Health reform report reveals true costs of care
The Council of Ministers is to discuss a potentially controversial report this week on the status of health care reforms first implemented Jan. 1, 1999.
In the report, Anna Knysok, the minister responsible for carrying out the reforms, proposes to increase individual health-care contributions from 7.5% to 9%. Under the national health-care insurance system, individual contributions are transferred to the 17 regional Patients' Funds responsible for contracting and financing medical services in the public and private sectors.
"Thanks to the report it's possible for the first time since introducing the reforms to assess what the costs of medical care really are," said Zbigniewa Nowodworska, spokeswoman for Anna Knysok. The proposed increase could cause a stormy debate within the government, since the Finance Ministry has already announced that it won't allow changes in its envisioned budget.
One of the report's main arguments for the increase is a growing demand for specialized medical services and the greater number of private health-care companies that Patients' Funds are contracting. "Private medical centers will gradually dominate the primary health-care market," Nowodworska said. "On average, they provide much better services than public companies and they care for their patients."
Last year, the Patients' Funds signed contracts with 2,668 non-public vs. 1,599 public entities. By February, the number of contracted private outpatient medical centers increased to 4,729, the Health Ministry said.
"The data is still incomplete, but we can already estimate that this year, contracts signed with non-public health centers account for 43% of all services, as compared to 20% last year," Nowodworska said. The Patients' Funds also reported an increase in the number of contracted private specialized outpatient centers, up to 2, 242 from 1999's figure of 1,246.
But this reported growth in private primary health care's market share doesn't include inpatient care. While last year the Patients' Funds signed contracts with 116 non-public hospitals, this year that number has been reduced to 110. Worse still, the Patients' Funds are continuing to prop up public institutions that did not restructure in 1999 and are even more unlikely to do so this year.
"Health-care funds shouldn't be spent on social needs, such as providing employment at all costs in places where a hospital or a clinic should be closed down for economic reasons," Nowodworska said. "But political pressure exerted on Patients' Funds by local authorities eventually makes contracts for services a tool for (aiding or retarding) restructuring."
In theory, the Patients' Funds do not need to worry about the restructuring of the public health-care sector because that is the domain of local government authorities. But a refusal to sign contracts with public institutions on the part of Patients' Funds something no fund has yet dared to do would sound a death knell for the unreformed dinosaurs.
"The Mazowiecka (Warsaw) Patients' Fund planned to sign just a three-month contract with several of Warsaw's public hospitals to let them know that the transition period was over," Nowodworska said. "But pressure exerted on the fund was so strong that it gave up" and the three-month contracts were extended to one year.
Last year, in accordance with the health insurance law, all Patients' Funds were obliged to sign contracts with public health centers regardless of their financial condition to give them time to adjust to the reforms. Such protectionist practices have continued this year. "I know hospitals that deserve better contracts and more money (and) are suffering because of the losers," Nowodworska said. "We're disappointed that the impact (of Patients' Funds) on the reform of the ailing public hospitals has turned out to be so great."
Marek Krobicki, the director of the formerly state-owned Szpital Bonifratrow, last week failed to renegotiate his hospital's contract with the Malopolska Patients' Fund. He said that private inpatient medical companies like his are still underutilized by the reformed system. "Under the current situation, increasing health-care contributions is not an ideal solution to the financial problems of the health-care system in Poland," he said. "We also need fewer politics and (more) transparency during the contracting process, and a better monitoring of the funds' effectiveness in spending."
The Malopolska Patients' Fund's decision-making council contains only two doctors and 19 local-authority representatives, who according to Krobicki are not likely to take risky decisions. "Hospitals and clinics, which have already become reliable partners due to the serious changes they have undergone, deserve better contracts, which allow for further restructuring, " Krobicki said.
The shape of future health-care reform depends partly on difficult political decisions, which may not be made before the next presidential and parliamentary elections. "Politicians don't make risky and costly decisions if they don't have at least several years in power ahead of them," Krobicki said.
In addition, the fate of the Patients' Funds rests with the Social Insurance Office (ZUS), whose transfers of individual health-care contributions to particular funds last year were chronically late due to the introduction of a new computer system. In 1999, ZUS transferred 96.5% of contributions to the funds. "As a result of the reduced collection rate ... the funds started the new year with a more than zl. 1 billion ($256 million) budget deficit," Nowodworska said. They survived thanks to a zl. 1 billion state budget loan.
"With that knowledge, we planned a 2000 budget based on a 95% collection rate, but after consultations with ZUS we updated our plans," Nowodworska said. Based on a 96.9% collection rate, the Patients' Funds' 2000 budget amounted to zl. 22.4 billion ($5.09 billion). "At the time when we were introducing the health-care reform, we mistakenly expected no problems with ZUS," Nowodworska said. "This year ZUS is doing better and our transfers are not in danger."
