Rudolf Zajac

1
Healthcare Reform in Slovakia
Rudolf Zajac
2
I. Introduction - Slovakia

• Population 5.4 million people
• Living Standard 51 of EU average
• Middle income country

3
Expenditure on Health Care
Expenditure on health care as of GDP
USA
GER
CZ
SVK
DEN
ESP
IRE
ROM
GDP per capita at PPP in USD
source OECD
4
Deficit of Public Finances ( of GDP)
5
Breakdown of Current System
solidarity
excess of solidarity over resources
resources
5 (income from privatisation)
17 (informal payments)
8
23 (taxes)
(direct payments)
47 (payroll taxes)
solidarity
0
resources
6
Consequences

• Excess of demand over supply

3
1
Expenditure
2
Prices / spending
3
Infinite demand
1
Volume
7
Efficiency gap
LUX
CZ
SVK
HUN
Through corrections in pay levels, employment and
age structure it RISES to a ratio of Input
Output 0,526 0,612
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Efficiency in Health Care
The Netherlands
Slovakia
Efficiency 1.000
Efficiency 0.612
9
Slovakia, the leader in Reforms?

• Tax Reform (2003) Corporate and Wage Tax 19
• Pension Reform (2003) Two pillars (public and
  private)
• Public Administration Reform (2004) Fiscal
  Decentralization
• Labour Market Reform (2003) Modern Labour Code
• Health Care Reform - Stabilization (2003)
  - Reform Acts (2004)

10
Pre-reform "preparation" of citizens, or
stabilisation (June 2003) Application of
marginal co-payments
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The Reform Jigsaw
Healthcare Act
Healthcare legislation and supervision of health
care
Healthcare Providers and Professional Bodies Act
Health Insurance Act
Act on the Scopeof Health Care Covered by
PublicHealth Insurance
Healthcare Emergency Services Act
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Principles of Reform

• Equal care for equal need
• Ability to pay
• Universal coverage
• Protection of patients' rights
• Enforcement of fair play
• Health care is a technical service and an ethical
  vocation
• Guaranteed free access for licensed providers to
  the healthcare market

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Main Philosophial Changes

• Increased responsibility of health insurers for
  the purchase of health care and the financial
  protection of the patient
• Increased responsibility of providers for health
  care provision
• Increased responsibility of patients for their
  health

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Health Care

• Basic principle
• Health care is a technical service and an ethical
  vocation

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Clear definitions and rules

• Definition of procedure "lege artis"
• Definition of urgent treatment
• Definition of informed consent
• Access to and provision of medical records and
  protection of patients' personal information
• Catalogues of actions leading to diagnosis and
  treatments leading to the cure of illnesses (see
  the law on scope)
• Integrated European Charter of Patients' Rights
  (e.g. the right to choose a provider, to
  respectful treatment of patient by doctor, to
  information on their health condition,...)
• Principles of bioethics (transplantation,
  sterilisation, biomedical research)

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Health insurance

• Respects
• solidarity
• ability to pay
• Must ensure
• universal coverage without regard to the social
  status of the recipient

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Health insurance
Public health insurance (solidarity) Emp 104
Scope set by special legislation, compulsory
Individual health insurance
Covers individual needs, optional
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Redistribution according to rating of costs (risk)
Objective for all insured to have access to an
equal volume of resources corresponding their
risk rating
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Healthcare legislation and supervision of health
care

• Health insurers
• Duty to provide health insurance
• Option of individual insurance
• Option of sickness insurance
• Transformation of the current public institutions
  into joint stock companies
• Supervisory office
• Issues permission (licenses) to health insurers
• Monitors the solvency of health insurers
• Supervises and monitors
• whether insurers have purchased health carein
  the scope required by law
• whether providers have provided it "lege artis"

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Multiple insurers yes or no?
SELECTION
SELECTION
SELECTION
REDISTRIBUTION
PURCHASE OF HC
PURCHASE OF HC
PURCHASE OF HC
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Instruments of Purchase
Selection of provider by quality and price

• Health insurance provider

Quality standards
The law does not stipulate the payment mechanism
to be used
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Objective to increase the responsibility of the
insurer
Patient Management
Hospital
Patient
Health insurance provider
MD (GP, Specialist)
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Healthcare Emergency Services

• Part of the integrated emergency system (IES)
• Organisation of a network of healthcare emergency
  services so that in cooperation with IES, 98 of
  citizens can be reached in under 10 minutes

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Healthcare Providers Act

• Basic principles
• Ensure free access to authorised (licensed)
  providers
• Transfer the performance of first level state
  administration to professional bodies
• The act contains an ethical codex for providers,
  obligation to provide lifelong learning and
  monitoring
• Transforms the largest hospitals into joint stock
  companies whose shareholders will be
  universities, towns and regions

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Act on Scope

• Basic principle
• Equal care for equal need

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List of citizens' priorities
source FOCUS, January 2004
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Categorisation criteria ( 9)

• The categorisation of diagnoses takes into
  consideration
• the seriousness of the illness,
• the ability of diverse groups of patients to
  cofinance their treatment
• - the amount contributed by the insured can
  depend on symptoms, age and the priorities of
  health policy.

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Catalogues of actions
Establishment of a standard diagnostic and
therapeutic procedure(Act on Health Care)
Actions leading to the diagnosis of
illness(diagnostic actions)
ILLNESS
Actions leading to the cure of illness
(treatment actions)
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Categorisation model
ACTIONS
1 2 3 ... cca 9 000
ILLNESSES
- actions fully covered
- actions not covered
- actions partly covered
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Social Balance

• The amount that citizens contribute does not
  change,
• but the structure of expenditure changes
• according to priorities.

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Categorisation Model in Use
1 2 3 ... cca 9 000

• Critical risks
• financial protection of patients against the risk
  of high costs
• urgent treatment
• chronic illnesses

ILLNESSES
???????????
High level of cofinancing ? ?
insurers
5
??????????????????? Low level of
cofinancing ??????????????????
Optimal level ? Cofinancing ?
???
3
3
the ministry
experts
- payment by pulic insurer
- cofinancing by patient
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Patient's responsibility

• Specification of the patient's responsibility for
  prevention and adherence to the treatment
  programme
• The health insurer has the right
• To enforce claims against the insured for
  repayment of costs of health care where it was
  demonstrably provided as a result of a breach in
  a treatment programme or the use of an addictive
  substance,
• To pay the insured partial costs corresponding to
  the cofinancing by the patient if the insured
  regularly receives a preventative check-up,
  innoculations and follows a healthy lifestyle.

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Role of political decisions

• What resources?

Increase effectiveness and decrease the
expectations of citizens
Efficiency
Netherlands
Slovakia
What benefits ?
1,000
0,612
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NEW PLAYERS
Supervisory office
HI Supervision
HI Supervision
Finances
Health insurer
Providers
Finances
of Health Care
Scope
Permission
Licence
Prof. Bodies
Regional govt., SR MH
Licence
Permission
Finances
Emergency services
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... ??? ...
We're lucky that the hole is not on our side
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THANK YOU FOR LISTENING

• We welcome your comments
• and you can obtain further information from
• www.zdravotnictvo.sk
• and
• www.reformazdravotnictva.sk