with Ewa Kopacz, Minister of Health, Ministry of Health
Voivodeships, Polish expenditure on health care system per one resident is still below the European average.
In regards to the issue concerning the „expenditure on health care system”, I would like to inform you that the financial plan of the National Health Fund for 2011 provides that costs of health care services in regional branches of the National Health Fund amount to PLN 57,098,437 thousand PLN, which marks a growth by 2.32% (i.e. by 1,293,140 thousand PLN), compared to the initial exercise of the National Health Fund financial plan for 2010 (in the amount of 55,805,297 thousand PLN). Increase in outlays allows better access to health care services.
Between 2007 and 2011, outlays on health care services costs in regional branches of the National Health Fund grew by 42.85% (i.e. by 17,126,339 thousand PLN). A detailed juxtaposition has been annexed hereto.
What are the main challenges to ensure unlimited access to health care for a 38-million population, taking into account real public funds allocated for this purpose?
It needs to be noted, that limitations concerning access to health services are found in many countries, even well-developed ones. The reasons for this are, among others, constantly growing health needs resulting from the ageing of the population, quickly growing costs of medical technologies and financial expectations of medical staff. Due to limited funds at the National Health Fund’s disposal, the existence of waiting lists cannot be avoided. It is important to provide equal access to services, taking into account, among others, health status and acceptable waiting time for a given patient to receive service. In Poland, depending on health status, a patient is granted urgent or stable status, which means that the order of patients is not only established on the basis of the date of reporting to a doctor, but also on the basis of medical indications.
It is also significant to guarantee a patient an access to reliable information on where a given service can be received most quickly. Information on the waiting time for each patient is collected by service providers; it is transferred to the National Health Fund and published online.
Actions aimed at streamlining the waiting time management and ensuring reliable data on the actual number of waiting patients and waiting time are also vital. Taking the abovementioned factors into account, the Minister of Health has prepared solutions reinforcing the supervision over the regularity of waiting lists management. Reliable information will allow the National Health Fund to monitor waiting lists and gain knowledge on specializations in which serious shortages in health services occur. Changes provide that as regards health services where the waiting time is the longest, additional information will be collected, so as to better monitor whether queues for deficit health services are managed correctly. In this regard, irregularities arise not only due to improper functioning of certain service providers, but also from the fact that certain patients willing to be entered on several waiting lists (to several doctors) concerning the same service, do not inform other service providers about other lists they are on after having received the service. Solutions currently under preparation at the Ministry are undergoing internal arrangements, to perfect them in this scope on the basis of received remarks.
Systemic changes in health care, proposed in the so-called health package, elaborated at the Ministry of Health and sent to Sejm on 15 October 2010, will also influence better access to services. For example, solutions proposed in the draft legislation on health care information system which provide for collecting information enhancing patients’ security could be indicated. Facilitated access to medical data, including the medical history and information of services provided or prescriptions fulfilled, will limit the risk of undergoing an improper treatment. The Internet Patient Account will allow a patient to review own personal data (laboratory results, visits, referrals and sick leaves, prescriptions, treatment costs etc.), as well as administer own account, including authorising access to the account for selected doctors and the possibility to print reports. The improved medical knowledge of the society, faster diagnosing and better treatment effects are the unquestionable benefits arising from the introduction of knowledge bases in the field of medicine and pharmacy.
Poland was the only „green island” on the red map of European recession and the only EU Member State which escaped the slump. To what extent can good economic condition of the Polish health care sector influence the security of funds for reimbursement?
Good economic condition of the Polish health care sector will indirectly influence the security of funds for reimbursement in a positive way. The draft legislation on the reimbursement of medicines, food for particular nutritional uses and medical devices has provided for the total reimbursement budget indicator at the level no higher than 17% of expenditure on total health care, which guarantees that access to reimbursed products will be gradually wider, along with increased the budget for total health care.
The governmental draft of the reimbursement act has been deemed controversial. According to the Polish Press Agency message of 10 February 2011, the Ministry of Health states that „the reimbursement act raises controversy since it favours patients instead of pharmaceutical companies” These concerns have been confirmed by Focus Reports at preparing to execute the project in Poland. The draft legislation on reimbursement is quite often criticized by pharmaceutical industry for the lack of uniformity and the fact of being a compilation of regulations borrowed from various West-European legal systems. What sort of challenges crop up at transposing the provisions of the new reimbursement act to the Polish legal system? How is the Minister of Health going to convince other partners to the pharmaceutical market (patients, medicine producers) to accept provisions of the reimbursement act if they fear increased prices and limited (regulated) market mechanisms?
The draft legislation on the reimbursement of medicines, food for particular nutritional uses and medical devices is there to comprehensively regulate issues related to the reimbursement system, so that it corresponds to the highest possible extent to current social demand on medicines, food for particular nutritional uses and medical devices covered by reimbursement as part of available public funds.
Medicines financed from public funds are within a regulated part of the market. Medicines not covered by reimbursement are a subject of free marketing. The price of medicines (or the amount patients need to pay) influences patients’ access to them the most, therefore reimbursement policy should aim, taking into account financial capacities of the health care system, at reducing burdens of patients using medicines they need for medical purposes. On the other hand, a vital interest of producers is to gain the reimbursed product status for their products, since it guarantees higher and more stabilized revenues in comparison to the free market.
As part of medicines policy execution, the Minister of Health is obliged to ensure that citizens have proper access to safe and efficient medicines, and at the same time to reduce patients’ share in treatment costs. From the point of view of the system, only those products which have proved their efficiency and guarantee a safe use should be reimbursed. Balancing the expectations of various stakeholder groups should take place according to specified rules.
Health and lives of citizens are the ultimate good, protected by the basic law (Article 68 (1) of the Constitution).In order to execute the right for health protection, it provides that regardless of material situation, each citizen is granted equal access to public health care services provided by public authorities (Article 68 (2) of the Constitution).In none of its subparagraphs does the Basic Law indicate priorities regarding the selection of particular tools – groups of public health care services – used to achieve the abovementioned goal, leaving the establishment of the total health care system to the legislation. Thus, it does not grant privilege to material services and service providers. Acting under constitutional competences, the Government has presented the proposal for solutions where it is guided by the principle of sustainable management of public funds, understood as the maximization of effects at assumed level of expenditure, as well as minimization of expenditure at assumed output. At the same time, the principle of sustainable management excludes the possibility for making arbitrary decisions in this scope by the Minister of Health. The Constitutional Tribunal has repeatedly referred to the position found in its case law, according to which the balance of public finance is a value subject to constitutional protection (K 47/01, K 41/02).
Therefore, it needs to be stated that free market mechanisms cannot be applied on the reimbursed medicines market to the extent to which they serve the purpose of increasing demand on consumption goods market. An external stimulation of demand not resulting from objective health indications determined by professional relation between a doctor and a patient, apart from posing a risk to a patient’s health in the case of administering medicines not justified by medical reasons, limits the right of all patients to have access to public health services (both to other medicines not covered by reimbursement and other health services). Preventing sustainable management of assigned public funds results in wasting the common good.
Current functioning of the reimbursement system is marked by cumulated pathologies leading to irrational management of public funds. On the basis of long term experience, it is legitimate to say that the current reimbursement system requires thorough changes.
Further maintaining the current legal status would allow the pharmaceutical companies to gamble unfettered with public funds and patients’ health in order to gain maximum profits. Aggressive marketing, promotions, offering prizes for purchasing reimbursed products lead to the unnatural creation of demand which results in medically unjustified expenditure, both on the part of the National Health Fund, and on the part of patients themselves. These products are often purchased and collected in volumes exceeding the possibility for their use. Frequently, patients are not guided by the will to improve their health, but to gain additional profits from buying reimbursed products.
Moreover, the draft legislation on the reimbursement of medicines, food for particular nutritional uses and medical devices does not exclude all free market mechanisms. Establishment of the product price will still be the domain of an entity applying for reimbursement and the final price will be negotiated with the Economic Committee.
European Union Member States apply various interdependent mechanisms. The draft legislation on the reimbursement of medicines, food for particular nutritional uses and medical devices is not special in this regard. Mechanisms introduced by the Act provide stability and predictability of expenditure on the reimbursement of medicines at limited funds of the National Health Fund. Lack of objective mechanisms would undermine the point of the Act and also would be able to inhibit the process of improving patients’ access to medicines, both in the context of reducing co-payment and introducing new therapies.
Increasing the number of medicines in the lists of reimbursed medicines is a clear signal that Polish pharmaceutical market is entering a mature phase. However, combined with other Acts (of the so-called health package) being proceeded in the Parliament, it seems that issues related to pharmacological treatment are given more prominence than medical procedure treatment. Is it really the case? Which groups of patients will benefit the most from the provisions of the new reimbursement act (i.e. will have better access to medicines)?
Tools proposed by draft legislation on the reimbursement of medicines, food for particular nutritional uses and medical devices will allow the stabilization of the National Health Fund’s financial situation, which is now prone to unplanned reimbursement growth resulting in the inability to execute contracts concluded with service providers. Protection of patients’ needs as regards pharmacological treatment will positively influence patients’ access to hospital treatment, specialist outpatient treatment, medical rehabilitation, health resorts, highly specialist treatment.
A predicted decline in medicine prices will be beneficial mostly for patients suffering from chronic diseases (including cancerous diseases) requiring long-term therapies. Payment level depends on the burden of expenditure incurred by a patient applying treatment using a given medicine, whereas according to the Reimbursement Act, all medicines issued free of charge or on a flat-rate basis will remain at their previous payment level.