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REFORM PUZZLE

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

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REFORM PUZZLE

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  1. 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

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

  3. CONTENTS • Stabilisation measures • Reform puzzle • New players 27. 01. 2004 Ministry of Health of the Slovak Republic

  4. I. STABILISATION MEASURES 2003 • The rise in drug expenditure slowed down significantly • Number of doctor visits declined • Debt growth slowed by half + 8% - 10% + SKK 4.8 bil.

  5. The basic hypothesis for the introduction of fees • Reduce unnecessary demand for healthcare services (reduce the number of doctor visits and drug consumption) • Reduce the degree of corruption • Increase patients’ co-responsibility for their health (educational character)

  6. 10% decrease in the number of primary outpatient care visits(comparison of 2003/2002) Source: General Health Insurance Company, 2004

  7. Only 1.5% of patients stopped visiting doctors 22.0% 1.5% 18.0% 58.5% Source: FOCUS, January 2004

  8. Only 2.1% of patients stopped having medicines prescribed 23.2% 2.1% 54.2% 20.5% Source: FOCUS, January 2004

  9. The rise in drug expenditure has significantly slowed down (in billions of SKK)

  10. The growth dynamics of payments by health insurance companies and financial burden on the patient are declining (in %)

  11. Healthcare availability has not decreased The original hypothesis has been fulfilled in that • Only the number of unnecessary visits declined • Availability of healthcare services has not decreased • The degree of perceived corruption has declined (from 32 to 10%)

  12. Act on healthcare Act on health insurance companies and healthcare oversight Act on healthcare providers and vocational organisations Act on health insurance Act on the scope of healthcare covered by public health insurance Act on emergency health service II. REFORM PUZZLE

  13. Healthcare expenditure USA GER CZ SVK DEN ESP IRE ROM Healthcare expenditure as % of GDP Per capita GDP in PPP (USD) Source: OECD Source: OECD, 1999

  14. REFORM PRINCIPLES • Equal care for equal need. • Ability to pay. • Universal coverage. • Protection of patients’ rights. • Enforcement of the rules of the game. • Healthcare is technically a service and ethically a mission. • Guaranteeing free access of licensed providers to the healthcare market.

  15. 1. SCOPE: LIST OF PRIORITIES Basic principle: Equal care for equal need.

  16. LIST OF PRIORITIES ACCORDING TO PEOPLE Source: FOCUS, January 2004

  17. New law on the scope of healthcare PHILOSOPHY • transform the performance model into a model of a list of regular services leading to the identification of the diseaseandelimination 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 cataloguingservices and categorising participation

  18. National list of diseases(by priority) Code Disease C91 Acute lymphoblastic leukaemia E10 Diabetes mellitus begin-ning N18 Chronic kidney failure I21 Acute myocardial infarction L91 Fibroma pendulans J10 end Flu K02 Dental decay

  19. National list of diseases(basic priorities) Critical risks: • financial protection of patients from the risk of high costs • urgent care • chronic diseases

  20. 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.

  21. Cataloguing commission 3 Health insurance companies who appoints it: the ministry? government? parliament? 3 Ministry of Health 5 Specialised companies

  22. Cataloguing of services Definition of a standard diagnostic and therapeutic procedure Services leading to the identification of the disease (diagnostic services) DISEASE Services leading to the elimination of the disease (treatment services)

  23. Categorisation is a division by payments and participation • Diseases – diagnoses (for now through services) • Medicinal products, drugs and dietetic food • Health aids

  24. Categorisation commission 5 Health insurance companies 3 Ministry of Health 3 Specialised companies

  25. Categorisation model SERVICES 1 2 3 ... 9 035 DISEASES fully covered service partially covered service uncovered service

  26. Current situation 1 2 3 ... 9 035 DISEASES

  27. Political decision no. 1 êêPARLIAMENTêê Politicalè decisionsè no. 2 è Categorisation model in practice 1 2 3 ... 9 035 DISEASES covered by public health insurance patient’s participation

  28. 2. INSURANCE ACT Basic principles: Ability to pay Universal coverage

  29. 2. INSURANCE ACT Public health insurance Scope defined by a special law Individual health insurance Voluntary contract exceeding the scope defined by a special law

  30. 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)

  31. 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

  32. 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

  33. 2. Risk index

  34. 3. OVERSIGHT AUTHORITY Basic principles: Protection of patients’ rights Enforcement of the rules of the game

  35. 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”

  36. 3. HEALTH INSURANCE COMPANIES Public health insurance Licensed health insurance company Individual health insurance All (including health) insurance companies

  37. 3. COMPETITION BETWEEN INSURANCE COMPANIES COLLECTION COLLECTION COLLECTION REDISTRIBUTION PURCHASE PURCHASE PURCHASE

  38. GOAL: PATIENT MANAGEMENT Hospital Patient Health insurance company Doctor (general, specialist)

  39. Public and minimum public network of providers Public network everyone Minimum public network Uncontracted providers

  40. Patient management: contracted providers • Insurance relationship • List of contracted providers 2. Fee + possible participation 3. Payment on the basis of contracted prices 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.

  41. Patient management: uncontracted providers Insurance relationship 1. Acquisition of consent 3. Benefit for the patient up to the amount usual for a contracted provider Waiting list management 2. The patient covers the full cost 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

  42. 4. EMERGENCY SERVICE Basic principle: Ensure such organisation of the network of emergency service providers so that they reach the patient within 10 minutes.

  43. 5. HEALTHCARE Basic principle: Healthcare is technically a service and ethically a mission.

  44. 6. LAW ON PROVIDERS Basic principle: Guaranteeing free access of licensed providers to the healthcare market.

  45. III. NEW PLAYERS Oversight Authority Oversight of healthcare services Oversight of health insurance Finance Health insurance company Providers Finance Scope Healthcare Licence Permit Chambers Regional self-government, Ministry Licence Permit Finance Emergency service

  46. THANK YOU FOR YOUR ATTENTION We will welcome your comments. You can find further information at www.zdravotnictvo.sk and www.reformazdravotnictva.sk

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