Department of Health Insurance Rafał Bułanowski

Purchasing of health care services in Polish health insurance system

Institutional framework of health care purchasing

Act on health care benefits financed from public resources (regulates i.a.: organization and functions of the National Health Fund, supervision of NHF by MoH, rules of

selective contracting/ tendering procedures…)

Minister of Health - decrees determining the basket of health benefits

- decree specifying some general principles of contracting

President of the National Health Fund - ordinances concerning conditions of contracts

(regulating: requirements imposed on providers, organization of health care provision, settlement of costs)

16 regional branches of the NHF

Tariffs Agency

NHF 1 GP

amb. spec. hospital

LTC

Financial framework for contracting

• Financial basis for contracting with health care providers is the yearly financial plan of the NHF;

• Financial plan of the NHF is prepared on the basis of projections concerning revenue from health insurance contributions and draft financial plans of the 16 RB-NHF to be submitted to the NHF central office by 25 June of each year;

• Financial plan of the NHF for next year should be submitted to the Minister of Health for approval by 15 July;

• Financial plan of the NHF includes several reserves, e.g. general reserve - 1% of projected revenue from health insurance contributions.

Projected NHF spending according to NHF financial plan for 2016

category of expenditure volume (€ million)

Hospital care 6849

Primary care 2156

Reimbursement of (prescription) drugs and medical aids/ devices 1961

Outpatient specialist care 1253

Psychiatric care 508

Rehabilitation 472

Emergency (ambulance) care 422

Dental care 410

Long term care 261

Spa treatment 147

Palliative care 95

other 443

Total expenditure for health services (including reserves) 15 941

Administrative costs 169

Basic principles of contracting

• Health care providers operating within the public health insurance scheme must have contracts with their respective regional branch of the NHF (RB-NHF);

• Each RB-NHF concludes contracts only with providers established in the particular region;

• In principle contracts are awarded by means of competitive tenders - with exception of PHC providers;

• Contracts may have the duration of several years - generally up to 5 years (up to 10 years for hospitals);

• Precise financial volume of contracts is set for each year (until 30 November of previous year);

• Overall financial volume of contracts concluded in particular region cannot exceed the budget of the RB-NHF projected for the next year.

Tendering proces

• Tenders are organized by each RB-NHF on it’s territory, based on the purchasing plan for next year;

• Invitation to tender indicates:

- categories of health services,

- volumes,

- geographical areas covered,

- number of providers to be selected;

• All competing providers must comply with minimum requirements laid down in the basket decrees issued by MoH;

• Tender commission selects the best offer(s) taking into account a variety of criteria that can be subsumed under 4 categories:

- continuity,

- complexity,

- accessibility and quality,

- prices offered;

• Bidders may appeal against the decisions of the tender commission to the director of the RB-NHF; decision of the director can be challenged in court;

• NHF publishes detailed information on all contracts on its website.

Numbers and volumes of contracts - 2014

category of health care number of contracts total volume (€ million)

Primary health care 10 427 1768

Ambulatory specialist care 7497 1244

Hospital care 2157 7128

Rehabilitation 4089 481

Long term care 2486 251

Dental care 13 347 398

Activities of the RB-NHF

RB-NHF are responsible for securing access to health care in their regions. In particular they are responsible for:

- planning,

- selection of providers and conclusion of contracts,

- monitoring accessibility of health services and supervision of providers,

- settlement of health care costs,

- informing patients on accessibility of health services/ waiting times.

Reimbursement of health care providers

• Providers are paid every month on the basis of invoices and supporting reports to

be submitted to the RB-NHF by the 10th day of the month following the reporting

month;

• Payment should be effectuated within 14 days from submission of complete

settlement documents;

• In general providers are reimbursed up to the financial ceilings determined in

contracts;

• Some health services are financed regardless of financial ceilings (e.g. some

cardiologic interventions, transplantations, births…); from 2015 limits don’t apply

to most cases of cancer diagnostic and treatment.

primary health care

o annual capitation payment per patient registered with a GP (paid in monthly

installments) - basic rate of 144 PLN (patients between 20 - 39 Y/A) is

adjusted for other age groups: x 2 for 0-6, x 1.2 for 7-19, x 1.1 for 40-65,

x 2 for over 65);

o fee for service rate:

- 45 PLN - for single consultation in case of patients not registered with the

PHC-provider (in emergency cases) and patients from other EU/ EFTA countries,

- 50 PLN - for issuing the „cancer diagnostics and treatment card”;

o daily lump sum - out of ours PHC centers

outpatient specialist care

o fee for service rates (relative weights expressed in point numbers):

- different rates for 24 various types of specialist consultations (including diagnostic procedures) of varied complexity,

- rates for selected expensive diagnostic procedures that are reimbursed separately (e.g. CT, MRI, colonoscopy…),

- rates for small surgical procedures performed in ambulatory care settings;

o annual capitation payment for each person enrolled in an integrated care program for patients with diabetes

hospital treatment

o case based payments - Polish version of DRG system with about 530 groups (with relative weights expressed in points),

o per diem rates for some kinds of hospitalizations/ additional per diem rates supplementing some DRGs,

o fee for service rates for a number of procedures,

o daily lump sums for emergency wards

long term care/ palliative care/ psychiatric hospital care

o per diem rates

New payment models

• Agency for Health Technology Assessment and Tariffs works on developing new

reimbursement methods that should enhance coordination of care and reward better

clinical outcomes, e.g.:

- bundled payments for treatment of patients undergoing cardiovascular interventions full cycle of care, including rehabilitation and secondary prevention after the operation, reimbursed as one comprehensive health service,

- bundled payments for some orthopedic interventions and rehabilitation (e.g. for patients in need of hip replacement);

• NHF prepares 3 various models of contracting coordinated health care to be tested in

pilot projects: GP-fund holding; comprehensive ambulatory care for patients with

chronic conditions; integration of ambulatory and basic hospital care.

Mapping of health care needs and capacity planning

Regional maps of health needs - new planning instrument for efficient health care purchasing, implemented from 2016

• Based on epidemiological and demographic analyses regional maps will contain prognoses concerning prevalence of various diseases and resulting demand for health services (e.g. number of hospital beds);

• Regional maps will be prepared for a period of five years, by special bodies (one in each region) composed of medical experts on main areas of medicine, representatives of: local self government on regional and county level, RB-NHF, National Institute of Public Health and regional statistical offices;

• Regional map will become legally binding upon its formal issuance of the voivode (head of regional government administration) and its approval by the Minister of Health;

• Regional maps will be the basis for setting regional health priorities and elaboration of yearly health benefits purchasing plans prepared by each RB-NHF

Opinions about the justification of new investments in health care

infrastructure - new instrument of capacity planning

• Voivode issues the opinion, based on the regional map of health needs, on request of an entity (public or private) intending to create a new hospital, hospital ward or a larger ambulatory care facility;

• Positive opinion gains a provider additional points when bidding for contract with the RB-NHF;

• Opinions will be issued from July 2016 (after publishing of the first maps of health needs).

Thank you for your attention !