The private healthcare sector is a fundamental agent in our country in terms of creating welfare and wealth, and contributing to economic and social development. It is also an important strategic ally of the public healthcare system, contributing significantly to the sustainability of the system and to achieving fundamental objectives in healthcare such as equity, sustainability, accessibility and quality.

This report demonstrates the value contributed by the private healthcare sector in terms of three different aspects:

Healthcare spending in Spain stood at 8.8% of the GDP in 2013, a decrease of 2 tenths compared to the latest figures published by the OECD in 2012 (Graph 1). This decrease is mainly caused by the strong budgetary constraints that have affected public healthcare spending in recent years.

Healthcare spending in relation to the GDP positions Spain slightly behind the OECD average (8.9%) and some major neighbouring countries such as Germany (11.0%) and France (10.9%), while it is in line with Italy (8.8%) and above the UK (8.5%) (Graph 2).

Public funding in 2013 represented 71.5% of total healthcare spending, meaning private healthcare spending was at 28.5%. Compared with our neighbours, Spain is positioned as one of the countries where the weight of private healthcare spending to total healthcare spending is highest, ranking ahead of countries like Germany (23.7%), Italy (22.6 %), France (21.3%) and Sweden (15.9%) (Graph 3).

In terms of trends, private healthcare spending relative to GDP registered a growing trend in recent years, going from 2.2% (€20.094 Bill.) in 2005 to 2.6% (€26.944 Bill.) in 2012. In 2013, however, it lost a tenth over the previous year falling to 2.5% of GDP (€26.174 Bill.), which implies a slight decrease in spending of 2.8% (Graph 4). This reduction is motivated by the difficult economic and social situation experienced in Spain in 2013, one of the years in which the economic crisis hit most intensely. Therefore, this decrease is considered exceptional and is not expected to be a shift in the trend of private healthcare spending, as it is expected to continue on its path of growth in future years.

Public spending continues the downward trend that started at the beginning of the economic crisis, going from 6.8% of GDP in 2009 (€73.036 Bill.) to 6.5% in 2012 (€68.263 Bill.). In 2013 it lost two tenths (6.3%) compared to the previous year (€65.719 Bill.), meaning a decrease of 3.7% in spending, a bit more than €2.5 Bill. (Graph 5).

Regarding the composition of private healthcare spending, it is important to stress that it is composed mainly of out-of pocket spending, private insurance, and non-profit institution spending. In 2013, these items represented 2.1%, 0.4% and 0.03% of GDP respectively (Graph 6). In the area of private insurance, compared with our neighbours, Spain ranks ahead of countries like the United Kingdom (0.3%) and Italy (0.1%) but behind France (1.5%), Germany (1.0%) and Switzerland (0.8%) (Graph 7).

Furthermore, a percentage of public health spending is allocated to private provision funding through agreements, which stands at 11.6% (Graph 8).

In terms of GDP, it is estimated that these agreements make up 0.7%, of which 0.55% corresponds to autonomous regions, 0.15% to civil servant mutual societies and the remaining 0.03% to the Social Security System (Graph 9).

Given the above and adding spending for these agreements and private healthcare spending, we find that the total healthcare spending on private provision, according to estimates, represented 3.2% of GDP in 2013, meaning approximate spending of 33.797 billion euros (Graph 10).

 

Private insurance

Spain has 7.4 million insured individuals which helps to unburden the public system and save it money, as it is a model of double insurance where citizens with private insurance do not consume or only partly consume public health resources. The savings generated for the National Healthcare System by private healthcare varies depending on use of the public system. In this sense, it is estimated that a patient using only the private system saves a total of approximately 1,091 euros per year (not including pharmaceutical spending or mutual society spending for civil servants) by not using any public health resources. In the case of a patient using a combination of healthcare, thus using both public and private healthcare, it is estimated that they save public healthcare 566 euros per year.

Given the number of insured individuals in Spain (7.4 million), the total savings generated the National Healthcare System is estimated to be in a range between 4.204 and 8.103 billion euros, depending on their use of public healthcare (Illustration 1). At present, the insurance sector remains crucial to ensuring the proper functioning of the healthcare system. On the one hand, the private system plays a complementary role, providing healthcare in those geographical areas where public healthcare does not have sufficient infrastructure. On the other hand, it plays a supplementary role in areas with all public healthcare resources as it provides the same health coverage, allowing the user to choose one or the other.

Regarding spending, it is estimated that total spending nationwide is €1,790, in which public spending per capita amounts to 1,260 euros, compared to the 530 euros representing private healthcare spending per capita, which comprises out-of-pocket expenses (408 euros) and insurance expenses (122 euros) (Graph 11).

Geographically, the Basque Country, Navarre and Asturias are the autonomous regions with the highest healthcare spending per capita with 2,284 euros, 2,089 euros and 2,060 euros respectively.

Andalusia and Murcia, on the other hand, have the lowest spending on healthcare with 1,531 euros and 1,610 euros respectively (Graph 12).

In relation to private healthcare spending per capita, Madrid, Catalonia and the Basque Country are the regions with the highest figures, with 693 euros, 654 euros and 584 euros respectively. At the other end of the scale, Extremadura, Murcia and the Canary Islands have the lowest private healthcare spending per capita, with 400 euros, 405 euros and 406 euros respectively (Graph 13).

As for public health spending, and in keeping with previous years, all regions recorded deviations of an excess of public health spending in relation to budgeted spending except the Basque Country (-3%) and the Canary Islands (-1%). The largest deviations occur in Murcia (25%), La Rioja (16%), Extremadura (15%), Valencia (12%) and Catalonia (11%). In this respect, Catalonia, with a difference of 973 million euros, the Region of Valencia, with 707 million, and Murcia, with 519 million, account for 61% of the deviation of the entire national territory (Table 1).

On the other hand and despite the economic crisis, the insurance sector has managed to maintain positive growth rates in recent years. Therefore, in the period 2011-2014, the volume of premiums increased by 3.1% per year to reach 6.893 billion euros.
Estimates for 2015 predict a growth in the volume of premiums of 3.5% compared to 2014, which means a volume of premiums of 7.132 billion euros (Graph 14).

In 2015, 9.3 million insured parties were reached, of which 72% correspond to healthcare (without administrative mutualism), 21% to administrative mutualism and the remaining 7% to reimbursement of expenses (Graph 15).
Regarding the penetration of private insurance, despite the absence of a statistical correlation between it and the public healthcare budget per capita, it can be observed, as in previous years, that certain autonomous regions with greater private insurance penetration, such as Madrid, Catalonia and the Balearic Islands, have a lower public healthcare budget per capita than most regions of the country (Illustration 2).

At market level, the health insurance sector continues to show a high degree of concentration, with the top 5 companies representing a 71% market share in volume of premiums, which increases to 82% if we look at the top 10 insurance companies (Graph 16).

 

Private sector activity

The activity undertaken by private healthcare contributes to and helps achieve compliance with the healthcare objectives of the public system, such as reducing waiting lists, while helping complete the expectations of professionals and being loyal to its contribution to the healthcare system, creating jobs and economic attraction in the country.

The activity carried out by private healthcare in relation to national healthcare activity is very relevant. Specifically, in 2013 private hospitals carried out 29% of surgical procedures (1.4. million), covered 23% of discharges (1.2 million) and attended to 22% of emergencies (5.8 million) throughout the country (Illustration 3). Activity data in the private sector remain generally stable over the previous year, although the increase recorded in the volume of consultations and emergencies is noteworthy (Table 2).

The average stay in private hospitals reached 6.25 days5 in 2013, while the average stay recorded in public hospitals was 7.95 days. Taking into account the "Study on Health Outcome Indicators in Private Healthcare: RESA 2015”, published by the IDIS Foundation, the EMAC (average stay adjusted by casuistry) of the private hospitals analysed was 3.3 days, a figure significantly lower than the 6.25 days since it is an EMAC and it mainly corresponds to acute care hospitals.

By care area, those which recorded the highest number of stays in the private sector are: Medicine and Medical Specialisations (2 million), Psychiatry (1.4 million), Extended Stay (1.2 million) and Surgery and Surgical Specialisations (900,000) (Table 3).

In relation to the volume of discharges, the most represented care areas in the private sector are: Orthopaedic surgery and Traumatology (33.4%), Surgery and Surgical Specialisations (27.8%) and Obstetrics and Gynaecology (24.3%) (Table 4).

In terms of surgical procedures, private healthcare carried out 32% of procedures with hospitalisation and 26% of major outpatient surgery procedures recorded in 2013 (Table 5).

By specialisation, private hospitals performed 34% of Orthopaedic Surgery and Traumatology procedures, 33% of Neurosurgery procedures, 32% of Gynaecology and Obstetrics, 31% Angiology and Vascular Surgery procedures, and 30% of General and Digestive Surgery (Table 6).

 

Improves the public's accessibility to healthcare

The private healthcare sector offers a large number of centres that contribute to improving the public's accessibility to healthcare and cover the demands of patients in terms of the professionalism of its employees, advanced technology and agility in responsiveness to their needs.

In recent years, the private healthcare sector has experienced significant growth in number of centres, improving the accessibility of patients as understood from the perspective of centre location and the after-hour care provided.

The ample care network available to the private healthcare sector provides a wide range of services and activities, highlighting, among others, hospitals, medical centres (healthcare establishments dedicated to the provision of health services that do not require hospitalisation), diagnostic imaging centres, clinical laboratories, assisted reproduction centres, home hospitalisation equipment and private consultations.

Accessibility of care provided by private healthcare is clearly seen in the results obtained in the last Healthcare Results Study (RESA) (Table 7). In this sense, private hospitals have a high degree of agility in responding to the needs of the public, as evidenced by the following data:

• Delays in appointments for additional tests are less than 12 days on average.
• Delivery times of reports is under 4 days.
• Waiting times for consultation appointments for the busiest specialisations are between 10 and 14 days.
• The average times for medical attention in emergency care are less than 24 minutes, including triage which is around 7 minutes.
• Waiting times for surgical procedures are less than 44 days.
• The time between diagnosis and treatment in oncological procedures is around 16 days in the case of breast cancer, 14 days in the case of colon cancer and 10 days in the case of lung cancer

Collaborates with the public system

The private healthcare sector is still an important strategic ally of the public healthcare system; the collaboration between the two sectors is essential to ensure sustainability and accessibility to the Spanish healthcare system.

The collaboration between the public sector and the private sector is the ideal formula for achieving a sustainable and efficient healthcare system which avoids redundancies and duplications, and establishes synergies while providing the necessary financial strength in the present, and allowing it to secure guarantees for the future.

The utilisation of all healthcare resources, regardless of ownership, allows for optimum levels of proper care for the population, which must be the ultimate and primary objective for both the public and private sectors. In this sense, our country has a long tradition of using some of public private partnership formulas, such as the agreements in place between regional healthcare services and private centres, administrative mutualism and administrative concessions that include the management of healthcare services (Illustration 6).

 

Agreements

Agreements with private centres in different areas of activity (hospitals, medical centres, diagnostic imaging, haemodialysis, etc.) contribute significantly to achieving the fundamental values of the public system, such as equity, accessibility, reducing waiting lists and helping to comply with the maximum response times.

Eliminating agreements with the private healthcare sector can be a handicap for the proper care of patients within a reasonable time period, mainly due to increased periods of waiting lists and the burden for care in public health centres.

As previously noted in the report, a significant percentage of public healthcare spending (11.6%) is allocated to the budget item of agreements, reflecting the importance and impact of this item.

Carries out highly complex activity using the most recent technological advances.

The private healthcare sector is an important dynamic agent and diffuser of innovation in the realm of technology, it has advanced medical equipment and highly complex technology that allows it to act with medical excellence.

The use of technology in healthcare offers a range of benefits to the patient, the professional and the healthcare system in general, which include:

• Contributes to the prevention of diseases, reducing the need for future healthcare and, consequently, healthcare costs.
• Improves diagnosis and helps in the early detection of diseases, allowing for more effective therapy.
• Improves therapy in terms of speed, efficiency and effectiveness.
• Supports patient monitoring.
• Allows for better management of clinical data.
• Favours new ways of working that are more efficient, connected and global.

Acquiring state-of-the-art equipment and the latest technology is a key aspect of the private healthcare sector. The progress made in recent years allows us to diagnose more patients, treat them better and in less time, resulting in both better clinical results and lower costs per treatment.

The private hospital sector is clearly committed to investing in high-tech equipment, as evidenced by the fact that it possesses 56% of MRI, 47% of PET and 36% of CAT equipment (Graph 40).

Analysing the high-tech equipment of public and private healthcare from different regions shows that Madrid, Andalusia, Region of Valencia and Catalonia have the greatest amount of high-tech equipment.

Among the regions with the highest percentage of equipment in private centres, Catalonia (46%) and the Balearic Islands (37%) are found at the top. Regarding the number of equipment units in private healthcare, the main autonomous regions are Catalonia (448) and Madrid (370) (Graph 41).

Private hospitals perform increasingly complex activity, developing new and pioneering techniques and procedures.

In terms of diagnostics, in 2013 the private sector conducted a significant percentage of the tests carried out throughout the national healthcare system, with 994,257 MRIs (39%), 695,224 CAT scans (16%), 26,601 PET and PET-CT (27%), and 15,453 SPECT (12%). (Illustration 9).

Regarding surgical activity, in 2013 the private sector carried out a significant volume of complex care activity, with 295,668 Orthopaedic Surgery and Traumatology procedures (34%), 291,371 General and Digestive Surgery procedures (30%), 141,310 Gynaecology and Obstetrics procedures (32%), 34,449 Angiology and Vascular Surgery procedures (31%), 22,608 Neurosurgery (33%) procedures and 8,680 Heart Surgery procedures (20%). (Illustration 10).

 

Generates employment and helps train healthcare professionals

To support undergraduate training, the private healthcare sector has a total of 22 university hospitals in the autonomous regions of Madrid, Catalonia, Valencia, Andalusia and Navarre (Illustration 12). Of the 22 university hospitals, 6 are hospitals using the administrative concession model for healthcare service management. As for operators, Quirónsalud and HM Hospitales are the greatest exponents in this type of training with 7 and 6 hospitals respectively.

Regarding specialised healthcare training, in 2016 the Ministry of Health, Social Services and Equality has called for a total of 166 places for the residency system in private healthcare facilities (including the places at privately managed public hospitals) (Graph 42).

Private centres and public centres with private management that have specialized healthcare training places through the residency system are located in 6 regions; Madrid, Navarre and Valencia have the greatest number places (Illustration 13).

As for centres, the Fundación Jiménez Díaz and the Clínica Universidad de Navarra have the greatest number of places, with 53 and 45 respectively.

The specialisations with the greatest number of training places are Orthopaedic Surgery and Traumatology with 16 places, Internal Medicine with 13 places and Anaesthesiology and Ophthalmology, with 11 places each (Table 13).