1. Health reform process in Slovakia EMK workshop Budapest, 3.6.2003
Rudolf Zajac
Minister of Health
Peter Pažitný
Advisor to the Minister of Health

2. 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

3. I. Fiscal position of Health Sector

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

5. Deficit of Public Finances (% of GDP)

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

7. Coverage of the Deficit (% from GDP)

8. … 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

9. 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)

10. 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

11. 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)

12. II. Basic data about Slovakia

13. Life expectancy at birth
Source: WHO, 2000

14. Hospital beds, # per
Source: WHO, 2000

15. Physicians
Source: WHO, 2000

16. Length of stay
Source: WHO, 2000

17. In-patient care admissions
Source: WHO, 2000

18. Bed occupancy rate
Source: WHO, 2000

19. Outpatient contacts
Source: WHO, 2000

20. III. The current system

21. Financing
Annual payment
Contributions
Taxes
Citizens

22. Structure of sources, %

23. 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.

24. 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"

25. Organization: Privatization

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

27. 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

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

29. 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

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

31. V. Stabilisation measures

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

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

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

35. 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

36. 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

37. 2. Impact on patients
53 Sk monthly

38. 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

39. … 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

40. VI. System measures

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

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

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

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

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

46. 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

47. 2. New insurance act Risk index

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

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

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

51. 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

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

53. VII. Network measures

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

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

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

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

58. ... ??? ...
We are lucky, the hole is not on our side

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