1. Advisor to the Minister of Health
Health reform process in Slovakia Zdravotnictví ČR Strategie – Financovaní – Kvalita Praha,
Rudolf Zajac
Minister of Health
Peter Pažitný
Advisor to the Minister of Health

2. … bez ministra …

3. Content Fiscal position of Health sector Basic data about Slovakia
The current system
Where is the beginning of the circle?
Stabilisation measures
System measures
Network measures

4. I. Fiscal position of Health Sector

5. Gap is widening (Cumulative real growth of GDP, 1990=100)
USA
EU 15 SR

6. Deficit of Public Finances (% of GDP)

7. Fiscal position of Health sector (% of GDP)
Expenditures
Resources
Deficit

8. Coverage of the Deficit (% from GDP)

9. … growing debts (in bln. Sk)
Annual change 2002 … 2003
VAT and deregulation … 1,0
Providers: 16,2 … 22,0
Health insurance funds: 13,2 … 15,4

10. Structure of the external debt (SKK billion)
Pharmacies (7,0)
HIF
Without Perspektiva
(2,2)
Without Redistrib. Fund (3,8)
Contributors
Unpaid insurance (11,0)
Fines, Penalties (8,5)
Public finances (2,2)
Primary and secondary care (1,3)
Drugs (4,5)
Inpatient facilities
Public finances (4,1)
Energy (2,9)
Others (4,6)

11. Receivables after maturity
Maturity dates
Annual expenditures
SKK billion
Receivables after maturity
Maturity dates
in days
Public pharmacies
20,2
7,0
Hospital pharmacies
5,1
4,5
Energy suppliers
1,3
2,9

12. How much is that? (SKK billion)
Annual health budget in 2002:
SKK 68 billion
GDP in 2002:
SKK 1062 billion
Pharmacies (7,0)
Public finances (2,2)
Primary and secondary care (1,3)
26,6
Drugs (4,5)
Public finances (4,1)
40,0%
2,5%
Energy (2,9)
Others (4,6)

13. II. Basic data about Slovakia

14. Life expectancy at birth
Source: WHO, 2000

15. III. The current system

16. Financing
Annual payment
Contributions
Taxes
Citizens

17. High correlation with real economy
A change in salaries by 1 per cent causes a change in resources by 1.14 percent
But in employment it causes a change by as much as 1.24 percent.

18. Payment mechanisms Date of change POC SOC in-patient facilities
1 Jan 1993
capitation
fee for service
bedday according to specialization and types
1 Apr 1993
universal point system
1 May 1994
"hotel and point flat rate"
1 July 1994
bedday according to types
1 Sept 1994
1 Apr 1995
combined system
1 Apr 1997
1 Dec 1998
budgets
1 Jan 1999
capped fee for service
interventions with upper limit
1 May 1999
"prospective budget"
1 June 2000
age criteria of capitation
"maximum prices"
1 Jan 2002
capitation + fee for service (for prevention)
"orders for interventions"

19. Organization: Privatization

20. IV. Where is the Beginning of the Circle?

21. Challenges and Reactions of the Reform
Growing expectations of the citizens
Increasing Costs
Limited ability to pay
Decreasing of expectations of the citizens
Increasing of efficiency
Mobilisation of Resources

22. Position of Political Decisions
How much Resources ?
Decreasing of high expectations of the citizens
Efficiency
How wide Treatment Act?

23. Where is the Beginning of the Circle?
Health Care Act
Treatment Act
New Insurance Act
CONSTITUTION
Health Insurance Act
New Treatment Act
Health Care Surveillance Authority Act
Chambers Act
Health Care Occupations Act
Health Care Providers Act

24. Schedule of reform steps
Network
measures
New
system
System
measures
Stabilisation
measures
2002
2003
2004

25. V. Stabilisation measures

26. Goals Stopping the growth of debts Financial stabilisation of system

27. Stabilisaton measures
Modern definition of the Health Care
Introduction of marginal co-payments for Providers
New initiatives in Drug Policy

28. 1. Modern definition of the Health Care
Related services:
Transport
Food
Accomodation

29. 2. Application of marginal co-payments for Providers
Health Insurance Fund
Provider (pharmacy)
Primary care
20 Sk
0 Sk
Secondary care
Accomodation and food in inpatient care
50 Sk
Transport
2 Sk/km
Prescription fee
15 Sk
5 Sk

30. 2. Vulnerable groups freed from co-payments
People in material need
Inconscious people
People in health status, that doesnt allow the permission of agreement
Mother with children (6 year)
Blood donors
Psychiatric patients
Long-term ill patients

31. 2. Impact on patients
53 Sk monthly

32. 3. New initiatives in Drug policy
New composition of categorization committee (11 members, prevalence of economists over doctors)
New concept of Appendix 2
Fixing additional payments of patients in the case of partly reimbursed drugs

33. … stabilisation of debts (in bln. Sk)
Annual change 2002 … 2003
VAT and deregulation … 1,0
Total savings 2,5 - 3,8 bln. Sk
Providers: 16,2 … 19,6
Health insurance funds : 13,2 … 14,2

34. VI. System measures

35. Goals Decreasing of expectations of citizens
Raising the efficiency of the system
Mobilisation of Resources (particularly private)

36. System measures NEW Treatment Act NEW Insurance Act
NEW Health Care Surveillance Authority Act

37. 1. New Treatment Act A Fully reimbursed B Partially reimbursed C
Not reimbursed
Performance
Drugs
Tools and material

38. 1. New Treatment Act
Price
Onco
Cardio
Trauma
Chronic
Frequency

39. Beyond scope of Treatment Act
2. New Insurance Act
Voluntary insurance
Beyond scope of Treatment Act
Compulsory
insurance
Covering BBP in
Treatment Act

40. 2. New Insurance Act Voluntary insurance Every licenced Insurance Fund
Compulsory
insurance
Licenced Health Insurance Fund

41. 2. The need of redistribution
We are building a system with universal coverage
Minimazing cream skimming
Eliminate adverse selection

42. 2. The rules of redistribution
Decentralized premium collection
Subject to redistribution: cash revenues
The revenues under 95 percent of prescribed premium will be sanctionized
These claims have to be paid by the insurance fund
Percentage of redistribution: percent

43. 2. New insurance act Risk index

44. 2. Where will be the competition?
VÝBER
VÝBER
VÝBER
REDISTRIBUTION
Purchasing
Purchasing
Purchasing

45. Goal: Active role purchaser
Purchasing of goods
Drug policy
Influencing the price
Purchasing of services
Provider

46. Instruments for purchasing
New Payment mechanisms
HIF
Selective purchasing
Quality standards

47. 3. Regulator> Health Care Surveillance Authority
Strong regulatory body, which monitors:
Licences for HIF
Risk Indexes
Solvency of Health Insurance Funds
Minimum 3 % of collected premiums
Quality of provided Health Care
Lege artis

48. New „Players“ HCSA Suppliers Lobby Elastická sieť HIF Risk Risk Riziko
Chambers
Emergency

49. VII. Network measures

50. Current conditions – there is no feedback in the system
Hospitals and LZZ
SKK
Health Insurance Fund
Patient
Primary care
Secondary care
SKK

51. Goals Increasing technical efficiency Increasing Quality
Enhancement of effective access
Reinforcement of competition
Equality of chances

52. Quality Award

53. Network measures NEW Chambers Act
NEW Health Care Providers and Institutions Act
NEW Health Care Occupations Act

54. Goal: Management of the patient in the future - interaction
Hospitals and LZZ
Patient
Purchaser
Primary and secondary care

55. ... ??? ...
We are lucky, the hole is not on our side

56. Thank You for Your Attention
We are looking forward to Your comments and for further information attend