Setting prices for hospital care within public health insurance schemes in seven Central and Eastern European countries – a comparative analysis

Setting prices for hospital care within public health insurance schemes in seven Central and Eastern European countries – a comparative analysis | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Setting prices for hospital care within public health insurance schemes in seven Central and Eastern European countries – a comparative analysis Katarzyna Dubas Jakóbczyk, Krisztina Davidovics, Antoniya Dimova, and 12 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6518063/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 26 Jan, 2026 Read the published version in Health Economics Review → Version 1 posted You are reading this latest preprint version Abstract Background: The price setting process constitutes the core element of health care providers’ payment schemes, which are used to steer providers’ behaviour towards realisation of pre-defined health policy objectives. Objectives: This study aimed to: 1) describe and compare systems for setting prices for hospital care services in the public health insurance systems of seven Central and Eastern European (CEE) countries (Bulgaria, Estonia, Czechia, Hungary, Lithuania, Poland, and Slovenia) and 2) identify current challenges. Methods: The methods involved three consecutive steps: 1) defining a conceptual framework and developing a data collection form; 2) consultations with national experts, and 3) a comparative analysis. Results: Results show that the process of setting prices for hospital care varies between CEE countries. The main difference is the existence of a structured hospital costing data collection system (present in five out of the seven analysed countries), while there are numerous additional differences in the details of the remaining system elements (e.g. cost standards, scope of reported hospital cost data, the role of provider negotiations, and the objectives and application of final price adjustments). Conclusions: Despite differences, the analysed countries face similar challenges in building effective price setting systems: 1) incomplete and/or low quality cost data collected from hospitals, 2) insufficient institutional capacities on the part of both hospitals and organisations responsible for tariffication; 3) methodological challenges of the costing model; and 4) barriers driven by the overall health system context. Data infrastructure investment and system governance improvement are needed in all analysed countries. Health Economics & Outcomes Research hospital pricing tariffication hospital’s costs Central and Eastern Europe Figures Figure 1 1. BACKGROUND Pricing (setting tariffs) constitutes a core element of health care providers’ payment process. It defines the exact amount of money that a purchaser pays the health care provider for delivering a given service/unit of activity (1,2). Payment schemes, defined as payment methods as well as other supporting elements (e.g. contracting rules), are used to influence provider behaviour to realise predefined health policy objectives (e.g. improving efficiency and quality of care) (3). There are a diversity of payment methods, and each provides a specific set of incentives (2,4,5). Yet, when the price is not appropriate (too high or too low), it can easily overshadow the intended incentives and prompt undesired provider behaviour (2). International evidence indicates that the regulatory frameworks for price setting can vary significantly between countries, as well as within the same country, for different types of providers, regions, and/or payers (2). Final tariff values depend on a mix of factors (the cost of delivering services, available resources, negotiation with providers, and policy objectives) but they are ultimately a policy decision (6). To date, cross-county comparative evidence detailing the price setting process in health care has focused mostly on countries outside the Central and Eastern European (CEE) area and/or on one element of the process, e.g. costing approaches (2,7–9). At the same time, a recent study has shown that among CEE countries, tariff system modifications are one of the most common changes within health care provider payment schemes (10). Adjusting the rules and/or methods of the tariffication process for the price to better reflect the actual cost of services/units of activities was identified as a common reform objective across all provider types (10). While the previus study mapped the current payment methods and main changes within payment schemes in nine CEE countries, in the present work we aim to provide a deeper analysis of the price setting arrangements for hospital care, including both the costing approach as well as process governance issues. The focus on hospital care is due to common characteristics of many CEE countries, such as overcapacity in hospitals and a high share of current health expenditure allocated to hospitals (11), as well as converging trends in hospital sector reforms (12,13). In all CEE countries (European Union (EU) members), public hospital care prevails in terms of both hospital bed ownership and sources of funding (11). Many CEE countries struggle with the problem of financial debts generated by public hospitals driven, among many other factors, by inadequate (below the actual cost level) pricing of hospital services (14–16). The specific objectives of our work were to: 1) describe and compare the systems for setting prices (tariffs) for hospital care services in the public health insurance systems (paid by public payers) of seven CEE countries (Bulgaria, Estonia, Czechia, Hungary, Lithuania, Poland, and Slovenia); 2) identify current challenges. Our study fills in an important research gap and helps to build a knowledge base around the topic. 2. METHODS The methods applied followed the Health Policy guidelines for cross-country comparative analyses (17) and involved three consecutive steps: 1) defining a conceptual framework and developing a data collection form; 2) consultations with national experts, and 3) a comparative analysis. 2.1. Conceptual framework and data collection form Current international literature indicates that the final price of medical care is influenced by four main factors: 1) the cost of the delivered medical care; 2) available resources; 3) negotiations with providers; and 4) policy objectives (2,6). Each of these factors can be complex with diverse subcomponents (Fig. 1 ). For example, for average (true/real) cost calculations, the quality of the available cost data, the calculation method (micro vs gross costing, top-down vs bottom up approaches (7–9)), and the chosen payment methods (tariff base) are important variables. Source: authors’ own work based on (2,6–9) Following this conceptual framework as well as the available literature describing the core elements/steps of the health care services price settings systems in high income countries (2), a standardised data collection form was developed. The form included five main sections, each with a list of questions to be answered. The sections focused on the following aspects of hospital characteristics: 1) overall sector capacities and current payment schemes, including payment methods for different type of care (inpatient, outpatient, and emergency care); 2) existence of costing standards (e.g. obligatory vs voluntary guidelines); 3) the process of collecting cost data from hospitals (e.g. institutions involved, the scope of gathered cost data, frequency); 4) the process of price (tariff) setting (e.g. the tariff base, the scope of negotiations with providers, price adjustments); 5) the challenges of the price setting process. Table S1 in the Supplementary File presents an overview of the data collection form. An additional comparative analysis of the basic quantitative indicators characterizing the hospital sector in the selected countries was conducted based on Eurostat data (11). 2.2. Consultations with national experts National health system experts from CEE countries (European Union members) were contacted to fill-in the data collection form and provide adequate references whenever available. Purposive sampling and the snow-ball method were used to identify the experts. The national representatives of the Health System and Policy Monitor (HSPM) Network functioning under the auspices of the European Observatory of Health System and Policies, were contacted. HSMP members have in-depth knowledge of the organisation and financing of their national health systems (18). They received both the study’s short proposal description as well as the data collection form. The invitation also included an example of a complete data form (filled-in with Polish data) and a request to indicate another national expert with adequate expertise in the case of non-participation. Originally all 11 CEE countries (EU members) were targeted, yet for some countries no adequate experts who were willing to participate could be identified. Thus, the final analysis covered only seven countries. 2.3. Comparative analysis The collected data were analysed and presented in tabular forms. The analysis focused on the five main areas, as defined by the main sections of the data collection form. The draft comparative results were shared with all national experts with a request for validation and/or clarification. Two rounds of comparative result validation were conducted between November 2024 and March 2025. Any additional ambiguities were clarified iteratively through further correspondence. 3. RESULTS 3.1. Hospital sector’s capacities and payment schemes The group of analysed countries is diverse in terms of both geographical area and total population (e.g. their populations range from 1.4 million in Estonia to 36.6 million in Poland), (11) which corresponds to diversity in terms of hospital sector total capacity. The estimated total number of hospitals (defined as acute care, inpatient stay over 24h units) ranges from approx. only 30 in Estonia to 700 in Poland (Table S2 in the Supplementary File). In 2022, all of the surveyed countries (with the exception of Estonia) had more hospital beds per 100,000 inhabitants than the EU average of 516.3. In all countries, public ownership of hospital beds prevails (11). Public health insurance constitutes a dominant health care funding model in all of the surveyed countries. Table 1 presents a general comparative overview of payment systems for hospital care. In the majority of countries, a single, centralised payer operates. The exemptions are: Czechia (multiple payers, but with limited competition) and Slovakia (three competing insurance companies). With the exemption of Czechia, in all of the countries, the total expenditures for hospitals, measured in purchasing power standard (PPS) per inhabitant, are much below the EU average of 1342.7 (2022). In all of the countries, publicly funded expenditures for hospitals constitute the vast majority of total expenditures for hospitals. All countries use blended payment methods for hospital care. In most countries, diagnosis related groups (DRGs) prevail as a dominant payment method for inpatient care (a stay longer than 24h), used either directly or for volume targets in prospective budgets (in Czechia, Poland, and Slovakia). In all of the countries, diverse variables are used to classify cases, whose total number ranges from 435 clinical pathways and procedures in Bulgaria to as many as 1793 DRGs in Czechia. In most countries, the total number of DRGs ranges between 700 and 800 (Table S3 in the Supplementary File). For outpatient care, most countries use fee-for-service (FFS), usually supplemented by other methods. Emergency care and maintaining a state of preparedness is usually financed via lump sum (diverse versions of fixed payments). Table 1 Overview of the payment systems for hospitals (as of December 2024) Country/ Feature Health insurance payer structure Total expenditures for hospitals in PPS per inhabitant (2022)* Share (%) of public expenditures for hospitals in total expenditures for hospitals (2022)** Payment methods applied for care provided in hospitals (within publicly funded systems) Inpatient care (> 24h) Outpatient Care Emergency Care Bulgaria single payer, centralised (with 28 regional branches) 655.3 92.1% Case payment (clinical pathways and clinical procedures); per diem Case payment (ambulatory procedures) Lump sum (fixed payment), FFS Czechia multiple payers, with limited competition 1353.3 96.9% Global budget (based on DRG volume targets), DRGs, Fixed payment (for palliative care) FFS + Case payments (day surgeries), P4P elements (dialysis providers) Lump sum (fixed payment), FFS Estonia single payer, centralised 846.4 96.4% DRGs, FFS, Per diem, Bundled payments (for knee and hip replacement and stroke patients), Global budget (for rural and small general hospitals) FFS Lump sum (fixed payment), FFS Hungary single payer, centralised 779.5 96.4% DRGs (for active care), Fixed payment (for salaries), per diem FFS + Fixed payment (for salaries) Lump sum (fixed payment), DRGs, FFS Lithuania single payer, centralised 724.9 93.5% DRGs, FFS, Per diem Case payment, FFS (for expensive procedures and examinations) Lump sum (fixed payment) Poland single payer, centralised (with 16 regional branches) 826.8 95.2% Global budget (based on DRGs volume targets) for hospital included in network, DRGs, P4P elements, FFS, per diem Per visit payments (adjusted for number and type of services) + FFS, P4P elements (oncological network) 24 hours lump sum (fixed payment) Slovakia three competing payers (insurance institutions) 664.1 87.7% Prospective budget (based on DRG volume targets) FFS Lump sum, FFS *EU average 1342.7 PPS (purchasing power standard) per inhabitant **Calculated as expenditures for hospitals financed from HF1 (Government schemes and compulsory contributory health care financing schemes) per expenditures for hospitals financed from TOT_HF (All financing schemes); EU average 95.45% 3.2. Application of costing standards The analysed countries have diverse approaches regarding the existence and applicability of costing standards for hospitals. In Czechia, Poland, and Slovakia, obligatory costing standards exists for all hospitals contracted by the public payer (regardless of hospital ownership). In all three countries, these standards were developed by a dedicated government agency responsible for the health service tariffication process. The costing standards usually provide detailed guidelines on how to classify costs in hospitals, define costs centres, and assign direct and indirect costs, as well as how to calculate the final product costs (e.g. per DRG). In Estonia, similar guidelines exist, developed by the payer in collaboration with hospitals to support structured data collection, and are applied on a voluntary basis. In Hungary, guidelines on hospital cost measurement were published in the early 1990s during the introduction of the DRG system. They are still occasionally used by the payer when assessing the inclusion of new services. Additionally, methodological handbooks are available for hospital controlling units, covering both case-level and department-level cost measurement. However, their application is not mandatory, and case-level cost measurement has so far been adopted in only one hospital. In Lithuania and Bulgaria, no dedicated costing standards for health care providers exists and general accounting rules apply. In Lithuania however, public hospitals, as non-for-profit organisations, are obliged to follow dedicated accounting rules for public sector institutions. 3.3. Collecting cost data from hospitals In five out of seven of the analysed countries, a structured process of collecting cost data from hospitals for the tariffication purposes exists. Yet it can differ significantly, e.g. in terms of hospital coverage, obligation to provide data, frequency, and the scope of reported cost data (Table 2 ). Usually, it is a government and/or public administration institution that is responsible for gathering and analysing cost data from hospitals. It is the payer (the national health insurance fund – in Estonia and Lithuania), a government agency supervised by the Ministry of Health (MoH) (in Czechia and Poland), or the MoH itself (in Slovakia). The capacity of these institutions, measured in the total number of employees, varies from just few specialists (full time equivalent – FTE) in Estonia and Lithuania to approx. 60 specialists (FTE) in the dedicated Tariffication Department in the Agency for Health Technology Assessment and Tariff System in Poland. In both Hungary and Bulgaria, the national health insurance fund is responsible for setting the prices, yet cost data are not systematically gathered from hospitals for tariffication purposes. In Bulgaria, the MoH regularly collects general financial data from both state and municipal hospitals, yet these are used mostly to monitor hospitals’ financial situation/debt levels, and not for the purposes of hospital service tariffication. In Hungary, some department-level hospital cost data can be retrieved from the centralised hospital management system operated by the National Directorate General for Hospitals, yet these are not routinely used for the price setting processes. Across the five countries with structured cost reporting systems, the share of hospitals that provide cost data varies between the countries, as well as within a given country, depending on the purpose and/or scope of tariff adjustment (Table 2 ). For example, in Czechia cost data are provided by a dedicated group of reference hospitals with whom the government agency responsible for tariffication process (The Institute of Health Information and Statistics of the Czech Republic) signs agreements. In 2023, this group included 34 acute care hospitals, which constituted approx. 20% of all acute care hospitals. In Estonia, the number of hospitals providing cost data depends on the purpose of tariff adjustments: for revision of specific cost components (e.g. utility costs) across all tariffs - six (out of 20) network hospitals provide cost data; for adjusting the price for a specific type of service/clinical area - a purposive sample of providers is chosen (e.g. providers whose financial volume of the respective services constitutes 70% of the total financial volume of those services contracted for by the Estonian Health Insurance Fund, or from the four healthcare providers with the largest financial volumes of the respective services). In Lithuania the hospital cost reporting is determined by the payment method: in case of medical care financed via DRGs − 60 hospitals report cost data (approx. 68% of all hospitals in Lithuania); for care financed outside DRGs - a purposive sample of providers is selected for cost reporting (up to 10 providers that offer at least 50% of the evaluated services). In Slovakia and Poland, all hospitals providing services within the public health insurance system (regardless of ownership) are obliged to report cost data. For example, in Poland, the provision of cost data was made mandatory in 2021 (when dedicated costing standards for hospitals were implemented); however, no penalties for not fulfilling this obligation were planned. In consequence, the share of Polish hospitals reporting cost data can vary depending on the scope of services being reviewed (Table 2 ). In general, in most countries, reporting cost data is obligatory and there is no dedicated remuneration for provision of data. However, in Czechia, hospitals are partially remunerated for being reference hospitals, while in Poland, providers that report cost data receive additional points to use while submitting offers to provide services under the contract with public payer (in open tender competitions). The scope and level of detail of reported cost data varies across countries (Table 2 ). Usually, the reporting covers both cost and utilisation data related to providing medical services (with research and educational costs excluded). In most countries, medical costs are reported per cost centre (e.g. hospital ward) and specific procedure/hospitalisation case using standard cost categories (e.g. remuneration, pharmaceutical, medical devices, etc). The process of reporting case/hospitalisation specific costs can vary between the countries as well as within a given country depending on the scope of services undergoing evaluation. For example, in Lithuania, hospitals are required to conduct detailed micro-costing estimations (indicating quantitatively all resources used during specific procedures and the respective costs) only in relation to services financed outside DRGs, while in Poland it is a standard requirement for the complete data set. The frequency of data reporting varies across countries as well. As a standard procedure it can take place annually (in Czechia and Slovakia) or every two years (in Estonia). It can also depend on the scope of services undergoing tariff revision. In both Lithuania and Poland, a tariffication plan is published (for four years and annually, respectively), indicating which services will be evaluated (thus it may happen that the same hospital will be obliged to provide data even a few times a year). In all five countries where cost data are reported, they undergo quality checks. These usually involve diverse validation protocols, cross-check templates, and/or iterative verification in cooperation with reporting hospitals. In both Lithuania and Poland, educational sessions/trainings for providers are offered to enhance quality of the reported data (Table 2 ). Table 2 Collecting cost data from hospitals for the tariff (price) setting purposes (as of December 2024) Country / Element of the process Institution involved (What institution collects the cost data?) Hospital coverage (Which hospitals provide the cost data? What share of the total number of hospitals do they constitute?) Obligation/Remuneration (Is it obligatory to provide cost data? Is there remuneration for providing data? Scope (What types of cost data are reported?) Frequency (How often are cost data reported?) Data quality control (How are data verified?) Bulgaria n/a n/a n/a n/a n/a n/a Czechia Government Agency: The Institute of Health Information and Statistics of the Czech Republic (UZIS) (supervised by the MoH) A purposive sample of reference hospitals – in 2023: 34 acute care hospitals (approx. 20% of all acute care hospitals) Voluntary / Partially remunerated (for being reference hospital) All costs related to providing medical services (costs of educational and research activities are excluded). Reporting includes both cost and utilisation data. Hospitals report relevant direct and indirect costs per hospitalisation case according to predefined categories (e.g. wages, pharmaceuticals, medical devices, etc.). Annually Yes (e.g. automatic cross-check within the data file matrix and with external databases, the National Register of Reimbursed Services) Estonia Public payer: Estonian Health Insurance Fund (EHIS) Depends on purpose of tariff adjustment: • 6 (out of 20) network hospitals (2 central, 2 regional and 2 local) to review a specific cost component for all tariffs; • a purposive sample of providers for reviewing tariffs in a given clinical area Voluntary / No remuneration All costs related to providing medical services (costs of educational and research activities are excluded). Reporting includes both cost and utilisation data. Hospitals provide a list of resources and their unit costs for delivering particular services (in a given clinical area). Depends on the purpose of tariff adjustment: • every second year (standard procedure) • on request (e.g. when the process is initiated by the specialty association) Yes (e.g. cross-check within data files and purchaser invoices on service utilisation) Hungary n/a n/a n/a n/a n/a n/a Lithuania Public payer: The National Health Insurance Fund Depends on the payment method used for a given scope of services undergoing tariff adjustment: • 60 hospitals (approx. 68% of all hospitals) for services financed via DRGs; • a purposive sample of providers for services financed outside DRGs Obligatory / No remuneration All costs related to providing medical services (depreciation of medical equipment as well as the costs of educational and research activities are excluded). Reporting includes both cost and utilisation data. For services financed via DRGs: an excel reporting matrix encompasses: cost centres , structures of cost categories (e.g. wages, medicines, etc.), bases for cost allocation, and drivers for the allocation of indirect costs per cost centre. For services financed outside DRGs: hospitals are requested to provide comprehensive micro-costing estimations, including the average duration of personnel labour (per type of personnel) for certain procedures . Depends on the scope of services undergoing tariff adjustment (as indicated in the service calculation plan, current version 2024–2027). Yes (automatic cross-check within Ms Excel matrix; direct communication with providers; trainings for providers) Poland Government agency: The Agency for Health Technology Assessment and Tariff System (supervised by the MoH). All hospitals contracted by the public payer (regardless of ownership) have an obligation to report cost data. However, the final sample depends on the scope of services undergoing tariff revision (a purposive, representative sample of providers with a pre-defined volume of particular services provides data on the services undergoing tariff adjustment). Obligatory / No remuneration (there are, however, additional points to use while competing for public payer contracts) All costs related to providing medical services (costs of educational and research activities are excluded). Reporting includes both cost and utilisation data. Costs are reported for both cost centres as well as specific procedure . Per cost centre (e.g. hospital ward), the data cover cost per type (e.g. personnel and equipment costs) as well as capacity data (number of beds, number and type of personnel). Per specific procedure, the data cover the number of procedures, drugs and medical equipment utilisation, length of stay, and medical workforce utilisation. Hospitals are asked to provide very detailed, micro-costing estimations (e.g. the average time of personnel work, per personnel type for specific procedures). Depends on the purpose of tariff adjustment and/or the scope of services undergoing tariff adjustment (as indicated in the annual tariffication plan). It may happen that a hospital will be obliged to report data even a few times a year (e.g. for both staff cost adjustments in all tariffs and for some specific type of care). Yes (automatic cross-check within the data file matrix; direct communication with providers; trainings for providers) Slovakia Ministry of Health (Department of the Centre for Classification System) All hospitals (regardless of ownership) providing services within the public health insurance system. Obligatory / No remuneration All costs related to providing medical services (costs of educational and research activities are excluded). Reporting includes both cost and utilisation data. Costs are reported per cost centre and for defined categories as well as their allocation to specific procedures/hospital cases . Annually Yes (validation protocol, direct communication with providers) 3.4. The process of price setting The tariff/price bases are directly linked to the payment methods, thus most countries use relative weight and/or points per DRG for hospital inpatient care. These are often supplemented by prices set per service and/or per diem, which are used for other types of care as well (Table 3 ). In most countries, the institutions responsible for the tariffication process publish methodological guidelines (and/or regulations) (Table S4 in the Supplementary File), including statistical methods used and additional variables included in the price calculation formula. The process usually involves calculation of the average actual cost per DRG/service, based on the cost data reported by hospitals, and its reflection in relative weight or points (in Lithuania, weights are imported from the Australian DRG systems and adjusted to the local context). Most often, different versions of the micro-costing approach (top-down, bottom-up or mixed) are used for the average actual cost calculation while experts’ opinions are used to calculate the average cost of newly introduced technologies/services. In Estonia, experts’ opinions are also used to calculate the ‘optimal cost’, indicating the most effective use of resources (e.g. the equipment costs are calculated assuming their most effective usage while the staff costs reflect the formal, collective agreements on wages for medical professionals). In most countries, to calculate a price, the tariff bases (weights, points) are then multiplied by base rates/basic prices defined in the payer’s projected budget. In consequence, although the general objective is for the price to cover the average actual costs, this depends on the payer’s available budget for a given year. In both Bulgaria and Hungary, DRG/pathway weights are not calculated on an annual basis (as there is no cost reporting system). In Hungary historical weights are used, while the base rate has remained the same since 2018 (increased costs for hospitals are offset by a large and growing targeted wage subsidy). However, as of writing this paper, a pilot project has been launched by the payer aimed at implementing a standardised, case level cost collection methodology across ten hospitals. In Bulgaria, the payer adjusts the prices from previous years by variables mostly related to the payer’s projected budget and service volumes. Among the five countries where cost data are systematically gathered for tariffication purposes - the time lag between the data acquisition and the implementation of an adjusted price is usually one year in Czechia, Estonia, and Slovakia, and can vary from a few months to approx. two years in Lithuania and Poland. There can, however, be diverse exemptions. For example, in Estonia, in cases where newly calculated tariffs have a budget impact that exceeds the payer’s (the Estonian Health Insurance Fund) budget limits, the tariff increase can be implemented gradually over a period of a few years. In Poland, the general rule is that the payer (the National Health Fund) implements the new tariff up to four months after its publication by the Agency for Health Technology Assessment and Tariffs System. However, the time spent calculating new tariffs can vary significantly. It is usually much shorter when a single cost component (e.g. remuneration) across all tariffs is being adjusted than when tariffs for a pre-defined range of DRGs are being revised. In most countries, some form of negotiations with providers is conducted regarding health service cost reimbursement (Table 3 ). However, these negotiations can focus on other aspects than direct price negotiations. For example, in both Czechia and Slovakia, collective negotiations (e.g. with associations of providers) help define the priorities of the payer’s budget, e.g. the percentage share of different types of care. Bulgaria is the only country where collective negotiations focus on the final price of a particular item. Individual price negotiations, held prior to signing agreements with individual hospitals, take place in Czechia, Poland, and Slovakia. For example, in Poland, while submitting an offer during an open tender announced by the payer, a hospital can negotiate both the price per 1 unit of tariff base (usually 1 point) as well as the volume limits of services. The payer indicates the proposed price, while the provider submitting an offer can indicate a price lower (e.g. to get more points during the offer assessment) or higher than the one proposed by the payer. However, during the actual negotiation stage the provider can only decrease its price offer (it cannot be increased above the value indicated in the offer). In summary, in four out of seven analysed countries, the prices are set unilaterally (they are the same for all hospitals across the country). Most countries apply different price adjustments, usually taking the form of a percentage increase or decrease of the basic price. Their objectives are usually to compensate for higher costs (e.g. in highly specialised and/or technologically costly services in Czechia, Lithuania, and Slovakia) or to encourage provision of specified services (e.g. psychiatric care in Czechia, specialised cardiovascular and oncology care in Slovakia, care for children in Poland). In Poland, numerous price adjustments have been implemented within the last few years with the objective of shifting emphasis from in- to out-patient care (e.g. for ophthalmology and orthopedic surgeries performed in day care settings). None of the analysed countries apply geographical price adjustments (e.g. for rural vs urban hospitals), while Slovakia seems to be the only country where price levels differ depending on the hospital type (the higher reference level of hospital the higher base rate). In most of the analyzed countries, both the calculation methods and tariffs are published online. Table 3 Price (tariff) setting processes (as of December 2024) Country / Element of the process Tariff base (What tariff bases are used?) Price calculation (How is the reference/average cost calculated and what is its relation to the final tariff? How is the price calculated?) Costing approach (What is the dominant costing-approach for the average cost calculation?) Time lag (What is the time lag between cost data acquisition and price setting?) Negotiations (Are negotiations with providers involved? If yes – individual vs collective) Price adjustments (Are price adjustment used? If yes, what type and what are their objectives?) Information disclosure standards (What type of price setting process data is publicly available?) Bulgaria Clinical pathway/procedure; No systematic cost calculations are conducted. Prices from previous years are usually adjusted based on variables related to the payer’s projected budget and service volumes. Experts’ opinions are used to calculate the price of new services. Top-down gross-costing n/a Collective negotiations (with the Bulgarian Union of Physicians) are held on prices (after which, the payer applies the same negotiated prices across the country) Per type of patient and diagnosis (e.g. a correction factor of 1.14 for children diagnosed with a specific disease), aimed at compensating for higher costs. Performance specific (e.g. lower prices when specific types of volume threshold are met) aimed at increased efficiency. Tariffs and general reimbursement rules are published online. Czechia Relative weights per DRG Average actual cost per DRG is calculated (outliers are removed). The unified base rate is calculated based on the total expected budget for acute inpatient care. Thus, the actual reimbursement (final price) might be lower than the valorised average total costs in the reference hospitals. Mixed top-down and bottom-up micro-costing 1 Year Both individual (prior to signing individual contracts) and collective negotiations (annual, while planning the payer’s budget for the upcoming year) Per type of service (e.g. a correction factor of 1.05 for highly specialised services) aimed at compensating for higher costs. Per type of medical care (e.g. a correction factor f 1.03 for providing acute psychiatric care or mental care), aimed at encouraging provision of specific types of care. Tariffs and calculation methods are published online Estonia DRG, Service, Per diem Average actual cost (based on cost data reported by hospitals) is compared with optimal cost (based on experts’ opinions of the resources needed to provide a given service as well as optimal resource use – e.g. effective equipment use). Costs are calculated per service and per diem, which are then use to adjust DRG prices. Top-down micro-costing (Activity based costing) 1 Year Unilateral price setting by the payer (there are, however, individual negotiations on the volume limits) No price adjustments per type of service or patient (there are, however, correction factors if hospitals exceed the agreed contract: 0.7 for outpatient and day care services and 0.3 for inpatient services, aimed at limiting overprovision) Tariffs and calculation methods are published online Hungary Weights per DRG, per diem No systematic cost calculations are conducted. Average actual cost is valorised per DRG, calculated based on historical data (1999). The unified base rate is calculated based on the expected budget for acute inpatient care. Thus, the actual reimbursement (final price) might be lower than the valorised average total costs in the reference hospitals. (No update since 2018.) The payer conducts cost estimations for newly introduced procedures (experts’ opinions are used). Mixed: bottom-up and top-down micro-costing n/a Unilateral price setting by the payer (no negotiations) Per type of services (e.g. a correction factor of 1.1. for one-day surgeries, and large prosthetic procedures), aimed at reducing waiting times Tariffs and calculation methods are published online Lithuania Weights (per DRG), Service DRG weights are imported from the Australian system and adjusted to the local context. A verage actual cost per DRG is calculated (outliers are removed) to assess the tariff base while the ‘ base rate’ is determined by dividing the pubic payer’s budget by a weighted number of active treatments. For services financed outside DRGs the price reflects the average actual costs. Mixed top-down and bottom up gross-costing (for DRGs) and bottom-up micro-costing for services financed outside DRGs Varied (depending on the scope of services undergoing evaluation), from two months to as much as two years Unilateral price setting by the payer (no negotiations) Per type of service (e.g. for services requiring costly technological components), aimed at compensating for higher costs. Tariffs and calculation methods are published online Poland Points (per DRG); Service, Patient day As a standard procedure, average actual cost per DRG is calculated (outliers are removed) to assess the tariff base. It is then multiplied by a ‘ base rate’ defined by the payer’s budget. In some cases a multiplier of cost changes over time is applied with the objective of updating the tariff to reflect the actual cost at the moment of tariff application, and to provide a ‘development bonus’ (covering prospective cost increases). It consists of three components: staff costs, capital costs, and overall prices increase/inflation. Depending on the scope of services undergoing tariffication, the final report can also include international and commercial price comparison. Mixed top-down and bottom-up micro-costing Varied (depending on the scope of services undergoing evaluation), from several months to more than 2 years Individual negotiations (both the price per 1 unit of tariff base as well as the volume limits of services can be negotiated) Per type of service (e.g. a correction factors of 1.1–1.2 for defined ophthalmology and orthopedics surgeries performed in day care settings; a correction factor of 1.6. for providing emergency outpatient services), aimed at increasing provision of day/outpatient care and thus improving efficiency as well as limiting waiting times. Per type of patients (e.g. a correction factor of 1.2. for care for children) aimed at increasing provision of services for vulnerable patients and limiting waiting times. Tariffs and calculation methods are published online Slovakia Relative weight per DRG Relative weight per DRG (based on cost data from hospitals) are calculated, but the final tariff is determined by a ‘ base rate’ which reflects the capacity of the state budget for in-patient care (there are six categories of base rates - reflecting six hospital reference levels) Top-down micro-costing 1 Year Both individual and collective negotiations (the latter related to contracting rules and the payer’s budget) Per type of service (the higher reference level of hospital, the higher base rate), aimed at compensating for the higher cost of highly specialised hospitals. Per type of care (e.g. for specialised cardiovascular and oncology care), aimed at increasing provision of specialised care. Tariffs and calculation methods are published online. 3.5. Challenges of the process Numerous challenges of the price setting process can be identified across the group of analysed countries (Table 4 ). They can be classified into four main areas: 1) completeness and quality of the cost data gathered from hospitals (relatively low hospital participation, low quality and insufficient representativeness of the reported data); 2) institutional capacities of the involved organisations (insufficient human and technical resources in both the organisation responsible for gathering cost data and analysing and setting the tariffs, as well as hospitals during the cost reporting process); 3) methodological approach (challenges related to: including special hospital characteristics, highly complex costing models, accuracy in cost valuation, and the impact of inflation); and 4) the context of the overall health system (the impact of insufficient funding and challenges related to process governance). Table 4 Challenges of the price setting process Area Examples Completeness and quality of the cost data gathered from hospitals • Hospital participation : a relatively low number of providers reporting data when participation is voluntary (Estonia) or when there are no regulatory tools to enforce the obligation to provide data (Poland), both of which can affect the final data sample representativeness; a lack of systematic hospital cost reporting processes for the purposes of tariffication (Bulgaria, Hungary) • Quality of the reported data : low quality reported data, e.g. when data are not complete (Slovakia, Poland) or not reported according to the pre-defined standards (Poland) Institutional capacities of the involved organisations • Institutional capacities of the leading organisations : a limited number of employees (with adequate expertise) in the organisations responsible for the tariffication process (Estonia, Hungary, Lithuania) • Institutional capacities of the hospitals : technical limitation of the hospitals’ IT systems that do not allow for effective data processing (Slovakia) or interoperability (Poland); lack of adequate skills among administrative staff or lack of cooperation between medical and administrative staff needed for conducting micro-costing estimations (Poland) Methodological approach • Including hospital characteristics : lack of mechanism for including differences in hospital costs depending on location, specialisation, or additional task carried out by hospitals, e.g. local hospitals vs university clinics (Bulgaria, Czechia, Poland) • Complexity of the costing model : highly complex methodological approach limits providers’ understanding (Poland) • Accuracy of depreciation costs : concerns about appropriateness of including depreciation costs for long-term assets acquired from different investment sources (Lithuania) • Adjusting for inflation : the lack of regular adjustment for inflation, especially in cases when the time lag between the cost data acquisition and setting prices is long, leads to situations where a new tariff is already outdated at the moment of implementation (Estonia, Bulgaria, Hungary, Lithuania,) Health system context • Payer’s budget : insufficient available funding reflected in the base rate can impact the final price to be below the average actual costs (Bulgaria, Hungary, Lithuania, Slovakia) • Process governance : insufficient communication between the involved stakeholders (Slovakia) or lack of transparency (Bulgaria) undermine provider’s trust; lack of strong political leadership hinders implementation of dedicated system at the health system level (Hungary) 4. DISCUSSION Our study shows that the process of setting prices for hospital providers varies between CEE countries. In five countries (Czechia, Estonia, Lithuania, Poland and Slovakia), it involves three general steps: 1) cost data are reported by hospitals (usually a defined sample of providers) based on a pre-defined costing template; 2) a dedicated government institution gathers and analyses the data and calculates the bases of the tariffs based on pre-defined methodological guidelines, which usually involves calculation of average actual costs per specific item of care; 3) to calculate prices, the tariff bases are multiplied by a base rate (amount of money per tariff base unit), defined by the payer’s budget capacities. In most of the analysed countries, the payer also adjusts the final price of specific services (or care provided for a specific group of patients) by implementing diverse correction factors (usually a percentage increase of the price) in order to meet pre-defined health policy objectives. However, the details of each step can vary between the countries (e.g. in relation to the scope of hospitals reporting cost data, the role of negotiations with providers, the application and objectives of final price adjustments). In the cases of the two remaining countries (Bulgaria and Hungary) there is no structured hospital cost data collection system for tariffication purposes (historical tariff bases are adjusted). The results indicate that although in most countries the overall price setting processes reflects those in Western Europe (2,7,8), the CEE countries can be at different levels of policy development and system maturity. In two (Bulgaria, Lithuania) out of the seven analysed countries, there are no dedicated costing standards for hospitals. Such standards can help providers to adjust their accounting systems to better meet the relevant cost data reporting rules and thus allow for more reliable and comparable data acquisition (8,9,19,20). In addition, detailed costing standards can help hospital managers to calculate the actual cost of a given service/unit of activity on a regular basis (9). For example, in Poland, hospitals can share such individual cost calculations with the agency responsible for the tariffication process (these calculations are later included in a final tariffication report). This helps to build a more evidence-based approach and strengthens the transparency of the whole process. While, in some countries, adjusting prices for inflation is a standard procedure (in Czechia and Slovakia) in others it happens more sporadically (in Estonia, Lithuania, Poland), or inflation is not taken into consideration at all (in Bulgaria and Hungary), which can pose a significant long-term financial risk for hospitals (21). Our study also points towards the existence of similar trade-offs between the accuracy of the price setting process and system feasibility as those identified in Western European countries (8). More complex systems can support better data accuracy. For example, a higher number of specific DRG groups and a bottom-up micro costing approach gives greater chances of accurately reflecting actual recourses use (6,22). However, at the same time, there are also increased transactional costs. Our study has shown that one of the challenges of the pricing system is providers lacking understanding of the costing model among and therefore having difficulties conducting micro-costing estimations. There is a similar trade-off regarding hospital coverage. On the one hand, a high share of hospitals reporting cost data makes it possible to see the complete picture, with full data representation (8). On the other hand, this increases the administrative burden for both hospitals and the institution responsible for processing the data. International evidence indicates that in many high income countries the technical task of cost calculation (carried out by independent agencies) is separated from the more political task of carrying out negotiations with providers (carried out by the payers) (2). This is the case in two of the analysed CEE countries (Czechia and Poland). In the remaining three countries (with cost reporting systems) the cost calculations are carried out by dedicated teams in the Ministry of Health (Slovenia) or directly within the payer structures (Estonia, Lithuania). The latter, may elicit, on the one hand, controversies about the political independence of the process, but on the other, it may limit the administrative burden and enhance effective governance (e.g. when decisions related to prices, volume, and budget are all made within a single institution). Regardless of the institutional landscape, good governance rules and data transparency remain crucial. In three out of the seven analysed countries, unilateral price setting takes place (there are no negotiations with providers regarding prices) which is perceived as a good approach to limit price discrimination and contain cost growth (2). At the same time, most of the countries follow international trends (2,6,23) and apply varied price adjustments (e.g. percentage increases in prices) aimed at meeting pre-defined policy objectives (e.g. incentivizing provision of specific services, reducing waiting times, etc.). To the authors best knowledge this is the first study providing a structured overview of the price setting process for hospital care in CEE countries. There are, however, two main limitations to be noted. The first consists in the risk of bias and the potential influence of arbitrary factors during the data collection process. We have tried to limit this by encouraging respondents to provide references whenever available, as well as seeking out professionals with expertise in the analysed topic (in most of the countries, the originally contacted HSMP Network member has collaborated with another specialist, often a practitioner in the related field). The second limitation derives from the study scope, which, by focusing on hospital care within public health insurance systems, does not provide a full picture of the pricing system. We have not analysed processes within private/voluntary health insurance schemes and out-of-pocket payments. However, as shown in Table 1 , in the group of analysed countries, these other sources of funding have a marginal role in the context of hospital care. Despite these limitations, our study provides important implications for both future research and health policy. In terms of the former, a qualitative analysis of different stakeholders’ perspectives could provide deeper insight into the challenges of implementing an effective price setting process and thus providing more specific and better tailored policy recommendations. Also, quantitative costing studies, e.g. aimed at comparing costs between different providers, could help in providing evidence for enhancing tariffication methodology. Our results indicate that regardless of country specific differences in the pricing process, the data infrastructure and governance systems are of crucial importance. Hospital managers need clear guidelines on costing methodology, including continuous training/education options. This must be supported by adequate IT infrastructure. There is growing literature on the use of digital solutions, including artificial intelligence and big data analytics within health financing systems (24–26). Such solutions have proved effective, e.g. in automated data extraction from medical documentation (27,28), and thus can also be used for utilisation and cost data tracking. These solutions could enhance process efficiency by limiting the potential trade-off between the timeliness, completeness, and accuracy of the cost data reporting and feasibility constraints. However, their implementation must be complemented by an adequate regulatory framework, including cybersecurity protocols and strong leadership of both regulatory bodies and individual hospitals. At the same time, improving different stakeholders’ cooperation and data transparency could help in building more participatory consensus in health policy design. Due to the similar health system contexts of CEE countries, there is a huge potential to share cross-country knowledge. 5. CONCLUSIONS The systems of pricing hospital services within public health insurance schemes in the seven analysed CEE countries (Bulgaria, Estonia, Czechia, Hungary, Lithuania, Poland, and Slovenia) are at different stages of development. While in some countries, hospitals must follow detailed costing standards and report comprehensive data, including micro-costing estimations, in others there are neither dedicated costing standards for hospitals, nor any structured cost reporting systems. 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Centre for Classification System of DRG, Ministry of Health, Bratislava, Slovakia","correspondingAuthor":false,"prefix":"","firstName":"Angelika","middleName":"","lastName":"Szalayova","suffix":""},{"id":447317126,"identity":"e13c01fd-d6dc-47f1-a7e1-2d138f83bab3","order_by":12,"name":"Artur Szetela","email":"","orcid":"","institution":"Institute of Public Health, Faculty of Health Sciences, Jagiellonian University Medical College, Krakow, Poland","correspondingAuthor":false,"prefix":"","firstName":"Artur","middleName":"","lastName":"Szetela","suffix":""},{"id":447317127,"identity":"0c69a7f9-f5c2-4249-bd68-3c4b97cab58f","order_by":13,"name":"Lenka Šlegerová","email":"","orcid":"https://orcid.org/0000-0003-0486-7384","institution":"Institute of Economic Studies, Faculty of Social Sciences, Charles University, Prague, Czechia","correspondingAuthor":false,"prefix":"","firstName":"Lenka","middleName":"","lastName":"Šlegerová","suffix":""},{"id":447317128,"identity":"30174d8e-9a87-4c1c-b492-8dc06f9ddf86","order_by":14,"name":"Roman Topór-Mądry","email":"","orcid":"https://orcid.org/0000-0002-3091-6760","institution":"Interdisciplinary Health Data Centre, Jagiellonian University Medical College, Krakow, Poland","correspondingAuthor":false,"prefix":"","firstName":"Roman","middleName":"","lastName":"Topór-Mądry","suffix":""}],"badges":[],"createdAt":"2025-04-24 07:14:06","currentVersionCode":1,"declarations":{"humanSubjects":false,"vertebrateSubjects":false,"conflictsOfInterestStatement":false,"humanSubjectEthicalGuidelines":false,"humanSubjectConsent":false,"humanSubjectClinicalTrial":false,"humanSubjectCaseReport":false,"vertebrateSubjectEthicalGuidelines":false},"doi":"10.21203/rs.3.rs-6518063/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6518063/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s13561-026-00730-2","type":"published","date":"2026-01-27T00:00:00+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":81349640,"identity":"1b3f8791-c2dd-4971-9826-a572e9ff243c","added_by":"auto","created_at":"2025-04-25 06:04:04","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":33927,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eConceptual framework of the medical care price setting process\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-6518063/v1/944f45fe51caac5742b3dfce.png"},{"id":101424716,"identity":"778559c5-26bc-4301-bf3a-a0cad3a853e2","added_by":"auto","created_at":"2026-01-29 14:18:43","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2828845,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6518063/v1/98394d60-1882-4e6d-a04d-b9a53330cad7.pdf"}],"financialInterests":"The authors declare no competing interests.","formattedTitle":"\u003cp\u003e\u003cstrong\u003eSetting prices for hospital care within public health insurance schemes in seven Central and Eastern European countries – a comparative analysis\u003c/strong\u003e\u003c/p\u003e","fulltext":[{"header":"1. BACKGROUND","content":"\u003cp\u003ePricing (setting tariffs) constitutes a core element of health care providers\u0026rsquo; payment process. It defines the exact amount of money that a purchaser pays the health care provider for delivering a given service/unit of activity (1,2). Payment schemes, defined as payment methods as well as other supporting elements (e.g. contracting rules), are used to influence provider behaviour to realise predefined health policy objectives (e.g. improving efficiency and quality of care) (3). There are a diversity of payment methods, and each provides a specific set of incentives (2,4,5). Yet, when the price is not appropriate (too high or too low), it can easily overshadow the intended incentives and prompt undesired provider behaviour (2). International evidence indicates that the regulatory frameworks for price setting can vary significantly between countries, as well as within the same country, for different types of providers, regions, and/or payers (2). Final tariff values depend on a mix of factors (the cost of delivering services, available resources, negotiation with providers, and policy objectives) but they are ultimately a policy decision (6).\u003c/p\u003e \u003cp\u003eTo date, cross-county comparative evidence detailing the price setting process in health care has focused mostly on countries outside the Central and Eastern European (CEE) area and/or on one element of the process, e.g. costing approaches (2,7\u0026ndash;9). At the same time, a recent study has shown that among CEE countries, tariff system modifications are one of the most common changes within health care provider payment schemes (10). Adjusting the rules and/or methods of the tariffication process for the price to better reflect the actual cost of services/units of activities was identified as a common reform objective across all provider types (10). While the previus study mapped the current payment methods and main changes within payment schemes in nine CEE countries, in the present work we aim to provide a deeper analysis of the price setting arrangements for hospital care, including both the costing approach as well as process governance issues. The focus on hospital care is due to common characteristics of many CEE countries, such as overcapacity in hospitals and a high share of current health expenditure allocated to hospitals (11), as well as converging trends in hospital sector reforms (12,13). In all CEE countries (European Union (EU) members), public hospital care prevails in terms of both hospital bed ownership and sources of funding (11). Many CEE countries struggle with the problem of financial debts generated by public hospitals driven, among many other factors, by inadequate (below the actual cost level) pricing of hospital services (14\u0026ndash;16).\u003c/p\u003e \u003cp\u003eThe specific objectives of our work were to: 1) describe and compare the systems for setting prices (tariffs) for hospital care services in the public health insurance systems (paid by public payers) of seven CEE countries (Bulgaria, Estonia, Czechia, Hungary, Lithuania, Poland, and Slovenia); 2) identify current challenges. Our study fills in an important research gap and helps to build a knowledge base around the topic.\u003c/p\u003e"},{"header":"2. METHODS","content":"\u003cp\u003eThe methods applied followed the Health Policy guidelines for cross-country comparative analyses (17) and involved three consecutive steps: 1) defining a conceptual framework and developing a data collection form; 2) consultations with national experts, and 3) a comparative analysis.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e2.1. Conceptual framework and data collection form\u003c/h2\u003e \u003cp\u003eCurrent international literature indicates that the final price of medical care is influenced by four main factors: 1) the cost of the delivered medical care; 2) available resources; 3) negotiations with providers; and 4) policy objectives (2,6). Each of these factors can be complex with diverse subcomponents (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). For example, for average (true/real) cost calculations, the quality of the available cost data, the calculation method (micro vs gross costing, top-down vs bottom up approaches (7\u0026ndash;9)), and the chosen payment methods (tariff base) are important variables.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eSource: authors\u0026rsquo; own work based on (2,6\u0026ndash;9)\u003c/p\u003e \u003cp\u003eFollowing this conceptual framework as well as the available literature describing the core elements/steps of the health care services price settings systems in high income countries (2), a standardised data collection form was developed. The form included five main sections, each with a list of questions to be answered. The sections focused on the following aspects of hospital characteristics: 1) overall sector capacities and current payment schemes, including payment methods for different type of care (inpatient, outpatient, and emergency care); 2) existence of costing standards (e.g. obligatory vs voluntary guidelines); 3) the process of collecting cost data from hospitals (e.g. institutions involved, the scope of gathered cost data, frequency); 4) the process of price (tariff) setting (e.g. the tariff base, the scope of negotiations with providers, price adjustments); 5) the challenges of the price setting process. Table S1 in the Supplementary File presents an overview of the data collection form. An additional comparative analysis of the basic quantitative indicators characterizing the hospital sector in the selected countries was conducted based on Eurostat data (11).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e2.2. Consultations with national experts\u003c/h2\u003e \u003cp\u003eNational health system experts from CEE countries (European Union members) were contacted to fill-in the data collection form and provide adequate references whenever available. Purposive sampling and the snow-ball method were used to identify the experts. The national representatives of the Health System and Policy Monitor (HSPM) Network functioning under the auspices of the European Observatory of Health System and Policies, were contacted. HSMP members have in-depth knowledge of the organisation and financing of their national health systems (18). They received both the study\u0026rsquo;s short proposal description as well as the data collection form. The invitation also included an example of a complete data form (filled-in with Polish data) and a request to indicate another national expert with adequate expertise in the case of non-participation. Originally all 11 CEE countries (EU members) were targeted, yet for some countries no adequate experts who were willing to participate could be identified. Thus, the final analysis covered only seven countries.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003e2.3. Comparative analysis\u003c/h2\u003e \u003cp\u003eThe collected data were analysed and presented in tabular forms. The analysis focused on the five main areas, as defined by the main sections of the data collection form. The draft comparative results were shared with all national experts with a request for validation and/or clarification. Two rounds of comparative result validation were conducted between November 2024 and March 2025. Any additional ambiguities were clarified iteratively through further correspondence.\u003c/p\u003e \u003c/div\u003e"},{"header":"3. RESULTS","content":"\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003e3.1. Hospital sector\u0026rsquo;s capacities and payment schemes\u003c/h2\u003e \u003cp\u003eThe group of analysed countries is diverse in terms of both geographical area and total population (e.g. their populations range from 1.4\u0026nbsp;million in Estonia to 36.6\u0026nbsp;million in Poland), (11) which corresponds to diversity in terms of hospital sector total capacity. The estimated total number of hospitals (defined as acute care, inpatient stay over 24h units) ranges from approx. only 30 in Estonia to 700 in Poland (Table S2 in the Supplementary File). In 2022, all of the surveyed countries (with the exception of Estonia) had more hospital beds per 100,000 inhabitants than the EU average of 516.3. In all countries, public ownership of hospital beds prevails (11).\u003c/p\u003e \u003cp\u003ePublic health insurance constitutes a dominant health care funding model in all of the surveyed countries. Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e presents a general comparative overview of payment systems for hospital care. In the majority of countries, a single, centralised payer operates. The exemptions are: Czechia (multiple payers, but with limited competition) and Slovakia (three competing insurance companies). With the exemption of Czechia, in all of the countries, the total expenditures for hospitals, measured in purchasing power standard (PPS) per inhabitant, are much below the EU average of 1342.7 (2022). In all of the countries, publicly funded expenditures for hospitals constitute the vast majority of total expenditures for hospitals. All countries use blended payment methods for hospital care. In most countries, diagnosis related groups (DRGs) prevail as a dominant payment method for inpatient care (a stay longer than 24h), used either directly or for volume targets in prospective budgets (in Czechia, Poland, and Slovakia). In all of the countries, diverse variables are used to classify cases, whose total number ranges from 435 clinical pathways and procedures in Bulgaria to as many as 1793 DRGs in Czechia. In most countries, the total number of DRGs ranges between 700 and 800 (Table S3 in the Supplementary File). For outpatient care, most countries use fee-for-service (FFS), usually supplemented by other methods. Emergency care and maintaining a state of preparedness is usually financed via lump sum (diverse versions of fixed payments).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eOverview of the payment systems for hospitals (as of December 2024)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eCountry/ Feature\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eHealth insurance payer structure\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eTotal expenditures for hospitals in PPS per inhabitant (2022)*\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eShare (%) of public expenditures for hospitals in total expenditures for hospitals (2022)**\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c7\" namest=\"c5\"\u003e \u003cp\u003ePayment methods applied for care provided in hospitals (within publicly funded systems)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eInpatient care (\u0026gt;\u0026thinsp;24h)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eOutpatient Care\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eEmergency Care\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBulgaria\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003esingle payer, centralised (with 28 regional branches)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e655.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e92.1%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eCase payment (clinical pathways and clinical procedures); per diem\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eCase payment (ambulatory procedures)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eLump sum (fixed payment), FFS\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCzechia\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003emultiple payers, with limited competition\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1353.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e96.9%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eGlobal budget (based on DRG volume targets), DRGs, Fixed payment (for palliative care)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eFFS\u0026thinsp;+\u0026thinsp;Case payments (day surgeries), P4P elements (dialysis providers)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eLump sum (fixed payment), FFS\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEstonia\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003esingle payer, centralised\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e846.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e96.4%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eDRGs, FFS, Per diem, Bundled payments (for knee and hip replacement and stroke patients), Global budget (for rural and small general hospitals)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eFFS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eLump sum (fixed payment), FFS\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHungary\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003esingle payer, centralised\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e779.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e96.4%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eDRGs (for active care), Fixed payment (for salaries), per diem\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eFFS\u0026thinsp;+\u0026thinsp;Fixed payment (for salaries)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eLump sum (fixed payment), DRGs, FFS\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eLithuania\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003esingle payer, centralised\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e724.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e93.5%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eDRGs, FFS, Per diem\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eCase payment, FFS (for expensive procedures and examinations)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eLump sum (fixed payment)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePoland\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003esingle payer, centralised (with 16 regional branches)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e826.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e95.2%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eGlobal budget (based on DRGs volume targets) for hospital included in network, DRGs, P4P elements, FFS, per diem\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003ePer visit payments (adjusted for number and type of services)\u0026thinsp;+\u0026thinsp;FFS, P4P elements (oncological network)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e24 hours lump sum (fixed payment)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSlovakia\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ethree competing payers (insurance institutions)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e664.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e87.7%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eProspective budget (based on DRG volume targets)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eFFS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eLump sum, FFS\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"7\"\u003e*EU average 1342.7 PPS (purchasing power standard) per inhabitant **Calculated as expenditures for hospitals financed from HF1 (Government schemes and compulsory contributory health care financing schemes) per expenditures for hospitals financed from TOT_HF (All financing schemes); EU average 95.45%\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003e3.2. Application of costing standards\u003c/h2\u003e \u003cp\u003eThe analysed countries have diverse approaches regarding the existence and applicability of costing standards for hospitals. In Czechia, Poland, and Slovakia, obligatory costing standards exists for all hospitals contracted by the public payer (regardless of hospital ownership). In all three countries, these standards were developed by a dedicated government agency responsible for the health service tariffication process. The costing standards usually provide detailed guidelines on how to classify costs in hospitals, define costs centres, and assign direct and indirect costs, as well as how to calculate the final product costs (e.g. per DRG). In Estonia, similar guidelines exist, developed by the payer in collaboration with hospitals to support structured data collection, and are applied on a voluntary basis. In Hungary, guidelines on hospital cost measurement were published in the early 1990s during the introduction of the DRG system. They are still occasionally used by the payer when assessing the inclusion of new services. Additionally, methodological handbooks are available for hospital controlling units, covering both case-level and department-level cost measurement. However, their application is not mandatory, and case-level cost measurement has so far been adopted in only one hospital. In Lithuania and Bulgaria, no dedicated costing standards for health care providers exists and general accounting rules apply. In Lithuania however, public hospitals, as non-for-profit organisations, are obliged to follow dedicated accounting rules for public sector institutions.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003e3.3. Collecting cost data from hospitals\u003c/h2\u003e \u003cp\u003eIn five out of seven of the analysed countries, a structured process of collecting cost data from hospitals for the tariffication purposes exists. Yet it can differ significantly, e.g. in terms of hospital coverage, obligation to provide data, frequency, and the scope of reported cost data (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eUsually, it is a government and/or public administration institution that is responsible for gathering and analysing cost data from hospitals. It is the payer (the national health insurance fund \u0026ndash; in Estonia and Lithuania), a government agency supervised by the Ministry of Health (MoH) (in Czechia and Poland), or the MoH itself (in Slovakia). The capacity of these institutions, measured in the total number of employees, varies from just few specialists (full time equivalent \u0026ndash; FTE) in Estonia and Lithuania to approx. 60 specialists (FTE) in the dedicated Tariffication Department in the Agency for Health Technology Assessment and Tariff System in Poland. In both Hungary and Bulgaria, the national health insurance fund is responsible for setting the prices, yet cost data are not systematically gathered from hospitals for tariffication purposes. In Bulgaria, the MoH regularly collects general financial data from both state and municipal hospitals, yet these are used mostly to monitor hospitals\u0026rsquo; financial situation/debt levels, and not for the purposes of hospital service tariffication. In Hungary, some department-level hospital cost data can be retrieved from the centralised hospital management system operated by the National Directorate General for Hospitals, yet these are not routinely used for the price setting processes.\u003c/p\u003e \u003cp\u003eAcross the five countries with structured cost reporting systems, the share of hospitals that provide cost data varies between the countries, as well as within a given country, depending on the purpose and/or scope of tariff adjustment (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). For example, in Czechia cost data are provided by a dedicated group of reference hospitals with whom the government agency responsible for tariffication process (The Institute of Health Information and Statistics of the Czech Republic) signs agreements. In 2023, this group included 34 acute care hospitals, which constituted approx. 20% of all acute care hospitals. In Estonia, the number of hospitals providing cost data depends on the purpose of tariff adjustments: for revision of specific cost components (e.g. utility costs) across all tariffs - six (out of 20) network hospitals provide cost data; for adjusting the price for a specific type of service/clinical area - a purposive sample of providers is chosen (e.g. providers whose financial volume of the respective services constitutes 70% of the total financial volume of those services contracted for by the Estonian Health Insurance Fund, or from the four healthcare providers with the largest financial volumes of the respective services). In Lithuania the hospital cost reporting is determined by the payment method: in case of medical care financed via DRGs \u0026minus;\u0026thinsp;60 hospitals report cost data (approx. 68% of all hospitals in Lithuania); for care financed outside DRGs - a purposive sample of providers is selected for cost reporting (up to 10 providers that offer at least 50% of the evaluated services). In Slovakia and Poland, all hospitals providing services within the public health insurance system (regardless of ownership) are obliged to report cost data. For example, in Poland, the provision of cost data was made mandatory in 2021 (when dedicated costing standards for hospitals were implemented); however, no penalties for not fulfilling this obligation were planned. In consequence, the share of Polish hospitals reporting cost data can vary depending on the scope of services being reviewed (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). In general, in most countries, reporting cost data is obligatory and there is no dedicated remuneration for provision of data. However, in Czechia, hospitals are partially remunerated for being reference hospitals, while in Poland, providers that report cost data receive additional points to use while submitting offers to provide services under the contract with public payer (in open tender competitions).\u003c/p\u003e \u003cp\u003eThe scope and level of detail of reported cost data varies across countries (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Usually, the reporting covers both cost and utilisation data related to providing medical services (with research and educational costs excluded). In most countries, medical costs are reported per cost centre (e.g. hospital ward) and specific procedure/hospitalisation case using standard cost categories (e.g. remuneration, pharmaceutical, medical devices, etc). The process of reporting case/hospitalisation specific costs can vary between the countries as well as within a given country depending on the scope of services undergoing evaluation. For example, in Lithuania, hospitals are required to conduct detailed micro-costing estimations (indicating quantitatively all resources used during specific procedures and the respective costs) only in relation to services financed outside DRGs, while in Poland it is a standard requirement for the complete data set.\u003c/p\u003e \u003cp\u003eThe frequency of data reporting varies across countries as well. As a standard procedure it can take place annually (in Czechia and Slovakia) or every two years (in Estonia). It can also depend on the scope of services undergoing tariff revision. In both Lithuania and Poland, a tariffication plan is published (for four years and annually, respectively), indicating which services will be evaluated (thus it may happen that the same hospital will be obliged to provide data even a few times a year). In all five countries where cost data are reported, they undergo quality checks. These usually involve diverse validation protocols, cross-check templates, and/or iterative verification in cooperation with reporting hospitals. In both Lithuania and Poland, educational sessions/trainings for providers are offered to enhance quality of the reported data (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCollecting cost data from hospitals for the tariff (price) setting purposes (as of December 2024)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCountry / Element of the process\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInstitution involved (What institution collects the cost data?)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHospital coverage (Which hospitals provide the cost data? What share of the total number of hospitals do they constitute?)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eObligation/Remuneration (Is it obligatory to provide cost data? Is there remuneration for providing data?\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eScope (What types of cost data are reported?)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eFrequency (How often are cost data reported?)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eData quality control (How are data verified?)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBulgaria\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003en/a\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003en/a\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003en/a\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003en/a\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003en/a\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003en/a\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCzechia\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGovernment Agency: The Institute of Health Information and Statistics of the Czech Republic (UZIS) (supervised by the MoH)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003eA purposive sample of reference hospitals \u0026ndash;\u003c/b\u003e in 2023: 34 acute care hospitals (approx. 20% of all acute care hospitals)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eVoluntary / Partially remunerated (for being reference hospital)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eAll costs related to providing medical services (costs of educational and research activities are excluded). Reporting includes both cost and utilisation data.\u003c/p\u003e \u003cp\u003eHospitals report relevant direct and indirect costs \u003cb\u003eper hospitalisation case\u003c/b\u003e according to \u003cb\u003epredefined categories\u003c/b\u003e (e.g. wages, pharmaceuticals, medical devices, etc.).\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eAnnually\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eYes (e.g. automatic cross-check within the data file matrix and with external databases, the National Register of Reimbursed Services)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEstonia\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePublic payer: Estonian Health Insurance Fund (EHIS)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDepends on purpose of tariff adjustment:\u003c/p\u003e \u003cp\u003e\u0026bull; \u003cb\u003e6 (out of 20) network hospitals\u003c/b\u003e (2 central, 2 regional and 2 local) to review a specific cost component for all tariffs;\u003c/p\u003e \u003cp\u003e\u0026bull; \u003cb\u003ea purposive sample\u003c/b\u003e of providers for reviewing tariffs in a given clinical area\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eVoluntary / No remuneration\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eAll costs related to providing medical services (costs of educational and research activities are excluded). Reporting includes both cost and utilisation data.\u003c/p\u003e \u003cp\u003eHospitals provide a list of resources and their unit costs for delivering \u003cb\u003eparticular services\u003c/b\u003e (in a given clinical area).\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eDepends on the purpose of tariff adjustment:\u003c/p\u003e \u003cp\u003e\u0026bull; every second year (standard procedure)\u003c/p\u003e \u003cp\u003e\u0026bull; on request (e.g. when the process is initiated by the specialty association)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eYes (e.g. cross-check within data files and purchaser invoices on service utilisation)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHungary\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003en/a\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003en/a\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003en/a\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003en/a\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003en/a\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003en/a\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eLithuania\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePublic payer: The National Health Insurance Fund\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDepends on the payment method used for a given scope of services undergoing tariff adjustment:\u003c/p\u003e \u003cp\u003e\u0026bull; \u003cb\u003e60 hospitals\u003c/b\u003e (approx. 68% of all hospitals) for services financed via DRGs;\u003c/p\u003e \u003cp\u003e\u0026bull; \u003cb\u003ea purposive sample\u003c/b\u003e of providers for services financed outside DRGs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eObligatory / No remuneration\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eAll costs related to providing medical services (depreciation of medical equipment as well as the costs of educational and research activities are excluded). Reporting includes both cost and utilisation data.\u003c/p\u003e \u003cp\u003eFor services financed via DRGs: an excel reporting matrix encompasses: \u003cb\u003ecost centres\u003c/b\u003e, structures of cost categories (e.g. wages, medicines, etc.), bases for cost allocation, and drivers for the allocation of indirect costs per cost centre.\u003c/p\u003e \u003cp\u003eFor services financed outside DRGs: hospitals are requested to provide comprehensive micro-costing estimations, including the average duration of personnel labour (per type of personnel) \u003cb\u003efor certain procedures\u003c/b\u003e.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eDepends on the scope of services undergoing tariff adjustment (as indicated in the service calculation plan, current version 2024\u0026ndash;2027).\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eYes (automatic cross-check within Ms Excel matrix; direct communication with providers; trainings for providers)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePoland\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGovernment agency: The Agency for Health Technology Assessment and Tariff System (supervised by the MoH).\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003eAll hospitals\u003c/b\u003e contracted by the public payer (regardless of ownership) have an obligation to report cost data. However, the final sample depends on the scope of services undergoing tariff revision (a \u003cb\u003epurposive, representative sample\u003c/b\u003e of providers with a pre-defined volume of particular services provides data on the services undergoing tariff adjustment).\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eObligatory / No remuneration (there are, however, additional points to use while competing for public payer contracts)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eAll costs related to providing medical services (costs of educational and research activities are excluded). Reporting includes both cost and utilisation data.\u003c/p\u003e \u003cp\u003eCosts are reported for both \u003cb\u003ecost centres\u003c/b\u003e as well as \u003cb\u003especific procedure\u003c/b\u003e. Per cost centre (e.g. hospital ward), the data cover cost per type (e.g. personnel and equipment costs) as well as capacity data (number of beds, number and type of personnel). Per specific procedure, the data cover the number of procedures, drugs and medical equipment utilisation, length of stay, and medical workforce utilisation. Hospitals are asked to provide very detailed, \u003cb\u003emicro-costing estimations\u003c/b\u003e (e.g. the average time of personnel work, per personnel type for specific procedures).\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eDepends on the purpose of tariff adjustment and/or the scope of services undergoing tariff adjustment (as indicated in the annual tariffication plan). It may happen that a hospital will be obliged to report data even a few times a year (e.g. for both staff cost adjustments in all tariffs and for some specific type of care).\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eYes (automatic cross-check within the data file matrix; direct communication with providers; trainings for providers)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSlovakia\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eMinistry of Health\u003c/b\u003e (Department of the Centre for Classification System)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003eAll hospitals\u003c/b\u003e (regardless of ownership) providing services within the public health insurance system.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eObligatory / No remuneration\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eAll costs related to providing medical services (costs of educational and research activities are excluded). Reporting includes both cost and utilisation data.\u003c/p\u003e \u003cp\u003eCosts are reported \u003cb\u003eper cost centre\u003c/b\u003e and for defined categories as well as their \u003cb\u003eallocation to specific procedures/hospital cases\u003c/b\u003e.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eAnnually\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eYes (validation protocol, direct communication with providers)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003e3.4. The process of price setting\u003c/h2\u003e \u003cp\u003eThe tariff/price bases are directly linked to the payment methods, thus most countries use relative weight and/or points per DRG for hospital inpatient care. These are often supplemented by prices set per service and/or per diem, which are used for other types of care as well (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). In most countries, the institutions responsible for the tariffication process publish methodological guidelines (and/or regulations) (Table S4 in the Supplementary File), including statistical methods used and additional variables included in the price calculation formula. The process usually involves calculation of the average actual cost per DRG/service, based on the cost data reported by hospitals, and its reflection in relative weight or points (in Lithuania, weights are imported from the Australian DRG systems and adjusted to the local context). Most often, different versions of the micro-costing approach (top-down, bottom-up or mixed) are used for the average actual cost calculation while experts\u0026rsquo; opinions are used to calculate the average cost of newly introduced technologies/services. In Estonia, experts\u0026rsquo; opinions are also used to calculate the \u0026lsquo;optimal cost\u0026rsquo;, indicating the most effective use of resources (e.g. the equipment costs are calculated assuming their most effective usage while the staff costs reflect the formal, collective agreements on wages for medical professionals). In most countries, to calculate a price, the tariff bases (weights, points) are then multiplied by base rates/basic prices defined in the payer\u0026rsquo;s projected budget. In consequence, although the general objective is for the price to cover the average actual costs, this depends on the payer\u0026rsquo;s available budget for a given year. In both Bulgaria and Hungary, DRG/pathway weights are not calculated on an annual basis (as there is no cost reporting system). In Hungary historical weights are used, while the base rate has remained the same since 2018 (increased costs for hospitals are offset by a large and growing targeted wage subsidy). However, as of writing this paper, a pilot project has been launched by the payer aimed at implementing a standardised, case level cost collection methodology across ten hospitals. In Bulgaria, the payer adjusts the prices from previous years by variables mostly related to the payer\u0026rsquo;s projected budget and service volumes.\u003c/p\u003e \u003cp\u003eAmong the five countries where cost data are systematically gathered for tariffication purposes - the time lag between the data acquisition and the implementation of an adjusted price is usually one year in Czechia, Estonia, and Slovakia, and can vary from a few months to approx. two years in Lithuania and Poland. There can, however, be diverse exemptions. For example, in Estonia, in cases where newly calculated tariffs have a budget impact that exceeds the payer\u0026rsquo;s (the Estonian Health Insurance Fund) budget limits, the tariff increase can be implemented gradually over a period of a few years. In Poland, the general rule is that the payer (the National Health Fund) implements the new tariff up to four months after its publication by the Agency for Health Technology Assessment and Tariffs System. However, the time spent calculating new tariffs can vary significantly. It is usually much shorter when a single cost component (e.g. remuneration) across all tariffs is being adjusted than when tariffs for a pre-defined range of DRGs are being revised.\u003c/p\u003e \u003cp\u003eIn most countries, some form of negotiations with providers is conducted regarding health service cost reimbursement (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). However, these negotiations can focus on other aspects than direct price negotiations. For example, in both Czechia and Slovakia, collective negotiations (e.g. with associations of providers) help define the priorities of the payer\u0026rsquo;s budget, e.g. the percentage share of different types of care. Bulgaria is the only country where collective negotiations focus on the final price of a particular item. Individual price negotiations, held prior to signing agreements with individual hospitals, take place in Czechia, Poland, and Slovakia. For example, in Poland, while submitting an offer during an open tender announced by the payer, a hospital can negotiate both the price per 1 unit of tariff base (usually 1 point) as well as the volume limits of services. The payer indicates the proposed price, while the provider submitting an offer can indicate a price lower (e.g. to get more points during the offer assessment) or higher than the one proposed by the payer. However, during the actual negotiation stage the provider can only decrease its price offer (it cannot be increased above the value indicated in the offer). In summary, in four out of seven analysed countries, the prices are set unilaterally (they are the same for all hospitals across the country).\u003c/p\u003e \u003cp\u003eMost countries apply different price adjustments, usually taking the form of a percentage increase or decrease of the basic price. Their objectives are usually to compensate for higher costs (e.g. in highly specialised and/or technologically costly services in Czechia, Lithuania, and Slovakia) or to encourage provision of specified services (e.g. psychiatric care in Czechia, specialised cardiovascular and oncology care in Slovakia, care for children in Poland). In Poland, numerous price adjustments have been implemented within the last few years with the objective of shifting emphasis from in- to out-patient care (e.g. for ophthalmology and orthopedic surgeries performed in day care settings). None of the analysed countries apply geographical price adjustments (e.g. for rural vs urban hospitals), while Slovakia seems to be the only country where price levels differ depending on the hospital type (the higher reference level of hospital the higher base rate). In most of the analyzed countries, both the calculation methods and tariffs are published online.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePrice (tariff) setting processes (as of December 2024)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"8\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCountry / Element of the process\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTariff base (What tariff bases are used?)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePrice calculation (How is the reference/average cost calculated and what is its relation to the final tariff? How is the price calculated?)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eCosting approach (What is the dominant costing-approach for the average cost calculation?)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eTime lag (What is the time lag between cost data acquisition and price setting?)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNegotiations (Are negotiations with providers involved? If yes \u0026ndash; individual vs collective)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003ePrice adjustments (Are price adjustment used? If yes, what type and what are their objectives?)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eInformation disclosure standards (What type of price setting process data is publicly available?)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBulgaria\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eClinical pathway/procedure;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003eNo systematic cost calculations are conducted.\u003c/b\u003e\u003c/p\u003e \u003cp\u003ePrices from previous years are usually adjusted based on variables related to the payer\u0026rsquo;s projected budget and service volumes. Experts\u0026rsquo; opinions are used to calculate the price of new services.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTop-down gross-costing\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003en/a\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eCollective negotiations (with the Bulgarian Union of Physicians) are held on prices (after which, the payer applies the same negotiated prices across the country)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003ePer type of patient and diagnosis (e.g. a correction factor of 1.14 for children diagnosed with a specific disease), aimed at compensating for higher costs.\u003c/p\u003e \u003cp\u003ePerformance specific (e.g. lower prices when specific types of volume threshold are met) aimed at increased efficiency.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eTariffs and general reimbursement rules are published online.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCzechia\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRelative weights per DRG\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003eAverage actual cost\u003c/b\u003e per DRG is calculated (outliers are removed).\u003c/p\u003e \u003cp\u003eThe unified \u003cb\u003ebase rate\u003c/b\u003e is calculated based on the total expected budget for acute inpatient care. Thus, the actual reimbursement (final price) might be lower than the valorised average total costs in the reference hospitals.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMixed top-down and bottom-up micro-costing\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1 Year\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eBoth individual (prior to signing individual contracts) and collective negotiations (annual, while planning the payer\u0026rsquo;s budget for the upcoming year)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003ePer type of service (e.g. a correction factor of 1.05 for highly specialised services) aimed at compensating for higher costs.\u003c/p\u003e \u003cp\u003ePer type of medical care (e.g. a correction factor f 1.03 for providing acute psychiatric care or mental care), aimed at encouraging provision of specific types of care.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eTariffs and calculation methods are published online\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEstonia\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDRG, Service, Per diem\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003eAverage actual cost\u003c/b\u003e (based on cost data reported by hospitals) is compared with \u003cb\u003eoptimal cost\u003c/b\u003e (based on experts\u0026rsquo; opinions of the resources needed to provide a given service as well as optimal resource use \u0026ndash; e.g. effective equipment use).\u003c/p\u003e \u003cp\u003eCosts are calculated per service and per diem, which are then use to adjust DRG prices.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTop-down micro-costing (Activity based costing)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1 Year\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eUnilateral price setting by the payer (there are, however, individual negotiations on the volume limits)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNo price adjustments per type of service or patient (there are, however, correction factors if hospitals exceed the agreed contract: 0.7 for outpatient and day care services and 0.3 for inpatient services, aimed at limiting overprovision)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eTariffs and calculation methods are published online\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHungary\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWeights per DRG, per diem\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003eNo systematic cost calculations are conducted.\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003eAverage actual cost\u003c/b\u003e is valorised per DRG, calculated based on historical data (1999).\u003c/p\u003e \u003cp\u003eThe unified \u003cb\u003ebase rate\u003c/b\u003e is calculated based on the expected budget for acute inpatient care. Thus, the actual reimbursement (final price) might be lower than the valorised average total costs in the reference hospitals.\u003c/p\u003e \u003cp\u003e(No update since 2018.)\u003c/p\u003e \u003cp\u003eThe payer conducts cost estimations for newly introduced procedures (experts\u0026rsquo; opinions are used).\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMixed: bottom-up and top-down micro-costing\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003en/a\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eUnilateral price setting by the payer (no negotiations)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003ePer type of services (e.g. a correction factor of 1.1. for one-day surgeries, and large prosthetic procedures), aimed at reducing waiting times\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eTariffs and calculation methods are published online\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eLithuania\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWeights (per DRG), Service\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDRG weights are imported from the Australian system and adjusted to the local context. A\u003cb\u003everage actual cost\u003c/b\u003e per DRG is calculated (outliers are removed) to assess the tariff base while the \u0026lsquo;\u003cb\u003ebase rate\u0026rsquo;\u003c/b\u003e is determined by dividing the pubic payer\u0026rsquo;s budget by a weighted number of active treatments.\u003c/p\u003e \u003cp\u003eFor services financed outside DRGs the price reflects the average actual costs.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMixed top-down and bottom up gross-costing (for DRGs) and bottom-up micro-costing for services financed outside DRGs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eVaried (depending on the scope of services undergoing evaluation), \u003cb\u003efrom two months to as much as two years\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eUnilateral price setting by the payer (no negotiations)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003ePer type of service (e.g. for services requiring costly technological components), aimed at compensating for higher costs.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eTariffs and calculation methods are published online\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePoland\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePoints (per DRG); Service, Patient day\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAs a standard procedure, \u003cb\u003eaverage actual cost\u003c/b\u003e per DRG is calculated (outliers are removed) to assess the tariff base. It is then multiplied by a \u0026lsquo;\u003cb\u003ebase rate\u0026rsquo;\u003c/b\u003e defined by the payer\u0026rsquo;s budget.\u003c/p\u003e \u003cp\u003eIn some cases a \u003cb\u003emultiplier of cost changes over time\u003c/b\u003e is applied with the objective of updating the tariff to reflect the actual cost at the moment of tariff application, and to provide a \u0026lsquo;development bonus\u0026rsquo; (covering prospective cost increases). It consists of three components: staff costs, capital costs, and overall prices increase/inflation.\u003c/p\u003e \u003cp\u003eDepending on the scope of services undergoing tariffication, the final report can also include \u003cb\u003einternational and commercial price\u003c/b\u003e comparison.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMixed top-down and bottom-up micro-costing\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eVaried (depending on the scope of services undergoing evaluation), \u003cb\u003efrom several months to more than 2 years\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eIndividual negotiations (both the price per 1 unit of tariff base as well as the volume limits of services can be negotiated)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003ePer type of service (e.g. a correction factors of 1.1\u0026ndash;1.2 for defined ophthalmology and orthopedics surgeries performed in day care settings; a correction factor of 1.6. for providing emergency outpatient services), aimed at increasing provision of day/outpatient care and thus improving efficiency as well as limiting waiting times.\u003c/p\u003e \u003cp\u003ePer type of patients (e.g. a correction factor of 1.2. for care for children) aimed at increasing provision of services for vulnerable patients and limiting waiting times.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eTariffs and calculation methods are published online\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSlovakia\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRelative weight per DRG\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003eRelative weight per DRG\u003c/b\u003e (based on cost data from hospitals) are calculated, but the final tariff is determined by a \u0026lsquo;\u003cb\u003ebase rate\u0026rsquo;\u003c/b\u003e which reflects the capacity of the state budget for in-patient care (there are six categories of \u003cb\u003ebase rates\u003c/b\u003e - reflecting six hospital reference levels)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTop-down micro-costing\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1 Year\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eBoth individual and collective negotiations (the latter related to contracting rules and the payer\u0026rsquo;s budget)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003ePer type of service (the higher reference level of hospital, the higher base rate), aimed at compensating for the higher cost of highly specialised hospitals.\u003c/p\u003e \u003cp\u003ePer type of care (e.g. for specialised cardiovascular and oncology care), aimed at increasing provision of specialised care.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eTariffs and calculation methods are published online.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003e3.5. Challenges of the process\u003c/h2\u003e \u003cp\u003eNumerous challenges of the price setting process can be identified across the group of analysed countries (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). They can be classified into four main areas: 1) completeness and quality of the cost data gathered from hospitals (relatively low hospital participation, low quality and insufficient representativeness of the reported data); 2) institutional capacities of the involved organisations (insufficient human and technical resources in both the organisation responsible for gathering cost data and analysing and setting the tariffs, as well as hospitals during the cost reporting process); 3) methodological approach (challenges related to: including special hospital characteristics, highly complex costing models, accuracy in cost valuation, and the impact of inflation); and 4) the context of the overall health system (the impact of insufficient funding and challenges related to process governance).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eChallenges of the price setting process\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eArea\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eExamples\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCompleteness and quality of the cost data gathered from hospitals\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026bull; \u003cb\u003eHospital participation\u003c/b\u003e: a relatively low number of providers reporting data when participation is voluntary (Estonia) or when there are no regulatory tools to enforce the obligation to provide data (Poland), both of which can affect the final data sample representativeness; a lack of systematic hospital cost reporting processes for the purposes of tariffication (Bulgaria, Hungary)\u003c/p\u003e \u003cp\u003e\u0026bull; \u003cb\u003eQuality of the reported data\u003c/b\u003e: low quality reported data, e.g. when data are not complete (Slovakia, Poland) or not reported according to the pre-defined standards (Poland)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eInstitutional capacities of the involved organisations\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026bull; \u003cb\u003eInstitutional capacities of the leading organisations\u003c/b\u003e: a limited number of employees (with adequate expertise) in the organisations responsible for the tariffication process (Estonia, Hungary, Lithuania)\u003c/p\u003e \u003cp\u003e\u0026bull; \u003cb\u003eInstitutional capacities of the hospitals\u003c/b\u003e: technical limitation of the hospitals\u0026rsquo; IT systems that do not allow for effective data processing (Slovakia) or interoperability (Poland); lack of adequate skills among administrative staff or lack of cooperation between medical and administrative staff needed for conducting micro-costing estimations (Poland)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMethodological approach\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026bull; \u003cb\u003eIncluding hospital characteristics\u003c/b\u003e: lack of mechanism for including differences in hospital costs depending on location, specialisation, or additional task carried out by hospitals, e.g. local hospitals vs university clinics (Bulgaria, Czechia, Poland)\u003c/p\u003e \u003cp\u003e\u0026bull; \u003cb\u003eComplexity of the costing model\u003c/b\u003e: highly complex methodological approach limits providers\u0026rsquo; understanding (Poland)\u003c/p\u003e \u003cp\u003e\u0026bull; \u003cb\u003eAccuracy of depreciation costs\u003c/b\u003e: concerns about appropriateness of including depreciation costs for long-term assets acquired from different investment sources (Lithuania)\u003c/p\u003e \u003cp\u003e\u0026bull; \u003cb\u003eAdjusting for inflation\u003c/b\u003e: the lack of regular adjustment for inflation, especially in cases when the time lag between the cost data acquisition and setting prices is long, leads to situations where a new tariff is already outdated at the moment of implementation (Estonia, Bulgaria, Hungary, Lithuania,)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHealth system context\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026bull; \u003cb\u003ePayer\u0026rsquo;s budget\u003c/b\u003e: insufficient available funding reflected in the base rate can impact the final price to be below the average actual costs (Bulgaria, Hungary, Lithuania, Slovakia)\u003c/p\u003e \u003cp\u003e\u0026bull; \u003cb\u003eProcess governance\u003c/b\u003e: insufficient communication between the involved stakeholders (Slovakia) or lack of transparency (Bulgaria) undermine provider\u0026rsquo;s trust; lack of strong political leadership hinders implementation of dedicated system at the health system level (Hungary)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"4. DISCUSSION","content":"\u003cp\u003eOur study shows that the process of setting prices for hospital providers varies between CEE countries. In five countries (Czechia, Estonia, Lithuania, Poland and Slovakia), it involves three general steps: 1) cost data are reported by hospitals (usually a defined sample of providers) based on a pre-defined costing template; 2) a dedicated government institution gathers and analyses the data and calculates the bases of the tariffs based on pre-defined methodological guidelines, which usually involves calculation of average actual costs per specific item of care; 3) to calculate prices, the tariff bases are multiplied by a base rate (amount of money per tariff base unit), defined by the payer\u0026rsquo;s budget capacities. In most of the analysed countries, the payer also adjusts the final price of specific services (or care provided for a specific group of patients) by implementing diverse correction factors (usually a percentage increase of the price) in order to meet pre-defined health policy objectives. However, the details of each step can vary between the countries (e.g. in relation to the scope of hospitals reporting cost data, the role of negotiations with providers, the application and objectives of final price adjustments). In the cases of the two remaining countries (Bulgaria and Hungary) there is no structured hospital cost data collection system for tariffication purposes (historical tariff bases are adjusted).\u003c/p\u003e \u003cp\u003eThe results indicate that although in most countries the overall price setting processes reflects those in Western Europe (2,7,8), the CEE countries can be at different levels of policy development and system maturity. In two (Bulgaria, Lithuania) out of the seven analysed countries, there are no dedicated costing standards for hospitals. Such standards can help providers to adjust their accounting systems to better meet the relevant cost data reporting rules and thus allow for more reliable and comparable data acquisition (8,9,19,20). In addition, detailed costing standards can help hospital managers to calculate the actual cost of a given service/unit of activity on a regular basis (9). For example, in Poland, hospitals can share such individual cost calculations with the agency responsible for the tariffication process (these calculations are later included in a final tariffication report). This helps to build a more evidence-based approach and strengthens the transparency of the whole process. While, in some countries, adjusting prices for inflation is a standard procedure (in Czechia and Slovakia) in others it happens more sporadically (in Estonia, Lithuania, Poland), or inflation is not taken into consideration at all (in Bulgaria and Hungary), which can pose a significant long-term financial risk for hospitals (21).\u003c/p\u003e \u003cp\u003eOur study also points towards the existence of similar trade-offs between the accuracy of the price setting process and system feasibility as those identified in Western European countries (8). More complex systems can support better data accuracy. For example, a higher number of specific DRG groups and a bottom-up micro costing approach gives greater chances of accurately reflecting actual recourses use (6,22). However, at the same time, there are also increased transactional costs. Our study has shown that one of the challenges of the pricing system is providers lacking understanding of the costing model among and therefore having difficulties conducting micro-costing estimations. There is a similar trade-off regarding hospital coverage. On the one hand, a high share of hospitals reporting cost data makes it possible to see the complete picture, with full data representation (8). On the other hand, this increases the administrative burden for both hospitals and the institution responsible for processing the data.\u003c/p\u003e \u003cp\u003eInternational evidence indicates that in many high income countries the technical task of cost calculation (carried out by independent agencies) is separated from the more political task of carrying out negotiations with providers (carried out by the payers) (2). This is the case in two of the analysed CEE countries (Czechia and Poland). In the remaining three countries (with cost reporting systems) the cost calculations are carried out by dedicated teams in the Ministry of Health (Slovenia) or directly within the payer structures (Estonia, Lithuania). The latter, may elicit, on the one hand, controversies about the political independence of the process, but on the other, it may limit the administrative burden and enhance effective governance (e.g. when decisions related to prices, volume, and budget are all made within a single institution). Regardless of the institutional landscape, good governance rules and data transparency remain crucial. In three out of the seven analysed countries, unilateral price setting takes place (there are no negotiations with providers regarding prices) which is perceived as a good approach to limit price discrimination and contain cost growth (2). At the same time, most of the countries follow international trends (2,6,23) and apply varied price adjustments (e.g. percentage increases in prices) aimed at meeting pre-defined policy objectives (e.g. incentivizing provision of specific services, reducing waiting times, etc.).\u003c/p\u003e \u003cp\u003eTo the authors best knowledge this is the first study providing a structured overview of the price setting process for hospital care in CEE countries. There are, however, two main limitations to be noted. The first consists in the risk of bias and the potential influence of arbitrary factors during the data collection process. We have tried to limit this by encouraging respondents to provide references whenever available, as well as seeking out professionals with expertise in the analysed topic (in most of the countries, the originally contacted HSMP Network member has collaborated with another specialist, often a practitioner in the related field). The second limitation derives from the study scope, which, by focusing on hospital care within public health insurance systems, does not provide a full picture of the pricing system. We have not analysed processes within private/voluntary health insurance schemes and out-of-pocket payments. However, as shown in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, in the group of analysed countries, these other sources of funding have a marginal role in the context of hospital care.\u003c/p\u003e \u003cp\u003eDespite these limitations, our study provides important implications for both future research and health policy. In terms of the former, a qualitative analysis of different stakeholders\u0026rsquo; perspectives could provide deeper insight into the challenges of implementing an effective price setting process and thus providing more specific and better tailored policy recommendations. Also, quantitative costing studies, e.g. aimed at comparing costs between different providers, could help in providing evidence for enhancing tariffication methodology. Our results indicate that regardless of country specific differences in the pricing process, the data infrastructure and governance systems are of crucial importance. Hospital managers need clear guidelines on costing methodology, including continuous training/education options. This must be supported by adequate IT infrastructure. There is growing literature on the use of digital solutions, including artificial intelligence and big data analytics within health financing systems (24\u0026ndash;26). Such solutions have proved effective, e.g. in automated data extraction from medical documentation (27,28), and thus can also be used for utilisation and cost data tracking. These solutions could enhance process efficiency by limiting the potential trade-off between the timeliness, completeness, and accuracy of the cost data reporting and feasibility constraints. However, their implementation must be complemented by an adequate regulatory framework, including cybersecurity protocols and strong leadership of both regulatory bodies and individual hospitals. At the same time, improving different stakeholders\u0026rsquo; cooperation and data transparency could help in building more participatory consensus in health policy design. Due to the similar health system contexts of CEE countries, there is a huge potential to share cross-country knowledge.\u003c/p\u003e"},{"header":"5. CONCLUSIONS","content":"\u003cp\u003eThe systems of pricing hospital services within public health insurance schemes in the seven analysed CEE countries (Bulgaria, Estonia, Czechia, Hungary, Lithuania, Poland, and Slovenia) are at different stages of development. While in some countries, hospitals must follow detailed costing standards and report comprehensive data, including micro-costing estimations, in others there are neither dedicated costing standards for hospitals, nor any structured cost reporting systems. However, even in countries with a structured cost collection process, it usually only includes a purposively selected sample of providers while tariff updates often relate solely to a pre-defined scope of services. The analysed countries face similar challenges in building effective price setting systems. These challenges include 1) incompleteness and low quality of the cost data gathered from hospitals, 2) insufficient institutional capacities of both hospitals and the organisations responsible for tariffication; 3) methodological challenges of the costing model; and 4) barriers driven by the context of the overall health system (especially the payer\u0026rsquo;s budget capacity). Investment in data infrastructure and improved system governance are needed in all of the analysed countries.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003e Reinhardt UE. The Pricing of U.S. Hospital Services: Chaos behind a Veil of Secrecy. https://doi.org/101377/hlthaff25157. 2017 Aug 2;25(1):57\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e Barber S., Lorenzoni L., Ong P. Price setting and price regulation in health care: lessons for advancing universal health coverage [Internet]. 2019 [cited 2025 Feb 14]. Available from: https://iris.who.int/handle/10665/325547\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e Cashin C. (ed.). Assessing Health Provider Payment Systems: A Practical Guide for Countries Moving toward UHC | Joint Learning Network [Internet]. 2015 [cited 2025 Feb 14]. Available from: https://jointlearningnetwork.org/resources/assessing-health-provider-payment-systems-a-practical-guide-for-countries-w/\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e Designing and Implementing Health Care Provider Payment Systems : How-To Manuals. Designing and Implementing Health Care Provider Payment Systems [Internet]. 2009 May 14 [cited 2025 Feb 15]; Available from: https://hdl.handle.net/10986/13806\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e Better Ways to Pay for Health Care | OECD [Internet]. [cited 2025 Feb 15]. Available from: https://www.oecd.org/en/publications/better-ways-to-pay-for-health-care_9789264258211-en.html\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e Ozaltin A., Cashin C. (ed.). Costing of Health Services for Provider Payment: A Practical Manual | Joint Learning Network [Internet]. 2014 [cited 2025 Feb 14]. Available from: https://jointlearningnetwork.org/resources/costing-of-health-services-for-provider-payment-a-practical-manual/\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e Tan S. et al. DRGs and cost accounting: Which is driving which? In: Busse et al (ed) [Internet]. 2011 [cited 2025 Feb 16]. Available from: https://eurohealthobservatory.who.int/publications/m/diagnosis-related-groups-in-europe\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e Tan SS, Geissler A., Serd\u0026eacute;n L., Heurgren M., Martin Van Ineveld B., Ken Redekop W., et al. DRG systems in Europe: variations in cost accounting systems among 12 countries. Eur J Public Health [Internet]. 2014 Dec 1 [cited 2025 Feb 14];24(6):1023\u0026ndash;8. Available from: https://dx.doi.org/10.1093/eurpub/cku025\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e Raulinajtys-Grzybek M. Cost accounting models used for price-setting of health services: An international review. Health Policy (New York). 2014 Dec 1; 118(3):341\u0026ndash;53.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e Ndayishimiye C., Tambor M., Behmane D., Dimova A., Dūdele A., Džakula A., et al. Health care provider payment schemes and their changes since 2010 across nine Central and Eastern European countries \u0026ndash; a comparative analysis. Health Policy (New York) [Internet]. 2025 Feb 7 [cited 2025 Feb 14];105261. Available from: https://linkinghub.elsevier.com/retrieve/pii/S016885102500017X\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e Home - Eurostat [Internet]. [cited 2025 Feb 14]. Available from: https://ec.europa.eu/eurostat\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e Sowa PM. Governance of hospitals in central and eastern Europe. Governance of Hospitals in Central and Eastern Europe. 2016 Jan 1; 1\u0026ndash;260.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e Dubas-Jak\u0026oacute;bczyk K., Albreht T., Behmane D., Bryndova L., Dimova A., Džakula A., et al. Hospital reforms in 11 Central and Eastern European countries between 2008 and 2019: a comparative analysis. Health Policy (New York). 2020 Apr 1; 124(4):368\u0026ndash;79.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e Šimović H., Mihelja Zaja M., Primorac M., Šimović H., Mihelja Zaja M., Primorac M. Fiscal (un)sustainability of the Croatian healthcare system: additional impact of the COVID-19 crisis. Public Sector Economics [Internet]. 2021 [cited 2025 Jan 4];45(4):495\u0026ndash;515. Available from: https://EconPapers.repec.org/RePEc:ipf:psejou:v:45:y:2021:i:4:p:495-515\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e Jovanović T. Challenges of the Slovenian Healthcare System Exposed in Hospitals\u0026rsquo; Recovery Plans. Stud Health Technol Inform [Internet]. 2020 [cited 2025 Jan 4]; 272:354\u0026ndash;7. Available from: https://ebooks.iospress.nl/doi/10.3233/SHTI200568\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e Dubas-Jak\u0026oacute;bczyk K., Kozieł A. Towards Financial Sustainability of the Hospital Sector in Poland\u0026mdash;A Post Hoc Evaluation of Policy Approaches. Sustainability 2020, Vol 12, Page 4801 [Internet]. 2020 Jun 12 [cited 2025 Jan 4];12(12):4801. Available from: https://www.mdpi.com/2071-1050/12/12/4801/htm\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e Guide for authors - Health Policy - ISSN 0168\u0026ndash;8510 | ScienceDirect.com by Elsevier [Internet]. [cited 2025 Feb 14]. 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Available from: https://www.jclinepi.com/action/showFullText?pii=S0895435620311859\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":false,"highlight":"","institution":"Jagiellonian University","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"hospital, pricing, tariffication, hospital’s costs, Central and Eastern Europe","lastPublishedDoi":"10.21203/rs.3.rs-6518063/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6518063/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e The price setting process constitutes the core element of health care providers’ payment schemes, which are used to steer providers’ behaviour towards realisation of pre-defined health policy objectives.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eObjectives:\u003c/strong\u003e This study aimed to: 1) describe and compare systems for setting prices for hospital care services in the public health insurance systems of seven Central and Eastern European (CEE) countries (Bulgaria, Estonia, Czechia, Hungary, Lithuania, Poland, and Slovenia) and 2) identify current challenges.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e The methods involved three consecutive steps: 1) defining a conceptual framework and developing a data collection form; 2) consultations with national experts, and 3) a comparative analysis.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e Results show that the process of setting prices for hospital care varies between CEE countries. The main difference is the existence of a structured hospital costing data collection system (present in five out of the seven analysed countries), while there are numerous additional differences in the details of the remaining system elements (e.g. cost standards, scope of reported hospital cost data, the role of provider negotiations, and the objectives and application of final price adjustments).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions:\u003c/strong\u003e Despite differences, the analysed countries face similar challenges in building effective price setting systems: 1) incomplete and/or low quality cost data collected from hospitals, 2) insufficient institutional capacities on the part of both hospitals and organisations responsible for tariffication; 3) methodological challenges of the costing model; and 4) barriers driven by the overall health system context. Data infrastructure investment and system governance improvement are needed in all analysed countries.\u003c/p\u003e","manuscriptTitle":"Setting prices for hospital care within public health insurance schemes in seven Central and Eastern European countries – a comparative analysis","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-04-25 06:03:59","doi":"10.21203/rs.3.rs-6518063/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"c64ca803-5a4f-4f36-80e7-809ea03d5d34","owner":[],"postedDate":"April 25th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[{"id":47611419,"name":"Health Economics \u0026 Outcomes Research"}],"tags":[],"updatedAt":"2026-01-29T14:18:37+00:00","versionOfRecord":{"articleIdentity":"rs-6518063","link":"https://doi.org/10.1186/s13561-026-00730-2","journal":{"identity":"health-economics-review","isVorOnly":false,"title":"Health Economics Review"},"publishedOn":"2026-01-27 00:00:00","publishedOnDateReadable":"January 27th, 2026"},"versionCreatedAt":"2025-04-25 06:03:59","video":"","vorDoi":"10.1186/s13561-026-00730-2","vorDoiUrl":"https://doi.org/10.1186/s13561-026-00730-2","workflowStages":[]},"version":"v1","identity":"rs-6518063","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6518063","identity":"rs-6518063","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}