The framework of Polish health care system. Insurance and economic relations.

 

Dominika Cichońska, Anna Jacoń, Aleksandra Sierocka

 

The definition of health system understood as the system of health protection (health care system) was presented in the document of World Health Organization: () health system can be broadly defined as coherent whole, numerous parts of which related to each other acting together affect (positively) the state of health of the population.1 The health system comprises not only the system of health care, that is the activity of health service, but the whole social activity oriented at health protection. The health system consists of the system of health care and at the same time comprises definite elements and aspects of political, economic, social, cultural and educational system. Thus, the concept of health protection is in its scope broader than the concept of health care. Health care consists of an organized set of activities realized by medical and paramedical health care facilities and various medical institutions. However, health protection is a set of all activities undertaken in the state and in the society in order to strengthen the health state of the population and to maintain it on possibly the best available level.

The principles and the way of organizing the system of saving life and health protection in the given country result mainly from ideological assumptions of the official social policy and political imponderables of the current national masters.2 Such basic and universal goals and functions of this system are subordinated to these assumptions and imponderables:

               saving life;

               prophylaxis (from educational and instruction programmes to compulsory vaccinations);

               protection against the disease development;

               health restoration (through various forms of health service, mainly ambulatory and hospital);

               convalescent care;

               monitoring of the nations health state (mainly follow-up examinations);

               special health care services for pregnant women and in maternity period and for social groups particularly exposed to health hazard associated with the performed profession;

               health service for social and occupational diseases;

               therapeutic and rehabilitation programmes for children and adolescents;

               epidemiologic programmes.

To achieve these goals it is necessary to:

1.             Secure and provide full range of medical services the whole population require regardless of their economic, social, cultural and geographical status (the principle of health care availability).3

2.             Provide prophylactic-therapeutic and rehabilitation services and benefits at the highest possible level according to the level of knowledge and medical art and to the principles of good practice (the principle of the quality of medical care with the consideration of the rule of quality continuity and global approach).4

3.             Organize the care in the best possible way in order to guarantee maximal use of the existing material goods, financial and human resources health service base, financial resources allocated for its activity, medical staff and their qualifications (the principle of effectiveness).5

4.             Systematically implement activities improving the system and satisfying the recipients both patients and the staff (the principle of organization and management adequate for the achievement of social and economic development).6

5.             Employ the personnel professionally prepared to the activity in adequate branches of health care (the principle of competence).7

The most frequently applied typology of the models of health care systems introduces the following distinction:

-         Bismarckian model;

-         Beveridge model,

-         market model.

Thus, they invoke to three different traditions of building the systems: German, British and American. Apart from them, Semashko model should be mentioned which was represented in the former Soviet Union countries and in post-Communist countries of Central_Eastern Europe until the end of the 1990s. The functioning of five general types of national standards of health care system have been widely accepted: 8, 9

1.             Pluralistic (market) health care system It consists of various coexisting constitutional schemes to provide medical services and services related to them. Physicians have private practice, team practice or receive state salary. Specialists have significant autonomy in deciding on their professional affairs. The types of ownership of equipment serving for the needs of health care include private property, non-profit, co-operative, group and public property (national, regional and the like). The health care of the United States of America answers this description most precisely.

2.             Insurance health care system (Bismarck model) To a certain degree this system resembles pluralistic health care system but majority of money is transferred to institutions and practising physicians by a third party, that is by insurance agencies, government agencies or other institutions (e.g. trade unions). The main principles of the system are: financing based on obligatory fees of employres and employees (of changing proportions) and on state subsidy; management via politically independent institutions such as health insurance fund and benefits contracting.10, 11

3.             The goal of the model is to protect against unpredictable occurrence (illness) in consequence of which there usually comes to the loss of earnings and material safety of the family. This principle concerns first of all people of low financial status. Persons with higher income can participate freely in the existing funds or enter private insurance firms.12

4.               The insurance system in its pure form concerns only the form of applied financial mechanisms, which include e.g. taxes, the population premiums making up the fund covering in total or partly the benefits connected with treatment or hospitalization or with susidies to medical practice or medical institutions. The fact that third party is responsible for the system financing and for setting the obtained receipts is an element of potential control of the physicians and institutions. In reality physicians enjoy the same autonomy as in the pluralistic system. The health care system in Western Europe (except Great Britain) and in Japan corresponds to this definition.

5.             Service health care system (Beveridge model) It is a system in which majority of facilities are the total property of the government bodies and in which majority of physicians practitioners or consultants in hospitals are paid by the Treasury (in the form of uniform pay dependent on the number of patients or in the form of a salary or a fee). British National Health Service (NHS) is a prototype of such a system. Social care physicians consider themselves to be private practitioners having the right to select patients, in turn patients have the right to select a physician. Physicians have the same autonomy as in the previous two systems.

6.             Nationalized health care system (Semashko model) It is a system in which all facilities are the property and remain under the management of the state and in which nearly the whole health care staff are government employees. Physicians are usually responsible for patients assigned to them on the basis of territorial division or due to specific ailments requiring intervention of a specialist. The range of autonomy of a physician is relatively smaller than that in the previous three systems.

7.             Hybrid model the response to urgent needs of modern societies The description of the health care system may differ significantly from its real functioning. Such a situation exists in the case of a model found in Poland. Certain regions or social groups have difficult access to health care. Implementation of voluntary payments or corruption make the access to health services difficult or impossible for poor or socially handicapped people.13

The providing protective character of the system falls short of expectations of Polish citizens. The system designed after preliminary election in 2005 is to be both providing and insurance. In the assumptions of the authors, the system is solidaristic and pro-social but at the same time based on free-market basis. Thus this system can be regarded as hybrid combination of mutually complementary solutions.

The hybrid consists of two moduli:

        public insurance, that is common health premium;

        commercial insurance (partly obligatory), that is the system of copayment.14

In Poland constitution regulates the legal basis of the nation health policy. In the Constitution of the Republic of Poland established on 2 April, 1997 by National Assembly and adopted by the nation on 25 May, 1997 in general referendum, the problems of health care policy are not only regulated by commonly cited in this aspect Article 68 which states that:

1.      Everyone has the right to health care.

2.      Citizens, regardless of their economic status, shall be provided with equal access to health care services financed from the public funds. The conditions and the scope of services are to be detailed in the appropriate laws.

3.      Public authorities are obliged to provide special health care services to children, pregnant women, disabled persons and the elderly.

4.      Public authorities are obliged to counter epidemic diseases and prevent potentially health-threatening outcomes of environmental degradation.

5.      Public authorities support the development of physical culture, particularly among children and adolescents.

Other articles of the Constitution also comprise references to health policy, they are:

Art. 38. The Republic of Poland shall ensure the legal protection of the life of every human being.

Art. 39. No one shall be subjected to scientific experimentation, including medical experimentation, without their voluntary consent.

Art. 66. 1. Everyone shall have the right to safe and hygienic conditions of work. The methods of implementing this right and the obligations of employers shall be specified by statute.

2. An employee shall have the right to statutorily specified days free from work as well as annual paid holidays; the maximum permissible hours of work shall be specified by statue.

Art. 67. 1. A citizen shall have the right to social security whenever incapacitated for work by reason of sickness or invalidism as well as having attained retirement age. The scope and forms of social security shall be specified by statute.

2. A citizen who is involuntarily without work and has no other means of support, shall have the right to social security, the scope of which shall be specified by statute.

Art. 74. 1. Public authorities shall pursue policies ensuring the ecological security of current and future generations.

2. Protection of the environment shall be the duty of public authorities.

3. Everyone shall have the right to be informed of the quality of the environment and its protection.

4. Public authorities shall support the activities of the citizens to protect and improve the quality of the environment.

Art. 76. Public authorities shall protect consumers, customers, hirers or lessees against activities threatening their health, privacy and safety, as well as against dishonest market practices. The scope of such protection shall be specified by statute.

Art. 84. Everyone shall comply with their responsibilities and public duties, including the payment of taxes, as specified by statute.

Art. 86. Everyone shall care for the quality of the environment and shall be held responsible for causing its degradation. The principles of such responsibility shall be specified by statute.

It results from these articles of the Constitution that the term health care comprises various tasks of the public authorities i.e. ensuring health care, promoting healthy life style and eliminating health hazards.15 Fundamental constitutional principles related to public health care are found in Article 68 of the Constitution, particularly in the acts 2, 3 and 4. These regulations impose duties on public authorities to provide the citizens with the access to health care services from the public funds. Accepting that the system of public health care, being the basic link realizing constitutional duties of public authorities to ensure the access to health care services, should be built on the basis of economic rationality, the fact cannot be ignored that there exist impassable barriers of this system economisation. Passing the barriers makes the system incapable of fulfilling its constitutional functions. Art. 68 act 2 of the Constitution passes on the act the duty of determining the conditions of providing services from public funds and thus, among others, determining the organizational structure of public health service.

A lot of ordinary acts the Constitution refers to are its elaboration. In these documents there are contained decisions associated with the obligation of the state to ensure the citizens subjective law to health care and the undertaken by public authorities activities guided to health care of the whole population.16

In Poland financing of medical services is regulated with the Law on Health Care Services Financed from Public Fund. The Law is a continuation of reformist activities initiated at the beginning of the 1990s in the range of health care system and is based on the system of common insurance introduced in 1998.

The Law regulates among others: the scope, conditions of health care services financed from public funds, the tasks of public authorities to ensure equal access to services, the principles of functioning, organisation and activities of the National Health Fund, the principles of supervising and controlling financing and realisation of services.

Subjects employed on the basis of contract of employment (employees), farmers, subjects running non-agricultural business and persons co-operating with them, those performing outwork, agency agreement, mandatory contract or any other contract for supplying services are covered by health insurance on the compulsory basis. Since 2004 the contribution has increased annually by 0,25% from 8,25% to 9% of the tax basis at present. Subjects who were not specified in the Law can be provided with health insurance on voluntary basis.

According to the Law the persons covered by the general health insurance are entitled to financial benefits from public funds.

The funds are transferred by Social Insurance Institution to National Health Fund which on behalf of the insured enters contracts with the providers who have a contract on providing health services. National Health Fund was established in 2001 with 16 regional branches and the Head Office with the seat in Warsaw. Each branch individually enters contracts on providing health services within obtained financial means.

Table.1. Gross receipts from health insurance contributions

 

2005

2006

Gross receipts from health insurance contribution

33 792 090, 91 thousand zl

37 071 559, 46 thousand zl

Source: A study based on: the Report on National Health Fund activity in the year 2005 and the Report on National Fund activity in the year 2006.

 

Health services delivered and financed within the social health insurance for citizens with insurance rights:

1.             diagnostic tests including medical laboratory diagnostics,

2.             services aimed at health protection, prevention of diseases and injuries, early detection of diseases including compulsory vaccinations,

3.             primary health care,

4.             school health services,

5.             outpatient specialist services,

6.             rehabilitation care,

7.             dental care,

8.             in-patient care,

9.             highly specialized services,

10.         services of curative home care,

11.         psychological testing and therapy,

12.         logopedic testing and therapy,

13.         nursing care services including palliative hospice care,

14.         nursing care services for the disabled,

15.         health care services for women during pregnancy, labour and puerperium,

16.         health care services for breast-feeding women,

17.         prenatal, neonatal care and preliminary assessment of health state and development of a newborn,

18.         health care services for a healthy child, including assessment of health state and development up to 18 year of life,

19.         spa therapy services,

20.         supply of medical goods and materials,

21.         medical transportation,

22.         rescue services.

Table 2. Selected costs incurred by National Health Fund in the years 2005-2006 for health care services for the insured persons.

Costs of health care services for the insured (in thousands zl)

Execution of NHF financial plan

2005

2006

primary health care

3 619 323, 79

3 988 042, 23

Outpatient specialist services

2 341 600, 12

2 672 447, 38

in-patient care

14 525 526, 00

15 688 120, 55

psychiatric and substance abuse therapy

1 089 138, 00

1 169 877, 06

rehabilitation care

918 914, 00

1 035 827, 17

long-term care

523 829, 00

578 042, 77

Dental care

970 877, 00

1 058 123, 39

spa therapy

351 449, 00

346 362, 80

emergency aid and medical transportation

934 059, 00

1 015 510, 12

costs of prophylactic health programmes financed by NHF own resources

79 013, 00

103 266, 81

reimbursement of drugs

6 327 294, 00

6 695 760, 88

Source: The study based on: Report on National Health Fund activity in 2005 and the Report on National Health Fund in 2006.

 

Health services can be obtained from providers who in a competition have concluded contracts on providing health services with one of the regional branches of the National Health Fund. The health care provider might be:

-         health care facilities, group medical practices, group nursing or midwife practices, a person performing medical profession within individual practice or individual specialized practices,

-         individual person who obtained professional rights to provide health care services and provides them within economic activity,

-         budget unit formed and supervised by the Minister of Defence, the Minister of Interior or the Minister of Justice, having in its organisational structure an outpatient clinic, an outpatient clinic with sick-quarters or primary care physician,

-         subject realising activities in the range of supply in adjuvants, medical goods being orthopaedic appliances.

National budget is another source of financing. This financing comprises particularly highly specialised services covering of which was regulated by the decree-law of the Minister of Health from 13 December, 2004 concerning highly specialised services financed from the national budget from the part remaining at the disposal of an appropriate minister for health affairs. This decree-law determines not only the list and range of these services. It also specifies the terms of public funds provision, the way of establishing their price and financing and the subjects estimating the quality of the above mentioned services. Public funds are conveyed to service providers with whom the appropriate minister concluded contracts. The prices of the services are established taking into account the prices suggested by the provider and mean costs of particular procedures determined by the minister. The transfer of public funds which are exclusively meant for covering the costs resulting from the realisation of these services is made on the basis of a contract.

Table 3. The list of highly specialised services financed from the national budget from the part remaining at the disposal of an appropriate minister for health affairs is determined by annex No: 1 to the degree-law:

No.

Highly specialised services

1

Autologous bone marrow transplant

2

Autologous bone marrow transplant in HLA-identical siblings

3

Autologous bone marrow transplant from alternative donor*

4

Liver transplant

5

Kidney transplant

6

Kidney and pancreas transplant

7

Heart transplant

8

Lung transplant

9

Heart and lung transplant

10

Corneal graft

11

Immunoablation in the treatment of panmyelophthisis

12

Radiotherapy with the application of special irradiation technique: stereotaxic, conformal, non-coplanar

13

Brachytherapy with cerebral stereotaxis

14

Congenital heart disease surgery in newborns

15

Congenital heart disease and thoracic aorta surgery in extracorporeal circulation

16

Diagnostic cardiac catheterisation, cardiac muscle biopsy in children to 18 years of life

17

Interventional cardiac procedures in children to 18 years of life including percutaneous shant closure with closure device

* Journal of Laws 04.267.2661 amendment J. of L. 06.231.1687

 

According to the Art. 55 of the Act on medical care institutions, an independent public health care institution might obtain subsidies from the national budget for:

1.             realisation of tasks in the range of diseases and injuries prevention and on other health programmes as well as on health promotion.

2.             covering the costs of education and improvement of qualifications of subjects performing medical professions,

3.             investment including purchase of highly specialised apparatus and medical equipment,

4.             goals determined in art. 67a,

5.             special goals, granted on the basis of separate regulations.

Besides all the above mentioned decree-laws, one more deserves attention the government order on 20 December, 2004 concerning the way and procedure of financing health care services from the national budget granted to subjects other than those entitled to insurance. In Poland the third source of health care system financing - besides health insurance and national budget - is direct payment for the patients medical services. It comprises three types of situation:

               The patients payment for services not financed from public funds which, according to the law, include:

-                vaccinations not included in the compulsory vaccination package,

-                plastic and cosmetic surgery when it is not necessary treatment for malformation, injury, illness and consequences of its treatment,

-                gender change operations,

-                acupuncture except in case of chronic pain,

-                treatment by means of natural factors and rehabilitation in health-resort hospitals, spas and ambulatory spa treatment, not associated with basic disease being the direct cause of the referral to health-resort treatment,

-                psychoanalytic councelling.

               The patients payment for services only partly covered by health insurance or national budget. Such mixed source of financing concerns e.g services delivered by a dentist, dental materials, the range of which is determined in a decree-law of the Minister of Health from 24 November, 2004 concerning the list of guaranteed services of a dentist and dental materials and the type of a document confirming the rights to these servises. It also concerns the drugs and other medical products to which the patients are entitled to on the basis of a prescription from health insurance doctor. Basic drugs and prescription drugs are given out by the lump and supplementary drugs at 30% or 50% of the drug price. The lump cannot exceed 0,5% of minimal remuneration in the case of basic drug and 1,5% of minimal remuneration in the case of prescription drug. Detailed principles are determined in the decree-law of the Minister of Health from 17 December, 2004. Also patients residing at care and medical and nursing and care institutions (nursing homes, social welfare homes) must cover the cost of food and accommodation themselves.

               The payment for medical services which are reimbursed by social insurance system. It is a complex situation and results from one of three causes:

-                A patient has no status of an insured person and then he/she must cover the costs of all services delivered to him/her, even those financed from public funds.

-                A patient uses the services of private health care and the services providers have not concluded contracts on providing health services with the National Health Fund.

-                A patient uses the services of a provider having a contract with National Health Fund, but beyond the limit, and queue or pays extra for more expensive materials applied in procedures (special sutures, endoprostheses) or for additional nursing care.

The funds obtained as the result of the patients co-financing are estimated for about 20-25% of all the expenses on health service. However, they are mainly the costs associated with the realization of prescriptions and payment for drugs. Without the implementation of significant legal changes, the role of a patient in direct co-financing of health care system is and will still remain marginal.

 

Voluntary insurance

According to the assumptions of the first passed regulation in the range of health services financing, the possibility of their obtaining (purchasing) through other subjects than Health-Insurance Fund was to be a supplement to general health insurance. However, the lack of proper regulations concerning the functioning of these subjects made their establishing impossible. Looking for the sources of health care financing within reformatory activities announced by the government elected in 2005, after parliamentary election, the introduction of additional voluntary health insurance and additional nursing insurance into the health care system was suggested. These insurance funds are to be a supplement to the system based on the defined basket of guaranteed benefits.

The insurance funds comprise:

in additional voluntary health insurance:

-         services not included into the basket of guaranteed benefits,

-         above the standard hospitalisation conditions,

-         increased access to medical procedures performed on the basis of the contract with the insurer,

in additional nursing insurance nursing care for subjects incapable of individual existence due to diseases, injuries or advanced age.

 

Insurance funds, coupons and individual and group packages comprise a wide range of services which is similar to the offer presented by providers having contracts with National Health Fund. The range and quality of the obtained services evoke great interest of the society in this offer and are a serious competition for NHF providers. More and more Polish people are eager to pay a little more to get services in the standard desired by them. At present, at least 1,5 mln people (every 20th Polish citizen) use this system. It is not surprising though, if private medical firms attract the clients with a complex offer guaranteeing quick access to wide range of services in one place, access to a specialist without a referral, fast time of the realisation of the planned examinations, the possibility of the package adaptation to individual needs, modern medical equipment or high quality of services.17 Permanent medical care is also an attractive element of the employees and the employers social security.18 Quick development of this segment of economy we owe not only to the bad condition of public health care system but also to the economic growth due to which the financial status of numerous enterprises has greatly improved. Implementation of tax changes at the beginning of 2007 was also of great significance because they allowed the employer to count the cost of workers private health care into tax deductible expenses.

As the presented facts have indicated, Polish health care system representing until recently care and supply model, displays more and more distinct insurance signals and it converts into a hybrid model.


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