Introduction of independent medical specialists

• Abstract
• Purpose of health policy or idea
• Characteristics of this policy
• Political and economic background
• Purpose and process analysis
• Expected outcome
• References

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Abstract

MoH and the Medical Chamber of Slovenia work towards a system of independent medical specialists. It aims at developing more flexibility in the system, different types of employment, purchasing of services and new types of contracting arrangements. This move is to open the possibilities for medical specialists to deliver care at different locations and different providers and dropping certain limits to working hours, depending on the interest to undertake different posts and employments.

Purpose of health policy or idea

The main idea behind the concept is to make delivery of care at the point of medical specialists more flexible and more adapted to:

1. patient needs
2. provider needs
3. specialists' needs.

It should bring more diversity and open the road to additional employment for the very efficient and successful physicians. Currently, the system of salaried doctors leads to poor incentives at the individual level and offers poor leverage for intervention at the level of bigger providers. The proposing partners hope to see more availability of specialist care on average and more flexibility in provider structure and organisation of delivery.

Main points

Main objectives

The introduction of the concept of free medical specialist is expected to provide a new environment in which there would be increased flexibility of specialist care delivery, leading to professionals' mobility, increasing accessibility and promoting changes in the organizational structures of larger hospitals (as the main places of both in-patient and out-patient specialist care delivery). All of this should lead to an increased efficiency of the system, both from the managerial as well as from the patient and specialist point of view.

The main objectives:

1. offer the possibility to specialists of 'free' contracting with different providers without specific limits at the individual provider level
2. opening options for incentives both to providers and to specialists - financial and non-financial
3. increasing efficiency of care delivery and the throughput at the level of medical specialists.

The new system is at the conceptual point of defining ideas and the respective framework. It should be characterized by gradual abolishment of salaries for medical specialists, dropping of working hours limits set at the provider and individual levels (both currently rather strictly enforced), opening of possibilities for successful and efficient specialists to work at different locations, especially in the case of operative specialties.

Type of incentives

Financial:

Potentially better incomes of medical specialists are expected deriving from a more flexible type of employment, furthermore through more intensified delivery of care and more efficient use of additional working hours (currently only available through on call and night duties, both inefficient from the point of view of the system and of the individual physician).

Non-financial:

More flexibility for both providers and specialists in types of contracting of care /services. Providers should thus be given incentives to seek different types of organizing care and also solving contractual relations with other professionals.

Groups affected

medical specialists, hospitals, Health Insurance Institute of Slovenia

Innovationsgrad	traditionell		innovativ
Kontroversität	unumstritten		kontrovers
Strukturelle Wirkung	marginal		fundamental
Medienpräsenz	sehr gering		sehr hoch
Übertragbarkeit	sehr systemabhängig		systemneutral

Political and economic background

The concept proposed was outlined already by the previous government but it has never seen any further moves or steps towards implementation. Still, it was included as one of the options for new managerial approaches at the health system level already with the reform proposals of 2003. The new government placed relations with the medical profession very high on the agenda and has revived the idea by placing it as one of the key priorities in the short term plan.

Change based on an overall national health policy statement

Government?s plan for health care in 2005 and the general strategic outlines from the health reform drafted in 2003

Purpose and process analysis

Current Process Stages

	Idee	Pilotprojekt	Strategiepapier	Gesetzgebung	Umsetzung	Evaluation	Veränderung/Richtungswechsel
Implemented in this survey?

Origins of health policy idea

The idea is based and inspired by the experiences of medical specialists in the Netherlands and Canada. It was first developed as a concept in the strategy of the Medical Chamber of Slovenia. Later, that idea was picked up by the MoH. The main purpose is in offering more possibility and choice to medical specialists to practice for longer hours and in different settings, in a way outsourcing their own knowledge, skills and capacity. The driving forces at this point of the process are the MCS and the MoH, which are also its main promoters. They see potential for greater efficiency, better choice and, eventually, better access for patients.

There have been no small scale projects yet as this is still an idea under development.

Initiators of idea/main actors

• Regierung: The main promoter of the proposal was the Medical Chamber of Slovenia in its strategy from 2000. It got support by the MoH, which then in turn became the promoter of the idea at the political level.

• Leistungserbringer: The process of this change was initiated by the Medical Chamber in 2000.

Approach of idea

The approach of the idea is described as:
renewed: The model proposed is not an original one but it was inspired by similar models in place in the Netherlands and in Canada. Certainly, there will be adaptations and modifications when implemented in Slovenia.

Stakeholder positions

Apart from the stakeholders listed above there are the following stakeholders with some interest and/or influence in the change:

1. Association of public providers of health care - the association has not clearly expressed a position on these proposals, it is likely to be initially skeptical due to the effects the change might have on other professionals, on the developments with salaries and on the organizational changes within individual providers.
2. National Health Insurance - strong interest for any change that would increase efficiency and improve access; might be skeptical from the cost containment point of view and because of the possible effects on other parts of the health care system.

Actors and positions

Regierung
Medical Chamber of Slovenia	sehr unterstützend		stark dagegen
Ministry of Health	sehr unterstützend		stark dagegen
Hospitals	sehr unterstützend		stark dagegen
Leistungserbringer
Medical Chamber of Slovenia	sehr unterstützend		stark dagegen
Ministry of Health	sehr unterstützend		stark dagegen
Hospitals	sehr unterstützend		stark dagegen

Influences in policy making and legislation

The present reimbursement change has not yet led to any major or key legislation change, which will, however, be needed to adapt the labor legislation to the requirements and concepts of the policy change. Currently, the labor legislation does not provide for such flexibility in employments and specifically prohibits free combination of employments when employed in the public sector. On the other hand, when employed anywhere in health care, the concurrence clause applies and one cannot be active in the same field and service, both in public and private sectors simultaneously.

Actors and influence

Regierung
Medical Chamber of Slovenia	sehr groß		kein
Ministry of Health	sehr groß		kein
Hospitals	sehr groß		kein
Leistungserbringer
Medical Chamber of Slovenia	sehr groß		kein
Ministry of Health	sehr groß		kein
Hospitals	sehr groß		kein

Positions and Influences at a glance

Adoption and implementation

Key actors and stakeholders in the adoption process are the Government and the Ministry of Health and the Medical Chamber of Slovenia (MCS). The political consensus exists; the necessary following steps will be in changing the labor legislation, allowing for those changes that would enable the implementation of such a concept. The formal moderator will be the MoH and the role of the informal co-ordinator will definitely be with the MCS, also due to the fact that it represents the interests of private practitioners. These actors will definitely be leading the process. Indirect effects will happen on the side of the major (public) providers and the Health Insurance Institute (HIIS). There will be a selection process in which those practitioners that were now hiding in the averages may become excluded or not invited to join these processes. HIIS will have to participate in devising new techniques of reimbursement, which will include the new composition of costing for doctors' work.

The main obstacles will be on the formal side, since there will be opposition to grant some professionals to work additional hours and have enhances flexibility of employment. The Ministry of Labor might be worried of knock off effects if these demands were to spread across different sectors. Consumers' representatives may be concerned about maintaining a good level of services and at least the existing access. Definitely, it will be of paramount importance to work on assuring good access, continued availability of services and their reliability in spite of the new arrangements. All that alongside keeping a comparably similar extent of services under the compulsory insurance.

Monitoring and evaluation

The process is still at the level of developing ideas and concepts and therefore, has no formal arrangements yet for its follow-up. Given the political consensus it should not prove to be too difficult including it in the overall national health policy as one of the supported concepts. For the reason it is not possible to estimate on the types of prevention of undesirable effects.

Review mechanisms

Abschlussevaluation (intern)

Dimensions of evaluation

Struktur, Prozess

Expected outcome

The achievements of this policy depend largely on reaching further professional consensus and broader understanding of the changes. Increasing efficiency, making more use of doctor's time and knowledge irrespective of the setting where he/she is working and offering good access to high quality services may be those 'carrots' to be offered as very important incentives for the patients and providers.

Impact of this policy

Qualität	kaum Einfluss		starker Einfluss
Gerechtigkeit	System weniger gerecht		System gerechter
Kosteneffizienz	sehr gering		sehr hoch

References

Sources of Information

• Governmental Plan of Action for health care in 2005     
• White Paper on health care reform, 2003
• Strategy of the Medical Chamber of Slovenia, 2000 and 2004

Reform formerly reported in

One year after elections: Change or continuity? Process Stages: Strategiepapier, Idee

Author/s and/or contributors to this survey

Tit Albreht

Empfohlene Zitierweise für diesen Online-Artikel:

Tit Albreht. "Introduction of independent medical specialists". Health Policy Monitor, 17 August 2005. Available at http://www.hpm.org/survey/si/a5/2