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Benefit Basket - High Level Specialist Services

Country: 
Poland
Partner Institute: 
Institute of Public Health, Jagiellonian University Medical College, Krakow
Survey no: 
(15) 2010
Author(s): 
Iwona Kowalska
Health Policy Issues: 
Benefit Basket, Access
Reform formerly reported in: 
Law on Health Benefit Basket
Current Process Stages
Idea Pilot Policy Paper Legislation Implementation Evaluation Change
Implemented in this survey? no no no no yes no no

Abstract

Following the concept of the publicly financed health service basket introduced by law, the MoH issued an executive regulation on High Level Specialist (HLS) services. The respective regulation determines both the list of the guaranteed services financed from public sources and the delivery conditions. The HLS services are financed directly from the central state budget. The process of the service provision is regulated additionally by an agreement between health services providers and the MoH.

Recent developments

On the 31st of September, the package of 13 executive regulations, mentioned in the previous report on the Benefit Basket in Poland (14/2009), has been issued starting the process of the policy implementation. Each of them focuses on a certain scope of health services, i.e.: 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 (LTC services).

One of the most important parts of the Benefit Basket is the delimitation of the High Level Specialist Services (HLS) scope (and definitions of comprised services). According to the Law, the following High Level Specialist procedures have been included into public financing (examples): transplants of heart, liver, lung, heart and lung, pancreas cells and high level specialist craniological procedures like e.g. an inborn heart defect in children younger than one year or intervention of craniological surgery in case of children up to 18 years and others. There is a visible lack of transplantation procedures such as kidney transplant or bone marrow transplant within the list of HLS services defined by the Ministry of Health and included into the Benefit Basket.

The health service delivery conditions in the case of  HSL services concern aspects such as: placing a  patient on the national waiting list and the procedure for the selection of potential beneficiaries (according to the legal rules established in the Law from 1st of July 2005 on taking, keeping and transplanting cells, organs and tissues  (Dz. U. Nr 169, poz. 1411)).  Other issues regulated and stated as obligatory conditions in the regulation of the MoH are e.g.: place and conditions of the  surgery procedure, medical professionals qualifications, the number of provided health services recommended within one month and conditions for intensive care services delivery after the surgical procedure.  

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Characteristics of this policy

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

The described policy is rather innovative mainly due to the new advisory institutions established by the respective law - especially the Health Technology Assessment Agency (HTAA). However, the concept of the HLS services benefit basket construction is rather traditional.

The HLS Health Benefit Basket raises also controversies, especially with respect to the problem of healthcare services access mechanisms. Unfortunately, there is no public discussion concerning the issue at the moment. Media keep silent (probably till the moment of the first visible effects of regulation that will show the patient's exclusion cases - but even then it will not last as a widely expected subject for public discussion). The issue for sure is not quite recognized at the moment by the most interested - neither patients nor providers realize exactly the possible consequences of the new provisions.

Purpose and process analysis

Current Process Stages

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

Initiators of idea/main actors

  • Government: The concept of the benefit basket is expected to be one of the most promising changes (with the perspective of minor legal changes). The part comprising the high specialist services however is rather restrictive (both for the patients and service providers).
  • Parliament: The Parliament stated the amendment to the Law and opened the door for further MoH decisions implemented by executive regulations.
  • Providers: Medical professionals expressed scepticism. They are worried because of the different lacks identified in the basket, concerning for instance: proper registration within each high specialist procedure (identification of donor, medical certificate of death).
  • Payers: All payers generally supported the main idea of the basket (accepting even their own low impact on the process of detailed rules established by the MoH).
  • Patients, Consumers: Patient's knowledge of the HLS benefit basket regulations and consequent changes within the public services system is very low. They are not aware of effects and have no influence in the whole process.
  • Others: The President has the real influential power acting as the opponent to the Government at Parliament (he played such a role in case of many governmental legislative initiatives) but he has no means to interfere into the executive regulations. The Polish Confederation of Private Employers ?Lewiatan? noticed that in the executive regulation on HLS services financed from the public budget, the kidney transplantation procedure is missing.
  • Political Parties: All political parties declared to hold up to the concept of the benefit basket with no doubts concerning the policy idea and its necessity. The support was stronger among the parties of the Governmental coalition and only a bit weaker among the opponents.

Stakeholder positions

The stakeholders' positions towards the idea of the benefit basket policy have not been modified since the last report. The executive regulations precise the detailed baskets on the different medical levels and are of course much more controversial. The MoH regulations definitely changed the position of specific actors.

In case of the HLS services, the critical opinions towards the prepared MoH executive regulation project have been raised even among members of the Government. The opponent points of view have been presented by the Ministry of Labour and Social Policy and The Chairmen of the Permanent Governmental Committee - Micha Boni. The Minister of Labour and Social Policy noticed that the current practice shows that there is a lack of public resources spend for the high specialist procedures - the funding is definitely insufficient. There is a need to regulate the state waiting lists in case of such procedures and to determine the deadline for the services provision process - both in planned and urgent situations.

The Chairmen of the Permanent Governmental Committee - Micha Boni pointed out the lack of important information, such as: 

  • the level of public sources used for the guaranteed HLS procedures financing
  • the time of the health service qualification as the publicly guaranteed procedures
  • the payment of the additional costs (like accommodation costs and full board charge). 

Stakeholders opposing the new HLS procedures can be described as a group of highly qualified professionals (members of medical chambers, very skeptic towards the described regulation due to the different lacks identified in the new law - see above).  

The leadership role of bringing the policy forward  is still hold by the Ministry of Health. Its position and influence concerning the particular decisions in the process of potential changes regarding e.g., exclusion of a particular group of services from the benefit basket is very strong.   

Actors and positions

Description of actors and their positions
Government
MoHvery supportivevery supportive strongly opposed
MoFvery supportivesupportive strongly opposed
Ministry of Labour and Social Policyvery supportivesupportive strongly opposed
The Chairmen of the Permanent Committee of Government ? Micha Bonivery supportivesupportive strongly opposed
Parliament
Health Commissionvery supportivevery supportive strongly opposed
Providers
High Specialist Clinicsvery supportiveopposed strongly opposed
Medical Chambersvery supportiveopposed strongly opposed
Payers
NFZ (National Health Fund)very supportivevery supportive strongly opposed
private insureresvery supportivevery supportive strongly opposed
local governments (large)very supportivesupportive strongly opposed
local governments (small)very supportivesupportive strongly opposed
Patients, Consumers
Patientsvery supportiveopposed strongly opposed
Others
The Presidentvery supportiveneutral strongly opposed
The Polish Confederation of the Private Employers ?Lewiatan?very supportiveneutral strongly opposed
Health Technology Assessment Agencyvery supportivesupportive strongly opposed
Political Parties
PO (Civic Platform)very supportivevery supportive strongly opposed
PiS (Justice & Right)very supportivesupportive strongly opposed
PSL (Agriculture Party)very supportivevery supportive strongly opposed
SLD (Social Democrats)very supportivesupportive strongly opposed
current current   previous previous

Influences in policy making and legislation

The original proposal of the High Level Specialist Services executive regulation has not been significantly modified. The proposal has been prepared by the Ministry of Health and was consequently presented to the different stakeholders aiming at satisfying the consultation process requirements (focused on the HLS basket content).  Despite some critical opinions about the MoH proposal (see the position of high level medical specialists as described above), the MoH has not introduced changes to the regulation.     

Legislative outcome

Hold

Actors and influence

Description of actors and their influence

Government
MoHvery strongstrong none
MoFvery strongvery strong none
Ministry of Labour and Social Policyvery strongstrong none
The Chairmen of the Permanent Committee of Government ? Micha Bonivery strongneutral none
Parliament
Health Commissionvery strongweak none
Providers
High Specialist Clinicsvery strongweak none
Medical Chambersvery strongweak none
Payers
NFZ (National Health Fund)very strongvery strong none
private insureresvery strongweak none
local governments (large)very strongstrong none
local governments (small)very strongweak none
Patients, Consumers
Patientsvery strongnone none
Others
The Presidentvery strongnone none
The Polish Confederation of the Private Employers ?Lewiatan?very strongweak none
Health Technology Assessment Agencyvery strongstrong none
Political Parties
PO (Civic Platform)very strongvery strong none
PiS (Justice & Right)very strongvery strong none
PSL (Agriculture Party)very strongstrong none
SLD (Social Democrats)very strongweak none
current current   previous previous
Health Commission, private insureresMoH, PSL (Agriculture Party)NFZ (National Health Fund), PO (Civic Platform)local governments (small), SLD (Social Democrats)The Chairmen of the Permanent Committee of Government ? Micha BoniMinistry of Labour and Social Policy, local governments (large), Health Technology Assessment AgencyMoF, PiS (Justice & Right)The PresidentThe Polish Confederation of the Private Employers ?Lewiatan?PatientsHigh Specialist Clinics, Medical Chambers

Positions and Influences at a glance

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

Adoption and implementation

As a result of the executive regulation issued in autumn 2009, two important effects emerged. First, the concept of the health benefit basket was explicitly introduced into the Polish system. Even if the practice of a limited scope of services rendered to the people had been applied - by time consuming formal requirements, by waiting time - nevertheless for the first time it was officially proclaimed.

Apart from the Ministry of Health, the Ministry of Finance and a group of 38 high specialist clinics chosen by the MoH for HLS contracting were also involved in the implementation process. Patiens are the most affected group by the regulation, mostly due to the limitation of the high specialist procedures financed from the budget (e.g., lack of kidney or marrow transplant procedures in the described law).

Monitoring and evaluation

The Law on the benefit basket in health care contains general provisions regarding the monitoring and evaluation procedure performed by the Health Technology Assessment  Agency (HTAA). The HTAA has been involved in the process of the quality of high specialist services evaluation (services financed from the budged).

The evaluation is expected to be performed on the basis of the data received from the assessment questionnaires filled in by the heads of the clinics/ Senior Registers of the Wards that are the wards providing the high specialist level services financed from the state budget.

Information received by this way includes for instance the personnel data (e.g. number of highly qualified personnel employed in the unit, types and numbers concerning specialisation, competencies etc.), data concerning the unit equipment (rooms and cabinets).     

Expected outcome

The new MoH regulation on high level specialists' services provides a lower level of public finances (central budget) than it was stated in the executive Law on HLS services from 2004. Such scope of change is strictly connected to the extreme limitation of the overall number of such services available to patients. The new law determines also a strict list of 38 top qualified clinics and gives only to them the competencies (in a sense of a legal right) for the provision and contracting the subjective HLS services included in the basket.

The access to these services meets barriers caused not only by the services limitation itself but also resulting from the state waiting lists procedure requirements. All together the above mentioned problems seriously influence the patients' situation: apart from the difficulties concerning the access issues there is also a fundamental problem regarding the number of the organ's transplantation procedures in Poland - still quite low. It may have important effects in a sphere of the transplantation procedures development in future.

Impact of this policy

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

Regarding the HLS benefit basket there were two main reasons of criticism expressed by analysts and by patients' disappointment. However, the last one was not widely shown. Firstly, the criticism refers to the outcome of the new regulations concerning the limited access to services and the increase of patients' dependency on specialists' decisions. Secondly, the applied procedure deprived the general public (and politicians) of any influence regarding the finally adopted solutions. Such an attitude towards the health policy shows the ignorance towards the democratically made decisions as a base for fundamental systemic changes.

References

Sources of Information

1. Law on change of the Law on Health Care Services Financed from Public Sources and the Law on Prices, dated 25 June 2009, Journal of Laws No. 118, item 989. 

2. Decree of the Minister of Health dated 29 August 2009 regarding High Level  Specialist Services, Journal of Laws No. 140, item 1140.  

Reform formerly reported in

Law on Health Benefit Basket
Process Stages: Implementation, Legislation

Author/s and/or contributors to this survey

Iwona Kowalska

Iwona Kowalska (PhD), 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

Iwona Kowalska. "Benefit Basket - High Level Specialist Services". Health Policy Monitor, April 2010. Available at http://www.hpm.org/survey/pl/a15/1