Health Reform - will the government take doctors' advice?
Significant reform of the national health service, say experts, will inevitably not only mean bankrupt hospitals and jobless healthworkers, but also a rude awakening for Polish citizens. Even a substantially reformed health service would be unable to afford to provide universal, unlimited, high-standard health care out of the 30 billion zloty annual budget. Yet access to unlimited, high-quality state healthcare is seen by many as a constitutionally enshrined right, and the government may prove unwilling to be the messenger of disillusion.
Following a decision of the Constitutional Tribunal on January 7, which rejected the existing model for the National Health Fund (NFZ) as being unconstitutional, the issue of public health reform has assumed even more urgency than before. The government now has one year before the present arrangement loses legal validity.
A leading group of doctors and academics, including Krzysztof Bukiel, the leader of the General Association of Professional Doctors (OZZL), University of Wrocław Professor of Economics Wojciech Misinski and Piotr Gerber, the president of the Polish Union of Private Hospitals, has come up with comprehensive reform proposals. There proposals are supported by both the National Chamber of Commerce and the Medical Circles Alliance. There are plenty of other experts in the field willing to advise the government, but the degree of influence that practicing professionals will have on the final product will almost certainly be minor.
According to Stanisław Borkowski, director of the health department at PZU, Poland's best known insurance company, the State health service's chronically accumulating deficit (now estimated at about 9 billion złotys) is guaranteed to continue to swell, unless the national health system can remold itself to accommodate market dynamics.
"Being a system of limited financial contributions, offering unlimited benefits, the current system simply guarantees that the demand for services will always be greater than what is available, thus ensuring an inbuilt deficit," says Borkowski.
Health experts cite three main models as a solution to the problem. In the German, Dutch and Belgian 'opt out' models, those who choose to pay for private insurance may opt out of contributions to the national system. Under the British 'alternative' system, meanwhile, every citizen contributes to the state health service, regardless of whether he buys services on the private market as well. The French system requires that citizens pay part of the fees for certain health services, the rest being funded by the state.
The proposals of the reforming group centered around Wojciech Misiński and Krzysztof Bukiel do, however, support a solution modeled on the existing reform of the pension system, as does medical expert Adam Kruszewski, investment director at Enterprise Investors, Central Europe's biggest Investment Fund. Under these proposals, the state health insurance fund would simply become one of many insurance options operating on a competitive market. Citizens would pay national health insurance contributions not to a state fund, but to independent health insurers of their own choosing. Insurers would be refunded the costs of basic medical services at price levels fixed by parliament. Additional - or better quality - health services could be purchased for additional payments made either directly to hospitals or to independent health insurers.
Equally central is the question of restructuring the National Health Fund's relationship with health providers. The current ambiguous role of the National Health Fund, which operates simultaneously as a health insurer for the citizen and as a bottomless piggy-bank for debt-sunk hospitals, is widely considered as disastrous. Adam Kruszewski is one of many who stress that the National Health Fund, just like any other insurer on the market, should deal exclusively with the interests of its insurees, and not with the financial problems of health providers.
Quite separate from the debate surrounding the role of the National Health Fund is the issue of how funds will be distributed to state hospitals. Proposals supported by both Misiński and Bukiel recommend replacing the existing arrangement, in which funds are allocated to hospitals on the basis of central decisions, by a system where any hospital which fulfils established qualifications is eligible for funds.
And then there is the painful question of what should be done about inefficient hospitals. A recent report by the Supreme Auditing Chamber found that as many as 60 percent of beds at certain hospitals are used inefficiently. It also states that some 30 percent of funds allocated to state funded hospitals are managed ineffectively.
"Most Polish hospitals date from a time when hospital stays were much longer," says Piotr Gerber, "which has resulted in the current over-supply of beds." He goes on to add that hospital stays in this country are still sometimes more than twice as long as in the West.
"What we need is a total restructuring of the hospital system, allowing hospitals to compete for both funds and patients, and thus ensuring greater efficiency," he says.
The government's cheapskate approach to the list of refundable medicines, which make up about one third of the whole budget, is another target for criticism. The government's favoring of cheaper generics is not cost effective in the long term, say experts in health systems analysis. Since the government has very limited resources, their argument goes, the principles of pharmaceutical economics clearly demonstrate that the priority should be to prescribe effective drugs, even if they do cost more. The prescription of second class drugs, on the other hand, which may not be effective and could eventually lead to a stay in hospital, will cost the state much more in the long run.
There is no shortage of informed advice, but what shape the reforms will finally take is quite a different matter. Details of government health reform plans are still unknown, but are already widely feared in the industry. According to both Krzysztof Bukiel and Adam Kruszewski, the health ministry is unlikely to take the advice of health professionals. An equally gruesome possibility, however, is the implementation of professional proposals which are both partial and selective.
Recent steps taken towards the creation of a legal framework for private health insurers suggest that the government may indeed decide to introduce some element of private funding into the national health service. However, there are fears that by shying away from total restructuring, the government may in this way try to push private health insurers into financing unreformed health providers.
Meanwhile, a Government bill currently in parliament that plans to turn hospitals into limited liability companies, thus effectively forcing inefficient institutions into bankruptcy, has undergone a cushioning process, meaning that such institutions will be allowed to shift significant proportions of their debt on to their suppliers. This will indeed soften the blow for hospital employees, who recently demonstrated against the plans, but only by "hitting hard on drugs companies and small suppliers," says Adam Kruszewski.
"The government doesn't know what it wants," says Krzysztof Bukiel. "They say they want to introduce market dynamics, but they don't want to suffer the social consequences. We have to decide whether we want our hospitals to provide good healthcare to citizens, or just to provide jobs for the potentially unemployed,"
The government's press spokesman has been unavailable for comment on a daily basis.
Following a decision of the Constitutional Tribunal on January 7, which rejected the existing model for the National Health Fund (NFZ) as being unconstitutional, the issue of public health reform has assumed even more urgency than before. The government now has one year before the present arrangement loses legal validity.
A leading group of doctors and academics, including Krzysztof Bukiel, the leader of the General Association of Professional Doctors (OZZL), University of Wrocław Professor of Economics Wojciech Misinski and Piotr Gerber, the president of the Polish Union of Private Hospitals, has come up with comprehensive reform proposals. There proposals are supported by both the National Chamber of Commerce and the Medical Circles Alliance. There are plenty of other experts in the field willing to advise the government, but the degree of influence that practicing professionals will have on the final product will almost certainly be minor.
According to Stanisław Borkowski, director of the health department at PZU, Poland's best known insurance company, the State health service's chronically accumulating deficit (now estimated at about 9 billion złotys) is guaranteed to continue to swell, unless the national health system can remold itself to accommodate market dynamics.
"Being a system of limited financial contributions, offering unlimited benefits, the current system simply guarantees that the demand for services will always be greater than what is available, thus ensuring an inbuilt deficit," says Borkowski.
Health experts cite three main models as a solution to the problem. In the German, Dutch and Belgian 'opt out' models, those who choose to pay for private insurance may opt out of contributions to the national system. Under the British 'alternative' system, meanwhile, every citizen contributes to the state health service, regardless of whether he buys services on the private market as well. The French system requires that citizens pay part of the fees for certain health services, the rest being funded by the state.
The proposals of the reforming group centered around Wojciech Misiński and Krzysztof Bukiel do, however, support a solution modeled on the existing reform of the pension system, as does medical expert Adam Kruszewski, investment director at Enterprise Investors, Central Europe's biggest Investment Fund. Under these proposals, the state health insurance fund would simply become one of many insurance options operating on a competitive market. Citizens would pay national health insurance contributions not to a state fund, but to independent health insurers of their own choosing. Insurers would be refunded the costs of basic medical services at price levels fixed by parliament. Additional - or better quality - health services could be purchased for additional payments made either directly to hospitals or to independent health insurers.
Equally central is the question of restructuring the National Health Fund's relationship with health providers. The current ambiguous role of the National Health Fund, which operates simultaneously as a health insurer for the citizen and as a bottomless piggy-bank for debt-sunk hospitals, is widely considered as disastrous. Adam Kruszewski is one of many who stress that the National Health Fund, just like any other insurer on the market, should deal exclusively with the interests of its insurees, and not with the financial problems of health providers.
Quite separate from the debate surrounding the role of the National Health Fund is the issue of how funds will be distributed to state hospitals. Proposals supported by both Misiński and Bukiel recommend replacing the existing arrangement, in which funds are allocated to hospitals on the basis of central decisions, by a system where any hospital which fulfils established qualifications is eligible for funds.
And then there is the painful question of what should be done about inefficient hospitals. A recent report by the Supreme Auditing Chamber found that as many as 60 percent of beds at certain hospitals are used inefficiently. It also states that some 30 percent of funds allocated to state funded hospitals are managed ineffectively.
"Most Polish hospitals date from a time when hospital stays were much longer," says Piotr Gerber, "which has resulted in the current over-supply of beds." He goes on to add that hospital stays in this country are still sometimes more than twice as long as in the West.
"What we need is a total restructuring of the hospital system, allowing hospitals to compete for both funds and patients, and thus ensuring greater efficiency," he says.
The government's cheapskate approach to the list of refundable medicines, which make up about one third of the whole budget, is another target for criticism. The government's favoring of cheaper generics is not cost effective in the long term, say experts in health systems analysis. Since the government has very limited resources, their argument goes, the principles of pharmaceutical economics clearly demonstrate that the priority should be to prescribe effective drugs, even if they do cost more. The prescription of second class drugs, on the other hand, which may not be effective and could eventually lead to a stay in hospital, will cost the state much more in the long run.
There is no shortage of informed advice, but what shape the reforms will finally take is quite a different matter. Details of government health reform plans are still unknown, but are already widely feared in the industry. According to both Krzysztof Bukiel and Adam Kruszewski, the health ministry is unlikely to take the advice of health professionals. An equally gruesome possibility, however, is the implementation of professional proposals which are both partial and selective.
Recent steps taken towards the creation of a legal framework for private health insurers suggest that the government may indeed decide to introduce some element of private funding into the national health service. However, there are fears that by shying away from total restructuring, the government may in this way try to push private health insurers into financing unreformed health providers.
Meanwhile, a Government bill currently in parliament that plans to turn hospitals into limited liability companies, thus effectively forcing inefficient institutions into bankruptcy, has undergone a cushioning process, meaning that such institutions will be allowed to shift significant proportions of their debt on to their suppliers. This will indeed soften the blow for hospital employees, who recently demonstrated against the plans, but only by "hitting hard on drugs companies and small suppliers," says Adam Kruszewski.
"The government doesn't know what it wants," says Krzysztof Bukiel. "They say they want to introduce market dynamics, but they don't want to suffer the social consequences. We have to decide whether we want our hospitals to provide good healthcare to citizens, or just to provide jobs for the potentially unemployed,"
The government's press spokesman has been unavailable for comment on a daily basis.
