The Hellenic Competition Commission (HCC) published the Final Report of the sector inquiry on private health services and related insurance services, which is available here (in Greek).

This sector inquiry on the competitive conditions prevailing in the provision of Private Health Services and related Insurance Services and on the relevant regulatory framework, was designed and conducted with the aim of attracting the maximum possible participation of all interested parties/stakeholders (consumers, businesses at all levels of the value chain of products/services and institutional bodies). In this context, the HCC used a variety of methods to collect the necessary data, in particular by organising two public consultations/teleconferences (available at https://youtu.be/Wlu6jipb7lo and at https://youtu.be/eb5KnbgObVI) as well as by sending a series of questionnaires to/receiving memoranda from market participants, trade associations and public authorities.

The Final Report includes the following conclusions and proposals:

Private Health Services

• Over the last five years, there has been an increase in demand for healthcare services and the public health system is under pressure, with public spending and investment in health falling below the European average, a reduction in the number of public hospitals and a large proportion of overall health expenditure (35% in 2019 and 34% in 2023) being covered directly by households (out-of-pocket expenditure), mainly in the form of co-payments for medicines and direct payments for services, with private insurance covering a small part of total health expenditure (4.3%).
• The degree of market concentration is moderate, while the takeovers made by foreign investment funds in recent years have not dramatically changed the degree of concentration over the period running from 2019 to 2022. A vibrant mobility landscape is still apparent in the acquisitions of primary and secondary healthcare providers in relation to insurance companies.
• The existing legislative framework does not impose any constraints on increasing hospital bed capacity, but the conditions for increasing this capacity may make it difficult or impossible in practice. There are regulatory asymmetries due to the parallel application of three different licensing, operating, and capacity-expansion regimes for private clinics, which appear to distort competition as different standards are set for staff, equipment, premises and minimum number of hospital beds, resulting in the maintenance of a three-tier system of clinics.

Private Health Insurance Services

• Steady upward trend in demand for insurance policies in the three-year period 2021-2023 and growth of the health insurance market at an increasing rate (approximately 10%) in the two-year period 2023-2024.
• Significant drop in the number of long-term health insurance contracts during the period 2021-2023 and significant increase in non-guaranteed renewability contracts (i.e., annually renewable contracts), which provide a higher margin for covering other expenses.
• Moderate degree of concentration in the market for the provision of private health insurance services. All insurance companies participating in the survey cooperate with the largest hospital groups in Greece, either directly or through management companies. The four largest insurance companies negotiate the relevant contracts directly with hospital service providers. In addition, twelve of the thirteen insurance companies surveyed collaborate with at least one management company for the health insurance programs they offer, while nine of them collaborate with two management companies.
• Νo legal or practical barriers to entry or expansion in the hospital care insurance sector are identified. The legislative framework is justifiably strict to ensure financial solvency of insurance companies and the protection of insurance credit.
• The role of health insurance management companies is stressed, as they are primarily responsible for gatekeeping and managing insurance policies and compensation claims, acting on behalf of insurance companies.Furthermore, these companies often act as intermediaries in negotiations between insurance companies (especially small and medium-sized ones) and private clinics. These companies are few in number and two of them present the highest concentration in management services and are not supervised by the Bank of Greece or any other regulatory authority.  

Vertical integration

• There is a trend toward vertical integration of insurance companies through their activities in the health sector which, according to economic literature, may mainly lead to phenomena such as the patient steering effect and the enrollee steering effect. However, the private clinics surveyed in the context of the HCC’s relevant sector inquiry expressed the view that synergies between healthcare providers and insurance companies will spur most insurance customers towards large healthcare groups, which, in any case, is under examination by the competition authorities in the context of the ex-ante merger review. The phenomenon of vertical integration is also observed in Greece, initially with the acquisition of Ethniki Asfalistiki by the HHG group of CVC funds and, more recently, with the announcement of the acquisition of Euroclinic by Generali.

Cost and pricing of healthcare and health insurance services

• In recent years, there has been a steady increase in the cost of private healthcare services, while the ever-increasing cost of health insurance programs is a major concern, as health insurance customers are unable to foresee future developments.
• Overall, the increase in healthcare costs is attributed to the increase in the volume of services provided per case, the frequency of claims due to increased morbidity, aging, and the costs of hospital care in private hospitals, as well as an increase in the average cost of insurance payment per hospitalization.
• The issue of discriminatory pricing between customers and the lack of transparency in the pricing of health services was highlighted, which makes it extremely difficult to compare services and verify charges based on the published price lists of private clinics and secondary healthcare providers in the context of their relationships with insurance companies.
• A similar increase is also observed in the cost of private health insurance services, which is partly attributable to the increase in the cost and volume of health services provided. However, the sharp increase in the period 2024-2025 also seems to be due to the introduction of the Single Health Index (SHI).

• Pricing of private clinics’ services vis-à-vis private insurance companies is a result of bargaining between them, while there are also differential pricing and agreement between clinics of the same group and insurance companies. The size of the insurance company and the volume of persons insured are the key factors taken into account for pricing. As for which side has increased bargaining power, health care providers claim that insurance companies enjoy a bargaining advantage (notably by involving two large management companies), while insurance companies attribute bargaining power to health care providers. Overall, the survey reveals price differentiation for the same services, depending on the specific characteristics per customer category or even per individual customers.
• The pricing of health services provided to insurance companies in Greece currently follows the fee-for-service model, where health care providers and doctors are remunerated on the basis of the number and type of services they provide according to a detailed price list. Therefore, as the volume/number of services provided increases, so does the compensation to the provider.
• A discussion on any different way of such service pricing takes place with regard to the DRGs (Diagnosis Related Groups) system that is applied in Greece through SyKNY (Hospital Costing System) fr in public hospitals of the National Health System (known as E.S.Y.) for all hospitalizations and their billing and reimbursement by the National Organisation for the Provision of Health Services (EOPYY), but not applied in private clinics. The DRGs system has been adopted by most EU countries because of the need to systematically monitor hospital activity, control costs, and improve efficiency and quality of services provided, however its practical implementation varies between Member States.
• The extent to which the objectives of this system have been met varies from country to country, but empirical economic data on the evolution of expenditure is rather ambiguous and, although it has been adopted by many countries, its implementation has revealed deficiencies/problems.

Consumer information - Transparency

• The Sector Inquiry further highlighted the specific issue of lack of transparency in health services and health insurance charges. Although asymmetric information between the holder’s knowledge about the good of health compared to the patient's knowledge is an inherent feature of health service markets, the lack of transparency, predictability and comparability in both health services and health insurance service prices intensifies this problem and deprives the consumer/patient of any ability to make his own choice of a private clinic or insurance provider on the basis of cost and, ultimately, to have control over their spending on such an important good. In this context, it is certainly beneficial for the consumer that private clinics are required to make the price list of the services and products they provide publicly available by posting it on their website.

• Further enhancing consumer information and transparency regarding the terms of health insurance policies is expected to contribute to improving consumer's position in his search for an insurance company that will cover his needs and give him a better bargaining position, which will strengthen competition among insurance companies.

Upgrading service quality

• An important factor to be considered is that, with regard to health care, seen as a public good, it is socially desirable and beneficial to ensure competition in terms of quality and safety, and not only in terms of price. Therefore, any structural measures should be structured in such a way as to provide incentives to improve quality and disincentives to any quality deterioration.

Data and new technologies

• The Sector Inquiry has shown that an appropriate regulatory framework oriented towards the protection of, and the access to health data would contribute to enhancing competition and the development of start-ups as well as of the existing medical technology companies, resulting in increased innovation and enriched quality of medical services.
• It is considered that increased access to citizens' health data by health insurance companies may lead to distortion of competition and increased market power of specific health insurance providers.Furthermore, discriminatory treatment against categories of citizens and reduced access to health and insurance services cannot be excluded.
• A relevant European survey shows that the majority of consumers (85%) wish to have the right to choice and option regarding the use of their health data (i.e. to be able to choose which of their personal data may be accessible, as well as to whom and for what purposes). While, in general, consumers are more willing to share health data with entities closer to their healthcare provision, they are wary of granting cross-border access in the EU, even for health care purposes, and there is a general concern about data commercialisation under a healthcare pretext.
• Finally, the Sector Inquiry stresses the need for mechanisms to facilitate innovation, as well as the fact that the Hellenic Competition Commission can contribute in this regard through the application of Article 37A of Law No. 3959/2011.

The publication of the Final Report marks the completion of the HCC’s Sector Inquiry into the provision of private health services and related insurance services. This Sector Inquiry enables the HCC both to inform citizens and businesses and to intervene and take initiatives to promote specific competition policies or regulations in the relevant sectors, with a view to enhancing consumer welfare and competition.

More information is available on the HCC's dedicated webpage at https://www.epant.gr/en/information/sector-inquiries/health.html.

The Hellenic Competition Commission has already stressed the need for the inclusion of competition issues in public policy making and has published a guide on this issue^[1]. The creation, protection and strengthening of competitive markets is part of the wider public interest as competitive markets encourage undertakings to be efficient and innovative, thereby creating more choice for consumers, reducing prices and improving the quality of goods and services and hence a country’s economic performance. Government authorities should therefore also consider the impact of a policy or intervention on competition and opt for the course of action that is likely to lead to an increased, rather than reduced, competition between undertakings to the benefit of consumers. This assessment becomes even more effective when it is carried out from the outset of public policy making, so that it is included in the early stages of policy design in order to prevent distortions of competition which are detrimental for consumer welfare as well as the economy and citizens in general.

^[1]                 Available on the HCC’s website, at https://www.epant.gr/en/information/publications/guides/item/2688-odigos-gia-dimosies-politikes-en.html