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Petrifying concessions to primary care providers

Country: 
Poland
Partner Institute: 
Institute of Public Health, Jagiellonian University Medical College, Krakow
Survey no: 
(15) 2010
Author(s): 
Cezary Wlodarczyk
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 guaranteed health services basket, implemented by the amendment to the law, the MoH introduced a decree on Primary Health Care (PHC) services. A shortened time of access ? overnights and on weekends ? was approved as a rule for contracts between the payer and providers, together with a narrowed scope of competences attributed to PHC, increasing demand for specialist care. Advantages for one side, the PHC-providers, may prove to be rather dissatisfying for the other.

Recent developments

The recent decision concerning the decree on Primary Health Care (PHC) resulted from two lines of developments.

Firstly, it originated from the Government's and the MoH's efforts to improve the performance of health care. Coming to power in late 2007, the government developed many ideas for health care reform. The initiatives led to many bills - a package of laws - which were submitted to the parliament in early 2008, underwent the parliamentary procedure, were passed by two houses, but vetoed by the president. To keep the momentum of the reform, the MoH prepared a law on amending the Law on Health Care Services Financed from Public Sources - it was the idea of the health services basket. The MoH managed to get support from all authorities and the law went into force.

Secondly, it came from an evolving concept of PHC. Originally, PHC - and especially family medicine - was presented as an universal remedy ready to solve almost all problems the system was facing in the past. Unfortunately, under pressure of many circumstances, the concept degenerated and the damaged figure was petrified in the decree (see below).    

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Characteristics of this policy

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

In previous reports, the problem of PHC has not been raised so no evaluation has been expressed.

It should be emphasised that one of the essential problems - the role of PHC - was not solved by the law passed by the parliament, but by ministerial decree. Usually parliamentary debates are published that open the insight for the general public. Undoubtedly, patients are very much concerned with the rules regulating access to PHC and range of services provided at this level of the 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: Facing opposition by the president ? the health reform package of laws was vetoed ? the government sought a success. The concept of the services basket seemed to be one of the most promising as after minor legal changes decrees were sufficient.
  • Parliament: The parliament passed an amendment paving the way to further decisions made by decrees.
  • Providers: The overwhelming majority of family physicians welcomed the decree as an expression of justice freeing them from unfair burdens (extra-work at night and on weekends ).
  • Payers: All payers supported the idea of the basket, even if their impact on the process of issuing the rules by the MoH was weak.
  • Patients, Consumers: PHC patients were afraid that the new regulation would obstruct their access to services, both primary and specialist care. Especially limitation of PHC physicians competences were perceived as a danger.
  • Private Sector or Industry: The overwhelming majority of PHC providers operate in private arrangements (family practices or non-public institutions) so they supported the decree.
  • Others: The President being in opposition to the Government played a role ? frequently negative ? and obstructed many governmental legislative initiatives, but he could not interfere with the decree.
  • Political Parties: All political parties declared to hold up to the concept of the basket. The support was stronger among parties of the governmental coalition, slightly weaker in the opposition.

Stakeholder positions

Very first suggestions to enhance the role of PHC were voiced as early as in the beginnings of the eighties, together with first reports presented by the social movement "Solidarnosc". They were developed afterwards, being one of the prevailing topics during the Round Table talks. After a political breakthrough in 1989, in early phases of reform, PHC was believed to be a leading force of improvements and family doctors were propagated as potential leaders of progress. Due to their involvement, it was to be possible to run the system in a more rational way seeking savings in reduction of unnecessary ambulance services and emergency care provided overnight and on weekends.

Later on, it turned out that the co-operation between the payer (National Health Fund - NFZ) and PHC providers was difficult. A conflict referred mostly to questions of 24 hours availability of services and availability on Saturday mornings: providers intended to eliminate these obligations, NFZ tried to impose them. In a response, providers decided to set up an alliance (Porozumienie Zielonogorskie - PZ) to represent their common interests. The alliance has become an association of medical providers, active especially in primary health care, and family physicians. After months of fierce negotiations - that began in 2004 - the NFZ gave up and the PZ could announce the victory. It added a lot of prestige to the alliance, which has continued to fight in defense of its member's vested interests. Because of the position adopted by the PZ - and weaknesses of the NFZ - many potential benefits promised at commencements of the reform have found themselves in danger. Apparently, the agreement once achieved had a primordial impact on the decree finally adopted.

Actors and positions

Description of actors and their positions
Government
MoHvery supportivevery supportive strongly opposed
MoFvery supportivesupportive strongly opposed
Parliament
Health Commissionvery supportivevery supportive strongly opposed
Providers
Family doctorsvery supportivevery supportive strongly opposed
PZ membersvery supportivevery supportive strongly opposed
Other providersvery supportiveneutral strongly opposed
Payers
NFZ (National Health Fund)very supportivevery supportive strongly opposed
Private insurersvery supportivevery supportive strongly opposed
Local governments (large)very supportivesupportive strongly opposed
Local governments (small)very supportivesupportive strongly opposed
Patients, Consumers
PHC patientsvery supportiveopposed strongly opposed
Other patientsvery supportiveneutral strongly opposed
Private Sector or Industry
Most of family physiciansvery supportivevery supportive strongly opposed
Specialistsvery supportivesupportive strongly opposed
The President
The Presidentvery supportiveneutral 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 solution concerning PHC was an element of much broader issue - the basket of services guaranteed services to be financed by public sources. The Government raised this concept after having failed implementating a large "package of laws" containing many different mechanisms. Facing political opposition, it picked up the issue of the basket hoping to attract public attention. The concept passed a long way. First proposals to implement a basket were conceived as early as in the beginnings of the nineties. The basket was on the agenda of the former government, many huge documents were worked out but due to political barriers - disintegration of the coalition - the efforts failed. The efforts were renewed by the new government. When the parliament paved the way, the MoH was obliged to work out all necessary executive regulations. It fulfilled the task and published as many as 13 decrees - the one on Primary Health Care among the others. It should be emphasised that a change which had a very important significance for the patients was introduced by a decree, a rule of rather minor position among legal regulations.   

       

Legislative outcome

Enactment

Actors and influence

Description of actors and their influence

Government
MoHvery strongstrong none
MoFvery strongvery strong none
Parliament
Health Commissionvery strongweak none
Providers
Family doctorsvery strongweak none
PZ membersvery strongstrong none
Other providersvery strongweak none
Payers
NFZ (National Health Fund)very strongvery strong none
Private insurersvery strongweak none
Local governments (large)very strongstrong none
Local governments (small)very strongweak none
Patients, Consumers
PHC patientsvery strongnone none
Other patientsvery strongnone none
Private Sector or Industry
Most of family physiciansvery strongweak none
Specialistsvery strongweak none
The President
The Presidentvery strongnone 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, Family doctors, Private insurers, Most of family physiciansMoH, PZ members, PSL (Agriculture Party)NFZ (National Health Fund), PO (Civic Platform)Local governments (small), Specialists, SLD (Social Democrats)Local governments (large)MoF, PiS (Justice & Right)Other patients, The PresidentOther providersPHC patients

Positions and Influences at a glance

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

Adoption and implementation

When the result of the decree was issued in autumn 2009, there were two occurrences.

Firstly, the concept of the health benefit basket was explicitly introduced into the Polish system, even if the practice of limiting scope of the services rendered to the people had been applied - by time consuming formal requirements and waiting time - nevertheless, for the first time it was officially proclaimed.

Secondly, the limited range of services rendered by PHC providers was maintained. The decree petrified gains previously acquired by PZ: the time of services was indicated between 8 a.m. till 6 p.m., five days per week (Monday- Friday). Other decrees made in the same time reduced competences attributed to PHC physicians, and many medical actions are now reserved for specialists.     

Monitoring and evaluation

New regulations petrified the situation already existing. As the outcome of earlier concessions to providers their duties had been substantially reduced. The payer - NFZ - proved to be short sighted as it gave up, causing losses for patients whose access is hampered now. The decree damaged many chances bonded in the past with the strengthened role played by PHC.       

Expected outcome

The regulations consolidated a situation that is advantageous for one side only - PHC providers. Because of that it was welcomed by them and implementation proved to be easy. However, it was disadvantageous for patients whose access is more difficult now than it used to be. The patients - who generally are rather dissatisfied with quality and performance of health care - will likely realise that soon. If so - a new wave of criticism will appear. 

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 very low very high
current current   previous previous

The outcome of the new regulation is unavoidably limiting access and increasing patients' dependency on specialists. It was against all efforts to make the system more rationally arranged. 

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 guaranteed PHC services, Journal of Laws No, 140, item 1138.       

Reform formerly reported in

Law on Health Benefit Basket
Process Stages: Implementation, Legislation

Author/s and/or contributors to this survey

Cezary Wlodarczyk

Suggested citation for this online article

Cezary Wlodarczyk. "Petrifying concessions to primary care providers". Health Policy Monitor, April 2010. Available at http://www.hpm.org/survey/pl/a15/2