NEWS  ASSOCIATION  MEMBERS  FUTURE MEMBERS  OSSN STATUTE  CONTACT  PO POLSKU		Wrocław, 23 June 2003 The position of OSSN regarding changes to the system of healthcare in Poland (based on the position presented by the National Union of Doctors (OZZL) The system of healthcare in Poland must be: safe, reliable, varied, quality-based, and autonomous. Safety of the system means that each patient covered by the system will receive prompt and adequate medical assistance within the scope of guaranteed services and without incurring any additional costs not required by law. Waiting lists for medical services are only justified and permissible in case of natural constraints, such as limited number of appropriate transplant donors. Reliability means that all system participants (citizen, service provider, and the Payer) have specific laws and obligations and there are procedures for mutual assertion of their rights, ultimately by legal course. Variety of the system is a natural response to the various expectations of the public. This variety must be evident in the offers of both the Payer and the entities providing medical services. The system shall be quality-based by means of mechanisms favouring the purchase by the Payer (patient) of highest-quality services throughout the course of medical treatment. For an autonomous system the flow of money must be separated from political influences and the service providers must be responsible for their services. The primary condition for the functioning of a system of medical care which is safe, reliable, autonomous, and varied is its rooting in health insurance companies which will compete with one another for the premiums of the insured. This solution guarantees depoliticization of the system which will be run by competent professionals judiciously spending citizen's money rather than by people arbitrarily appointed by political parties. The construction of a safe (efficient) healthcare system requires mechanisms which would balance supply and demand for healthcare services. This requires the following: an appropriate organization of health services, including the financing of individual service providers by the Payer, and a reliable Payer. Proper organization of health services must ensure maximally economical provision of medical care while preserving an appropriate quality of services. It must also adjust flexibly to the needs of the patients, thus ensuring an appropriate allocation of resources. The above-mentioned conditions will be best met if there is competition among health service providers to win the patient and the resultant money allocated to healthcare. Appropriate competition among service providers is primarily assured by equal rights of all entities providing health services, irrespective or their organizational status or ownership structure. The acceptance of the above assumptions shall result in the following: Service providers shall be financed on the basis of actually provided services, according to the signed agreements, and not on the basis of budgets awarded to service providers. No service provider can be discriminated against or privileged in entering agreements on the provision of refundable services. Each entity allowed under the current legislation to provide specific medical services shall be allowed to provide medical services refunded by the state health fund, as long as the provider accept the terms of reimbursement. Because there is only one Payer, the above principle stands in contrast to the current practice of the selection of offers. The selection procedure is in fact a concealed form of voluntary licensing of service providers by the Payer which forces them to accept disadvantageous contract terms. Each service provider shall receive from the Payer the same price for the same service (irrespective of its definition) - this principle shall be observed at least at regional level. The price for a given service (irrespective of its definition) shall include all items contributing to the cost of service, including depreciation of equipment and buildings, which until now has not been taken into consideration during the contracting of services by regional health funs or the NFZ. The omission of the above items from price calculations resulted in different treatment of public entities (which received additional investment funds from taxes) and private entities, the latter of which had to fund investments with money obtained from the sale of services. The price calculated according to the above principles shall be subject to market verification. The patient shall have a free choice of his service provider. The Payer, civil servant, and the current law must not limit in any way the number of reimbursable medical services provided by a given service provider. This includes both direct limitation through definition of the maximum number of services and indirect limitation through definition of the maximum amount of money allocated to a service provider. Any shortage of the Payer's money shall be regulated using the methods applied by insurance companies (change of premium or contribution by the patient) while maintaining competitiveness among Payers. The principle of equal rights and free competition among service providers stands in contrast to e.g. the concept of hospital chains, the issuance of the so-called certificates of legitimacy for new hospitals, and the proposed (regional and national) medical protection plans, developed by public authorities and providing the basis for the contracting of services by the (monopolistic) Payer. The above objection does not cover forecasts and estimates of the number and scope of necessary services and - consequently - the requisite money, prepared by any Payer for his internal needs. In order to facilitate equal treatment of all entities providing medical services, their legal status must also be standardized. To foster competitiveness among entities, the best legal form for the existing healthcare establishments (both public and private) will be commercial law company, subject to all commercial regulations (including the statute of bankruptcy, uniform cost accounting, etc.) The adoption of this legal form only defines the "mechanism" of the functioning of medical establishments and does not eliminate their unique status as healthcare provides. This unique status shall be reflected in detailed regulations of the service quality, the premises, the equipment, and the professional qualifications of the personnel. Most importantly, the medical personnel must exhibit high moral standards but this, for obvious reasons, cannot be regulated. The principle of equal rights of service providers is also at odds with the concept of fixed definition of the scope of health services that can be provided by individual establishments, e.g. the ban on combination of primary healthcare with hospital or outpatient clinic treatment. Also, the organization of services must not be based on a single model, e.g. of an establishment providing the so-called integrated assistance. Another guarantee of the efficiency of healthcare system is an appropriate valuation of individual services. The presence of competing health insurance companies in the financing of healthcare services guarantees an appropriate valuation, because different Payers are vying with each other to win the insured and the service provider. When there is a monopolistic Payer (such as the health fund for the region or the NFL for the whole country), special procedures must be introduces to establish prices for individual services. Most importantly, the principle must be observed that the running costs of the healthcare system are not transferred to the service providers. Currently, the system of medical care operates thanks to the economic exploitation of service providers and, consequently, healthcare employees. There are several ways of determining the prices in the presence of a single Payer which observe the above principles. For example, such prices can be fixed arbitrarily by the Payer but in that case service providers must be able to introduce their own prices, and any possible difference between the two prices shall be covered by the patient. If no agreement is reached on direct contribution by the patient or the value of contribution is permanently fixed, then the price paid by the public (monopolistic) Payer is subject to agreement between the Payer and the duly authorised representative of the appropriate service providers. An efficient healthcare system requires appropriate mechanisms balancing supply and demand for health services. Such mechanisms must include: legal possibility of contribution by patients to the cost of some health services ability to change the premium amount by the Payer - when there is competition among different Payers ability to vary the premium amounts for individual persons to encourage healthy lifestyles Detailed solutions concerning the above problems (cooperation; change of premium amounts; method of payment of health services, including medicines) require further consultations. The Payers must define the scope of guaranteed services. An insurance contract must ensure that the Payer meets his obligations toward the citizen. The definition of the scope of guaranteed services calls for preparation of appropriate standards to be followed during the respective procedures (medical cases, etc.). The preparation of such scope and standards must be consulted with specialists in the respective medical disciplines. Introduction of fair competition terms among health service providers will undoubtedly result in increased privatisation of public institutions. Private establishments are, as a rule, more efficient and win a bigger market share than their public counterparts if they compete on the same level. Therefore, a legal basis must be developed for the privatisation of public healthcare institutions. Privatisation of healthcare establishments must be preceded by the introduction of a sound, efficient healthcare system based on the principles presented above. Of paramount importance in the healthcare is disease prevention and promotion of a healthy lifestyle. This financial burden must be distributed proportionally between the insurers and the public authorities: the state government with respect to national programmes and the local governments with respect to the local programmes. Detailed solutions in this regard should be prepared by specialists. Healthcare Payer must be first and foremost credible and reliable. A credible Payer will pay service providers with whom he has signed contracts for all performed and justified health services. A credible Payer must not limit the number of services performed by the service providers either directly or indirectly by fixing the maximum amount of money awarded to the service providers. A credible Payer must have the tools with which he will adjust the amount of money assigned for health services depending on the requirements expressed by the insured. Those tools must include the right to change the premium amount and to fix the value of reimbursement for a given service. The powers of the Payer in this regard can be statutorily limited. A credible Payer must be reinsured against the inability to cover the costs of services as a result of an unexpected rise in medicine reimbursements, rise in the number of services, etc. The above requirements for a credible Payer are best fulfilled by competing health insurance companies. If the money for the health services comes (at least initially) from public money, the Payer credibility requires that an appropriate amount of such money should be allocated with the decision of the Parliament to medical health. The money should amount to no less than 6% GDP (this corresponds with the minimum standards set by the WHO and is followed by the majority of European countries). Neither the state nor the local authorities must be involved in the organization of health services. Instead, they should be engaged in sanitary and epidemiological activities as well as disease prevention and promotion of a healthy lifestyle. The introduction of the proposed healthcare system should be preceded by short-short-term solutions which would prevent the total disintegration of the healthcare accompanied by chaotic and unforeseen events. The most urgent problems to be resolved include: restructuring of public hospitals - in order to stop the rapidly accumulating debt equal rights of entities in their access to public money definition of the basket of guaranteed services by participation in the system of social insurance introduction of a zero VAT rate on medical services in order to limit their cost introduction of a quality factor to the contracting of medical services for the year 2004