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The values and principles of the Luxembourgish health system are laid down in Article 11 of the Constitution of the Grand Duchy of Luxembourg dating back to 1868.
This is further specified in the Code of Health, the Code of Social Security, with sector-specific legislation as laws as well as regulations, plus Grand-Ducal and ministerial decrees and orders. Given this long historic evolution, legislation of the Luxembourgish health system was rather fragmented and has been subject to recent reforms in order to harmonize insurance schemes.
Key principles of the health system are:
A) universal coverage through a compulsory social health insurance (SHI) system, financed mainly by contributions B) SHI system consisting of three schemes for: (1) health care; (2) accident insurance; (3) long-term care. C) free choice of service providers for patients and direct access to specialist services D) a central role for self-employed physicians, who are: authorized to provide health services by the Ministry of Health; compulsorily accredited to the National Health Insurance (Caisse Nationale de Santé – CNS); reimbursed according to tariffs as agreed with the CNS. E) national planning of the hospital and pharmaceutical sectors by the Ministry of Health.
Regulatory responsibilities are split between the Ministry of Health and the Ministry of Social Security. Both ministries cooperate closely and share responsibility for the organization, legislation and financing of the health system. This includes implementing health policy, ensuring that health is considered in all aspects of policy, and coordinating actors and activities in the system. The Ministry of Health develops health policy; enacts laws and regulations that apply to health providers; plans and organizes the delivery of care; authorizes large hospital investments; and directly cofinances public health programmes. The Ministry of Social Security develops social policy; enacts laws and regulations relating to social policy; and oversees public institutions funded by the health, accident and long-term care insurance schemes.
The Ministry of the Family is responsible for licensing and inspecting long-term care facilities. The social security regime, under the remit of the Ministry of Social Security, is a compulsory insurance scheme, which protects individuals against social risks, namely illness and income loss due to maternity, disability, age, death, work accidents, occupational illness or old age dependency. Health insurance and long-term care insurance are managed by the National Health Insurance (CNS). The CNS was created by law in 2008 and is now the single payer fund for health benefits and long-term care insurance. In 2013, it covered 756 185 insured individuals (67% residents of Luxembourg and 33% commuters) providing a standardized benefit basket for their insured individuals (CNS, 2013a).
There is a separation between the primary care sector (dominated by office-based, single-handed physicians and other health professionals) and the hospital sector, which provides emergency care, specialized ambulatory services and secondary care in Luxembourg. Services in the two sectors differ in the way in which the Ministry of Health plans capacity and in how they are paid. Given the absence of a university-affiliated hospital, tertiary care is limited in Luxembourg. In addition to these two sectors, there are institutions that provide long-term care (nursing and residential care facilities), accredited by the Ministry of the Family.
The financing of health insurance – Bismarckian in origin – is based on a system of contributions from the working population, employers and the State; 40% of social contributions of the health insurance are accounted for by the State, the remaining 60% is equally shared between the insured population and employers. Long-term care insurance is financed by the State to 40% of the total expenditure, a contribution rate from insured persons and a small contribution of around 1% from electricity consumers of more than 1 million kW a year. The overall budget of the health insurance system is determined each year by the CNS for the following year, based on multiannual expenditure forecasts. The CNS negotiates annual budgets with individual hospitals for operating costs after the global budget has been agreed by the government. Additionally, the CNS enters into negotiations with different professional groups in the primary care sector. Agreements with professional groups, such as the Association of Medical and Dental Doctors in Luxembourg (Association des médecins et médecins-dentistes – AMMD), regulate details of tariffs and the providers who are accredited to apply them in Luxembourg. ( HSiT )