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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