Rudolf Zajac

1. Healthcare Reform in Slovakia Rudolf Zajac

2. I. Introduction - Slovakia Population: 5.4 million people Living Standard: 51% of EU average Middle income country

3. Expenditure on Health Care Expenditure on health care as % of GDP USA GER CZ SVK DEN ESP IRE ROM GDP per capita at PPP in USD source: OECD

4. Deficit of Public Finances (% of GDP)

5. Breakdown of Current System solidarity excess of solidarity over resources resources: 5 (income from privatisation) 17 (informal payments) 8 23 (taxes) (direct payments) 47 (payroll taxes) solidarity 0 resources:

6. Consequences Excess of demand over supply 3 Expenditure 1 2 Prices / spending 3 Infinite demand 1 Volume

7. Efficiency gap LUX CZ SVK HUN Through corrections in pay levels, employment and age structure it RISES to a ratio of: Input : Output 0,526 : 0,612

8. Efficiency in Health Care The Netherlands Slovakia Efficiency = 0.612 Efficiency = 1.000

9. Slovakia, the leader in Reforms? • Tax Reform (2003) – Corporate and Wage Tax – 19 % • Pension Reform (2003) – Two pillars (public and private) • Public Administration Reform (2004) – Fiscal Decentralization • Labour Market Reform (2003) – Modern Labour Code • Health Care Reform - Stabilization (2003) - Reform Acts (2004)

10. Pre-reform "preparation" of citizens, or stabilisation (June 2003) Application of marginal co-payments

11. The Reform Jigsaw Healthcare Act Healthcare legislation and supervision of health care Healthcare Providers and Professional Bodies Act Health Insurance Act Act on the Scopeof Health Care Covered by PublicHealth Insurance Healthcare Emergency Services Act

12. Principles of Reform • Equal care for equal need • Ability to pay • Universal coverage • Protection of patients' rights • Enforcement of fair play • Health care is a technical service and an ethical vocation • Guaranteed free access for licensed providers to the healthcare market

13. Main Philosophial Changes • Increased responsibility of health insurers for the purchase of health care and the financial protection of the patient • Increased responsibility of providers for health care provision • Increased responsibility of patients for their health

14. Health Care Basic principle: Health care is a technical service and an ethical vocation

15. Clear definitions and rules • Definition of procedure "lege artis" • Definition of urgent treatment • Definition of informed consent • Access to and provision of medical records and protection of patients' personal information • Catalogues of actions leading to diagnosis and treatments leading to the cure of illnesses (see the law on scope) • Integrated European Charter of Patients' Rights (e.g. the right to choose a provider, to respectful treatment of patient by doctor, to information on their health condition,...) • Principles of bioethics (transplantation, sterilisation, biomedical research)

16. Health insurance Respects: • solidarity • ability to pay Must ensure: • universal coverage without regard to the social status of the recipient

17. Health insurance Public health insurance (solidarity) Emp 10+4% Scope set by special legislation, compulsory Individual health insurance Covers individual needs, optional

18. Redistribution according to rating of costs (risk) Objective: for all insured to have access to an equal volume of resources corresponding their risk rating

19. Healthcare legislation and supervision of health care Health insurers • Duty to provide health insurance • Option of individual insurance • Option of sickness insurance • Transformation of the current public institutions into joint stock companies Supervisory office • Issues permission (licenses) to health insurers • Monitors the solvency of health insurers • Supervises and monitors • whether insurers have purchased health carein the scope required by law • whether providers have provided it "lege artis"

20. Multiple insurers – yes or no? SELECTION SELECTION SELECTION REDISTRIBUTION PURCHASE OF HC PURCHASE OF HC PURCHASE OF HC

21. Instruments of Purchase Selection of provider by quality and price Health insurance provider Quality standards The law does not stipulate the payment mechanism to be used

22. Objective: to increase the responsibility of the insurer Patient Management Hospital Patient Health insurance provider MD (GP, Specialist)

23. Healthcare Emergency Services • Part of the integrated emergency system (IES) • Organisation of a network of healthcare emergency services so that in cooperation with IES, 98% of citizens can be reached in under 10 minutes

24. Healthcare Providers Act Basic principles: • Ensure free access to authorised (licensed) providers • Transfer the performance of first level state administration to professional bodies • The act contains an ethical codex for providers, obligation to provide lifelong learning and monitoring • Transforms the largest hospitals into joint stock companies whose shareholders will be universities, towns and regions

25. Act on Scope Basic principle: Equal care for equal need

26. List of citizens' priorities source: FOCUS, January 2004

27. Categorisation criteria (§ 9) The categorisation of diagnoses takes into consideration: • the seriousness of the illness, • the ability of diverse groups of patients to cofinance their treatment* * - the amount contributed by the insured can depend on symptoms, age and the priorities of health policy.

28. Catalogues of actions Establishment of a standard diagnostic and therapeutic procedure(Act on Health Care) Actions leading to the diagnosis of illness(diagnostic actions) ILLNESS Actions leading to the cure of illness (treatment actions)

29. Categorisation model ACTIONS 1 2 3 ... cca 9 000 ILLNESSES - actions fully covered - actions partly covered - actions not covered

30. Social Balance The amount that citizens contribute does not change, but the structure of expenditure changes according to priorities.

31. êêPARLIAMENTêê Categorisation Model in Use 1 2 3 ... cca 9 000 Critical risks: • financial protection of patients against the risk of high costs • urgent treatment • chronic illnesses ILLNESSES  High level of cofinancing   insurers 5  Low level of cofinancing  Optimal level  Cofinancing   3 3 the ministry experts - payment by pulic insurer - cofinancing by patient

32. Patient's responsibility Specification of the patient's responsibility for prevention and adherence to the treatment programme The health insurer has the right • To enforce claims against the insured for repayment of costs of health care where it was demonstrably provided as a result of a breach in a treatment programme or the use of an addictive substance, • To pay the insured partial costs corresponding to the cofinancing by the patient if the insured regularly receives a preventative check-up, innoculations and follows a healthy lifestyle.

33. Role of political decisions What resources? Increase effectiveness and decrease the expectations of citizens Efficiency Netherlands Slovakia What benefits ? 1,000 0,612

34. NEW PLAYERS Supervisory office HI Supervision HI Supervision Finances Health insurer Providers Finances Scope of Health Care Licence Permission Prof. Bodies Regional govt., SR MH Licence Permission Finances Emergency services

35. ... ??? ... We're lucky that the hole is not on our side

36. THANK YOU FOR LISTENING We welcome your comments and you can obtain further information from www.zdravotnictvo.sk and www.reformazdravotnictva.sk