|Implemented in this survey?|
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).
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:
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).
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.
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.
Health Technology Assessment Agency - the main consultative group, patients - subjects to the new regulations, health care providers - subjects the new regulations
|Degree of Innovation||traditional||innovative|
|Degree of Controversy||consensual||highly controversial|
|Structural or Systemic Impact||marginal||fundamental|
|Public Visibility||very low||very high|
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.
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:
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:
|Implemented in this survey?|
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).
The approach of the idea is described as:
renewed: 2004 was the year the idea of a health benefit basket entered the debate.
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
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.
|Ministry of Health||very supportive||strongly opposed|
|President||very supportive||strongly opposed|
|The government coalition ( Citizens' Platform and Agricultural Party)||very supportive||strongly opposed|
|Right and Justice (opposition)||very supportive||strongly opposed|
|Social Democrats (opposition)||very supportive||strongly opposed|
|Specialists||very supportive||strongly opposed|
|Nurses||very supportive||strongly opposed|
|NHF||very supportive||strongly opposed|
|Patients||very supportive||strongly opposed|
|Health Technology Assessment Agency||very supportive||strongly opposed|
|National Consultants||very supportive||strongly opposed|
|Consultants Council||very supportive||strongly opposed|
|Trade Unions OPZZ (Nationwide Agreement of Trade Unions)||very supportive||strongly opposed|
|OZZL (Nationwide Trade Union of Physician)||very supportive||strongly opposed|
|SDPL(Social Semocrats of Poland)||very supportive||strongly opposed|
|NSZZ||very supportive||strongly opposed|
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.
|Ministry of Health||very strong||none|
|The government coalition ( Citizens' Platform and Agricultural Party)||very strong||none|
|Right and Justice (opposition)||very strong||none|
|Social Democrats (opposition)||very strong||none|
|Health Technology Assessment Agency||very strong||none|
|National Consultants||very strong||none|
|Consultants Council||very strong||none|
|Trade Unions OPZZ (Nationwide Agreement of Trade Unions)||very strong||none|
|OZZL (Nationwide Trade Union of Physician)||very strong||none|
|SDPL(Social Semocrats of Poland)||very strong||none|
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.
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.
Mid-term review or evaluation
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.
|Quality of Health Care Services||marginal||fundamental|
|Level of Equity||system less equitable||system more equitable|
|Cost Efficiency||very low||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.
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.