1. Ministry of Health of the Slovak Republic REFORM PUZZLE Healthcare Reform in Slovakia Ing. Peter Pažitný, MSc. Advisor to the Minister of Health MUDr. Rudolf Zajac Minister of Health 16.04.2004

2. Ministry of Health of the Slovak Republic... ???... We're lucky that the hole is not on our side

3. CONTENTS I. Stabilisation measures II. Reform puzzle III. New players Ministry of Health of the Slovak Republic 27. 01. 2004

4. 16.04.2004 Ministry of Health of the Slovak Republic I. STABILISATION MEASURES 1. The rise in drug expenditure slowed down significantly 2. Number of doctor visits declined 3. Debt growth slowed by half + 8% - 10% + SKK 4.8 bil. 2003

5. 16.04.2004 Ministry of Health of the Slovak Republic The basic hypothesis for the introduction of fees 1. Reduce unnecessary demand for healthcare services (reduce the number of doctor visits and drug consumption) 2. Reduce the degree of corruption 3. Increase patients’ co-responsibility for their health (educational character)

6. 16.04.2004 Ministry of Health of the Slovak Republic 10% decrease in the number of primary outpatient care visits (comparison of 2003/2002) Source: General Health Insurance Company, 2004

7. 16.04.2004 Ministry of Health of the Slovak Republic Only 1.5% of patients stopped visiting doctors 58.5% 18.0% 22.0% 1.5% Source: FOCUS, January 2004

8. 16.04.2004 Ministry of Health of the Slovak Republic Only 2.1% of patients stopped having medicines prescribed 54.2% 20.5% 23.2% 2.1% Source: FOCUS, January 2004

9. 16.04.2004 Ministry of Health of the Slovak Republic The rise in drug expenditure has significantly slowed down (in billions of SKK)

10. 16.04.2004 Ministry of Health of the Slovak Republic The growth dynamics of payments by health insurance companies and financial burden on the patient are declining (in %)

11. 16.04.2004 Ministry of Health of the Slovak Republic Healthcare availability has not decreased The original hypothesis has been fulfilled in that 1. Only the number of unnecessary visits declined 2. Availability of healthcare services has not decreased 3. The degree of perceived corruption has declined (from 32 to 10%)

12. 16.04.2004 Ministry of Health of the Slovak Republic II. REFORM PUZZLE Act on health insurance companies and healthcare oversight Act on health insurance Act on emergency health service Act on healthcare Act on healthcare providers and vocational organisations Act on the scope of healthcare covered by public health insurance

13. 16.04.2004 Ministry of Health of the Slovak Republic Healthcare expenditure Per capita GDP in PPP (USD) Healthcare expenditure as % of GDP Source: OECD, 1999 Source: OECD ROM IRE SVK CZ USA GER DEN ESP

14. 16.04.2004 Ministry of Health of the Slovak Republic REFORM PRINCIPLES 1. Equal care for equal need. 2. Ability to pay. 3. Universal coverage. 4. Protection of patients’ rights. 5. Enforcement of the rules of the game. 6. Healthcare is technically a service and ethically a mission. 7. Guaranteeing free access of licensed providers to the healthcare market.

15. 16.04.2004 Ministry of Health of the Slovak Republic 1. SCOPE: LIST OF PRIORITIES Basic principle: Equal care for equal need.

16. 16.04.2004 Ministry of Health of the Slovak Republic LIST OF PRIORITIES ACCORDING TO PEOPLE Disease% Cardiovascular diseases74.2 Cancer68.8 Diabetes, metabolic disorders26.2 Orthopaedic diseases16.6 Mental, psychiatric and nerve disorders and stress16.1 Flu12.1 Allergies10.9 Respiratory tract diseases8.68.6 Infectious diseases, jaundice, TBC and AIDS6.36.3 Incorrect diet, obesity6.26.2 Alcoholism, smoking, drug addiction4.64.6 Dental problems1.41.4 Skin diseases0.90.9 Gynaecological diseases0.80.8 Source: FOCUS, January 2004

17. 16.04.2004 Ministry of Health of the Slovak Republic New law on the scope of healthcare  transform the performance model into a model of a list of regular services leading to the identification of the disease and elimination of the disease (quasi DRG)  divide risk/diagnoses to those where patient participation cannot be required and those where we can require various forms of participation  make decision-making processes objective by cataloguing services and categorising participation PHILOSOPHY

18. 16.04.2004 Ministry of Health of the Slovak Republic National list of diseases (by priority) Flu J10 Fibroma pendulansL91 Acute myocardial infarctionI21 Chronic kidney failureN18 Diabetes mellitusE10 Acute lymphoblastic leukaemiaC91 DiseaseCode Dental decay K02 begin- ning end

19. 16.04.2004 Ministry of Health of the Slovak Republic National list of diseases (basic priorities) Critical risks: financial protection of patients from the risk of high costs urgent care chronic diseases

20. 16.04.2004 Ministry of Health of the Slovak Republic Cataloguing of services  creation of catalogues of justifiable services necessary for the identification and elimination of a disease  it has nothing to do with payments  a regular basis is being created – guidelines.

21. 16.04.2004 Ministry of Health of the Slovak Republic Cataloguing commission Health insurance companies Specialised companies Ministry of Health who appoints it: the ministry? government? parliament?

22. Ministry of Health of the Slovak Republic Cataloguing of services DISEASE Definition of a standard diagnostic and therapeutic procedure Services leading to the elimination of the disease (treatment services) Services leading to the identification of the disease (diagnostic services)

23. 16.04.2004 Ministry of Health of the Slovak Republic Categorisation is a division by payments and participation  Diseases – diagnoses (for now through services)  Medicinal products, drugs and dietetic food  Health aids

24. 16.04.2004 Ministry of Health of the Slovak Republic Categorisation commission Health insurance companies Specialised companies Ministry of Health

25. Ministry of Health of the Slovak Republic Categorisation model 1 2 3... 9 035 SERVICES DISEASES fully covered serviceuncovered service partially covered service

26. Ministry of Health of the Slovak Republic Current situation DISEASES 1 2 3... 9 035

27. Ministry of Health of the Slovak Republic 1 2 3... 9 035 DISEASES Categorisation model in practice Political  decisions  no. 2  Political decision no. 1  PARLIAMENT  covered by public health insurance patient’s participation

28. 16.04.2004 Ministry of Health of the Slovak Republic 2. INSURANCE ACT Basic principles: Ability to pay Universal coverage

29. 16.04.2004 Ministry of Health of the Slovak Republic 2. INSURANCE ACT Individual health insurance Public health insurance Voluntary contract exceeding the scope defined by a special law Scope defined by a special law

30. 16.04.2004 Ministry of Health of the Slovak Republic 2. INSURANCE ACT Basic theses: policyholder sends an application free choice of insurance company change possible once a year (as of 1 January) contributions paid in advance payments annual clearance of insurance contributions premiums are distributed on the basis of a risk index Annual calculation base: minimum: 12 times the minimum wage maximum: 36 times the minimum wage Rate: 14% (10% employer + 4% employee) the state pays 4% of average wage (link to the real economy)

31. 16.04.2004 Ministry of Health of the Slovak Republic 2. Insurance act Need for redistribution: we are building a system with universal coverage minimisation of “skimming the cream” or “picking the raisins out” elimination of adverse selection

32. 16.04.2004 Ministry of Health of the Slovak Republic 2. Redistribution rules  Decentralised collection of premiums Every insurance company on its own  Subject of redistribution: 95% of underwritten premiums  Volume of redistribution: 90 percent

33. 16.04.2004 Ministry of Health of the Slovak Republic 2. Risk index

34. 16.04.2004 Ministry of Health of the Slovak Republic 3. OVERSIGHT AUTHORITY Basic principles: Protection of patients’ rights Enforcement of the rules of the game

35. 16.04.2004 Ministry of Health of the Slovak Republic 3. OVERSIGHT AUTHORITY The oversight authority as the market regulator: Issues licences to health insurance companies Updates the risk index Checks the solvency of health insurance companies Inspects the quality of healthcare services Monitors and ensures “lege artis”

36. 16.04.2004 Ministry of Health of the Slovak Republic 3. HEALTH INSURANCE COMPANIES Individual health insurance Public health insurance All (including health) insurance companies Licensed health insurance company

37. 16.04.2004 Ministry of Health of the Slovak Republic 3. COMPETITION BETWEEN INSURANCE COMPANIES REDISTRIBUTION PURCHASE COLLECTION PURCHASE

38. 16.04.2004 Ministry of Health of the Slovak Republic GOAL: PATIENT MANAGEMENT PatientHealth insurance company Doctor (general, specialist) Hospital

39. 16.04.2004 Ministry of Health of the Slovak Republic Public and minimum public network of providers Public network everyone Minimum public network Uncontracted providers

40. 16.04.2004 Ministry of Health of the Slovak Republic Patient management: contracted providers When providing healthcare services from public health insurance, the patient pays a fee for services specified by law. The categorisation commission will decide on the extent of possible participation. 2. Fee + possible participation 3. Payment on the basis of contracted prices 1.Insurance relationship List of contracted providers

41. 16.04.2004 Ministry of Health of the Slovak Republic Patient management: uncontracted providers The patient visits the insurance company and asks for permission to go to an uncontracted provider. After the insurance company’s approval, the patient pays the whole cost of the services and then claims benefits from the insurance company up to the amount that the insurance company would have paid to a contracted provider 2. The patient covers the full cost 3. Benefit for the patient up to the amount usual for a contracted provider Insurance relationship 1. Acquisition of consent Waiting list management

42. 16.04.2004 Ministry of Health of the Slovak Republic 4. EMERGENCY SERVICE Basic principle: Ensure such organisation of the network of emergency service providers so that they reach the patient within 10 minutes.

43. 16.04.2004 Ministry of Health of the Slovak Republic 5. HEALTHCARE Basic principle: Healthcare is technically a service and ethically a mission.

44. 16.04.2004 Ministry of Health of the Slovak Republic 6. LAW ON PROVIDERS Basic principle: Guaranteeing free access of licensed providers to the healthcare market.

45. 16.04.2004 Ministry of Health of the Slovak Republic III. NEW PLAYERS Health insurance company Providers Emergency service Chambers Healthcare Scope Regional self- government, Ministry Oversight of health insurance Finance Oversight Authority Finance Oversight of healthcare services Permit Licence Permit Licence

46. 16.04.2004 Ministry of Health of the Slovak Republic THANK YOU FOR YOUR ATTENTION We will welcome your comments. You can find further information at www.zdravotnictvo.sk and www.reformazdravotnictva.sk