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07 January 2025 | Country Update
ePrescription helps patients avoid excessive pharmaceutical co-payments
3.4. Out of pocket payments
The share of OOP payments of current health expenditure in Czechia is relatively stable and, according to WHO data, hovered around 14% from 2015 to 2019, though ČSÚ data show this share dropping to 11.5% in 2020. OOP payments have accounted for just over 2% of total household expenditure over the same time, and the ČSÚ data furthermore show that OOP payments per capita dropped slightly from CZK 5803 in 2019 to CZK 5666 in 2020 (ČSÚ, 2022b).
OOP payments consist of direct payments for over-the-counter pharmaceuticals (26% of OOP payments in 2020); co-payments on prescription pharmaceuticals (20%); above-standard medical procedures and services in both inpatient and outpatient settings (22%, including for spa stays and cosmetic procedures); direct payments and surcharges for dental care (18%); and co-payments on medical aids and other devices (11%) (ČSÚ, 2022b).
Outpatient and inpatient health services are provided free of charge at the point of use, except for some prescription pharmaceuticals, medical aids and the user fee for accessing outpatient out-of-hours services (CZK 90; this fee is not collected if the visit results in a hospital stay). In 2008, more flat user fees were introduced, such as for physician consultations (CZK 30), stay per hospital day (CZK 60, increased to CZK 100 in 2011) and per collected prescription pharmaceutical (CZK 30), but were gradually dismantled and fully abolished due to popular and political opposition as of January 2015. No co-payment for “above-standard” medical treatment is possible; should a patient desire an alternative procedure or MDA, they would pay for the whole medical treatment. For a detailed description of user fee development in 2008–2014 and the above-standard opt-out experiment of 2012–2013, please refer to Alexa et al. (2015).
The out-of-hours user fee also applies to out-of-hours dental care; those living below the poverty line are generally exempt from any user fee.
3.4.1. Cost-sharing (user charges)
Reference pricing is in place for prescription pharmaceuticals (see Table3.4). Therapeutic substitutions are applied for setting the ATC reference groups with at least one pharmaceutical being fully covered in each of these groups. Generic substitution is also permitted in pharmacies and SÚKL can regularly reassess the set maximum prices (in an administrative procedure) based on international benchmarking.
Table3.4
An annual ceiling of CZK 5000 was established in 2008 in line with user fee introduction. To date, this annual cap is used as an OOP payment maximum for prescribed pharmaceutical cost-sharing. The original annual limit of CZK 5000 has been lowered several times for select vulnerable groups and occurred most recently in January 2020 for people with moderate and severe disability, defined as those with a second or third disability level, according to Act no. 108/2006 Coll. They were assigned the lowest co-payment limit of CZK 500, which is the same limit as for people aged 70+ (introduced in 2017, when it was CZK 2500 previously). The limit is set at CZK 1000 for seniors aged 65–69 and for children below 18 (also reduced from CZK 2500 in 2017); everyone else has an annual cap of CZK 5000. HIFs reimburse members for defined co-payments on prescribed pharmaceuticals automatically and retrospectively after reaching the individual annual limit; the assessment is done on a quarterly basis. Retrospective reimbursements to patients for their prescribed pharmaceutical co-payments have steadily increased, from CZK 648 million in 2018 to CZK 864 million in 2020 (Health Insurance Funds, 2019, 2021).
There is no cost-sharing in place for inpatient stays. Spa treatments and rehabilitation inpatient services are also covered by SHI if prescribed by an attending physician (this can also be a GP); a co-payment exists for part of the associated spa hotel service costs, however.
Regarding reimbursed MDA, co-payments have been based on reference pricing since 2019 (see section 2.7.5). Some specialized medical care, such as physiotherapy, speech therapy and IVF, have set benefit maxima in terms of the number of treatments per given period or over the life (for IVF).
Starting from January 2025, patients only pay deductible co-payments for partially reimbursed medicines at the pharmacy up to the protective limit relevant to them. Prior to this, people also encountered co-payments exceeding this limit and were quarterly refunded by their health insurance fund (HIF).
This change was possible due to improvements in the monitoring of protective limits for deductible co-payments. Deductible co-payments are now registered online in the ePrescription system, and so pharmacists know when dispensing whether patients have reached their set limit based on their age. From 2025, the ePrescription system will also contain information on recipients of invalidity pensions. From 2026, it will contain information on the degree of invalidity as well.
Patients will continue to pay the non-reimbursable part of the co-payment, as well as the price of medicines that are not covered by statutory health insurance, as they do today.
3.4.2. Direct payments
Direct payments consist of payments for over-the-counter pharmaceuticals, medical products and non-SHI services, such as cosmetic surgeries and the use of higher-quality material in dental care; direct payments are limited in scope given the broad SHI benefits package. Direct payments also include more luxurious hotel-related services in inpatient settings and other non-curative services provided by physicians, such as fitness-for-employment evaluations.
Approximately 50% of dental care costs were funded privately through OOP payments in 2020, as the range of dental treatments covered by SHI is limited and restricted to the least expensive options (ČSÚ, 2022b). Most insured individuals choose to pay for higher-quality dental materials in full (although the treatment itself is usually covered by SHI). According to ČSÚ data (2022b), OOP payments on dental care accounted for 18% of total OOP expenditure on health care in Czechia in 2020.
3.4.3. Informal payments
There is little official evidence on informal payments in the Czech health system. According to the Transparency International Global Corruption Barometer, 10% of the population made informal payments in the health system in 2020, above the EU average of 6% (Transparency International, 2021). A European Commission study on corruption in the health system found that informal payments by patients are only relevant in relatively limited areas in Czechia, such as for quicker treatment of non-life-threatening but highly painful conditions, for example, hip replacements (European Commission, 2013). Informal payments similarly occur in gynaecology and obstetrics. The level of informal payments relative to official payments is not known, though it is widely seen as a negligible part of health financing due to the broad SHI benefits package, relatively low OOP payments reported in household surveys and low reported unmet needs.