Financing hospitals, outpatient specialist health care and basic health care by NFZ in the years 2003–2017

Mariusz Tarhoni1, Andrzej M. Fal2,1

1 Department of Organization and Economics of Health Care of National Institute of Public Health-National Institute of Hygiene in Warsaw, Poland.

2 Department of Public Health, Medical University in Wrocław, Poland

Abstract

The systems of financing health care benefits from the public resources are characteristic for considerable slowness in decision making about change, the process of change thus also the results of the change. It results from the complicated structure of management and the size and variety of tasks necessary for proper activity. Big impact on resources distribution and their level in the type positions of the financial plan have the relations of the Payer with the insured (beneficiaries) as well as benefits providers. Mutual relations in this triangle influence also the resistance of the system as a whole on errors in contacts and elimination during the unfavorable both for patients as well as for Payer. All trials of making fast significant changes in redistribution of financing provide unforeseeable distortions in the activities of the medical services market. It does not mean that such changes should not be designed, but only they should be done wisely. The curve of financial outlays increase on health protection in Poland from 1999 until now has characteristics close to steadily growing linear. In the presented material Payer’s expenditures on main types of health care benefits that is hospitals, AOS and POZ were analyzed. Analyzed was the period from 2003 until now. During the previous period, that is during the activity of Health Care Fund (in the years 1999 – 2003) there was bigger freedom in acceptance of financial plans in individual types of health benefits tied to self-government of these institutions. The chosen period of time, that is 2003 – 2017 is the most proper period for analyzing the resources distribution on individual types of benefits, reasons of financial changes in financing and results, which these changes cause in the market of providers of benefits. Provider’s revenues depend on economic situation of the country and the increase of PKB is translated into the increase of the state of NFZ financial resources (the process is delayed by 4- 6 months).

Key words: financial expenditures on hospitals, outpatient specialist health care, basic health care, cause of differences in financing individual types of benefits, financial flows between the chosen types of health benefits during the years

Public Health Forum 2017;III(XI)3(42):149-154

INTRODUCTION, TARGET DEFINITION

The planned during last years changes in the benefits financing more or less radical cause polemics of various social environments, patients, benefits providers, physicians and other medical personnel, managers of health, decision makers and office workers, also experts and science workers, environments and politicians. Various groups of interests are trying to influence the division of financial resources made by NFZ Central and Voivodship Branches. For comparison: self- governed Health Care Funds tried to adjust the ratio of each position of financial plan to the needs of Voivodship. The effect of such activity led to significant difference in proportions between individual types and ranges of benefits in various Regional Health Care Funds. However these differences were monitored by UNUZ. National Association of Health Care Funds and UNUZ tried, among others, to make the condition of equal access to the benefits fulfilled. These conditions persuaded authors to make analysis for the period of time where only 16 Voivodship Branches of NFZ were active. It should be remembered that in the system of Health Care Fund were 16 of them – regional and 17 BKChdSM (Branch Health Care Fund for the Uniformed Services such as military, police, fire department etc). After the 1st of April 2003 aggregation of resources being in possession of Branch Fund and its branches to the individual Voivodship Branches of NFZ. That is why for the use of this report most adequate period for making analysis would be during the years
2003 – 2017, after the aggregation and unification of the system.

Both the above assumptions as well as linear changes within the system expenses, which are clearly visible on Chart no 1 as the red line being the (average) polynomial image of state of resources spent by the Payer (NFZ) have decisive influence on all positions of financial plan. State of revenues and costs has been since 2003 reported every month (previously was monitored in decade reports). Summing up it can be ascertained that the payment system obligations in Poland have linear character. However revenues do not have such characteristic and remind of sinusoid with increasing amplitude. It can be seen on Chart 1.
– blue line (polynomial approximation). The increase of amplitude on the chart of state of financial resources results from the increase of contribution and deduction from the level of 7.50%, 7.75% up to current 9.00% (the increase of deduction and health contribution does not translate itself proportionally to the increase of revenues of the Payer, this subject in more exact way can be found in the article – Health and Management, ISSN 1506-882X volume VI no 2/2004 „Is the health insurance tax the subject of Laffer phenomenon? Analysis of financial situation of Polish health care system during the years 1999 -2003” by Mariusz Tarhoni, Aneta Didoszak, Mirela Siwik), PKB increase. The Fund is obliged to realize the expenditures for health benefits according to the approved financial plans. In the plans, among others are other amounts designed for the individual types of health benefits. The Fund has a lot of possibilities to match its real revenues to realize plans even during the period of deficit of financial resources that is when expenditures in certain period exceed the revenues. One of the methods is for example payment for the provided benefits later time. To investigate the deviations in financing the chosen for analysis types of health benefits the question of revenues in that sense has smaller meaning.

The purpose of this study is presentation, in the long term, changes in financing of three important positions of the NFZ financial plan, that is hospital treatment (without psychiatry), outpatient specialist health care (AOS) and basic health care (POZ). Determination of financing parameters of these types of benefits in this time interval will allow to find the decisive factors for passing and correcting financial plans thus bigger or smaller financing of benefits of this kind.

Often lower or higher increase of financing of a certain kind of benefits took place several years in a row. Therefore in this material it has been decided to compile all changes and deviations from the linear process regarding the amount of inputs on chosen benefits. Subsequently the real, legislative and substantive causes, which were the base of this changes, were checked. Using other terms and looking from the perspective of the financing results mutual dependencies can be described in such order: 1. idea for the change (for instance hospital treatment, introduction of homogeneous groups of patients) – changes in the method of settlements with the Payer and regulation of the stream of funds • 2. increasing financing (in this example in the type hospital treatment) • 3. results in other types of benefits resulting from the decreased stream of funds. Another example will be the analysis of the results of increased financing of some of treatment procedures (moved from hospitals ) on AOS in the years 2002 – 2003. Therefore, having in mind the target that is aggregation of data regarding hospital treatment financing, AOS, and POZ in the long term the cause of change in financing should be determined and what results those changes will bring for the whole system of the health care. So far there were no works done which in such a broad way would provide the inventory of the system in the aspect cause – effect. This method of looking on mutual relations might in future help decision makers design changes in a way to minimize unwanted effects “next to”, in other types and even ranges of benefits.

People involved in financing of health benefits professionally an for the scientific needs warn against introducing of fast changes on the level and method of financing in individual types, because there are created than, as a rule hard to foresee results of the changes, needing next regulations (financial) in other sectors of the medical services market. It may concern for example solutions regarding regulations of payments, proportions between work agreements and civil law, outsourcing of services etc. Many theorists think that this way system errors in financing benefits can be eliminated. Unfortunately, payments systems should evolve in time, because their inertia is based, among others, on hard to being foreseen results of certain change and complicated ties even impossible to be foreseen theoretically. There is a well known example in comparing payment systems to calibrated oscilloscope, which shows the image of the course of phenomenons in the payment system where violent regulations with amplitude or frequency lead to loosing of the monitored image of the phenomenon. This is warning against introducing untested changes, it does not matter whether the cause is favorable modification of the range of or in the system of compensation for the benefits. Keeping in practice the tripartite of the stakeholders of public system of health care, that is the Insured (patients, beneficiaries), Payer and Benefits Providers it should be remembered that the relations are complicated, dependent of many variables such as pro-health awareness of the insured or due place of prophylactic. They regard all the above mentioned, because they are bound by cause and effect, cultural and customary etc, relationships. Patients from one country (not taking into consideration language barriers) would have problems in using medical services at benefits provider in another country because of these differences. In other words, patterns given as examples of good solutions elsewhere may not verify themselves in Poland. It might also regard the planned changes regarding the method of financing, staff qualifications, computerization of settlements, etc leading to radical solutions as budgeting of hospital treatments, replacement of hospital services with network or on smaller scale preferring the benefits of coordinated health care. The authors are not evaluating any of these solutions, but only trying to analyze in order to draw conclusions regarding fluctuation in financing chosen types of benefits.

Introduced in 2015, so called the oncological packet has not fulfilled hopes placed in it, however it did shorten the waiting time for admission and beginning of treatment for some part of the oncology patients. Probably preparing pilot program and securing financial resources first, would have given better results (evaluation of the oncology program – NIK report).

FINANCING OF THE HOSPITAL TREATMENT

On the Chart 2. financing of hospital treatment in the years 2003–2016 (implementation) and 2017 (plan) has been presented. The trend of this process was also marked as polynomial form (on the chart – red full line). In individual years the increase of financial outlays for hospital treatment was always bigger from the eventual increase of financing consistent with the line of financing increase of all positions (of financial plan) of the types of medical services, medicaments refunding and other costs of the system.

The increase of financing in 2008 seen on Chart 2 is bound to introduction of new rules financing benefits based on the system of homogeneous groups of patients (JGP) – they were introduced in Poland on the 1st of July, 2008 by order of President of National Health Fund no 32/2008/DSOZ dated June 11, 2008 concerning defining conditions of signing and realization of agreements in the type hospital treatments. Similarly in AOS from the July 1st 14, 2011 by the rule of NFZ President no 29/2011/DSOZ of June 14, 2011 concerning determination of the conditions of signing an realization of agreements in the type outpatients specialist health care.

The dependence cause – effect is clearly visible. The fact that trying to modify the work of certain type of benefits proper amount of financial resources is also important. The change in long term may also influence savings, but as a rule it needs financial support.

Chart 3 presents changes in the amounts of financing in individual NFZ Voivodship Branches. The highest increases occur in the biggest NFZ Voivodship Branches – Mazowieckie, Śląskie, Wielkopolskie, Małopolskie etc in the order. On Fig. 1 the same data is placed on the administrative map of Poland – it illustrates in better way the differences between individual OW NFZ.

FINANCING OF OUTPATIENT SPECIALIST HEALTH CARE

The amount on expenditures for AOS in the years 2003−2017 are presented on Chart 4. To compare in case of hospital treatment, the outlays of the previous year have never been lower than the trend defined by a straight line, and also from the real line of trend presenting bulk outlays for health care (resembles straight line). However, analyzing financing within AOS we can ascertain that in the years 2006, 2007 and 2010 the increase of outlays was lower than resulting from the line of trend.

In certain time interval decrease of financing in Śląskie Voivodship and lack of financing increase in many branches can be seen on the chart for OW NFZ (Chart 5).
AOS financing characteristics are more flat than the analogical characteristics for hospital treatment, which means keeping for several years similar level of financing.

FINANCING OF BASIC HEALTH CARE (POZ)

The basic health care has been, from the beginning of introducing PUZ reform (January 1st, 1999), on capitation financing. The Payer has specified for this kind of benefits tasks and minimums regarding physicians and nurses (midwifes and community nurses) as well as medical transportation and infrastructure. Minimum and maximum number of insured people designated for one physician and other conditions were precisely determined. Rules of NiŚPL (night and holiday health care) have been separated and changed. POZ is a gatekeeper in the system, it has abilities of directing patients to specialists and part of laboratory and image diagnostics and other.

Financing of basic health care (POZ) in the years
2003–2016 (implementation) and 2017 (plan) was presented on the Chart 6. Increase of this kind of benefits financing in years 2007–2009 can be seen seen after the period of plateau in the years 2010–2014 and increase of financing in years 2015–2017 (year 2017 planned amount of financing).

Legislation changes had influence on financing in POZ, also in NFZ implementation provisions. One of them was introduction of fast oncology therapy so called oncology packet on January 1st, 2015 (changed on July 1st, 2017) pursuant to the law from the July 22nd, 2014 about changes of law regarding health care benefits financed from the public resources and some other laws (Dz. U. of 2014, pos.1138 with later changes) and law from March 9th, 2017 about the change of law regarding health care benefits financed from the public resources (Dz. U. of 2017 pos. 759) and Minister of Health regulation from December 5th, 2014 regarding the pattern of diagnostic card and oncology therapy (Dz. U. of 2017 pos. 1250). The packet range consists of increased of the competences of family doctors and higher number of medical tests are being done, which results from Minister of Health regulation of October 20th 2014 changing the regulation regarding guaranteed benefits in the range of basic health care (Dz. U. from 2014 pos. 1914). Secondly, equally substantial is President of NFZ regulation no 86/2014/DSOZ of 17th December 2014 changing the regulation regarding defining conditions and realization of agreements for providing the benefits such as basic health care, where appraisal of capitation rate was increased, introduced two levels of motivation financing and new correcting indicator in the age group 40 – 65 years. In effect POZ financing was supposed to increase to the level 6.2 billion PLN. The changes can be seen on Chart 6 – increase of financing in the years 2014/2015 until now. Characteristics of financing (POZ) benefits for all sixteen OW NFZ is presented on Chart 7. For better illustration of these data on Fig. 3 data from Chart 7 were presented keeping proportions.

COMPARISON OF FINANCING HEALTH CARE BENEFITS IN THE TYPE OF HOSPITAL TREATMENT, AOS, POZ, COLLECTIVELY, ONCE A YEAR AND IN PERCENTAGE

Presented above distribution of financing in chosen individual types of benefits should be put together in such a way, that it would be possible to compare dynamics in relations contained in financial plans in respective years. On the Chart 8 presented are the amounts implemented (years 2003 – 2016) and planned for 2017 on one chart. Trend lines were designated. Because the budget for hospital treatment, AOS, POZ differ in size from each other, it is hard to ascertain how regulating with the stream of financial resources influenced the markets of these benefits in Poland. Only unquestionably domination in hospitals financing increase compared to AOS and POZ can be seen. Noticeable (Chart no 8) financial increase in all analyzed types of benefits in the years 2016 – 2017 were caused by introducing so called wage increase for nurses and midwifes by Minister of Health regulation of September 8th, 2015 regarding the general conditions of agreements of providing health care benefits (Dz. U. from 2016, pos. 1146) and Minister of Health regulation from October 14th, 2015 changing the regulation regarding the general conditions of agreements of providing health care benefits (Dz. U. from 2015 pos. 1628).

For better illustration the same data was presented on Chart 8A, however in the percentage formulation, assuming as a reference year 2003 equal to 100% and presenting financial gain in respective years (2003, 2005, … 2016 implementation and plan for 2017) taken into consideration in this work.

On the Chart 9 the increase of financing of hospital treatment, AOS and POZ in percentage terms, as compilation year to year was shown. The increase of financing in 2004 (2004/2003) are higher than in other years. This is due to the fact that in the first quarter of 2003 Health Funds (Kasy Chorych) still existed (in liquidation), there were 17 of them. Revenues of Branch Fund (BKChdSM) were in second quarter of this year aggregated to each of the regional Funds according to territorial key (the branches of Branch Fund were not territorially equal to voivodships). Aggregation of resources rose the revenues in this type of benefits thus non-standard higher increase of financing in this year in all three types analyzed benefits. On Chart 9 we can see in percentage terms differences in the amounts of financing increase (in 2010 in AOS and POZ financing decreased – negative dynamics. In the years 2003, 2004 till 2008 hospitals financing increased by several percent a year (the same situation was in AOS). POZ financing during the years 2003, 2004 until 2009 was characterized by a few percent increase in a year. It is the result of good situation of increase of revenues in in the whole NFZ system (Chart 1).
The blue full line on this chart represents financial resources collectively in the payment system. In the years 2003–2009 we deal with their increase (the state of financial resources and liabilities of the payment system in Poland in the years 1999 – 2014 thoroughly described in: 2015; 2;
101 – 107 Hygiene Public Health Forum – „Podział środków pieniężnych na poszczególne regionalne kasy chorych oraz oddziały wojewódzkie NFZ w latach 1999−2014 uzyskany w wyniku przyjętych algorytmów podziałowych oraz plan wyrównania finansowego dla oddziałów NFZ na rok 2015” – Mariusz Tarhoni, Krzysztof Kuszewski, and „Sytuacja ekonomiczna płatnika publicznego a finansowanie świadczeń medycznych w latach 1999–2010” – Mariusz Tarhoni , Krzysztof Kuszewski, Epidemiology Survey 2010; 64; 109 – 114). The same chart illustrates also changes in financing benefits by NFZ during the period of increase of the financial resources in the years 2012–2015, where AOS is in the plateau phase, however inputs on POZ and slightly on hospital treatment increase.

On the Chart 10 the same data in cash value as on Chart 9 were presented, which allows illustrating the financing dynamics of benefits. You can draw conclusion from the chart, that on financing in the chosen types of health benefits in individual years translate the financial situation in the Fund. State of financial resources is precisely presented on Chart 1. State of financial resources in the resources of the Payer depends on economic situation of the country. It can be assumed that it is the reflection of PKB state, shifted by 4 to 6 months13 (Financial situation of public Payer system in the years 1999 – 2016 [full version] – National Institute of Public Health National Hygiene Agency, Organization and Economics of Heealth Protection and Hospitals Agency – Mariusz Tarhoni, Warszawa, July 2015 (supplemented in January 2017) page 9, chart; Figure no3, Financial state of NFZ and PKB system until Marrch 31, 2015.)

It is not the only determinant different from linear that is proportional changes in benefits financing. Second important factor influencing deviations from linear distribution are changes in financial plans in the fund resulting from statutory regulations and government department regulations. Legislative changes on all levels translate into the size of financial streams transferred to the benefits providers by fund for financing types and range of health benefits.

CONCLUSIONS

The above analysis of financial data regarding NFZ expenses on hospital treatments, AOS and POZ leads to the following conclusions:

• Other than linear increases of resources values in the system depend on economic situation of the Country in PKB.
On the Chart 11 changes in revenues of Payer in the years 1999–2017 were presented against the changes of PKB during the same period of time. It can be seen that changes in the state of cash resources in the payment system correspond to the PKB changes with shift (delay) of 4 to 6 months. Independent of the shifts being the consequence of economic situation, financing of individual benefits are influenced by various kinds of activities of systems character implemented by law, regulations or orders of NFZ President. In the Organization and Economics of Health Protection and Hospitals Agency works aiming at precisely describing of system of health benefits financing. Chart 11.

• Feedback system and mutual dependencies. Rule of dominoes. Shift in financing individual types of benefits are mutually dependent.

• Some legislative changes can be called, the ones, which influenced the deviations in financing hospital treatment, outpatient specialist health care and basic health care. Chronologically, the acts of law of rank of law which introduction/revocation might influence the amount of benefits financing illustrates Table 1.

• Changes in the input of the system (distribution of financial resources) cause repeatedly bigger results in the output (market play of the benefit providers) – development or stagnation of modification in the improvement direction. It means that the decision makers introducing various solutions, which are supposed to modify the system in some part, do not take into consideration all effects, which they cause. In the eighteen years of history of financing health care benefits system many such examples have been known.

• Hasty putting into practice organizational reforms, leads to the phenomenon of self-driving of demand by improper financial stimulation in certain type of benefits. It leads to selective influencing the pro-health awareness bound to unnecessary benefits consumption.

Summing up, financing of the chosen and belonging to the biggest position of the yearly financial plans of the NFZ is dependent of revenues of the financing system of health benefits, medicine refunding, other positions of the plan and legislative regulation of different levels of decision making regarding system management.

The presented material should be treated as a trial of broader look on the ties, which is evoked in the complicated system of health care by distribution of resources destined for health care. Authors treat this material as a preface to more detailed studies. According to the principle – from generalization to detail it is the first part necessary for further works on the subject.

REFERENCES

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http://www2.nfz.gov.pl/zarzadzenia-prezesa/uchwaly-rady-nfz/uchwala-nr-282005i,1606.html

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Address for correspondence

Mariusz Tarhoni

Zakład Organizacji i Ekonomiki Ochrony Zdrowia

Oraz Szpitalnictwa

Narodowy Instytut Zdrowia Publicznego − PZH, Warszawa

ul. Chocimska 24, 00-791 Warszawa

e-mail: mtarhoni@pzh.gov.pl

Received: 10.09.2017

Accepted: 25.09.2017

Mariusz Tarhoni, Andrzej M. Fal

DYNAMICS OF FINANCING INCREASE AND ITS IMPACT THE CHOSEN TYPES ON HEALTH BENEFITS IN THE YEARS 2003−2017 IN POLAND

Mariusz Tarhoni, Andrzej M. Fal

DYNAMICS OF FINANCING INCREASE AND ITS IMPACT THE CHOSEN TYPES ON HEALTH BENEFITS IN THE YEARS 2003−2017 IN POLAND

Tabel 1 The decrees of law influencing the amount of benefits financing. Self elaboration.

Binding force of the law in legal system

Act of Law

Revocation on 1 October 2004

The decree of 23 January 2003 on general insurance in National Health Fund (Dz. U. of 2003 no 45 pos. 391 with later changes

Entery into force on 1 October 2004

The decree of 27 August 2004 on health care benefits
financed from public resources (currently Dz. U.
of 2016 pos. 1793 with later changes. The decree was significantly changed several times

Entry into force of decree binding since 21 May 2005

The decree of 15 April 2005 on public help and
restructurisation of public health care institutions
(Dz. U. of 2005 no 78 pos. 684 with later changes)

Entry into force of decree binding since 6 September 2006

The decree of 22 July 206 on transferring financial resources to benefits providers to increase wages
(Dz. U. of 2006 no 149 pos.1076 with later changes)

Entry into force on 1 January 2007

The decree of 8 September 2006 about State Medical Rescue Service (currently: Dz. U. Of 2016 pos. 1868)

Entry in force on 5 June 2009

The decree of 6 November 2008 on accreditation in health care (currently: Dz. U. of 2016 pos. 2135)

Entry into force on 1 January 2010

The decree of 2 December 2009 on Physicians’ Chamber (currently: Dz. U. of 2016 pos. 522).

Revocation on 1 July 2011

The decree of 30 August 1991 on Health Care Institutions (Dz. U. of 2007 no 14 pos.89 with later changes)

Revocation on 1 July 2011

The decree of 5 July 1996 on nurse and midwife profession (Dz. U. of 2009 no 151 pos 1217 with later changes)

Entry into force on 1 July 2011

The decree of 15 April 2011 on therapeutic activity
(currently: Dz.U. of 2016 pos 1638 with later changes)

Entry into force on 1 January 2012

The decree of 28 April 2011 on information system in health care (currently: Dz. U. of 2016 pos 1535 with later changes)

Entry into force on 1 January 2012

The decree of 12 May 2011 on medicine, nutrients
of special purpose food or medical products refund
(currently Dz. U. Of 2016 pos 1536 with later changes)

Entry into force on 1 January 2012

The decree of 15 July 2011 on nurse and midwife profession (currently: Dz. U. of 2016 pos 1251)

Entry into force on 1 January 2017

The decree of 4 November 2016 on support for pregnant women and families „For Life” (Dz. U. of 2016 pos 1860)

Mariusz Tarhoni, Andrzej M. Fal