Under the knife
By : Anna KociNska
Poles could find themselves facing another overhaul of the national healthcare insurance service after the Democratic Left Alliance (SLD) (http://www.sld.org.pl) announced last week it will dismantle Patients' Funds (http://www.kasa-chorych.gov.pl) and strengthen the health minister's grip on medical care if it wins the September parliamentary elections.
The Civic Platform (PO) and the Peasants Party (PSL), both high in the opinion polls, also favor abolishing the current system of 17 regional Patients' Funds, which are widely criticized for being ineffective and overly bureaucratic.
"We will create four to six regional funds with their management appointed by the health minister," said Seweryn Jurgielaniec, an SLD MP, doctor and deputy head of the parliamentary health committee. "The existing Patients' Funds created states within the state and introduced health policies on their own, so we propose that the minister should have direct control over the entire system."
While the Health Insurance Supervision Office (UNUZ) monitors the Patients' Funds now, under the SLD plan, the Health Ministry (http://www.mz.gov.pl) would set up a new department to oversee the financial operations of the four to six regional funds. The minister would then establish standard medical-service fees for every hospital and clinic throughout Poland. SLD is giving itself two years to implement the changes.
The proposal prompted serious criticism last week, especially among Solidarity Election Action (AWS), which in a coalition with the Freedom Union (UW) introduced the healthcare reform in January 1999. "Introducing new solutions now, when patients and doctors have just learned how to act under the system, is extremely irresponsible and harmful," said Deputy Health Minister Anna Knysok, who carried out the reform.
The Patients' Funds system was supposed to give patients more choice, better care and faster service than under the previous system. Under the old model, funds were distributed from the central government to the Health Ministry, which then doled out cash to hospitals and clinics without regard to patient levels or types of treatment provided.
This cumbersome, communist-era healthcare insurance system was replaced by the 17 regional Patients' Funds. Under this system, individual contributions (deducted from personal income taxes) are transferred to the funds, which are then responsible for contracting and financing medical services in the public and private sectors. Critics have accused the funds of being too politically driven and not as transparent in the contracting process as they ought to be. Spending practices have also come under fire. In addition, critics complain about the mounting bureaucracy within the funds, which employ 3,500 people.
But SLD's proposal met with disapproval by those who had earlier criticized the blunders of the fledgling system.
"Creating a new system only two years after the introduction of the previous one is a way to create total chaos," said Tadeusz Zielinski, member of the parliamentary health committee and the Freedom Union (UW). "If I were friendly toward SLD I would advise them not to do it because they are going to get themselves into trouble. Instead, we suggest improvements to the current (system)."
He also accused SLD of mimicking the ideas of others and dismissed last week's proposal as electoral rhetoric. "They say they will create funds, but we already have funds and we call them Patients' Funds," he said. "And we (UW) also proposed to diminish the number of Patients' Funds but this amendment was rejected by the Sejm."
Meanwhile, Jurgielaniec said SLD would employ personnel from the present system in the new funds. "The funds will simply take over the Patients' Funds' role to contract medical services," he said. "So there will still be some market economy in (the changed system)." SLD's proposal to raise the contribution rate for healthcare insurance from 7.75% to 9% isn't new either. Knysok proposed the same increase last year.
Meanwhile, industry insiders throughout the country are not taking SLD's announcements too seriously.
"I'm not even taking into account that (there would be no Patients' Funds)," said Marek Krobicki, director of Krakow-based hospital Szpital Bonifratrow Sw. Jana Grandego. "What they say is only politics. Introducing a new system will only add to the current problems and it's not a good method to ruin what was created at such cost." Szpital Bonifratrow, once an ailing state-owned hospital, was returned to its original owner, the Order of St. John of God, almost 50 years after it had been nationalized. Today it provides private medical services and has a contract with the Malopolska Patients' Fund. "Besides, what they say is only playing with names," Krobicki said. "You can always merge five Patients' Funds and call them a fund."
For its part, the SLD said it isn't simply proposing cosmetic changes. It intends to finance massive investments in healthcare via the state budget and block the privatization of hospitals and clinics proposed by Knysok (see the WBJ, June 4-10). "We are against the privatization of hospitals, it's unacceptable," Jurgielaniec said. "We don't rule out, though, the possibility of closing down those state-owned hospitals that prove unnecessary in particular regions."
SLD is also proposing to standardize medical-services fees. At present, rates are agreed upon following painstaking negotiations between the Patients' Funds, hospitals and outpatient clinics. "We need one fee for the same service throughout Poland because those services do not differ, no matter where they are provided," Jurgielaniec said. The fixed fees would be established by the health minister, he added. Critics said that SLD's plan to standardize hospital fees is unrealistic and would mean a return to central planning. "What we need is a transparent and clear system for the way those fees are calculated but they cannot be equal everywhere in Poland," Krobicki said.
Alicja Stachowiak, spokeswoman for Poznan-based Wielkopolska Patients' Fund, said the fees must differ because costs of living and wages differ throughout the country. "And healthcare infrastructure also differs in Poland," she said. "While in Wielkopolska a great part of outpatient clinics have been privatized and thus depend very much on market conditions, other regions are in a different situation."
UW's Zielinski was skeptical about SLD's plan. "They only benefit from the current system's weaknesses and the fact that it's rather badly perceived by society," he said. "But was the old system praised?"
