Not what the doctor ordered

After almost a year in office, Health Minister Mariusz Łapiński has done little to soothe the concerns of private healthcare providers, whose worries about his plan to scrap the three-year-old regional Patients Funds healthcare system and return to a Warsaw-centered model have reached a fevered pitch in recent weeks. They're afraid that Łapiński's goal of recentralizing healthcare would favor public healthcare institutions, particularly those that have close political connections with the Health Ministry, leaving no funds available for private companies. As a result, doctors groups, such as the Bielsko-Biała-based Non-public Healthcare Employers Association, have launched a battle to defend their interests. In numerous appeals to politicians of all colors, private healthcare providers complained that they still had no detailed information about the ministry's plans except for general statements about its intention to abolish the 17 Patient Funds and replace them with a single fund controlled in Warsaw. When the previous government in 1999 set up the current regional healthcare system, the aim was for both public and private providers to benefit from healthcare-tax contributions to the state. As a result, many private healthcare practitioners set up shop believing they could lure patients from public institutions by providing better quality service. "So far, both the Silesian Patients Fund and the local government have run a similar policy," said Leszek Berezowski, the chairman of the Non-public Healthcare Employers Association. "They almost forced financially ailing public institutions to privatize. Many doctors set up businesses because we trusted that the new system would support us. And, so far, patients have benefited from the changes introduced by the 1999 reform because we have real competition now." According to doctors from the Silesian Patients Fund who asked not to be named, private healthcare investments have stopped since the Health Ministry announced its plan to dump the regional system next January. "We are not investing, and many of the Patients Funds are not starting contracting procedures for specialist services (which are dominated by private providers)," one source said. "We're all waiting."

Beyond the facade Under the minister's still murky plans, individual 7.5% contributions deducted from personal income taxes would flow to Warsaw's central budget and be distributed to the regional departments of a new National Healthcare Fund. Instead of the current system's 17 directors overseeing funding contributions for their own regions, the health minister would have the power to allocate healthcare funding for the entire country. Private healthcare providers fret that the new system would make it difficult for cash to flow from public channels to private medical companies, and that local governments, which would be responsible for their own healthcare budgets, would favor state-owned institutions. The Health Ministry, which had planned in July to finalize the new law scrapping the Patients Fund system, is now battling rumors that Łapiński might be sacked even before his draft bill is discussed by the government. Industry sources said that the bill has met with strong criticism from both other ministers and the medical community alike. Off the record, politicians say that Łapiński might have gone too far. Even before last September's parliamentary elections, the victorious Democratic Left Alliance (SLD) had said it would reduce the number of insolvent Patient Funds, describing them as "states within states," and that the new minister would strengthen his grip on the entire system. On the record, though, deputies are more careful in evaluating the minister's plans. Most private doctors were also reluctant to express their concerns, saying they feared punishment if they were too critical of the minister's plans. "We're getting signals we could be persecuted," according to a source who asked not to be named. "We cannot afford attacks against the ministry; the adversary is too strong. Even politicians from the ruling SLD who criticize Łapiński admit that the SLD parliamentary club would vote for his plan anyway." But other doctors said they've been sending their criticisms to the Sejm and Senate health committees in the names of numerous medical associations to which they belong. They are also trying to create national lobbying groups to defend their interests.

Stating the obvious Representatives of the Non-public Healthcare Employers Association arrived in Warsaw last week to meet their peers from similar organizations and to talk to Sejm deputies about the reform. "We're scared," said Berezowski, who also owns a private medical center and a surgical ward in which he's invested zł. 10 million ($2.43 million). "My family's entire property served as collateral to get the bank loans. We have no clear picture of the minister's program, we know nothing about the future contracting methods, and the minister's draft law keeps changing. We've seen several versions of his program so far, but the important details remain unknown." Teresa Gilowska, one of the association's 700 members, said she had come to Warsaw to defend the 1999 reform's main achievement - decentralizing healthcare financing. "With the 1999 reform, healthcare in Poland is no longer financed from the budget," she said. "It seemed that politics will no longer decide about disbursing funds. We're afraid that private doctors will not be treated in the same way we are now and that it would lead to our bankruptcy." Under the current system, all 17 Patient Funds contract medical services with both public and private centers on the basis of price and quality. In the past three years, the number of non-public clinics and medical centers contracted by the Patient Funds has grown. As of June 2002, the Patient Funds had contracted more than 14,000 non-public healthcare providers and nearly 12,000 public ones, according to estimates by Urząd Nadzoru Ubezpieczeń Zdrowotnych (UNUZ), the government's healthcare watchdog. In Silesia, where Gilowska owns an outpatient medical center and employs 30 people, healthcare, apart from hospitals, is almost entirely privatized. In 1999, there were 670 non-public healthcare providers that signed contracts with the Silesian Patient Fund (ŚRKCh) as opposed to 231 public entities. So far this year, there are 2,157 private medical companies vs. 243 public institutions that have contracts with the ŚRKCh. Some 9,000 doctors are employed by private healthcare providers, accounting for 42% of the total number of doctors in the Silesian region. "One national fund distributing all healthcare funding?" Berezowski said. "We've had that before, so we would be going back to what we had before the reform. There is really nothing to talk about. We agree that there are lots of things that need to be corrected and improved, but you don't ruin all you've created to improve it. You simply copy the best parts in the entire system."

New breed of doctors Family doctors, who under the 1999 reform were meant to make up for the dominance of specialists, are also concerned. They were to be trained and equipped to handle a range of health issues affecting family life. As a result, there are now 6,000 family doctors in Poland, most of whom have their own medical centers. Anna Brzostowicz set up her family practice in 1995 in Kłodzko, south of Wrocław, where she provides basic medical services to 2,400 patients. After seven years, she said her business has stabilized. "I follow all the planned changes because it's 'to be or not to be' for family doctors like myself with their own businesses," she said. "I'm a little bit scared because the (minister's) program has flaws, and if they're not corrected, we'll go bankrupt." Brzostowicz worries that under the Health Ministry's draft bill family doctors will have to pay for specialist tests ordered by specialist-care doctors. "I get zł. 2 a month per patient for specialist tests, and such tests cost at least zł. 20 each, so after one year with the Patients Fund, a typical patient cannot afford the cheapest specialist test," she said. "I can barely afford to pay for the tests that I prescribe, so I really don't know what happens if the new law goes into effect." Brzostowicz belongs to the Family Doctors Group. The group's chairman, Adam Windak, is preparing a statement about the proposed legislation. "There are a lot of things we don't like in the (minister's) program," he said. "First, the program will result in the further monopolization and centralization of the market. We have only one contractor (Patients Fund) in the region because the (1999) Parliament didn't approve the introduction of competition, such as private funds. Now we'll have one only contractor for the entire country!" Windak doubts that the medical community's opinions will have much of an impact on the Health Ministry's plans. "Our statement wouldn't matter a lot," he said. "So far, our opinions haven't been taken into account, but we'll send them to the Sejm and Senate anyway."

Reasonable proposal Łapiński's plan does have supporters, including a number of doctors. Piotr Olźdzki, the chief executive officer of Medycyna Rodzinna, a network of 12 medical centers with 140,000 patients, said the minister's plans are reasonable. "One needs to support reasonable proposals, and this is a reasonable proposal," Olźdzki said. "When I look at Łapiński, it's obvious he's the kind of minister who really wants to do something. To be able to introduce a universal system of standard medical-service fees, we need one national fund. It will be this fund that will fix the contracting rules and will contract services at the same time. And unlike the 1999 reform, the changes proposed by the ministry will not result in a revolution. Patients and healthcare providers will practically see no difference." Olźdzki was skeptical about the possibility of introducing a universal system for the existing 17 Patient Funds. "It's impossible because the funds are too sensitive to the influence of local communities," he said. "Poland is the kind of country where someone has to dictate the rules."