"Q&A": Mariusz Łapiński

The Democratic Left Alliance (SLD)-led government last month approved a plan to dump the three-year-old system of regional Patients Funds and replace it with a national health fund controlled in Warsaw. The architect of the new system is Health Minister Mariusz Łapiński, who hopes that by abolishing the regional funds the ministry can gain direct control over the health care system, which he says has become too liberal and deregulated. Łapiński estimated the cost to revamp the present system at zł. 10 million ($2.5 million), though staff cuts would yield zł. 90 million ($22.5 million) in savings. Opponents of the plan, who have so far been shut out of consultations on the changes it would introduce, said Łapiński's system would mean a return to central planning. Łapiński, meanwhile, said the national health fund draft bill is nearly ready and that the new system would be in place by Jan. 1, 2003. Łapiński talked to the WBJ's Anna Kocińska about his concepts for an efficient national health care system. The following is a translated, edited version of their conversation.

Q: What model will you follow when introducing serious changes to the current system? A: We want to get out of this no-win situation of health care that we're in. What we've created in Poland is a kind of a hybrid of two systems. National health care is financed according to the German model with Patients Funds and structurally it's organized like the British budgetary system with family doctors and public hospitals.

Q: So you want to only fix the current system or replace it with something completely new? If so, what kind of system are we talking about? A: Like I said we are trying to be rational and act with great prudence but it's hard to talk about concepts for a system when there is practically no system working now. Definitely we would like to create a really universal health-care insurance system. But one thing we won't change: health care fund will remain separated from the state budget. We'll still have a body that would contract and pay for medical services. It's one of few good solutions introduced in the 1999 reform. So there will be no return to the days before 1989 because Poland is a different country today.

Q: In your national health-care program you proposed introducing one, centralized health fund instead of 17 regional Patients Funds. How would you distribute the funds? A: You call it central but it's not really. It works like a bank with local branches. Those branches are independent from the bank's headquarters. They collect money that they invest and the bank's headquarters introduces certain regulations, similar standards and procedures and that's what make this system uniform. Under the current system, such standardization is impossible because every Patients Fund has its own health policy when it comes to contracting services. You can easily find two nearby hospitals where the same medical services have different prices and nobody knows why.

Q: So to avoid such inconsistencies, we need a national fund to manage the money? A: There must be someone to manage the funds spent on health care.

Q: Someone like you, for example, since under your program the health minister would be the national fund's ultimate supervisor. Which way is easier to manage zł. 30 billion ($7.5 billion) annually, within a national health-care system or via regional funds? A: The system we're proposing is more rational. It's not that we are going to allocate funds from some central offices because those funds will stay in the regions. They will be available in specific regions, at regional health-care funds, where contracting of services will take place.

Q: So what will you need the national fund for? A: Someone must impose rational solutions. We need to make the system uniform. Nobody has done it for the past three years and we need someone to do it.

Q: Wouldn't it be easier to simply amend the health-care law and introduce changes into the current system to make it more homogeneous? A: And who would obeys the current law in the first place?

Q: Can you guarantee that someone will obey the new law? A: There must be someone who will introduce standards and that's why we're proposing a national fund that would impose similar rules for the entire country. We need similar criteria for contracting services and similar pricing of medical procedures. Introduction of a national health fund is now the quickest and most rational way to achieve these goals. Actually, there is no other solution because the system of Patients Funds is collapsing and by the end of this year we will have a huge crisis with some hospitals closing.

Q: Shouldn't you blame the directors of the Patients Funds for mismanagement? A: I blame the system, which over the past three years hasn't been properly organized.

Q: But there are Patients Funds that, according to reports filed by UNUZ (the health-insurance watchdog), are doing well and are debt free. A: You know very well that Minister (Anna) Knysok (deputy health minister in the previous government) manipulated the system. In two weeks the number of insured in the Śląska Patients Fund increased by 400,000 and that's why the fund was getting more money than others. The Śląska Patients Fund was clearly favored by the minister so it's no wonder it's the only Patients Fund that generated profits. So I wouldn't call it good management but providing forged data.

Q: So the bottom line is the system is chaotic and the Patients Funds fell short of expectations? A: The Patients Funds lost face. As a minister I have to perceive the system as a whole and not according to some regional differences. You are saying that some funds are doing well but some are in very bad shape and that produces inequality.

Q: Wouldn't it be sufficient to fix the bad elements in the current system? A: It's not that easy. We think it isn't possible to fix the current system.

Q: According to your program, the health minister will be supervising the national health fund. Aren't you afraid that you may be accused of manipulating your position? A: Do you think I will contract services at, for instance, a hospital in Zabrze? Is that what you think?

Q: I hope not. A: Going back to your charges regarding the centralization of the system. According to public opinion surveys conducted by Pentor, 50% of respondents want a centralized system and only 38% are against the idea.

Q: So you would build a system that needs to be rational and efficient according to public opinion polls? A: And what should we take into account? We simply draw conclusions from a lot of mistakes committed by the former government. There are five Patients Funds that are close to collapse and at the same time we have one fund, which has a surplus of zł. 500 million ($125 million) in a long-term bank account.

Q: Would it be better if that fund were in debt? A: But it was according to forged data that resources were allocated to that fund.

Q: Why are you so unfavorable, even hostile toward the Śląska Patients' Fund? It's the only fund that managed to introduce an IT system monitoring medical services and registering the insured. Is that a reason for criticism? A: But medical institutions in Silesia have debts of zł. 242 million ($60.5 million).

Q: It's not the Patients Funds that own the hospitals and clinics. It's local governments that own them. A: But it's the Patients Fund that contracts medical services. Under the system, hospitals are paid on the basis of the 'fee for service' rule and Patients Funds contract services in such a way that allow them to dictate the lowest possible fee for the highest possible number of services. This kills the hospitals because they try to get as many patients as possible to get as much funding as possible. In the first year of the reform, the number of hospitalizations surged by 40%.

Q: A lot of hospitals may have cheated the Patients Funds so far, but it's possible to change that if an IT system to monitor services is introduced like the one working in Silesia. A: But you have to do that on a national scale not only in one fund. Each fund has been trying to build or has been building its own system and that's why we don't have information about what's going on in the system about the flow of resources. We still don't have control over public money except for one director of one Patients Fund.

Q: In the IT system you are planning to build for the entire country, will you utilize the Silesian START system, which is now handling more than 4 million people? A: We'll pick up the most rational solution that would be binding for the entire country. There are a lot of possibilities such as using the existing identification cards (dowody osobiste) to avoid multiplying plastic cards in public use.

Q: Have you been to Silesia to see how the START system works? A: No, I haven't but I talked about the system. Why should I go anyway? A lot of experts said it's not working that well.

Q: According to computer engineers, it shouldn't be a problem to make START part of a national system. A: I'm not saying we would rule out using START and that it couldn't be absorbed by a more global system.

Q: Let's go back to your program. What is the exact model that your strategy is based on? A: We're planning to introduce a national health fund that would allow us to control cash flow and reintroduce the government's constitutional responsibility for health-care policy. Under the current system, we've assumed too liberal solutions and we've allowed for too little control over the system so we've come to a situation where nobody really controls it. There was a lot of talking about a free-market model (in health care) but there is no free market. There is no free market and the free market solved nothing in Poland.

Q: What about basic health-care clinics that used to be public but the moment they were privatized they stopped running into debts? You declared yourself that you're not going to change anything about basic health care because it's working OK. A: Nevertheless, there are places where it's not working. But we'll support current changes in basic health care. It's practically the only element of the current system where the money really tracks patients (the main purpose of the 1999 reform).

Q: What I would have to do if I owned a clinic that used to have a contract with a Patients Fund and would like to be contracted again under the system you plan to introduce? A: I'm not going to talk about such details. We'll introduce the new system as of Jan. 1, 2003 and right now we're working on the details. I won't say more than the "National Health Care" program made public at the end of March described.

Q: But all I'm asking for is a description of a general mechanism you plan to implement in Polish health care. A: We're still working on the details to be able to introduce rational solutions. Relax and wait several months until we're able to present details of the system.

Q: What role will regional branches play in a national fund? A: They will contract medical services.

Q: So there is really little difference between those branches and the current Patients Funds? A: The difference is that the branches of the national fund will contract services in a standardized way. It's absolutely crucial.

Q: Who will decide how much of the funds will flow from the national fund to the regions? A: That's something I still need to discuss with the finance minister (Marek Belka). I'm prepared for the discussion but it's too early to talk about it.

Q: How will you guarantee equal access to medical services for patients from a small town in western Poland and in Warsaw, where wages are five times bigger and the cost of living is incomparably higher? A: We want to make it equal through an appropriate management of cash flow. The state is obliged to provide equal access to medical services.

Q: How are you going to make it happen? A: I would simply prefer that the funds belonging a Patients Fund were not deposited in a bank while another fund was practically bankrupt. We cannot forget about the regions that are poor. We cannot accept a situation that somewhere people are dying because the region is poor.

Q: Please be specific and tell me how are you going to pay for contracts under the new system. A: Rationally. Details will be worked out in the near future. I don't want to talk too much about it. We'll definitely abolish the 'fee-for-service' payment model with hospitals, which caused a 40% increase in hospitalizations in 1999. Q: You will have to pass a lot of legislation in Parliament. Do you believe you have enough time to abolish the Patients Funds by Jan. 1? A: No problem.

Q: Only months before dumping the Patients Funds you want to amend a law regarding their supervisory councils. Under the amendments you'll be able to select most of the members. Why are you doing this? A: I need to regain control over the Patients Funds.

Q: This will mean more politics in health care. A: It's the government that is responsible for the health-care system. The former government felt free of that responsibility. Q: Is this why the government and not local governments will select council members? A: We're simply getting prepared to abolish the funds. I think that we should be able to take over the funds by the end of June to actually save the system from disaster.

Q: So you are first saving the funds to destroy them later? A: I could simply wait until everything collapses so that people would see we're right about what we want to do. But unfortunately we're dealing with the health and lives of people and we're not going to wait until it all falls to pieces and that's why we're saving it now. I think that eventually people will support it.