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Long Term Care - Guaranteed Services Basket

Country: 
Poland
Partner Institute: 
Institute of Public Health, Jagiellonian University Medical College, Krakow
Survey no: 
(15) 2010
Author(s): 
Anna Mokrzycka
Health Policy Issues: 
Long term care, Funding / Pooling, Benefit Basket, Access, Remuneration / Payment
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

The Law from 25th of June 2009 is the legal basis for the executive regulations determining and regulating particular groups of services included into the basket: it states the rules of inclusion and the MoH obligation to prepare 13 of such executive regulations comprising the lists of health services (financed from the public financial resources: NHF, central budget or others). The MoH executive regulation from 31.08.2009 on guaranteed services for long term care is the subject of this report.

Recent developments

The main purpose of the described health policy idea initiated in the Law from 25.06.2009 (commonly known as Health Services Basket Law, Survey 14/2009) was the determination of the so called guaranteed health services comprised in the Polish health benefits basket - on a legal provision basis. The law, introducing general rules how to include health services in the basket, was expected to be a basic contribution to the health services evaluation rationalization. Its influence should affect positively the financial condition of hospitals, clinics and the waiting time problem.

It was often underlined by a great number of policy stakeholders that such legislation would be a fundamental step for further reforms: namely for the introduction of new forms of health insurance. One of the projected systemic reforms that has been planned is the long term care (LTC) separate insurance establishment in Poland. For a very long time the discussion on such policy ratio evoked the German insurance example. In this context the mentioned MoH executive regulation from  31 August 2009 may be seen as a first step for the following decisions, it is expected to be the answer to the question: what kind of LTC services can and what cannot be financed from public resources? Poland is going to introduce the German model of separate insurance for some LTC services (mostly concerning the elderly population) in a few years (2012) but the idea of such an insurance structure and of the scope of services covered and provided, as well as the group of beneficiaries is still not quite clear.

Due to the new law from the 25th of June the services included in the health services basket are financed fully or partly from public resources. The same rule concerns the respective regulation on LTC services. For a patient it should be a source of clear information concerning his knowledge, decisions and choices: Knowing which services are financed within the system, the patient decides on eventual additional insurance or undertakes the risk and pays for the rest out of pocket.

In the context of the proposed policy idea focused on exclusion of LTC services from the basic obligatory insurance (potential introduction of a new pillar to the system), the role of  this executive regulation is not clear - would it be a supplementary insurance for the basket created in this regulation or will the whole scope of guaranteed LTC services be excluded from the basic obligatory health insurance?

The MoH regulation on LTC, as each of the 13 executive regulations determining particular groups of health services, concerns a certain scope of health services. The criteria for services differentiation were obviously mostly focused on the objective scope of health services, types and specifics of care. LTC services are easily indicated as a specific group of services - they include nursing and protective care addressed to patients who need services for a long time, mostly for the rest of their life.

The fundamental provisions of the Law from the 25th of June 2009 created legal definitions, determined the level of health services publicly financed and the method and conditions of delivery. All the services included into the basket have been evaluated on the basis of the economic cost-effect criterion, but the MoH was obliged to take into account also opinions and recommendations of:  the Health Technology Assessment Agency (HTAA), the Consultation Council, the National Health Fund (NHF) and of the national medical consultants. This particular obligation would not be infringed in case of a MoH decision undertaken against the HTAA recommendations (legal provisions provide such exclusion from the scope of consultation obligation). A very important factor influencing the further process of changes within the separate lists is also the MoH's prerogative to introduce such changes correspondingly to its own decision. There is no provision stating the obligation for consultancy in this case.

After the first MoH executive regulation from the 31st of August 2009 concerning LTC was implemented, two novelisations were introduced just a few months later (MoH executive regulation from 8th December 2009 and MoH executive regulation from 16th December 2009). Important changes resulted as a response to the Nurse Chamber's reaction to the first MoH regulation. They expressed the opposite opinion at the stage of social consultancies but with partial success. The second change from the 16th December 2009 is the MoH response to the further criticism concerning the exclusion of nurses as medical professionals from the scope of services included into the LTC services basket. At the beginning - in the original project that underwent social consultancies - there were only doctors mentioned in the provisions.

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Characteristics of this policy

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

The regulation does not introduce any innovative instruments or mechanisms. However, as it was described before, the method of a benefit basket delimitation may be commented as such (it was critisized for formal reasons - arguments for the higher level of legislation needed for such fundamantal issues of legal regulation). The controversies concerning the role of the MoH (and NHF) in this respect are fully applicable also to the described regulation on LTC services. There will be no impact for the system structure, and public visibility is still very low (no interest of the media, they rarely commented or discussed in this particular context at the moment). The introduced changes are not transferable for the rest of the whole system. 

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: MoH executive regulations constitute the main instrument in the process of guaranteed health services basket determination. The MoF is responsible for financing high-level specialist services.
  • Providers: According to the MoH executive regulations the issue of LTC, included into the defined health benefit basket, causes a very important problem in a context of public financing (nursing care for long-term disease cases).
  • Payers: NHF elaborated the great part of the benefit basket. A natural role for the institutional payer for publicly financed h.c. was to participate actively at every stage of the benefit basket preparation, as well as at the further implementation and adoption.
  • Patients, Consumers: Patients, however not involved at the moment of basket preparation, may be seriously afraid of new solutions. They hardly accept the rules and level of the proposed co-payments in health care services financing as well as some basket limitations.
  • Civil Society: NGO's are not involved in the process of benefit basket elaboration and implementation. NGO's will obviously play the main role in future regarding patient's having difficulties in co-payment requirements fulfillment.
  • Scientific Community: Researchers have been deeply involved in the discussion concerning the benefit basket elaboration for a long time. They are aware of the importance of the issue but often critisize the implementation process and MoH choices.
  • Media: Media at the moment show no further interest. The implementation process is not the hot issue and comments can be rarely observed in press or TV. Media react in regard to spectacular cases concerning particular services exclusion from the benefit basket.

Stakeholder positions

1. The policy background:

The Polish Minister of Health is the main powerful actor in the context of benefit basket evaluation. However, the idea of this policy was created quite a long time ago. The process of policy implementation depends on the MoH's activity in the sphere of executive regulations - the described regulation concerning LTC constitutes an important part of the whole package of the MoH's 13 executive regulations on the health services basket. The MoH very often expressed the opinion that the new regulation in this context will be implemented with regard to patients' benefits. The important statement in this matter was focused on the government position against any additional payment for healthcare services. As it was described in the report 14(2009), co-payments as a rule may be introduced for the same group of services that was defined in previous regulations (dental care, sanatoriums, health or rehabilitation equipment). The MoH was obliged by the law to establish and implement the mentioned 13 executive regulations and together with the NHF (due to an informal agreement between the two bodies) elaborated the health benefit basket list that became the base for regulations.

From the beginning, the process had to face the parliamentary opposition. The main forces in this respect were Social-Democrats and different trade unions: the General Polish Association for Trade Unions (OPZZ ), the General Polish Trade Union of Physicians (OZZL) and the Independent Autonomous Trade Union Solidarity (NSZZ Solidarnosc). The opposition tried to influence upon the President decision concerning the law on the Health Benefit Basket  - the legal base for the further executive regulations of the MoH. Moreover, the opposite bodies submitted to the Constitutional Tribunal the conclusion concerning the potential infringement of Polish Constitution due to the respective legislation. The claim underlined the unclear and ambiguous definition of the guaranteed services. The opposition stressed that the rule of social solidarity may be infringed as well.

The separate important argument was focused on formal solutions concerning the benefit basket delimitation process. The opposition concluded that the law allows the MoH to undertake individual and arbitrary decisions concerning the scope of publicly financed services. They supported the opposite point of view claiming that such an issue should be regulated at the level of parliamentary legislation, under democratic mechanisms control.

2. The regulation subject (basic aspects)

The regulation defines in §1 the two issues:

  1. The list of services and conditions of services delivery.
  2. The level of medical transport financing (in cases not included into the  regulation concerning the general rules for medical transport)

It also defines the two basic conditions for services delivery: 

  1. So called stationary LTC (delivery within nursing care units). 
  2. LTC services delivered at patient's home.

Services included into LTC at home are delivered by teams for LTC (in cases of mechanical ventilation) - and in these cases patients should receive the adequate equipment from the defined LTC team - or by LTC nurses.

In §4 the regulation listed the services included into the LTC category, the list defines the groups services: services delivered by doctors, delivered by nurses, psychologists, general rehabilitation services at the basic level, activity therapy, pharmacological therapy, diet treatment, medical products and equipment delivery (used for  the guaranteed services delivery), health education services (self care methods, family care at home), diagnostic treatment and drugs. All the services included into the scope of this paragraph are delivered to patients who need all day care (Barthel scale 40 points or less - children excluded from such evaluation). From such a group of patients (evaluated with the use of the Barthel scale) those with advanced cancer disease, psychiatric disease or addicts have been excluded. In the following §9 the other conditions required for the patient's qualification for the guaranteed LTC services has been stated. From this list of strictly medical conditions a patient has to "fulfil" one of them (for instance the need for the tracheotomy care). In every case the patient's need for service has to exceed the stated period of time - 14 days.   

Further, the same §4 defines the list of cases of medical transport financed from public resources to the level of 40 percent of the service price (16 different types of disease, disabilities or dysfunctions ) under the condition that the patient needs help of a third person when using means of  public transportation.  

Actors and positions

Description of actors and their positions
Government
MoHvery supportivevery supportive strongly opposed
MoFvery supportivevery supportive strongly opposed
Presidentvery supportivevery supportive strongly opposed
Providers
Medical doctorsvery supportivesupportive strongly opposed
National Chamber for Nursesvery supportiveopposed strongly opposed
Reginal Chambers for Nursesvery supportiveopposed strongly opposed
Payers
NHFvery supportivesupportive strongly opposed
MoHvery supportivesupportive strongly opposed
Patients, Consumers
Patientsvery supportiveneutral strongly opposed
Civil Society
NGO'svery supportiveneutral strongly opposed
Scientific Community
Public health researchersvery supportivesupportive strongly opposed
Medical Universitiesvery supportivesupportive strongly opposed
Media
TVvery supportiveneutral strongly opposed
Pressvery supportiveneutral strongly opposed
current current   previous previous

Influences in policy making and legislation

The original policy -  formulated as a law described in previous reports - has been specified and detailed in the described executive regulation comprising the LTC services. The implementation of policy depends fully on the following regulations, among them the hereby described one. The bodies most engaged in this particular context - LTC services - are nurses and organizations representing them. All the Chambers expressed their opinion concerning the regulation, stressing that it does not define the role of nurses in this sphere of health care and ignores them as a key group of professionals. It is true that the regulation does not provide any provisions concerning work rules and conditions for nurses dealing with LTC patients. The Regional Chamber underlined that the regulation defines only services guaranteed by doctors and two categories of nursing specializations  - anaesthesiology and surgery nurses. The comments described above were submitted during social consultations.

The regulation concerning LTC was not included into the MoH system of opinion submission in respect to the process of executive regulations novelisation (available on the MoH website). Out of the 13 regulations only two have been included into the system of opinion submission: the one concerning hospital treatments and the second on specialized health care services (with the adequate NHF President ordinances). It seems that LTC servicesare not at the very centre of MoH's attention at the moment. The proposed version of regulation by the MoH  has not been changed so far despite the critisizing opinions mentioned before.  

Legislative outcome

n/a

Actors and influence

Description of actors and their influence

Government
MoHvery strongvery strong none
MoFvery strongvery strong none
Presidentvery strongvery strong none
Providers
Medical doctorsvery strongneutral none
National Chamber for Nursesvery strongweak none
Reginal Chambers for Nursesvery strongweak none
Payers
NHFvery strongvery strong none
MoHvery strongvery strong none
Patients, Consumers
Patientsvery strongnone none
Civil Society
NGO'svery strongneutral none
Scientific Community
Public health researchersvery strongneutral none
Medical Universitiesvery strongneutral none
Media
TVvery strongstrong none
Pressvery strongstrong none
current current   previous previous
MoH, MoF, PresidentMedical doctors, Public health researchers, Medical UniversitiesNHF, MoHPatientsNGO'sTV, PressNational Chamber for Nurses, Reginal Chambers for Nurses

Positions and Influences at a glance

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

Adoption and implementation

In the process of adoption, the particular group of nurses and other medical professionals who work at the institutions offering LTC services are -  and will be - involved, together with patients who are directly affected by this regulation. Patients are not so much aware of the regulation effects yet but there are opinions, expressed mostly by the groups of nurses, that they will be the losers - they underlined that the regulation concerns mostly services delivered by doctors and in fact LTC is in a great part a sphere of nursing care.

Such opinions, expressed by the nurses representatives, resulted in the novelisation of the original MoH regulation: the first one - not important in this context - dated on 8 December 2009 and the second from 16 December 2009. The second novelisation introduced the phrase: "services delivered by a nurse" into §9 and important changes to the attachment no. 4 to the respective executive regulation - defines standards and conditions for a nurse work concerning the maximum number of patients cared for by one nurse (6 patients per nurse if they live in different places - home care, and 12 patients per nurse if they are treated in at the same place - e.g. social and nursing care institution).

Monitoring and evaluation

The described regulation does not provide any monitoring and evaluation procedure. In the case of LTC it can be quite difficult to evaluate outcomes and influence at the patient's situation.

Expected outcome

The intended objectives were the same as in the case of the law from 25th of June 2009 - a first delimitation of services included into the benefit basket and due to such instrument - systematic savings. The expected effects on overal costs should limit public financing of LTC. The access and equity issues may also be affected, LTC services are mostly delivered to patients who are in a difficult financial situation due to their health status. Quite often they will not be able to cover services not included into the basket (e.g. part of the medical  transport costs).  

Impact of this policy

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

The only visible impact that can be commented at the moment is the impact on access and equity (see above).

References

Sources of Information

  • The Law from 25th of June 2009 on change the Law on health care services financed from the public sources and the Law on Prices. OJ no 166 clause 1377.
  • MoH executive regulation from 31.08.2009 on the long term care guaranteed services, O.J no 140, clause 1147.
  • MoH executive regulation from 08.12.2009 changing the MoH execytive regulatiuon from 31.08.2009 on the long term care guaranteed services, O.J no 211, clause 1645.
  • MoH executive regulation from 16.12.2009 changing the MoH execytive regulatiuon from 31.08.2009 on the long term care guaranteed services, O.J no 217, clause 1688.
  • Adam Kozierkiewicz, Wojciech Trabka, 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.

Reform formerly reported in

Law on Health Benefit Basket
Process Stages: Implementation, Legislation

Author/s and/or contributors to this survey

Anna Mokrzycka

Lecturer and researcher at the Health Policy and Management Department, Institute of Public Health, Jagiellonian University. Research on social protection system, disability, health insurance. Phd in Social Protection and Labour Law.

Suggested citation for this online article

Anna Mokrzycka. "Long Term Care - Guaranteed Services Basket". Health Policy Monitor, April 2010. Available at http://www.hpm.org/survey/pl/a15/3