1. Advisor to the Minister of Health
Health reform process in Slovakia Egészségugyi Menedzserképzo Kozpont Semmelweis Egyetem
Rudolf Zajac
Minister of Health
Peter Pažitný
Advisor to the Minister of Health

2. Content Fiscal position of Health sector The current system
The first steps
The reform „puzzle“

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. 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)

11. ... ??? ...
We are lucky, the hole is not on our side

12. II. The current system

13. Financing
Annual payment
Contributions
Taxes
Citizens

14. Structure of sources, %

15. High correlation with real economy senzitivity of 1%
A change in salaries causes a change in resources by 1.14 percent
The employment causes a change by as much as 1.24 percent.

16. 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"

17. Organization: Privatization

18. III. The first steps

19. 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

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

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

22. Stabilisaton measures 2003
January Decentralization
May The „Creditor“ projekt
June New definition of Healthcare
June Introduction of co-payments
July New payment mechanisms
October New initiatives in drug policy
Novembr New employment rules

23. 1. Decentralization and debt development

24. 2. The „Creditor“ projekt
State owned joint stock company
Financial resources from National Property Funds

25. 2. The „Creditor“ project
receivables
HIF
Pharmacies (7,0)
Special agency “Creditor”
Purchase of receivables from creditors
Public finances (2,2)
Primary and secondary care (1,3)
receivables
Inpatient facilities
Drugs (4,5)
Public finances (4,1)
Energy (2,9)
Others (4,6)
cash

26. 3. Modern definition of the Health Care
Related services:
Transport
Food
Accomodation

27. 4. Introduction of co-payments
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

28. 4. 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

29. 4. Impact on patients
53 Sk monthly

30. 4. The co - payment effects
The number of patients decreased by 10 to 30%
Not relevant as evidence
without seasonal adjustment
measured on small population

31. 4. Co - payment effects in drug policy

32. 4. … and the reactions …

33. 5. New payment mechanisms
Broad – band DRG
Strong prevention focus
Hypercholeszterolémia
Ocult bleeding / colorectal carcinoma/
Strengthtining the specialized doctors sector
One day medicine

34. 6. 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

35. 6. New initiatives in Drug policy
Market negotiations (three rounds)
Effect: general decrease of prices
Effect: cca 10% reduction of drug budget (savings: cca 3% of total budget)

36. 7. New employment rules Cancelling the central wage tables
Managed change
Guarantee of current level of wage
Setting criteria for hospital managers

37. 8. Quality Award

38. … 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

39. IV. The reform puzzle

40. Goals on macro level Decreasing of expectations of citizens
Raising the efficiency of the system
Mobilisation of Resources (particularly private)

41. Goals on micro level Increasing technical efficiency
Increasing Quality
Enhancement of effective access
Reinforcement of competition
Equality of chances

42. Surveillance Authority
The reform - puzzle
Surveillance Authority
Insurance Act
Basic Benefit Package
Providers Act
Health Care Act

43. 1. Basic Benefit Package is a Priority List
Essential principle:
Equal treatment to equal needs

44. 1. Basic Benefit Package is a Priority List
Diagnosis
Explanation
Standard Therapeutical Process
Reimbursement from public health insurance
DG 1
DG 561
DG 3002

45. 1. The principes of Priority List
Financial protection (High costs)
Emergency
Chronic diseases
Non - insurability

46. Essential principles:
2. New Insurance Act
Essential principles:
1. Universal coverage
2. Ability to pay

47. 2. New Insurance Act Voluntary insurance Beyond scope of BBP
Compulsory
insurance
Covering BBP

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

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

50. 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

51. 2. New insurance act Risk index

52. 2. Where will be the competition?
Collection
Collection
Collection
REDISTRIBUTION
Purchasing
Purchasing
Purchasing

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

54. 2. Instruments for purchasing
New Payment mechanisms
HIF
Selective purchasing
Quality standards

55. 3. New Act on Healthcare Surveillance Authority
Essential principle:
Protecting patient rights
Enforcing the “game rules”

56. 3. The Regulator: Healthcare 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

57. 4. New Provider Act Essential principles:
Guarantee free entrance to health market

58. 4. Provider Act Now - No feedback in the system
Hospitals and LZZ
SKK
Health Insurance Fund
Patient
Primary care
Secondary care
SKK

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

60. 5. New Healthcare Act Essential principles:
Healthcare is technically a service but ethically a mission

61. 5. Healthcare Act

62. New „Players“ HCSA Suppliers Lobby Elastic network HIF Risk Risk Risk
Chambers
Emergency

63. Lessons learned
Reform requires many clear decisions on day-to-day basis
You always have only imperfect data to support your decision

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