Beating the system

Last year a Śląska ambulance doctor treated a patient for a head injury. The next day the doctor treated the same patient for a chest trauma. The day after that a leg injury. Next the doctor found an object in the patient's right eye, diagnosed a hand injury and finally the patient was said to have fallen down a flight of stairs. This patient, registered with the Śląska Patients Fund (ŚRKCh), never suffered any of those injuries. But an ambulance services provider in Śląsk actually filed claims to ŚRKCh saying the patient did.

This type of fraud is not uncommon in Poland's 17 regional Patients Funds, set up under the last government's health care reform in 1999. But while most of the funds have been heavily criticized for poor management, corruption and their inability to properly track patient records, ŚRKCh is one of the only funds that is able to immediately recognize when hospitals are making fraudulent claims. The reason, according to the fund's director, Andrzej Sośnierz, is ŚRKCh's state-of-the-art computer system. "The data they sent us (in the above example) is obviously phony," Sośnierz said. "If the ambulance visits someone several times in one week instead of taking him to the hospital, it's crystal clear to me that it's faked. Why did it happen? They try to log as many assignments as possible, even if some of them have to be made up since we pay them per assignment."

We're watching you Three years ago, Sośnierz would not have been able to spot a hospital trying to cheat the fund. But today, ŚRKCh is putting the finishing touches on START, a computer system that allows the fund to register patients, monitor medical services and settle accounts with service providers on a biweekly basis. The system covers the region's 4.7 million residents and links the fund with 160 hospitals, spas and mental hospitals, and about 3,000 clinics and pharmacies - all of which signed contracts with the fund and are obliged to submit regular reports on services rendered. ŚRKCh is also in the process of finalizing the distribution of nearly 4.7 million patient smart cards that contain basic information about the insured. The system cost the fund about zł. 5 per person and the smart cards zł. 3 each. Patients register in a clinic, hospital or spa using their smart cards. The cards are read in a local computer and the patient receives a special coupon with his or her bar code imprinted on it. The date and results of a medical examination and the doctor's name are added to the patient's account, which is accessible after scanning the coupon's code. All new data is transmitted to the ŚRKCh's central database on a daily or weekly basis. As a result, the fund receives hundreds of pages of printouts on medical services conducted in the region, allowing it to track fraudulent. But while having the ability to sniff out counterfeit claims is crucial, Sośnierz said the fund's goal is not to check every hospital all of the time. "We just want to send a message to the medical community that we know what they're doing and sooner or later they'll start to check themselves," he said. Pharmacies are also equipped with special bar code machines that allow them to check information on prescriptions. "Thanks to information coming from pharmacies we can crack down on forgeries and this way we can lower the costs of drug refunding," said Jacek Kopocz, ŚRKCh spokesman.

In 1999, the ŚRKCh spent zł. 430 million ($102.3 million) on drug refunds. In 2000 the figure grew to zł. 554 million ($131.9 million) and last year refunding cost the ŚRKCh zł. 637 million ($151.6 million). "These figures illustrate the scale we're talking about," Kopocz said. "Now they account for 18% of our budget, so if we can lower drug refund costs by 10% - and it's possible thanks to START - it will be financially relevant." According to Tadeusz Jedynak, an analyst in the ŚRKCh's planning department whose team processes up to 800,000 patient records per month, the database has already proved extremely useful. "For instance, we can make use of a lot of information during negotiations with medical services providers and very often directors are surprised how much we know about their hospitals," Jedynak said. Some hospitals and clinics have already learned their lesson. According to Sośnierz, one of Silesia's 130 hospitals recently returned zł. 700,000 it owed for forged services. "We tell our partners: Listen, we can see you," Sośnierz said. "This is how honesty can be enforced. Obviously, it's a question of years before we reach the stage where we no longer receive reports in which a single patient has lost his left leg three times."

Racing against time But time is something ŚRKCh doesn't have. This week the Health Ministry is expected to present the details of its plan to dump the current regional Patients Funds system and reintroduce a national system centered in Warsaw. Health Minister Mariusz Łapiński has already said he would abolish all of the funds by next January and that by this summer he would issue a tender for a zł. 500 million ($119 million) national computer system to register and monitor medical services. Dominik Żochowski, director of the IT systems center at the Health Ministry, said the concept for the system is still being worked out but it could be installed by the middle of next year. As a result, ŚRKCh, which has spent three years and zł. 23.5 million ($5.59 million) implementing START, is afraid that if the ministry goes ahead with its plan not to integrate its system into the national one, all of their hard work will be wasted. "What the minister wants to do on the national basis already works in Silesia and we had visitors from Germany who praised our system," said Wojciech Jędrzejczyk, an analyst with ŚRKCh's medical services registration section. "We've built a team here and we've got implementation experience to share but that has been totally underestimated in Poland," said Tomasz Krupa, head of IT at the ŚRKCh. The fund's IT team criticized the idea of a central system, questioning its ability to process nearly 10 times as much information as the ŚRKCh's database. "One can easily assess how centrally introduced systems, such as the computer system at ZUS (the national pension office), work," Jędrzejczyk said. ZUS, which signed a contract more than five years ago with Prokom Software to build its national computer system, is still far from completing the job. As a result, the lack of a proper IT system has caused huge payment delays at ZUS. Meanwhile, Kopocz said that if necessary START could be made compatible with any other system. "We have absolute certainty (about this)," he said. It's based on a careful analysis. But Minister Łapiński, who hasn't responded to our invitations to visit the ŚRKCh, said he would dismantle everything."

Keeping them in suspense The idea to introduce a national computer system, or ORUM, isn't new. The former government toyed with the concept but never managed to agree on a framework. "It's a very difficult project and for years there have been debates on how it should work," Sośnierz said. "On top of that, the Patients Funds couldn't agree on one standard vocabulary of medical services. I support the idea to launch a national system, but from what the minister says I assume he doesn't know that START is already working and could simply be copied on a larger scale. I would personally hesitate to do it in a centralized way, though. It might be better for the minister to set up standards that individual funds would have to comply with when introducing their regional systems." The Health Ministry's Żochowski declined to comment on the ministry's plans for the regional system apart from vague promises that the ministry would use the experience gained from the implementation of START. But decisions announced earlier by the Urząd Nadzoru Ubezpieczeń Zdrowotnych (UNUZ), the health-insurance system watchdog, suggest that the government is not interested in integrating any regional systems and would do everything from scratch.

Other Patients Funds, such as the Wielkopolska fund and the Małopolska fund were also planning to introduce smart cards and systems that would allow them to monitor medical services, but the UNUZ ordered them to suspend their work. Tenders were annulled after last fall's parliamentary elections and so was the opportunity to have 10 million Poles registered in a START-like computer system. "We had plans to introduce smart cards this year," said Alicja Stachowiak, spokeswoman for the Wielkopolska Patients Fund. "We were only waiting for other funds to agree on a standard medical-services vocabulary. But UNUZ asked us to suspend the project, so we didn't even start the tender." According to Stachowiak, the ŚRKCh had more luck getting its system implemented because it started all the necessary procedures three years ago. "If the politicians who planned the (1999) health care reform lacked something it was imagination," said Jacek Kukurba, director of Małopolska Patients Fund, which was also close to introducing the smart card system. "They didn't predict that a four-year term wouldn't be enough to finalize the reform's implementation. Now the new government is talking about doing something completely new and different. It's utopia because what we should be doing now is improving the current system."

Forward to the past Health Minister Łapiński is determined to overhaul the present system and, as he puts it, regain control over public health care by abolishing the 17 Patients Funds so that order and accountability can be restored within the system. To achieve his goal of a national network, Łapiński plans to establish a centralized national health fund that would oversee the regional entities. According to recent surveys published in Rzeczpospolita daily, most Poles are critical of the Patients Funds, which they accuse of corruption and mismanagement. Generally, patients complain about poor access to medical services. But critics of the minister's plans say that the legislation means a return to central planning. "I know of public hospitals where there are three doctors per bed whereas the international standard says about one doctor per 11 beds," Kukurba said. "In the case of public hospitals (Patients Funds) often pay for 100% of the beds of which only 45% are really used. We won't get rid of it by introducing central planning."

Opponents of the government's plan also say that while many of the Patients Funds have been accused of scandalous spending practices and are struggling to stay financially liquid, the ŚRKCh, Małopolska, Podkarpacka, Wielkopolska and Warmińsko-Mazurska Patients Funds are proof that the present system can work efficiently. In 1999, when revenues from health care contributions paid to ZUS were lower than expected, the ŚRKCh, Małopolska, Podkarpacka and Warmińsko-Mazurska funds generated surpluses while the others recorded losses, according to UNUZ. In 2000 Wielkopolska joined the list of solvent funds. By last June, none of the five funds had tapped their financial reserves. In Śląska alone, the fund's number of specialist consultations increased from 8.5 million in 1999 to 15 million last year, while its number of tomography tests jumped from 53,500 before the reform to 170,000 in 2001. "But the media have been ignoring such statistics." Sośnierz said. "No wonder that the Patients Funds' image is so twisted."