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Law on Health Benefit Basket

Country: 
Poland
Partner Institute: 
Institute of Public Health, Jagiellonian University Medical College, Krakow
Survey no: 
(14) 2009
Author(s): 
Iwona Kowalska
Health Policy Issues: 
Benefit Basket, Access
Current Process Stages
Idea Pilot Policy Paper Legislation Implementation Evaluation Change
Implemented in this survey? no no no yes yes no no

Abstract

On the 26th of July a law on the health benefit basket has been passed by the Polish parliament. The law determines the rules of how to include healthcare services into benefit basket of guatanteed services. Regarding the new regulation, the MoH is obliged to prepare 13 executive regulations comprising the lists of health services financed from the public financial resources (NHF or others).

Purpose of health policy or idea

The main purpose of the described  health policy idea is to establish a list of healthcare services financed from public resources. The Ministry of Health indicates the criteria of health services included into the lists of the guaranteed benefit baket. The services included in the basket are fully or partly financed by public resources. The list of the guaranteed services will also serve as source of information for patients on which services are financed within the obligatory health insurance (or by other public funds) and for which they have to pay themselves- partly or in full.

The body responsible for  assessment and recommendation concerning the proper selection of services included into the list is the Health Technology Assessment Agency (HTAA).

The Polish Ministry of Health (MoH) established the HTAA in 2005 as an advisory body to support the decision-making process. Its core activities comprise:

  • evaluation of healthcare technologies;
  • assessment of medical procedures with a special focus on contracted services;
  • collection, provision and dissemination of results, methodology and recommendations of health technology assessments (HTAs) generated within or outside Poland; and
  • recommendation of medical procedures to the MoH.

The agency also participates in work concerning  the basic benefit package coordination and in the Polish guidelines for producing HTA reports development ( also see Wlodarczyk, Cezary. "The Agency for Health Technology Assessment II". HealthPolicyMonitor, April 2008. www.hpm.org/survey/pl/a11/5). HTAA  is a member of the International Network of Agencies for Health Technology Assessment (INAHTA).

Main points

Main objectives

The Ministry of Health has just finished the process of establishing the 13 executive regulations. Each of them concerns the separate scope of health services as follows: health programs, primary care, hospices and palliative care, emergency, high level specialist services, spa (health-resort) services, dental care, rehabilitation, psychiatric care and addiction, hospital care, outpatients specialist care, orthopedic  products, nursing and protective care within long-term care. 

The health benefit basket defines the level of health services financing as well as the method and circumstances of their realization. The issue of drugs reimbursement has been excluded from the  MoH regulations. None of them does  concern this question -  the rules of publicly financed drugs are the subject of different regulations on the drugs reimbursement lists. 

Healthcare services are included into the guaranted services basket on the basis of the economic cost -efect criterion.

In the process of decision-making, the MoH should take into consideration the opinions and recommendations of the following institutions:  Health Technology Assessment Agency, Consultation Council, National Health Fund and national medical consultants. However, the MoH is legally entitled to take its decision against the recommendations of the HTAA. The decision on the frequency of changes concerning  the separate lists of health services belongs also to the MoH's own competencies.

Type of incentives

The Law is an important contribution to the rationalization of the health services evaluation process and will positively influence not only the financial condition of hospitals and clinics  but also the problem of waiting lists for medical treatment.

Groups affected

Health Technology Assessment Agency - the main consultative group, patients - subjects to the new regulations, health care providers - subjects the new regulations

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Characteristics of this policy

Degree of Innovation traditional rather innovative innovative
Degree of Controversy consensual controversial highly controversial
Structural or Systemic Impact marginal rather fundamental fundamental
Public Visibility very low low very high
Transferability strongly system-dependent system-dependent system-neutral

The described policy is rather innovative mainly due to the new advisory institutions which the described law established within the system - especially the HTAA.  The Health Benefit Basket is also a controversial subject which always influences healthcare access mechanisms. Unfortunately there is no public discussion on the issue at the moment. It seems that  both patients and providers are not informed about consequences of the new regulations. 

Political and economic background

The issue of "health benefit basket" has been hotly publicly debated for years in Poland: among professionals, politicians, researchers, payers and many other gremiums. The situation changed in 2004, for two reasons:

  1. The judgement of the Polish Constitutional Tribunal on the infringement of the Polish Constitution by the existing health insurance law and, 
  2. Poland entering the European Union.

The first problem has been partly solved by the defining of a list of specific exclusions in the law and a promise to establish an institution for health technology assessment. The second issue remains open, although to some extend it is being dealt with legally by regulations issued from the Ministry of Health on acceptable waiting times for health services. In this context, the change can be described as the political direction.                                                         

There are various legal acts and documents defining the scope of services and required conditions. In the hierarchy of regulations the most important and most general are the laws based upon the Polish constitution. More specific are the laws ratified by Parliament and the President that regulate certain areas of social life and activities. The laws listed below include the legal provisions concerning the public organs' and institutions' obligations to provide and ensure health benefits to persons in need:

  • The health insurance law which regulates the public obligatory insurance scheme that covers about 99% of Polish citizens and a large proportion of non-citizens, residents, both short- and long-term (Law from the 27th of August 2004 on healthcare services financed from public funds, O.J. No 210 from 2004 clause 2135).
  • The labor code and occupational medicine law that  regulates relations between employers and employees, including the fee for health protection that employers are obliged to pay (Law from the 26th of June 1974,  Labour Code, O.J. No 21 from 1998, clause 94 and amendments; Law from the 27th of  June 1997 on occupational medicinelaw…, O.J. No 96 clause 593).
  • Laws that regulate the obligations of public authorities and individuals regarding protection  and coping with specific problematic health areas, such as infectious diseases (Law from the 6th of September 2001 on infectious diseases, O.J.  No 126 from 2001, clause 1384 witn amendements), mental health (Law from the  19th of  August 1994 on the mental health protection, O.J .  No 111, clause 535 with amandments), drugs (law from the 24th of  April 1997 on the addictions profitactic , O.J. from 2003 No 24, clause 198 and No 122, clause 1143), and alcohol abuse (law from the 26th of  October 1982 on the upbringing in sobriety and alcohol addiction prevention, O.J. from 2002 No 147, clause 1231, with amendments).
  • Laws on the emergency system (law from the  25th of July 2001 on the National Medical Emergency, O.J No 113, clause 1207 with amendments) and services (Law from the  6th of December 2002 on the medical emergency services delivery, O.J. No 241, clause 2073 and from 2003 No 99, clause 920) which regulate  functioning and financing of the national emergency system and care provided to persons in need.
  • The social security law that establishes rules for social security coverage for various population groups, including persons that are at occupational age and older as well as unemployed (Law from the 13th of October 1998 on the social security system, O.J. No 137, clause 887 with amendments).
  • The penal code that regulates the penalty in case of crimes and treatment of persons convicted (Law from the 6th of January 1997, Executive Penal Code, O.J. No 90, clause 557, with amendments).

Purpose and process analysis

Current Process Stages

Idea Pilot Policy Paper Legislation Implementation Evaluation Change
Implemented in this survey? no no no yes yes no no

Origins of health policy idea

As it was described above, the subject of a "health benefit basket" has been hotly debated in Poland for years. The important moment in this discussion and regarding the further potential decisions was the year 2004 because of the judgement of the Constitutional Tribunal concerning the health insurance law in force and - at the same time - Poland's accession to the European Union. 

After the judgement of the Constitutional Tribunal there was a need to work fast on the new law on the health insurance system in Poland. The Minister of Health at that time (Leszek Sikorski) appointed the group of experts responsible for the creation of the guidelines to the new systemic law. The head of the team of experts was Professor Cezary Wlodarczyk. They drew up a multi -layered document concerning the most demanded changes in the Polish health insurance system, underlining  the necessity of establishing a health benefit basket. It was one of the first suggestions of a health benefit basket structure that represented the current complex approach.

In the following years 2005- 2007 the next  MoH (Professor Religa) prepared the large document compounding the medical procedures which should be financed from public resources.

The process of defining the list of products was not finished until 2005 when a formalized process of setting general conditions for contracting services was established (under the NHF protectorate and with the participation of the providers associations representing more the 10,000 professionals). The catalogues were published in a form of appendices to the procurement documentation in the process of purchasing health services and goods within the public health insurance system. The "products" from catalogues are the basis for the contracts between the NHF and the providers of the services

The main purpose of the health policy idea is to establish a list of the healthcare services financed from public sources called the guaranteed health services basket.

The main legal tools used to achieve this policy's principles and ideas are the mentioned 13 executive regulations of the Ministry of Health concerning the separate scope of health services and the role of the Health Technology Assessment Agency in this process.

The driving force behind this idea was the MoH (also the main actor of the described policy together with the HTAA, National Health Found and national medical consultants).

Initiators of idea/main actors

  • Government: Ministry of Health was the main actor in the process of the law's preparation and implementation. The Ministry of Finance is responsible for financing high-level specialist health services and medical emergencies. The president signed the law - a decision that surprised deputies both from the governmental coalition and from the parliamentary opposition. The president sees the law as important for patients but also underlines many dangers (like the co-payment problem).
  • Parliament: The parliamentary opposition (SLD and partly the PIS party) criticize the new Law due to the potential co-payment mechanisms which are established in the 13 executive regulations of MoH.
  • Providers: According to the 13 executive regulations on the health benefit basket, major specialist care will be covered from public sources, but there will be a problem to receive nursing care for long-term disease cases.
  • Payers: The important part of the new benefit basket was prepared by the National Health Found as a payer institution. In this case NHF is involved at every stage of the process: the preparation, implementation and adoption proceedings.
  • Patients, Consumers: Patients worry about the effects of the new regulation. They are especially afraid of the part concerning co-payments.
  • Others: There are three consultant bodies important for the process of health services recommendation for the the MoH lists of services included into one of the 13 regulations.
  • Political Parties: Opposition to the new law has been formulated by trade unions and by one of the socialist parties (Social Democrats of Poland).

Approach of idea

The approach of the idea is described as:
renewed: 2004 was the year the idea of a health benefit basket entered the debate.

Stakeholder positions

The current Polish Minister of Health (Ewa Kopacz) underlined that the new law is profitable for patients and does not implement any additional payment for healthcare services. Co- payment rules concern only the same group of services as it was stated in previous regulations: dental care, spa (health resort), health or rehabilitation equipment. The MInister played the leadership role in bringing forward the policy and she was responsible for formulating and implementing the main law and the following 13 executive regulations. The informal agreement between the National Health Fund and the Ministry of Health concerning the health benefit basket preparation was also very important in the whole described process of the policy's implementation.

The parliamentary opposition  was the main oponent to the policy (Social - Democrats) as well as the different trade unions (General Polish Assotiation for Trade Unions (OPZZ ), General Polish  Trade Union of Physician (OZZL) and Independent Autonomus Trade Union Solidarity (NSZZ Solidarnoœæ)). All of the organizations tried to convince President Lech Kaczynski that he should not sign the Law on the Health Benefit Basket and ask the Constitutional Tribunal for judgement concerning the question of Polish Constitution infringement by such legislation.

Accordingly to the Trade Unions' opinion the Law introduces an unclear and ambiguous definition of the guaranteed services and it may contradict the rules of social solidarity. They criticized the idea of the policy - the division of the subjective benefit basket problem into

  1. the legislation level  (the Law on benefit basket) and
  2. the 13 executive regulations level (which in fact  determine the scope of healthcare services financed form public sources). 

The deputies from the parliamentary opposition claimed that such a solution gives  all the power in the decision-making proces  to the Minister of Health. 

Actors and positions

Description of actors and their positions
Government
Ministry of Healthvery supportivevery supportive strongly opposed
Presidentvery supportivesupportive strongly opposed
Parliament
The government coalition ( Citizens' Platform and Agricultural Party)very supportivevery supportive strongly opposed
Right and Justice (opposition)very supportiveneutral strongly opposed
Social Democrats (opposition)very supportiveopposed strongly opposed
Providers
Specialistsvery supportivesupportive strongly opposed
Nursesvery supportiveopposed strongly opposed
Payers
NHFvery supportivevery supportive strongly opposed
Patients, Consumers
Patientsvery supportiveopposed strongly opposed
Consultants
Health Technology Assessment Agencyvery supportivesupportive strongly opposed
National Consultantsvery supportivesupportive strongly opposed
Consultants Councilvery supportivevery supportive strongly opposed
Political Parties
Trade Unions OPZZ (Nationwide Agreement of Trade Unions)very supportiveopposed strongly opposed
OZZL (Nationwide Trade Union of Physician)very supportiveneutral strongly opposed
SDPL(Social Semocrats of Poland)very supportivestrongly opposed strongly opposed
NSZZvery supportiveopposed strongly opposed

Influences in policy making and legislation

The original proposal of the health benefit basket did not change in the process - the parliamentary coalition PO and PSL effectively rejected all changes proposed by the opponents in the parliamentary commissions.

The most powerful actor involved in the guaranteed health services basket regulation process was the Ministry of Health who established the mentioned  executive regulations. The second important stakeholder was the Health Technology Assessment Agency. The new law assumes changes within  the organizational structure and changes in the status of the HTAA.  The Institution has been given formal status of a legal entity and responsibility for the final recommendations  proposed  to the Minister of Health (concerning the inclusion of healthcare services into the health benefit basket lists). 

The final decision however is to be taken by the MoH (after consultations with the National Health Fund, the National Medical Consultants and the Consultation Council). The Consultation Council has the status of the consultative and advisory body. The  Council is composed by the following members: 7 representatives from the Ministry of Health, 1 representative from the medical universities, 1 representative  from  the Main Medical Chamber, 1 representative  from the Main Pharmaceutical Chamber,1 representative  from the Main Nursing and Midwife Chamber and  1 representative from the National Health Fund.

Legislative outcome

success

Actors and influence

Description of actors and their influence

Government
Ministry of Healthvery strongvery strong none
Presidentvery strongvery strong none
Parliament
The government coalition ( Citizens' Platform and Agricultural Party)very strongvery strong none
Right and Justice (opposition)very strongstrong none
Social Democrats (opposition)very strongweak none
Providers
Specialistsvery strongstrong none
Nursesvery strongweak none
Payers
NHFvery strongvery strong none
Patients, Consumers
Patientsvery strongnone none
Consultants
Health Technology Assessment Agencyvery strongstrong none
National Consultantsvery strongstrong none
Consultants Councilvery strongvery strong none
Political Parties
Trade Unions OPZZ (Nationwide Agreement of Trade Unions)very strongneutral none
OZZL (Nationwide Trade Union of Physician)very strongneutral none
SDPL(Social Semocrats of Poland)very strongweak none
NSZZvery strongneutral none
Ministry of Health, The government coalition ( Citizens' Platform and Agricultural Party), NHF, Consultants CouncilSpecialists, Health Technology Assessment Agency, National ConsultantsPresidentOZZL (Nationwide Trade Union of Physician)Right and Justice (opposition)PatientsSocial Democrats (opposition), NursesTrade Unions OPZZ  (Nationwide Agreement of Trade Unions), NSZZSDPL(Social Semocrats of Poland)

Positions and Influences at a glance

Graphical actors vs. influence map representing the above actors vs. influences table.

Adoption and implementation

As it was described above the main stakeholders involved in the adoption process toward implementation are: MoH, Health Technology Assessment Agency, National Consultants, and Consultation Council. Apart from the above institutions and organs the adoption process will also be influenced by  all types of providers (from primary care to the high specialist providers) and by the National Health Fund (which is responsible for the health services contracting process). The process of successful implementation of the described policy is going to be monitored by the MoH.

The adoption of the described regulations will also affect patients who do not have any knowledge about the services financing : they can not differentiate between  services that are financed by public resources  and those that are not (e.g. according to the new regulations high-level specialist cardiology hybrid surgery is guaranteed from the budget but full nursing care service for patients in "average condition" - like when the patient can swallow the sustenance - are not included into basket).

At this stage it is hard to judge how successful the further implementation may be - especially that there was any action done to convince the opponents (the trade unions, providers, patients) to suport the policy.  

Monitoring and evaluation

The HTAA prepares reports on the evaluation of benefit baskets, mainly the particular services included there - drugs and medical equipment are excluded from such evaluation.

The new law also regulates the procedure of excluding healthcare services from the guaranteed health benefit basket. In this case, the HTAA prepares the report with the detailed justification for such exclusion form the guaranteed services list.  Also the other consultation bodies, e.g. National Medical Consultants and Consultation Council, can put forward a motion to the Ministry of Health aiming at  removal of particular  healthcare service from the list of services financed from public resources.

 

Review mechanisms

Mid-term review or evaluation

Expected outcome

The law on the health benefit basket opens the door to implement an additional health insurance system in Poland. The Law is also a barrier for the implementation of new technologies in the guaranteed health services basket (such technologies  will partly be removed from the benefit basket and be shifted into in the private insurance companies' offers).

The law can also positively influence the waiting time for healthcare services.

The new policy is based on cost- effect evaluation and should improve access to  health care.

Impact of this policy

Quality of Health Care Services marginal rather fundamental fundamental
Level of Equity system less equitable system more equitable system more equitable
Cost Efficiency very low very high very high

The idea of building a health benefit baskets is fundamental for assess mechanisms. It aims at the creation of  a more equitable system due to the limitation of guaranteed healthcare services (quantity) and consequently  due to the reduction of waiting lists for medical services. The main criteria that are taken into account in the process  of the  guaranteed  health benefit basket 's establishment are cost - effect and cost- efficiency indicators. 

References

Sources of Information

  • Adam Kozierkiewicz, Wojciech Tr¹bka, Artur Romaszewski, Krzysztof Gajda and Dariusz Gilewski, Definition of the "Health Benefit Basket" in Poland. Eur J Health Econ. 2005 November; 6(Suppl 1): 58-65. Published online 2005 November 24. doi: 10.1007/s10198-005-0320-3.
  • The Law from 25th of June 2009 on change the Law on health care services finance from the public sources and the Law on Prices. www.mz.gov.pl

Author/s and/or contributors to this survey

Iwona Kowalska

Iwona Kowalska, lecturer, Institute of Public Health, Medical College, Jagiellonian University. She graduated in Political Science at the Faculty of Law and Administration, Jagiellonian  University. Her main areas of research are: health and social policy, European health policy and healthcare systems.

Suggested citation for this online article

Kowalska, Iwona. "Law on Health Benefit Basket". Health Policy Monitor, October 2009. Available at http://www.hpm.org/survey/pl/a14/1