support reform that works. The increasingly weary Spanish public needs to know their taxes are being spent efficiently. REFERENCES 1. World Bank. World Development Indicators. Washington, DC, 2011. 2. Gili, M., et al. The mental health risks of economic crisis in Spain: Evidence from primary care centres, 2006 and 2010. Eur. J. Public Health 23:103–108, 2013. 3. Eurostat Press Office. Provision of Deficit and Debt Data for 2012. April 22, 2013. http://epp.eurostat.ec.europa.eu/cache/ITY_PUBLIC/2-22042013-AP/EN/2-22042013AP-EN.PDF (accessed July 25, 2013). 4. Kingdom of Spain. Stability Programme Update, 2012–2015. http://www.thespanish economy.com/en-GB/Paginas/home.aspx (accessed July 25, 2013). 5. Instituto Nacional de Estadística. Encuesta de población activa. http://www.ine.es/ ss/Satellite?pagename=INEHome%2FHOMELayout&L=0 (accessed July 25, 2013). 6. Centro de Investigaciones Sociologicas. Barómetro Sanitario, 2010 (Primera Oleada). Study No. 2832, March 2010. http://www.cis.es/cis/export/sites/default/ Archivos/Marginales/2820_2839/2832/Es2832.pdf (accessed July 25, 2013). 7. Martin-Moreno, J. M., et al. Spain: A decentralised health system in constant flux. BMJ 338:b1170, 2009. 8. Organisation for Economic Co-operation and Development. Health Data 2013. How Does Spain Compare? June 27, 2013. www.oecd.org/health/healthdata (accessed July 25, 2013). 9. García-Armesto, S., Campillo-Artero, C., and Bernal-Delgado, E. Disinvestment in the age of cost-cutting sound and fury: Tools for the Spanish National Health System. Health Policy 110:180–185, 2013.

Financial Crisis and Health Care in Spain

/ 47

10. Gené-Badia, J., et al. Spanish health care cuts: Penny wise and pound foolish? Health Policy 106:23–28, 2012. 11. García-Armesto, S., et al. Spain: Health system review. Health Syst. Transit. 12: 1–295, 2010. 12. Ministerio de Sanidad, Servicios Sociales e Igualdad. El Consejo Interterritorial. http://www.msssi.gob.es/organizacion/consejoInterterri/home.htm (accessed July 25, 2013). 13. Lopez-Casasnovas, G., Costa-Font, J., and Planas, I. Diversity and regional inequalities in the Spanish ‘system of health care services.’ Health Econ. 14(Suppl 1): S221–S235, 2005. 14. Organisation for Economic Co-operation and Development. StatExtracts, 2012. http://stats.oecd.org/index.aspx?DataSetCode=HEALTH_STAT (accessed July 25, 2013). 15. PricewaterhouseCoopers SL. Diez temas candentes de la Sanidad española para 2012. http://www.pwc.es/es/sala-prensa/multimedia/informe-sanidad.jhtml (accessed July 25, 2013). 16. Informe SESPAS (Sociedad Española de Salud Pública y Administración Sanitaria) 2012. La atención primaria: Evidencias, experiencias y tendencias en clínica, gestión y política sanitaria. Gaceta Sanitaria 26(Suppl 1), 2012. http://www.elsevier.es/es/ revistas/summary/gaceta-sanitaria-vol26-num-supl1 (accessed July 25, 2013). 17. Organización Médica Colegial. Profesión médica y reforma sanitaria. Propuestas para una acción inmediata. Madrid, December 2012. 18. Sahuquillo, M. R. 6.700 millones menos para sanidad. El País, February 16, 2013. 19. Castedo, A. Boi Ruiz quiere recortar hasta un 10% los sueldos en la sanidad pública. El País, April 11, 2013. 20. Güell, O. Los recortes de la Generalitat incendian la sanidad catalana. El País, April 8, 2011. 21. Metges de Catalunya. El pressupost de Salut confirma les advertències de Metges de Catalunya, January 30, 2012. http://metgesblog.com/2012/01/30/el-pressupostde-salut-confirma-les-advertencies-de-metges-de-ca/ (accessed July 25, 2013). 22. García Rada, A. Privatisation in Spain provokes protests among doctors. BMJ 345:e7655, 2012. 23. Legido-Quigley, H., et al. Will austerity cuts dismantle the Spanish healthcare system? BMJ 346:f2363, 2013. 24. McKee, M., et al. Austerity: A failed experiment on the people of Europe. Clin. Med. 12:346–350, 2012. 25. SEMFYC (La Sociedad Española de Medicina de Familia y Comunitaria). Informe sobre los recortes en los servicios sanitarios de las Comunidades Autónomas, June 2012. 26. Unsigned. Decenas de municipios se quedan sin urgencias nocturnas en toda España. El País, January 16, 2013. 27. Real Decreto-ley 16/2012. BOE-A-2012-5403, pp. 31278–31312. April 20, 2012. 28. Karanikolos, M., et al. Financial crisis, austerity, and health in Europe. Lancet 381:1323–1231, 2013. 29. Ministerio de Sanidad, Servicios Sociales e Igualdad. Datos provisionales de facturación de receta médica. http://www.misssi.gob.es/profesionales/farmacia/ datos/marzo2013.htm (accessed July 25, 2013).

48

/ Bosch et al.

30. Ministerio de Sanidad, Servicios Sociales e Igualdad. Facturación de recetas médicas. http://www.mspsi.gob.es/profesionales/farmacia/datos/home.htm (accessed July 25, 2013). 31. Farmaindustria. Encuesta anual y trimestral de deuda por suministros hospitalarios, December 2011. 32. Sahuquillo, M. R., and De Benito, E. Las listas de espera se agravan. El País, October 27, 2012. 33. Pérez-Molina, J. A., and Pulido Ortega, F. Assessment of the impact of the new health legislation on illegal immigrants in Spain: The case of human immunodeficiency virus infection. Enferm. Infecc. Microbiol. Clin. 30:472–478, 2012. 34. Reginato, E., and Grosso, R. European Federation of Salaried Doctors. European Hospital Doctors’ Salaries. Document F11-071 EN, September 13, 2011. 35. Gili, M., et al. The mental health risks of economic crisis in Spain: Evidence from primary care centres, 2006 and 2010. Eur. J. Public Health 23:103–108, 2013. 36. De Lago, M. Organ donors and transplantations decrease in Spain, the leading country in both. BMJ 342:d242, 2011. 37. Martin-Moreno, J. M., et al. The effects of the financial crisis on primary prevention of cancer. Eur. J. Cancer 46:2525–2533, 2010. 38. Vila Córcoles, A., et al. Evolution of the antipneumococcal vaccination coverage among children in the region of Tarragona, Spain, 2002–2011. Rev. Esp. Salud Publica 86:637–643, 2012. 39. Elola, J., Rincón, R., and Castedo, A. El hambre se cuela en el colegio. El País, June 15, 2013. 40. Defensor del Pueblo. La Defensora del Pueblo investiga el impacto de la crisis en los hogares con niños y en la calidad de su alimentación, June 19, 2013. http://www. defensordelpueblo.es/es/Prensa/Notas/contenido_1371636566768.html (accessed July 25, 2013). 41. Unsigned. Cortes de tráfico contra el tijeretazo en sanidad. El País, April 13, 2011. 42. Menéndez, M. La presión ciudadana frena el cierre de dos hospitales en Mallorca. El País, August 11, 2012. 43. SEMFYC (La Sociedad Española de Medicina de Familia y Comunitaria). Análisis ético ante la retirada de asistencia sanitaria a inmigrantes sin permiso de residencia, June 30, 2012. 44. Organización Médica Colegial y Consejo General de Enfermería. La alternativa de los médicos y enfermeros para garantizar la sostenibilidad del Sistema Nacional de Salud. Análisis e investigación, April 2013. http://www.actasanitaria.com/fileset/ file_Resultados_85_Alterantivas_SNS_Medicos_y_Enfermer_6694431042059128656. pdf (accessed July 25, 2013). 45. García Vega, M. A. La salud privada aprovecha el tijeretazo público. El País, April 8, 2012. 46. Sahuquillo, M. R. Los españoles se blindan con la sanidad privada pese a la crisis. El País, December 15, 2011. 47. García-Rada, A. Conservative win in Spain’s general election will boost role of private sector in healthcare. BMJ 343:d7297, 2011. 48. Prats, J. La gestión privada de la sanidad se extiende en las autonomías del PP. El País, November 3, 2012.

Financial Crisis and Health Care in Spain

/ 49

49. Benito, B., Montesinos, V., and Bastida, F. J. An example of creative accounting in public sector: The private financing of infrastructures in Spain. Crit. Perspec. Accounting 19:963–986, 2008. 50. Acerete, B., Stafford, A., and Stapleton, P. Spanish healthcare public private partnerships: The ‘Alzira model.’ Crit. Perspec. Accounting 22:533–549, 2011. 51. Prats, J. Un modelo rescatado y desigual. El País, January 6, 2013. 52. National Health Service European Office. The search for low-cost integrated healthcare. The Alzira model from the region of Valencia. Brussels, 2012. http://www. nhsconfed.org/Publications/Documents/Integrated_healthcare_141211.pdf (accessed July 25, 2013). 53. Sevillano, E. G. El bastión de la ‘marea blanca.’ El País, November 10, 2012. 54. García Rada, A. Largest healthcare privatisation plan in Spain is to go ahead, despite massive opposition. BMJ 346:f236, 2013. 55. Marcos, J. Las concesionarias de los hospitales reducirán un 20% el gasto por paciente. El País, April 18, 2013. 56. Organisation for Economic Co-operation and Development. Economic Outlook, Analysis and Forecasts. November 2012. http://www.oecd.org/eco/economicout lookanalysisandforecasts/spaineconomicforecastsummary.htm (accessed July 25, 2013). 57. Unsigned. The Spanish patient. The Economist, July 28, 2012. 58. Ipsos. International Healthcare Report Card: Citizen-Patients in 15 Countries Assess Improvement to Healthcare. June 11, 2013. http://www.ipsos-na.com/news-polls/ pressrelease.aspx?id=6141 (accessed July 25, 2013). 59. Organisation for Economic Co-operation and Development. Health at a Glance: Europe 2012. November 16, 2012. http://dx.doi.org/10.1787/9789264183896-en (accessed July 25, 2013). 60. Pericás, J. M., et al. Should alternatives to conventional hospitalisation be promoted in an era of financial constraint? Eur. J. Clin. Invest. 43:602–615, 2013. 61. World Health Organization Regional Office for Europe. The Tallinn Charter. 2008. http://www.euro.who.int/_data/assets/pdf_file/0008/88613/E91438.pdf (accessed July 25, 2013). 62. World Health Organization Regional Office for Europe. Health 2020. http://www. euro.who.int/en/what-we-do/health-topics/health-policy/health/health-2020 (accessed July 25, 2013). 63. Gómez, M. V. Los sindicatos reclaman un gran pacto ante la emergencia nacional del paro. El País, May 1, 2013. 64. De Belvis, A. G., et al. The financial crisis in Italy: Implications for the healthcare sector. Health Policy 106:10–16, 2012. 65. European Commission. Europe 2020. http://ec.europa.eu/europe2020/index_en.htm (accessed July 25, 2013). 66. Eurostat Press Office. At Risk of Poverty or Social Exclusion in the EU27. December 3, 2012. http://epp.eurostat.ec.europa.eu/cache/ITY_PUBLIC/3-03122012-AP/EN/ 3-03122012-AP-EN.PDF (accessed July 25, 2013). 67. Sanjurjo Martínez, A. Emergencia nacional. El País, May 5, 2013. 68. Prats, J., and Sevillano, E. G. El Gobierno volverá a subir el copago a los dependientes. El País, May 1, 2013. 69. Prats, J. La dependencia retrocede. El País, June 3, 2013.

50

/ Bosch et al.

70. Colegio de Registradores de la Propiedad. Panorama registral de impagos hipotecarios de vivienda, April 12, 2013. http://www.registradores.org/detalle_nota_ prensa.jsp?DS48.PROID=21679 (accessed July 25, 2013). 71. CGPJ (Consejo General del Poder Judicial). El CGPJ informa, March 22, 2013. http:// www.poderjudicial.es/cgpj/es/Poder_Judicial/En_Portada/Los_concursos_aumentaron_ en_2012_un_28_por_ciento (accessed July 25, 2013). 72. Unsigned. El Senado aprueba el proyecto de ley sobre desahucios sin introducir cambios. El País, May 3, 2013. 73. Rajmil, L. Destruction of a less developed welfare state and impact on the weakest, the youths. BMJ (rapid response), March 1, 2012. http://www.bmj.com/content/ 343/bmj.d7973?tab=responses (accessed July 25, 2013). 74. Tambor, M., et al. Diversity and dynamics of patient cost-sharing for physicians and hospital services in the 27 European Union countries. Eur. J. Public Health 21:585–590, 2011. 75. Goldman, D. P., Joyce, G. F., and Zheng, Y. Prescription drug cost sharing: Associations with medication and medical utilization and spending and health. JAMA 298:61–69, 2007. 76. Nishi, A., et al. Health benefits of reduced patient cost sharing in Japan. Bull. World Health Organ. 90:426A–435A, 2012. 77. Selden, T. M., et al. Cost sharing in Medicaid and CHIP: How does it affect out-of-pocket spending? Health Aff. (Millwood) 28:W607–W619, 2009. 78. Blumenthal, D., and Dixon, J. Health care reforms in the USA and England: Areas for useful learning. Lancet 380:1352–1357, 2012. 79. Gemmill, M. C., Thomson, S., and Mossialos, E. What impact do prescription drug charges have on efficiency and equity? Evidence from high-income countries. Int. J. Equity 7:12, 2008. 80. World Health Organization. Health Policy Responses to the Financial Crisis in Europe. Copenhagen, 2012. 81. Barros, P. P. Health policy reform in tough times: The case of Portugal. Health Policy 106:17–22, 2012. 82. Miró, O. State of emergency medicine in Spain. Int. J. Emerg. Med. 3:219-226, 2010. 83. Bosch, X., et al. Quick diagnosis units versus hospitalization for the diagnosis of potentially severe diseases in Spain. J. Hosp. Med. 7:41–47, 2012. 84. Bosch, X., Jordán, A., and López-Soto, A. Quick diagnosis units: Avoiding referrals from primary care to the ED and hospitalizations. Am. J. Emerg. Med. 31:114-123, 2013. 85. Abellán Perpiñán, J. M., and Del Llano Señarís, J. Un NICE español, ¿misión imposible? Economía y Salud, Issue 73, March 2012. 86. Barlow, J., Roehrich, J., and Wright, S. Europe sees mixed results from publicprivate partnerships for building and managing health care facilities and services. Health Aff. (Millwood) 32:146–154, 2013. 87. Basu, S., et al. Comparative performance of private and public healthcare systems in low- and middle-income countries: A systematic review. PLoS Med. 9:e1001244, 2012. 88. Tiemann, O., Schreyögg, J., and Busse, R. Hospital ownership and efficiency: A review of studies with particular focus on Germany. Health Policy 104:163–171, 2012.

Financial Crisis and Health Care in Spain

/ 51

89. Sevillano, E. G. Who owns the Madrid region’s hospitals? El País (English Edition), March 22, 2012. 90. Pollock, A. M., Price, D., and Liebe, M. Private finance initiatives during NHS austerity. BMJ 342:d324, 2011. 91. Pollock, A., and Godden, S. Independent sector treatment centres: Evidence so far. BMJ 336:421–424, 2008. 92. Barnaclínic. Group Hospital Clínic. http://www.barnaclinic.com/quienes-somos/en_ barnaclinic.html (accessed July 25, 2013). 93. Castedo, A. Los servicios privados aumentan en los hospitales públicos catalanes. El País, April 15, 2013. 94. Camps Cervera, V., et al. Les prestacions privades en les organitzacions sanitàries publiques. Fundació Víctor Grífols i Lucas, Issue 4, 2006. http://www. fundaciongrifols.org/portal/es/2/7353/ctnt/dD10/_/_/cbx/04-Las-prestaciones-priva das-en-las-organizaciones-sanitarias-p%C5%93blicas.html (accessed July 25, 2013). 95. Ballart, X. A new model of primary health care in Catalonia. In Elites, Ideas and the Evolution of Public Policy, ed. M. Smyrl et al. Palgrave, London, 2008. 96. Generalitat de Catalunya. Llei 11/1995 (September 29, 1995) and Llei 15/1990 (July 9, 1990). 97. Ledesma Castelltort, A. Les entitats de base associativa (EBA) en la gestió dels serveis d’atenció primària a Catalunya. Referent 11:38–45, October 2012. http:// www.uch.cat/referent/num11/documents/referent%2011%2031oct12.pdf (accessed July 25, 2013). 98. Gallego, R. Introducing purchaser/provider separation in the Catalan health administration: A budget analysis. Public Adm. 78:423–442, 2000. 99. Bohmer, R. M. Leading clinicians and clinicians leading. N. Engl. J. Med. 368: 1468–1470, 2013. 100. Brand, H., et al. Austerity policies in Europe: Bad for health. BMJ 346:f3716, 2013.

Direct reprint requests to: Xavier Bosch, MD, PhD Department of Internal Medicine University of Barcelona Hospital Clínic Villarroel 170 08036-Barcelona, Spain [email protected]