ministry of health of the slovak republic reform puzzle healthcare reform in slovakia ing. peter...

Ministry of Health of the Slovak Republic

REFORM PUZZLE

Healthcare Reform in Slovakia

Ing. Peter Pažitný, MSc.

Advisor to the Minister of Health

MUDr. Rudolf Zajac

Minister of Health

16.04.2004

Ministry of Health of the Slovak Republic 16.04.2004

... ??? ...We're lucky that the hole is not on our side

CONTENTS

I. Stabilisation measures

II. Reform puzzle

III. New players

Ministry of Health of the Slovak Republic 27. 01. 2004

Ministry of Health of the Slovak Republic 16.04.2004

I. STABILISATION MEASURES

1. The rise in drug expenditure slowed down significantly

2. Number of doctor visits declined

3. Debt growth slowed by half

+ 8%

- 10%

+ SKK 4.8 bil.

2003

Ministry of Health of the Slovak Republic 16.04.2004

The basic hypothesis for the introduction of fees

1. Reduce unnecessary demand for healthcare services (reduce the number of doctor visits and drug consumption)

2. Reduce the degree of corruption

3. Increase patients’ co-responsibility for their health (educational character)

Ministry of Health of the Slovak Republic 16.04.2004

10% decrease in the number of primary outpatient care visits

(comparison of 2003/2002)

0,8

0,9

1

1,1

1,2

generalpractitioners,

gynaecologists

dentists first aid specialisedoutpatient care

hospitals

1q

2q

3q

4q

Source: General Health Insurance Company, 2004

Ministry of Health of the Slovak Republic 16.04.2004

Only 1.5% of patients stopped visiting doctors

I don't know, I didn’t need to

go to the doctor

I stopped going to the

doctor

less frequently

than before

as frequently as before

58.5%18.0%

22.0%

1.5%

Source: FOCUS, January 2004

Ministry of Health of the Slovak Republic 16.04.2004

Only 2.1% of patients stopped having medicines prescribed

I don't know, I didn't go to a

doctor

I stopped

less than before

equally as before

54.2%

20.5%

23.2%

2.1%

Source: FOCUS, January 2004

Ministry of Health of the Slovak Republic 16.04.2004

The rise in drug expenditure has significantly slowed down

(in billions of SKK)

13,015,3

16,9

19,6 20,6

1,5

1,82,0

12

14

16

18

20

22

24

1999 2000 2001 2002 2003

Payments bypatients

Payments byhealthinsurancecompanies

Ministry of Health of the Slovak Republic 16.04.2004

The growth dynamics of payments by health insurance companies and

financial burden on the patient are declining (in %)

8

16

11

15

9

19

0

5

10

15

20

25

2000 2001 2002 2003

Payments byhealthinsurancecompanies

Payments bypatients

Ministry of Health of the Slovak Republic 16.04.2004

Healthcare availability has not decreased

The original hypothesis has been fulfilled in that

1. Only the number of unnecessary visits declined2. Availability of healthcare services has not decreased3. The degree of perceived corruption has declined (from

32 to 10%)

Ministry of Health of the Slovak Republic 16.04.2004

II. REFORM PUZZLE

Act on health insurance companies and healthcare oversight

Act on health insurance

Act on emergency health service

Act on healthcare

Act on healthcare

providers and vocational organisations

Act on the scope of healthcare covered by public health insurance

Ministry of Health of the Slovak Republic 16.04.2004

Healthcare expenditure

0,00

2,00

4,00

6,00

8,00

10,00

12,00

14,00

0 5000 10000 15000 20000 25000 30000 35000 40000

Per capita GDP in PPP (USD)

Healthcare expenditure as % of GDP

Source: OECD, 1999Source: OECD

ROM

IRE

SVKCZ

USA

GER

DEN

ESP

Ministry of Health of the Slovak Republic 16.04.2004

REFORM PRINCIPLES

1. Equal care for equal need.

2. Ability to pay.

3. Universal coverage.

4. Protection of patients’ rights.

5. Enforcement of the rules of the game.

6. Healthcare is technically a service and ethically a mission.

7. Guaranteeing free access of licensed providers to the healthcare market.

Ministry of Health of the Slovak Republic 16.04.2004

1. SCOPE: LIST OF PRIORITIES

Basic principle:

Equal care for equal need.

Ministry of Health of the Slovak Republic 16.04.2004

LIST OF PRIORITIES ACCORDING TO PEOPLE

Disease %

Cardiovascular diseases 74.2

Cancer 68.8

Diabetes, metabolic disorders 26.2

Orthopaedic diseases 16.6

Mental, psychiatric and nerve disorders and stress 16.1

Flu 12.1

Allergies 10.9

Respiratory tract diseases 8.6

Infectious diseases, jaundice, TBC and AIDS 6.3

Incorrect diet, obesity 6.2

Alcoholism, smoking, drug addiction 4.6

Dental problems 1.4

Skin diseases 0.9

Gynaecological diseases 0.8

Source: FOCUS, January 2004

Ministry of Health of the Slovak Republic 16.04.2004

New law on the scope of healthcare

transform the performance model into a model of a list of regular services leading to the identification of the disease and elimination of the disease (quasi DRG)

divide risk/diagnoses to those where patient participation cannot be required and those where we can require various forms of participation

make decision-making processes objective by cataloguing services and categorising participation

PHILOSOPHY

Ministry of Health of the Slovak Republic 16.04.2004

National list of diseases(by priority)

FluJ10

Fibroma pendulansL91

Acute myocardial infarctionI21

Chronic kidney failureN18

Diabetes mellitusE10

Acute lymphoblastic leukaemia C91

DiseaseCode

Dental decayK02

begin-ning

end

Ministry of Health of the Slovak Republic 16.04.2004

National list of diseases (basic priorities)

Critical risks: financial protection of patients from

the risk of high costs urgent care chronic diseases

Ministry of Health of the Slovak Republic 16.04.2004

Cataloguing of services

creation of catalogues of justifiable services necessary for the identification and elimination of a disease

it has nothing to do with payments

a regular basis is being created – guidelines.

Ministry of Health of the Slovak Republic 16.04.2004

Cataloguing commission

Health insurance companies

Specialised companies

Ministry of Health

who appoints it:

the ministry?

government?

parliament?

Ministry of Health of the Slovak Republic

Cataloguing of services

DISEASE

Definition of a standard diagnostic and therapeutic procedure

Services leading to the elimination of the disease

(treatment services)

Services leading to the identification of the disease

(diagnostic services)

Ministry of Health of the Slovak Republic 16.04.2004

Categorisation

is a division by payments and participation

Diseases – diagnoses (for now through services)

Medicinal products, drugs and dietetic food

Health aids

Ministry of Health of the Slovak Republic 16.04.2004

Categorisation commission

Health insurance companies

Specialised companies

Ministry of Health

Ministry of Health of the Slovak Republic

Categorisation model

1

2

3

...

9 035

SERVICES

DISEASES

fully covered service uncovered service partially covered service

Ministry of Health of the Slovak Republic

Current situation

DISEASES

123

...

9 035

Ministry of Health of the Slovak Republic

123

...

9 035

DISEASES

Categorisation model in practice

Political decisions no. 2

Political decision no. 1

PARLIAMENT

covered by public health insurance

patient’s participation

Ministry of Health of the Slovak Republic 16.04.2004

2. INSURANCE ACT

Basic principles:

Ability to pay

Universal coverage

Ministry of Health of the Slovak Republic 16.04.2004

2. INSURANCE ACT

Individual health insurance

Public health insurance

Voluntary contractexceeding the scope defined by a special

law

Scope defined by a special law

Ministry of Health of the Slovak Republic 16.04.2004

2. INSURANCE ACT

Basic theses: policyholder sends an application free choice of insurance company change possible once a year (as of 1 January) contributions paid in advance payments annual clearance of insurance contributions premiums are distributed on the basis of a risk index

Annual calculation base: minimum: 12 times the minimum wage maximum: 36 times the minimum wage

Rate: 14% (10% employer + 4% employee) the state pays 4% of average wage (link to the real economy)

Ministry of Health of the Slovak Republic 16.04.2004

2. Insurance act

Need for redistribution:

we are building a system with universal coverage

minimisation of “skimming the cream” or “picking the raisins out”

elimination of adverse selection

Ministry of Health of the Slovak Republic 16.04.2004

2. Redistribution rules

Decentralised collection of premiums Every insurance company on its own

Subject of redistribution: 95% of underwritten premiums

Volume of redistribution: 90 percent

Ministry of Health of the Slovak Republic 16.04.2004

2. Risk index

0

1

2

3

4

5

6

risk index - women

risk index - men

Ministry of Health of the Slovak Republic 16.04.2004

3. OVERSIGHT AUTHORITY

Basic principles:

Protection of patients’ rights

Enforcement of the rules of the game

Ministry of Health of the Slovak Republic 16.04.2004

3. OVERSIGHT AUTHORITY

The oversight authority as the market regulator:

• Issues licences to health insurance companies• Updates the risk index• Checks the solvency of health insurance

companies• Inspects the quality of healthcare services• Monitors and ensures “lege artis”

Ministry of Health of the Slovak Republic 16.04.2004

3. HEALTH INSURANCE COMPANIES

Individual health insurance

Public health insurance

All (including health) insurance companies

Licensed health insurance company

Ministry of Health of the Slovak Republic 16.04.2004

3. COMPETITION BETWEEN INSURANCE COMPANIES

REDISTRIBUTION

PURCHASE

COLLECTION COLLECTION COLLECTION

PURCHASEPURCHASE

Ministry of Health of the Slovak Republic 16.04.2004

GOAL: PATIENT MANAGEMENT

Patient Health insurance company

Doctor (general, specialist)

Hospital

Ministry of Health of the Slovak Republic 16.04.2004

Public and minimum public network of providers

Public network

everyoneMinimum public network

Uncontracted providers

Ministry of Health of the Slovak Republic 16.04.2004

Patient management: contracted providers

When providing healthcare services from public health insurance, the patient pays a fee for services specified by law.

The categorisation commission will decide on the extent of possible participation.

2. Fee + possible participation

3. Payment on the basis of contracted prices

1. Insurance relationship

List of contracted providers

Ministry of Health of the Slovak Republic 16.04.2004

Patient management: uncontracted providers

The patient visits the insurance company and asks for permission to go to an uncontracted provider. After the insurance company’s approval, the patient pays the whole cost of the services and then claims benefits from the insurance company up to the amount that the insurance company would have paid to a contracted provider

2. The patient covers the full cost

3. Benefit for the patient up to the amount usual for a contracted provider

Insurance relationship

1. Acquisition of consent

Waiting list management

Ministry of Health of the Slovak Republic 16.04.2004

4. EMERGENCY SERVICE

Basic principle:

Ensure such organisation of the network of emergency service providers so that they

reach the patient within 10 minutes.

Ministry of Health of the Slovak Republic 16.04.2004

5. HEALTHCARE

Basic principle:

Healthcare

is technically a service and ethically a mission.

Ministry of Health of the Slovak Republic 16.04.2004

6. LAW ON PROVIDERS

Basic principle:

Guaranteeing free access of licensed providers to the healthcare market.

Ministry of Health of the Slovak Republic 16.04.2004

III. NEW PLAYERS

Health insurance company

Providers

Emergency service

ChambersHealthcare

ScopeRegional

self-government,

Ministry

Oversight of health insurance

Finance

Oversight Authority

Finance

Finance Oversight of healthcare services

Permit Licence

Permit Licence

Ministry of Health of the Slovak Republic 16.04.2004

THANK YOU FOR YOUR ATTENTION

We will welcome your comments. You can find further information at

www.zdravotnictvo.sk

and

www.reformazdravotnictva.sk