Raport II, nauka, zdrowie publiczne
[ Pobierz całość w formacie PDF ]
CASE-Doradcy Sp. z o.o.
Raport CASE-Doradcy we współpracy
z Collegium Medicum Uniwersytetu Jagiellońskiego
Projekt reformy systemu ochrony zdrowia w Polsce
Część II
ZARYS REFORMY
Przygotował zespół autorski w składzie:
Stanisława Golinowska
Cezary Włodarczyk
Ewa Kocot
Iwona Kowalska
Agnieszka Sowa
Jacek Grabowski
Panos Kanavos
Adam Kozierkiewicz
Witold Ponikło
Christoph Sowada
Koordynator:
Andrzej Cylwik
Warszawa, Czerwiec 2005
1
SPIS TREŚCI:
Executive Summary ................................................................................................................... 3
CZĘŚĆ 2: NOWY SYSTEM OCHRONY ZDROWIA W POLSCE - OD PROJEKTU DO
WDROŻENIA.......................................................................................................................... 12
1. Granice systemu ochrony zdrowia w Polsce.................................................................... 13
2. Podmioty (instytucje) systemu ......................................................................................... 17
2.1. Organizacja i usytuowanie płatnika
........................................................................ 18
2.2. Miejsce samorządu terytorialnego
........................................................................... 19
2.3. Relacje między płatnikiem a jednostkami samorządu terytorialnego
..................... 21
2.4. Status zakładów opieki zdrowotnej - problem samodzielności
................................ 22
2.5. Funkcje Rady Społecznej
......................................................................................... 23
3. Własność w systemie: sektor publiczny i prywatny......................................................... 25
4. Granice publicznej ochrony zdrowia................................................................................ 26
4.1. Koszyk świadczeń gwarantowanych
........................................................................ 27
4.2. Najważniejsze uwarunkowania i założenia, które powinny być brane po uwagę
przy tworzeniu koszyka
.................................................................................................... 28
4.3. Mechanizm wyboru świadczeń gwarantowanych
................................................... 29
4.4. Monitorowanie dostępu do świadczeń gwarantowanych
........................................ 30
4.5. Kolejność prac nad koszykiem i harmonogram realizacji projektu
....................... 31
5. Sektor prywatny i partnerstwo publiczno-prywatne ........................................................ 35
6. Nowa strategia zarządzania .............................................................................................. 37
7. W kierunku racjonalnej i wszechstronnej polityki lekowej: szczegółowe rozważania 42
7.1 Polityka cenowa
......................................................................................................... 42
7.2 Polityka refundacyjna
............................................................................................... 44
7.3.”Leki sieroce” i leczenie celowane – leki o wysokiej cenie, innowacyjne,
specjalistyczne dla niewielkiej populacji.
....................................................................... 48
7.4. Po stronie popytu indukowanego
............................................................................. 48
7.5 Polityka branżowa
..................................................................................................... 55
8. Współpłacenie jako mechanizm powiązany z projektem koszyka ................................. 58
9. Nowe zasady finansowania na szczeblu makro ............................................................... 60
10. Metody finansowania świadczeniodawców ................................................................... 61
10. 1. Uwarunkowania reformy mechanizmów finansowania producentów świadczeń
.......................................................................................................................................... 61
10.2. Podstawowe mechanizmy finansowania w opiece ambulatoryjnej
...................... 62
10.3 Podstawowe mechanizmy finansowania w opiece stacjonarnej
............................ 66
10.4. Finansowanie producentów świadczeń zorientowane na efekt i jakość
............... 70
11. Zwalczanie szarej strefy i korupcji w służbie zdrowia. ................................................. 71
12. Podstawowe rekomendacje i sekwencja ich wprowadzania .......................................... 75
13. Organizacja procesu reformatorskiego – uogólnione wnioski z analizy innych
doświadczeń......................................................................................................................... 83
Bibliografia........................................................................................................................... 87
Spis Tabel. ............................................................................................................................ 95
2
Executive Summary
The report
Proposal for healthcare system reform in Poland
is a comprehensive analysis of
the healthcare system, indicating operating deficiencies and guidelines for reform. The report
draws on a collected repository of existing materials describing the Polish healthcare system
and its recent transformations, as well as comparative materials illustrating healthcare systems
operating in other European Union states. In assessing the system’s effectiveness, the authors
have taken into account the development and the publication of the “Green Book”, which
examined the funding of the Polish healthcare system. In the opening section of the report, the
authors present a detailed analysis of the deficiencies of the current system. Possible and
recommended guidelines for reform have been highlighted in section two. In accordance with
the authors’ original intent, the report features unique recommendations for healthcare system
reform in Poland. The Polish healthcare system fails to operate efficiently and thus calls for
comprehensive improvements. This assessment of the situation reflects the opinions of
patients, service-providers and policymakers. Still, no constructive discussions are being
undertaken to identify how, how soon and at what expense the current system may be durably
improved. The authors of this report hope that the study will trigger this much-needed debate.
To facilitate this objective, the report identifies and provides an overview of key system
dysfunctions which have led to its diminishing effectiveness, and formulates respective
reform proposals.
Guidelines for changes aimed at achieving greater transparency of healthcare system
operations, and better effectiveness and efficiency, are presented against an in-depth analysis
of emerging problems. The recommended changes need to be implemented simultaneously in
a variety of areas. The process itself will be time-consuming as it embraces both short-term
objectives (to be implemented through 2-3 years) as well as long-term initiatives which may
be completed in 5 years’ time. The implementation framework of particular programs varies,
depending on the costs and complexity of introduced changes.
The initial period of reform is focused on preparations, including the development and
implementation of the reform infrastructure. The implementation of the changes featured in
the schedule should commence in the second year. Healthcare system transformations need to
be gradually introduced, as ‘instant’ and insufficiently-prepared solutions may cause more
damage than they bring benefits. Experience of Western countries clearly indicates that
reform can never be a closed process. This means that the healthcare system continuously
calls for appropriate adjustments. For this reason, we should assume that in the years to come,
reforms will be continued with the aim of achieving a higher quality of organizational and
operational structure for the Polish healthcare system. The recommendations contained in this
report are largely based on an in-depth analysis of the operations of the current Polish
healthcare system, and also acknowledge the abundant expertise of other European states,
which have successfully undertaken the difficulties and risk inherent in such initiatives. The
authors hope that the proposals highlighted in this report will become the starting points for a
constructive debate on guidelines for essential changes to improve the Polish healthcare
system.
3
Overview of the Report
The report contains two sections. Section one features an analysis and diagnosis of the
healthcare system, while section two presents the proposed guidelines for reform. The in-
depth diagnosis goes far beyond healthcare funding issues highlighted in previous studies
(e.g. the Green Book, Department of Health 2004) giving an insight into the healthcare issues
currently facing Polish society, the forecast effects of the progressive ageing of the Polish
population, an inventory of healthcare sector resources (human and material), and a
discussion on the effects of recent reforms and their fundamental deficiencies.
A special focus was put on drug policy issues. The diagnostic section analyzes particular
aspects of effective healthcare operations, illustrated by sample solutions applied by other
European states. Section two contains proposals for improvement of Polish healthcare system
operations. Key areas for improvement include:
•
Initiating a public debate on public expenditure priorities, with special focus on the
position of healthcare,
•
Systemic changes aimed at leveraging the financial aspect of the system and
improving the efficiency of healthcare-allocated resources while assuring their
medical efficacy,
•
Introduction of healthcare service rationing by identifying a guaranteed basket of
services,
•
Implementation of effective methods for funding service-providers,
•
Introduction of a rational and socially-acceptable co-payment system applicable to
non-medical services and services excluded from the guaranteed service basket,
•
Introduction and expansion of programs for the optimization and monitoring of costs,
as well as improvement of the management system on every level,
•
The long-term fight against corruption,
•
Introduction of a rational drug policy, giving patients wider access to drugs within the
restraints of the state budget,
•
Implementation of scheduled broad health education and disease prevention activities.
Section two of this report thoroughly discusses recommendations regarding the above-
highlighted areas for improvement and presents a framework for the implementation of the
recommended solutions.
Current Status of the Polish Healthcare System
Although the health status of the Polish population has undoubtedly improved since 1990, it
still seems to be unsatisfactory compared to average indicators for the European Union and
OECD states. The most frequently-used health indicators (e.g. life expectancy, HALE,
morbidity rate) position Poland amongst the lowest of the European Union states. Improved
health status has been largely attributed to greater diversification of food and changes in
lifestyle, including greater physical activity. It is still essential to roll out initiatives aimed at
further improvement of the health status of the Polish society, including activities carried by
the healthcare system to promote health and prevention, as well as to widen access to medical
services.
In order to achieve these goals, the Polish healthcare system underwent numerous changes
during the past decade with the key landmark being reforms of 1999, 2003, and 2004. The
six-year long period of preparations and implementation of healthcare reforms has not
4
brought us to a successful end. The reform process did not fail because the initial reform was
based on an ill-formulated concept, but because it was hindered by the incoherence of
subsequent reform measures. Eventually, each new coalition attempting to initiate new
systemic changes will be prone to additional difficulties resulting from public disillusionment
with the outcomes of recent reforms, claims for higher wages, reluctance of public healthcare
institutions to assume a greater financial responsibility or burden patients with higher medical
expenses.
The second factor – after organizational deficiency – responsible for the malfunctioning of
the Polish healthcare system is its permanent state of insufficient funding. Total healthcare
expenditures in Poland are the lowest among all OECD and European Union states – both in
terms of nominal value and purchasing power. Healthcare spending is almost twice as low as
in other transformation states, including the Czech Republic and Hungary. The overall low
level of healthcare spending in Poland has been combined with a consistent decrease in the
share of public expenditures in total healthcare spending, falling to barely 65% in 2004. At the
same time, the percentage of GDP of public healthcare spending in Poland has also steadily
declined, now at the lowest level among all EU states (3.87% in 2005). The scheduled
increase of the mandatory healthcare insurance by 0.25% per annum will generate an amount
under one billion Polish Zlotys (3% of total National Healthcare Fund resources), which is
insufficient to make a significant systemic difference and will not heal the operation of
healthcare system. The amount is not even sufficient to fully cover the debts of the system.
Given the insufficient funding and lack of effective healthcare management, we continue to
observe the growing instability of its revenue to cost ratio. This has led to the increasing debt
of healthcare institutions, a devaluation of the infrastructure and underpayment of medical
professionals. The mature debt of healthcare services at year-end 2003 exceeded PLN 5
billion. It should be also noted that problems with the recruitment of nurses or specialist
doctors have now become widespread, and medical students demonstrate an increased interest
in employment prospects across the EU.
One of the goals of the 1999 reform was to introduce primary care institutions as a measure
limiting access to more expensive specialist and hospital services. Still, the research indicates
that the goal to focus healthcare on more primary care and exercise stricter control over
specialist and hospital services was never actually achieved. Indicators point out that in the
years 1999-2003, the frequency of use of hospital and specialist services was increased (after
a temporary improvement, the percentage of population using primary healthcare services
declined from 47% in 1999 to 24% in 2003). We continue to observe a steady increase in
spending in the specialist hospital treatment segment, which clearly leads to further
constraints in the diagnostic and therapeutic capacity of general practitioners. Drug-related
expenditures rank first among total healthcare expenditures. At the same time, international
comparisons show that Poland is in the last place in Europe in terms of public expenditure on
drugs. Average drug spending per capita is half the amount as in Hungary and two or even
three times as lower as in 15 EU states. Poland also demonstrated the highest (reaching over
50%) drug co-payment level among all European Union states, with an unusually high share
of older generic drugs (about 60% in terms of value and 80% in terms of quantity). Poland is
the only European Union country where not a single innovative drug has been added to the
reimbursement system since December 1998. Another fundamental dysfunction of the Polish
pharmaceutical market is a lack of a monitoring process for prescribed drugs, leaving the
system open to abuse and corruption.
5
[ Pobierz całość w formacie PDF ]