Macroeconomic overview

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1 GYEMSZI National Institute for Quality- and Organizational Development in Healthcare and Medicines HUNGARIAN HEALTH SYSTEM SCAN Vol. 7 No.1 May 2013 Content - Macroeconomic overview - Health financing overview - Changes in the specialized care - Human resources - Changes in the pharmaceutical reimbursement system - The new office of legal protection Macroeconomic overview Table 1. Macroeconomic indicators of Hungary Source: Magyar Nemzeti Bank (Central Bank of Hungary) (forecast) 2013 (forecast) Real GDP growth General government balance as % of GDP Current account balance as % of GDP CPI Government debt as % of GDP (Maastricht definition)

2 The usual economic indicators show a diverse picture for Hungary in The most influential foreign factors effecting them were the situation in Greece the quasi-bankruptcy and the elections followed by a long and difficult government formation in spring, the slow expansion of the German economy (0.7 percent) throughout the year and the continuous prospect of IMF negotiations about a new credit for Hungary which has never gained momentum. Global tendency of slowing economic growth turned Hungary into recession and the GDP has shrunk approximately 1.4 percent annually. Also the consumer price index increased relatively fast (5.7 percent) however for 2013 the prospect is that it would exceed the three percent target only by a half percentage point. Also, the unemployment figures kept stable without significant improvement. Nevertheless, Hungary has fulfilled its promise to keep the deficit below three percent as it is expected to be 2.7 percent, and with that significantly lower than the European Union average. This also concluded in a reduced level of national debt by 2.4 percentage point to the level of 79 percent at a time when most OECD countries have been heavily spending. In order to keep the deficit low, the government increased the VAT by 2 percentage points to 27 percent which has been the highest in the European Union, the income tax exemption of the minimal wage was abolished and the termination of a de facto second range of the income tax, which was four percentage points higher and effective above HUF , was delayed to The government also decided to cut expenses higher education received 15 percent less support, early retirement was strictly limited. Agriculture and industrial production were both on decrease in 2012 the former due to unfavourable weather conditions, the latter because of the lack of demand. However, the new factory of Mercedes gradually started to produce, and therefore this sector has kept relatively favourable results. Nevertheless, the balance of trade has only improved in the first eight months, whereas decreased at the end of the year, so that in annual average the difference was insignificant, though positive. The monetary policy has been characterized by a steady interest rate at seven percent in the first half of the year and a continuous decrease in the second half, which led down to the level of 5.75 percent in December. Although the inflation level was above the target, new members of the Monetary Council were more concerned about economic growth. Meanwhile the exchange rate was appreciating in the first half of the year with some longer weakening due to the 2

3 Greek events in the spring and then steadily kept in the range of HUF/ euro. The financial position of households also improved to some extent and that was partly due to the shrinking volume of credits denominated in foreign currencies mainly in Swiss franc. The population has become heavily indebted such a way during the last decade and when the exchange rate depreciated, this threatened some layers of society with the possibility of bankruptcy. Therefore the government facilitated discounted prepayment options and rescheduling of payment. Table 2. Basic health indicators Year Value Population 2013 (January) Crude death rate per 1000 population Live births per 1000 population Life expectancy at birth, in years, female Life expectancy at birth, in years, male Infant mortality per 1000 live births SDR all causes, all ages, per * SDR, diseases of circulatory system, all ages per * SDR, external cause injury and poison, all ages per * SDR, malignant neoplasms, all ages per * Hospital beds per Physicians per Inhabitants per one GP and family paediatrician Total health expenditure as % of gross domestic product (GDP) Public health expenditure as % of total health expenditure Private health expenditure as % of total health expenditure Private households and health funds health expenditure as % of total health expenditure Source: Hungarian Central Statistical Office, *WHO 3

4 Health financing overview In the final accounts, the 2011 budget of the Health Insurance Fund had a revenue of HUF 1403 billion, an expenditure of HUF 1486 billion and a deficit of HUF 84 billion. According to preliminary data, in 2012 the Fund s revenue was HUF 1744 billion, its expenditure HUF 1791 billion and its deficit HUF 47 billion. For 2013 the Parliament set the estimated amount of both expenditure and revenue of the Health Insurance Fund to HUF 1804 billion. (Table 3 and 4) Revenues The continuous increase of the Fund s revenues between 2011 and 2013 is a result of increase in the amount of several items. In 2012, revenues from contributions have increased due mainly to the one percent increase of employee health insurance contribution. Besides this, the rate of the health service contribution expanded (from HUF 5100 to HUF 6390, which is paid by persons without legal rights to insurance) and the scope of other contributions widened (10 percent health contribution is paid on non-wage benefits after the amount determined by the income tax base). The significant decrease of contribution seen in the 2013 estimate can be traced to the effect of two factors. On the one hand, the former employer health insurance contribution which is paid as social contribution tax from 2012 does not go into the Health Insurance Fund, but from 2013 is part of the Pension Insurance Fund. On the other hand, the workplace action plan was launched in 2013, under which employers may receive contribution allowance for employing entrants under age 25, unskilled workers, and employees over age 55. To make up for the missing contributions, the central budget provides a compensation to the Health Insurance Fund, which appears as an item of budget compensations. This is one of the reasons for the increase of central budget compensations in 2013, and another one is that the financing of disability and rehabilitation provisions in 2012 was transferred from the Pension Insurance Fund to the Health Insurance Fund. The increase of revenues connected with health insurance arises from the surplus payments of pharmaceutical manufacturers and distributors, and from two new taxes introduced in 2012: accident tax (30 percent of the fee of mandatory vehicle liability insurance) and public health product tax. 4

5 Table 3. Revenues of the Health Insurance Fund HUF million Revenues of Health Insurance Fund Contribution revenues and social contribution tax Central budget compensations Other revenues connected with health insurance Revenues for operation Revenues from asset-management 2011 (budget estimate) 2011 (final account) 2012 (budget estimate) 2012 (payment) 2013 (budget estimate) * * *Together with moneys for the coverage of disability and rehabilitation provisions from the Pension Insurance Fund In 2013, 54 percent of the total revenues is planned to come from central budget compensations, which means that the proportion of tax financing exceeds contribution financing a consequence of a process started in the previous years. Expenditures With regard to the Fund s estimated and final expenditures in 2012, there appears to be a significant increase compared to the previous year. The main reason for this is the takeover of disability and rehabilitation provision from the Pension Insurance Fund, as mentioned earlier, with an estimated value of HUF 342 billion and a paid value of HUF 358 billion. Together with this, close to 31 percent of the Fund s expenditure consisted of cash benefits. The expenditures of curative-preventive provisions amounted to HUF billion, with a surplus of HUF 17.2 billion relative to the target. A significant part of the surplus (HUF 12.6 billion) was spent on improving the financial situation 5

6 and liquidity of health care service providers. (From 2012, the separate title of dispensary services ceased to exist and is subsequently financed from outpatient specialist care provisions.) The Convergence Programme s goals include the reduction of pharmaceutical reimbursement expenditures by the generic programme. From 2012, the effect of these measures to reduce costs appears to be more pronounced. In 2012, the expenditure of pharmaceutical reimbursement was HUF 315 billion, which exceeds the estimated expenditure by HUF 37 billion, but shows a decline of 16 percent compared to the previous year s final accounts. The 2013 estimate calculates with further decrease in reimbursement outflow. The amount of the estimated expenditures of the Fund for 2013, HUF 1804 billion, is more or less the same magnitude as in the previous year. Compared to the previous period there is a reduction in the expenditure of pharmaceutical reimbursement, which is set to HUF 280 billion (HUF 221 billion can be spent for the expenses of pharmaceutical reimbursement, HUF 10 billion for the expenses of pharmaceuticals with special acquisition, and HUF 49 billion are to be set apart as a reserve for pharmaceutical reimbursement): this is HUF 35 billion less than in the previous year, which in large part was reallocated to the expenditures of acute inpatient care. Pharmacies may also receive benefits of the Health Insurance Fund by means of different entitlements. From 2012, benefits were introduced for pharmacies that incentivise the dispensing of generic preparations in 2012 HUF 2.7 billion was allocated for this purpose. From 2013 a new service fee for public pharmacies has been introduced for the patient and drug safety review provided by pharmacists during the dispensing of prescription drugs and magistral preparations. An amount of HUF 4.5 billion is planned for this purpose. (In 2013, these sums feature among other expenditures of the Fund.) 6

7 Table 4. Expenditures of the Health Insurance Fund HUF million Expenditure of Health Insurance Fund Provisions in cash of the Health Insurance Fund 2011 (budget estimate) 2011 (final account) 2012 (budget estimate) 2012 (payment) 2013 (budget estimate) Provisions in kind Curative-preventive provisions in kind Primary care Service of dispensaries Special nursing at home Outpatient specialist care+ct, MRI (with laboratory fund) Inpatient care Other curativepreventive provisions in-kind Expenditures on pharmaceuticals Pharmaceutical reimbursement Reimbursement of therapeutical appliances Other provisions inkind Other expenditures of the Heath Insurance Fund Health insurance budgetary agencies and centrally managed estimates

8 Tax-free employer health insurance Due to legislative amendments, from January 2012 employers may offer taxand contribution-free private health insurance to employees as optional nonwage benefits. Earlier the personal income tax law provided tax exemption only for fees of accident insurance and permanent disability insurance. In January 2012, this was extended to fees of health insurance with no cash surrender value. In January 2013, additional amendments have been made to the income tax law, whereby risk insurance paid by another person becomes tax free if its monthly fee does not exceed 30 percent of the minimum wage. Risk insurance is life, accident or health insurance that has no expiration service and cash surrender value. The voluntary private health insurance of several private insurance companies covers diagnostic, screening and outpatient services in designated private service providers or contracted public hospitals without waiting times. In case of illness, the insured person calls the insurance company for health assessment. The insurance company then organises the care pathway for the person and pays the fee to the hospital. There is no co-payment incurred. Employer health insurance for groups can be obtained for a fee of about HUF 7000 per month independent of the employees age. The extra benefit package that includes VIP inpatient care starts from HUF per month. The insured people presumably benefit from such arrangements since they receive faster treatment then in the public system. They do not simply move ahead in the waiting list of patients covered by social insurance, but get out of this list and move into another, shorter line. This is possible due to unused capacities of public hospitals created by insufficient financial resources. In times of idleness, such capacities may be used for treating private patients. This way the social insurance waiting lists also get shorter. Many public health care institutions support this arrangement because it allows them to obtain extra income. Private health insurance may help hospitals finances by injecting additional funds into their operation. 8

9 Changes in the specialized care In Hungary, from 1 January 2012 health regions serve as territorial bases for the organization of health care. Accordingly, the following health regions have been created since the beginning of 2012: West Central Hungary, West Transdanubia, Northern Hungary, North Central Hungary, Northern Great Plains, South Central Hungary, South Transdanubia and Southern Great Plains. Health regions are accountable for the provision of health services to million insurees on each level of progressivity in the majority of specialties with public financing. The Regional Healthcare Management Centres operating in the health regions, among others deal with the tasks of patient pathway management, health service management and development policy. From 2012, the provision of inpatient and outpatient specialist care has become the responsibility of state authority. From 1 January 2012, 43 hospitals and their integrated outpatient departments owned by the self-governments of the counties and the capital have passed into state ownership, and since May 53 hospitals owned by local governments have also been taken over by the state. In the case of 8 institutions the property owned by self-governments to perform the taken over duties - passed into the ownership of the state. In state-owned national institutes came also under GYEMSZI s operation. The taking over of the institutions was organized by the National Institute for Quality and Organizational Development in Healthcare and Medicines (GYEMSZI). Henceforward, the missions of operation and property management will be coordinated by GYEMSZI. The centralization of the supervision and ownership of the larger segment of specialized health care aimed at a mild correction free from any political influence of the structural inequalities of the health care system, as well as promoting the development of health care with a view on efficiency, equity and real needs. The taking over of institutions by the state was initially associated with the re-regulation of capacities and territorial supply obligation of hospitals, and with the restructuring measures and changes in patient pathways, referral pathways. The organisation of healthcare is gradually replaced by the territorial concept, and the re-planning of the territorial supply obligation has already taken place with the adoption of the new strategy. 9

10 The newly determined obligations of territorial health care provision have been applied since 1 July 2012, and their use has taken place as a kind of pilot in the initial months. In the course of the restructuring measures, the number of about 42 thousand active hospital beds decreased by approximately two thousand, active care in 14 hospitals was discontinued, and from that time on, the capacities of these institutions serve chronic care, day care and outpatient specialized care. Closing down of institutions did not take place anywhere. For the safety and efficiency of care at the end of 2012 and the beginning of 2013 several institutional integrations had taken place. The basic form of the institutions that have passed into state property to perform their tasks has been the budgetary organisation, and hospitals that had operated earlier as companies, have become budgetary institutions since With the nationalization of hospitals, the three fourth of capacities calculated on the basis of service hours provided by specialized outpatient care is available in state-owned institutions at the outpatient departments of hospitals, or in outpatient institutions integrated to hospitals. In addition to these specialized outpatient care providers, about 270 outpatient care providers that work independently from hospitals may be found in the country, among them 90 larger outpatient institutions and 150 smaller outpatient practices practicing in one or two specialties. In the case of these autonomous specialized outpatient providers the retaining of local government s ownership was allowed by law. At the beginning of the year 2013, local governments gave a statement on whether they wanted to operate their outpatient care facilities further on or whether they would give them over to state ownership. The majority of local governments voted for the retaining of their outpatient facility. In consequence of this, the government decided not to take over the performance of tasks in the case of autonomous outpatient facilities, and that it should remain within the scope of local governments. At the same time, local governments maintaining autonomous outpatient services may decide to give this task over to the state with the connected assets. With the taking over of institutions by GYEMSZI, the assessment of hospital activities and the rationing and development of operating processes were started. The governance of institutions was taken over by new professional management evaluated by way of tenders. 10

11 One of the measures promoting the effectiveness of managing processes is the government decree setting out rules for the national centralized procurement system of medicines, medical appliances and disinfectants for secondary care institutions. The procurement of natural gas and electricity may be voluntarily joined by the institutions. By means of centralized natural gas procurement with the participation of half of the institutions being under the maintenance of GYEMSZI, about 20 percent of cost containment may be hoped for. Projects promoting the quality of health care have been started. Among them are the revision of existing Hungarian clinical practice guidelines issued since 2002, the development of new guidelines, and the adaptation by suitable methods of international guidelines based on evidence. Another area of similar importance is the project for the development of health care human resources monitoring, which by means of the resources obtained from the New Széchenyi Plan tries to provide support on the basis of monitoring the characteristics and trends of human resource in the sector to the development of opportunities to solve human resource shortages in the health sector. The development of the voluntary accreditation system for specialized outpatient and inpatient care and for the supply of pharmaceuticals to the population was targeted by the EU-supported program initiated in 2013 that focused on ensuring patient safety and developing the quality of health care. Human resources One of the main and most urgent problems of the Hungarian health care system is to provide the sufficient number of qualified workforce. There is a significant shortage of doctors and nurses due mainly to the fact that the earnings in the health sector are extremely low, compared to both the other sectors of the economy and the Western European countries. Additionally, there are big inequalities in the distribution of doctors, both in terms of geography and specialties. In general, the rate of physicians per 1000 inhabitants is higher in the more developed Western counties, in Budapest and the bigger cities. The specialties where parasolvency is widespread (e.g. surgery, gynaecology) are more attractive for fresh graduates, in other specialties where illegal payments are not so common (e.g. anaesthetics, diagnostics) severe workforce shortage can be observed. Owing to the low payments, many health workers emigrate to Western countries, but changing to another profession is also typical. Ageing of health workers aggravates the problem: due to low public pensions, many doctors work after retirement age. 11

12 The Semmelweis Plan drawn up by the Ministry of Human Resources gives priority to the human resource issue. In the short term, the task is to increase the earnings, transform the training conditions and improve the working conditions in the sector. In the long-term, the aim is to elaborate a career model for health workers working in the public or municipal health care system, which includes the planning of a career and qualification system and ensuring of its financial background. After extensive consultations with the advocacy groups, the Hungarian Government made a legislative commitment to improve the earnings of health professionals. The legislation refers to health workers working as employees at publicly financed health care providers owned by the state, a municipality, a church or a higher education institution. The regulations cover the employees of the outpatient and inpatient institutions, as well as ambulance, patient transport and blood supply providers specified in the implementation regulation. Special wage scales are defined for public servant nurses from 1 July 2012 and for public servant doctors from 1 January Both wage scales prescribe raised salaries compared to the general public wage scale used before. Some health professionals with higher education (e.g. pharmacists, psychologists, clinical psychologists, laboratory chemists, chemical engineers, biologists, special education teachers, speech therapists, etc.) received a monthly salary increase of HUF. The salary increases were provided retrospectively, from 1 January In the case of nurses, the salary increases were provided according to the new wage scale, while the doctors received a fixed monthly wage for the period between 1 January 2012 and 31 December 2012, which adjusted to the degree of the salary scale. The doctors whose monthly gross wages were below HUF on 30 June 2012, received a monthly gross increase of HUF. Doctors whose monthly gross wages were above HUF, received digressively decreasing salary increase amounts: in every band of HUF, they received a monthly salary increase of HUF less. For doctors whose monthly gross wages were above HUF, a monthly salary increase of HUF was provided. From 1 November 2012 earnings for primary care health workers were increased: capitation payments for GPs and dentists were raised by 14 per cent, for district nurse by 10 per cent. According to a government regulation, from 1 March 2013 public servant health professionals after retirement age (62 years) will not be able to employed (except for researchers and professors working in higher education institutions). Exceptions can be made in cases where the work of the person is indispensable, 12

13 but in every individual case an application must be submitted to the Prime Minister s Office. Another government regulation prohibits from 1 January 2013 that retired public servants receive both public employee remuneration and public pension. Healthcare workers who forgo their pension and continue to work may expect compensation. In 2013 healthcare workers may expect further wage increase. Changes in the pharmaceutical reimbursement system The Széll Kálmán Plan issued in March 2011 proposed the restructuring of the pharmaceutical reimbursement system in several stages, in order to reduce the reimbursement costs. The new measures of reimbursement policy have gradually come into force since July The use of generics has been promoted by several changes The preferred reference price zone was introduced in Initially, a drug pertaining to the preferred reference price zone could exceed the daily therapeutic costs of the reference product by maximum five percent in case of active substance-based fixed reimbursement and the average thereof by maximum ten percent in case of reimbursement based on fixed therapeutic costs. Products within the preferred reference price zone receive reimbursement in a sum equal to that of the reference product. Since 1 July 2012, the price zone has been extended from five to ten percent for active substance-based reimbursement. Medicines falling outside of the price zone receive as a reimbursement the value of the reimbursement of the reference product reduced by 15 percent. In 2011, those manufacturers whose prices exceeded the reference price by percent according to the classification based on active substance or therapeutic principle, did not receive any reimbursement. Since 1 July 2012, for drugs within the group of fixed reimbursement based on active substance the limit of reimbursement has become 50 percent instead of the previous 30 percent. So a given drug is to be excluded from reimbursement at the time when its daily therapeutic costs, or its price calculated on the basis of an active substance unit, exceeds the daily therapeutic costs of the reference product by at least 50 percent. Another method for promoting the use of generics is drug prescription by active substance. The prescription of drugs by international non-proprietary name (INN) had already been allowed earlier, but a new decree came into force that named 13

14 14 the medicines at present only cholesterol lowering drugs the prescription of which would be solely based on active therapeutic substance from 21 April 2012 on. The system providing incentives for the pharmacies to dispense generics aims to stimulate the pharmacists to increase the offer of generics instead of original drugs. In the frame of this system, from 2012, allocation from the health insurance fund may be granted to those pharmacies, where: - the proportion of the dispensing of drugs belonging to the preferred referential zone exceeds 35 percent of prescriptions or, - the proportion of the dispensing of drugs of which the daily therapeutic costs are equal or lower than those of the reference drug, exceeds 35 percent of prescriptions. In the reimbursement of drugs, patient adherence (the behaviour of patients complying with the recommendations agreed on with health professionals, their intake of medicines, diet and life style) may be taken into account, by which the reimbursement may be granted in differing percentages or limited to a previously determined sum. From July 2012, the medication of diabetic patients with high or increased indication (in addition to the exceptions specified by the decree) could have been continued after a year only if appropriate values of carbohydrate metabolism had been maintained on the basis of at least two measurements (HbA1c value lower than 8.0 percent 6 months preceding the specialist s proposal). From May 2013 on, this value must be attained twice out of three measurements within a year, and patients belonging to diabetes mellitus type 1 are not concerned by this rule. From July 2011 on, distributors have been charged for the distribution of publicly funded medicines and food preparations supplied in pharmacies by a payment obligation of 20 percent. The payment is charged for the proportion of the producer price or the import purchases of social insurance reimbursement. (Earlier a payment obligation of 12 percent had been in effect). From August 2012 on, the distributors of medicines where there is not another preparation with the same active substance as the given preparation and the product has already been granted public funding for six years, will be obliged to pay a further 10 percent. According to the guidelines of the European Union, a pharmacovigilance system has been established. The National Institute of Pharmacy one of the Directorates General of the National Institute for Quality and Organizational Development in

15 Healthcare and Medicines (GYEMSZI-OGYI) is responsible for the collecting, registering and assessing of the side-effects of pharmaceuticals. As it was already mentioned in connection with the governmental supervision of the hospital sector, centralized procurement of medicines, medical appliances and disinfectants has been prescribed for hospitals. In order to promote this objective among others, the National Council for Pharmaceutical Therapy came into operation as an advisory board for the Minister of Human Resources. Its main tasks are the setting up and continuous monitoring of the national, unified hospital medicine basic list, the professional preparation and assessments of the central procurement of pharmaceuticals, and the analysis of hospitals drug use and procurement focusing on professional and economic aspects. Another important task of the Council is to develop proposals on the basis of safe, effective and economic pharmaco-therapeutical concepts as well as on the supervision of the reimbursement of pharmaceuticals of outpatient care. The new office of legal protection At the end of the year 2012 the National Patient Rights and Documentation Centre (OBDK) was established as a central agency reporting to the Minister of Human Resources. The main function of OBDK is the assistance of patients, beneficiaries and children in the protection and enforcement of their rights established by law, as well as supporting the operation of the network of the patient rights representatives. All over the country there are 107 patient rights representatives employed by OBDK operating in 7 regional offices. The centre provides information on issues regarding the rights of patients, beneficiaries and children and gives assistance to the enforcement of rights connected with the access of health documentation, the practice of lodging a complaint, and assumes the role of a mediator in the out-of court settlement of contested issues among plaintiffs. It is within the scope of the OBDK to supervise the access to health services and the enforcement of rules related to the organization of health care, the referral system and patient information. It manages health documentation produced by health institutions that ceased their activity without a successor and allows patients the right of consulting documents. Beyond this, OBDK is the national contact point of cross-border health care, and in this respect it provides information on patients rights related to obtaining 15

16 cross-border health services and on the procedures of lodging complaints and appeals, as well as on Hungarian health care providers. National Patients Forum (NBF) National Patients Forum that has been created by non-governmental organizations representing patients suffering from various diseases, started its operation on the World Day of the Sick, 11 February The Forum consists of 15 departments, connected with different disease groups (e.g. diseases of the digestive system and the liver, rare diseases, diabetes and metabolic diseases, etc.). The National Patients Forum submits proposals to the Minister of Human Resources in issues of health policy and development related to the interests of patients, gives expert s opinions, draws up analyses and assessments, carries out advocacy and maintains contact with the concerned sections of the health professional association, the non-governmental organizations carrying out patient representation, competent chambers of health professionals, churches and foundations. Any non-governmental organization may join the National Patients Forum, and may delegate two representatives to the section related to its scope of activities. National Institute for Quality- and Organizational Development in Healthcare and Medicines Directorate General of IT and Health System Analysis Editors: Ilona Borbás Péter Mihalicza and Zsuzsa Ajtonyi, Péter Gyenes, Gabriella Merth, László Szirmai Technical editor: Erika Szóró HU ISSN Hold utca 1., H-1054 Budapest H-1243 Budapest, PO Box 637. Tel.: , Web: 16

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