2. The stable patient case - in case when the circumstances of their health condition are neither sudden nor urgent (causing emergency).

Transcription

1 Criteria to choose patients from waiting lists Country: Poland Partner Institute: Institute of Public Health, Jagiellonian University Medical College, Krakow Survey no: (6)2005 Author(s): Iwona Kowalska Health Policy Issues: Access Current Process Stages Idea Pilot Policy Paper Legislation Implementation Evaluation Change 1. Abstract On 27 August 2004 the new law on publically financed health services has been passed. According to this new legislation, it is obligatory to run a registry of patients waiting to be provided with health care services. To implement this new legislation an executive regulation of the Ministry of Health dated from 26 September 2005 on medical criteria has to be followed by the service providers while putting patients on waiting lists. 2. Purpose of health policy or idea A shortage of balance between patient's needs and possibilities of satisfying them still remains the main challenge of the Polish health care system. Access to health care, as in other countries with publicly funded health care systems, in some cases in Poland is very limited. The main targets of the waiting list system are: 1. To assure equal access to health services 2. To plan the quantity of accessible services 3. To maximize the resources of the public health care system 4. To limit the number of services realized in accordance with the E112 procedure. To resolve the increasing problems regarding waiting times for the health services has become the main objective of the proposed legal act. It is mostly seen as a problem of the service providers' obligation to maintain a registry of the patients waiting for the health care services. Additionally, the service provider has been obliged to provide the NHF unit on voivodeship level with proper informations about the number of patients on waiting lists and about an average waiting time (it should be reported annually). The maintenance of the lists of the waiting patients is an obligation of the service providers providing their services in the following areas: outpatients' department treatment, hospital treatment, - 1 -

2 rehabilitation, stomatology (also the ortodontal outfit and dentures), psychiatric treatment, long-term care. The Minister of Health determined in an executive regulation on the publicly funded health care services the medical criteria the service providers should follow while placing the patients on waiting lists. Main objectives See above. The objectives are to adjust increasing waiting times for health services for Polish patients by guaranteeing the obligation of a strict and clear patient's registry. It is assumed that during the process of waiting two patients categories would be taken as a basic division criteria. These two fundamental groups are the following: 1. The urgent patient case - when the need for emergency service exists (as a result of the illness process dynamics, its progressive character and as a possibility of rapid worsening of the patients' health conditions - or as the significant reduction of the chance for the good health status to return) and; 2. The stable patient case - in case when the circumstances of their health condition are neither sudden nor urgent (causing emergency). The following medical categories are supposed to be decisive in regards to putting a patient on a waiting list: 1. The health status of the patient; the assessment of the further development of the disease; 2. The co-morbidities (because of which the given health care service is to be provided and a danger of the appearance of consolidation or deepening of a disabled state). There are no detailed provisions in the mentioned above executive regulation concerning a schedule of placing the patients on the waiting lists. The same situation concerns a length of time the patients should wait for providing them with the health care service that would depend on the defined category. Neither was it precised what a schedule of creating the waiting lists is, what a form it should have, and what principles of its revealing are, as some doubts as for a range of the legislative. Type of incentives Non-financial. The initiative concerns mainly the problem of legal determining of medical criteria being a necessary condition for placing patients on waiting list by the services providers. Groups affected National Health Fund, Medical Providers, Patients 3. Characteristics of this policy Degree of Innovation traditional innovative Degree of Controversy consensual highly controversial - 2 -

3 Structural or Systemic Impact marginal fundamental Public Visibility very low very high Transferability strongly system-dependent system-neutral 1. The act gives an opportunity to introduce the first needed changes to solve the problem of waiting lists. 2. As it was pointed out before there is a need to prepare and implement the policy on admissible time of waiting for health services 3. The patients are usually less interested in the institutional nuances but more in accessibility and equity improvement. 4. Political and economic background Until 1999 the Polish health care system was dominated by the power on the central level (government). Health services were financed out of taxation in general. Medical treatment was not always free of charge. Because of the low level of services and the shortage in respect to health services in the official sector under - table - payment to have the access to services of a good quality were common procedure in the system. Most Poles felt insufficiently informed and during the first stage of health care reform, which was decisive as to its success or failure, did not know their rights and duties. Limitations on services, chaotic contracting policies linked with a huge dose of uncertainty on the part of service providers caused not only frustration among their staff, but also great difficulties in accessing specialised services. Currently promised increases in health care funding are confronted with economic stagnation and crisis on the labour market. Public discontent intensifies due to ever-increasing patient participation in the costs of health care within the system, especially as regards the purchase of medicines. The issues of difficulties in accessing the specialised services are one of the many problems which polish health care reform did not resolve. The old government (Social - democrats) implemented the health care reform in According to its rules a patient can freely choose the place which will provide any medical treatment for him/her. The direct consequence is the long waiting lists in the best hospitals - even one year waiting period. The new law on the waiting list problem was implemented in 2004 and 2005 (see above the specified description of it). There are many reasons for waiting lists creation in Poland, and if a unit has problems with long waiting times it can be related to one or more of the following conditions: The need for care has increased - caused by an ageing population (increased prevalence) and/or an increase in the incidence. Growing expectations and demand. New technologies leading to widening indications for treatment and an increase in demand. Managerial or administrative shortcomings - decreasing productivity. Logistic problems - 'bottlenecks'. Absence of data Decreasing resources

4 Medical practice - priority setting. Main problem is of course shortage of financial resources. Most of polish hospitals in the middle of October does not have any resources for providing services contracted with NHF. The solution for such critical situation may be as follows: 1. delivery of services - despite the lack of money that causes growing level of debts - or 2. determining the time for service providing in a distanced time (mostly beginning of the calendar year when the hospital can "take" money due to the new contract signed with NHF). Such situation occurred this year but NHF decided to deliver some amount of money (that should be send to Germany due to E111 and E112 financial liabilities) to the providers for present needs and waiting list problem solving. This money must be spent before the end of the year. It should be recalled that the European Council recommendation from 1998 suggests to member states that the priority should be given to patients who have the biggest need. The health risk evaluation and quality of life evaluation should be taken into account as well as the requirement that time of waiting should not exceed the period after which the health status could worse. Change of government The new law regulation (from 2004, 2005) were implemented by the leftist government (supported by the same coalition) but which has gradually loosed its support in the parliament (recently it has been the minor government but the parliamentary principles Complies with EU regulations - The E112 system, according to legal requirements of NHF, pays costs of planned treatment who have to wait to long for service in Poland. Change based on an overall national health policy statement Statement Title: Law of 27th of August 2004 on the heath care services financed from public finances. 5. Purpose and process analysis Idea Pilot Policy Paper Legislation Implementation Evaluation Change Origins of health policy idea The draft law was worked out by Ministry of Health in a special situation, because the Constitutional Tribunal in Poland stated that the Law on rules of health care system functioning was unconstitutional. In such case the new Law has been established and this one regulated - for the firs time - the problem of waiting for services. One year later the executive regulation has been issued (stating the criteria for lists placement). Main reason for these acts was patients' disapproval for period of waiting lengthening (leading for instance to under the table payments). The main tools to achieve the idea's principle purpose are: 1. Necessity of monthly reported situation on waiting list (by providers to NHF) 2. Introducing computer program for register of patients waiting for services and using unified criteria, known to everyone - 4 -

5 3. Introducing on local level NHF units web sites information including data on possible time of service providing (in the region closest to the place of living of patient). Initiators of idea/main actors Government: The government (the Health Minister) was interested only in a matter of solving the problem of the criteria set determining. Much more controversy will come together with the draft on admissible time of waiting for health services. It has been introduced as a part of Ministry of Health competencies (it is an executive legislation derived from law of 27th of August 2004 on the heath care services financed from public finances). Approach of idea The approach of the idea is described as: renewed: The problem aroused first time after the Sickness Funds introduction (the first year of SF existence). The context has changed? due to the structural and institutional change of the health care system amended: New regulation was the next step in unification and equalisation process ( in the context of equal accesses to the health care services Stakeholder positions 1. The Ministry of Health/ Government created common conditions on waiting list running process. Till now the formal circumstances were not set (e.g. how to run the waiting list in the medical provider's institution). As a result there are many cases of running such list in the form of "exercise book" by the head of the institution. The Ministry of health realised the policy (in the form of executive legislation) the main aim of which was created by the law cited above. 2. The National Health Fund- is interested to create the clear relationship with providers in the aspect of recording of all health care services and eliminate under the table payment. 3. The medical providers are officially interested in the problem of waiting list setting criteria and legal qualification of admissible waiting time solving but at the same time settlement of clear rules in this case will cause loss of under the table payments 4. Patients - they are interested in the widest possible access to health care services and the mechanism is supposed to be a tool used for the purpose of accessibility improvement. The discussion within the expert and public consultants (e.g. The Physician Chamber) lasted for longer time. The political discussions took place in the parliament (e.g. in the parliamentary commission) and Ministry of Health. In the public discussion ( e.g. The Physician Chamber, experts, media) the main disadvantage of the proposed solutions were indicated. As I wrote above we can expect that the draft on admissible time of waiting on health services will be much more controversial. Actors and positions Description of actors and their positions Government Medical Providers very supportive strongly opposed Patients very supportive strongly opposed NHF very supportive strongly opposed - 5 -

6 Influences in policy making and legislation The development of this idea lead to an executive legislation described hereby. The original proposal was discussed and consulted with all actors and subsequently modified. In fact the problem of set the criteria in choosing patients from waiting list does not belong to the legislative process, and the major position takes the Ministry of Health as an executive power. In accordance with the records of the legislative act (law on health services financed from public source - 27 of August 2004 ) an obligation of running, by the service renders, the registry of the patients waiting for providing them with the services of health care has been introduced. Legislative outcome Actors and influence Description of actors and their influence Government Medical Providers very strong none Patients very strong none NHF very strong none Positions and Influences at a glance Adoption and implementation Clearly the government is a central stakeholders in the implementation of the policy because it decide about the - 6 -

7 health policy in Poland (trough the legislative process, executive acts). In the adoption process the providers will be very much t involved, because they have to run the waiting list and set the criteria in choosing patients from such list. By the implementation of described policy will be affected not only providers but also patients, as a main group of recipients of this policy. To achieve the policy purpose realised by regulation there should be introduced a professional system of control and monitoring the waiting list service. Nowadays there is the computer system implemented by National Health Fund "Package of Health Care Provider" with the special part related to the problem of waiting list. The real implementation of described policy cannot be evaluated at the moment - the results of the regulation implementation will be know the next year (if the system would not be changed by the new government). The radical improvement might be achieved only due to the radical decisions: new executive draft on admissible time of waiting on health services. It will be very difficult now, because new Ministry of Health Prof. Religa has new idea of reforming the health care system. After parliamentary election the problem of waiting list is not so important as it was two months ago. Monitoring and evaluation As it was pointed out before (see above) - the results, monitoring and evaluation process cannot be described at the moment, it is necessary to wait until the next year. The Ministry of Health monitors the problem of waiting lists and waiting times due to the implemented computer system by National Health Fund "Package of Health Care Provider". There is a special part allowing manage the waiting lists service trough the information on e.g.: review of the waiting lists, review of the status in the waiting lists, review of the statistic, shift within the list, cancellation form the list etc. Review mechanisms Final evaluation (internal), Final evaluation (external) Results of evaluation As it was pointed out before (see above) - the results, monitoring and evaluation process cannot be described at the moment, it is necessary to wait until the next year. The Ministry of Health monitors the problem of waiting lists and waiting times due to the implemented computer system by National Health Fund "Package of Health Care Provider". There is a special part allowing manage the waiting lists service trough the information on e.g. : review of the waiting lists, review of the status in the waiting lists, review of the statistic, shift within the list, cancellation form the list etc. 6. Expected outcome The Government will probably try to achieve decreases in periods of waiting in future. Described executive act is a first attempt to settle the problem of waiting list in the direction of the criteria of choosing the patients from such lists set. The effect of the policies of providers undertaken in view to choose patients from waiting list is unclear yet. Unfortunate the political situation in Poland is caused by unstable policy at the government level (expected change) - 7 -

8 and because of this it is not possible to describe unexpected and undesirable effects. In case of slow and divided into steps process of changes the effects can be positive in a sense of accessibility improvement and equity improvement. Quality of Health Care Services marginal fundamental Level of Equity system less equitable system more equitable Cost Efficiency very low very high 1. Impact on quality of health care services would be neutral, because from one hand it does not influence the price for services, but from other hand it shows the clear criteria in choosing the patients from waiting list. 2. Due to the implementation of the regulation the system would be more equitable (clear criteria in choosing patients from waiting list, elimination under the payment mechanism) 3. Impact on cost - efficiency would be low, because implemented executive act sets the criteria in choosing patients form waiting lists and as such not influences directly the cost - efficiency mechanism. 7. References Sources of Information Regulation from 26th of September 2005 on set the criteria in choosing patients from waiting list (regulation establishing health care providers procedures)" Law from 27th of August 2004 on health care services financed from public finances, Journal of Laws no 210, clause 21350), article 137 p.10). Author/s and/or contributors to this survey Iwona Kowalska Suggested citation for this online article Iwona Kowalska. "Criteria to choose patients from waiting lists". Health Policy Monitor, October Available at -