The act on concessions and free specialists

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

Featured in half-yearly report: G-politik in Industrieländern 6

Abstract

15 years after the adoption of the Health Care Act, which defined the way private health care providers can run for programs financed through statutory health insurance schemes, it became evident that the solutions had been overtaken by the course of events. The Ministry of Health decided to more clearly define the process of granting concessions, their limitations and validity and to introduce the concept of a free specialist, who can be a candidate for services with other providers (1).

Purpose of health policy or idea

The main objectives of this policy are:

1. to better regulate the area of concessions in health care
2. to enhance the movement into private health care delivery for all those providers who fulfill the requirements and accreditation criteria
3. to open possibilities for new market opportunities in health care
4. to introduce the concept of the 'free medical specialist' as a new type of registered health care practitioner

The area of concessions was very loosely described in the existing legislation. It reflects the period when these legal acts were adopted. The Health Services Act from 1992 introduced private practice as a legally equal type of health care delivery. The conditions legally established are:

• to hold appropriate education for the service to be delivered and qualification for independent work
• not to be employed (exclusion clause preventing simultaneous employment in the public and the private sectors)
• be in possession of adequate premises, equipment and, if necessary, staff
• to have a consent of the respective professional chamber or association.

The first and the last clause are established by the respective chambers or associations. The second and the third are verified by a special commission appointed by the Ministry of Health. Private practitioners and other private health care providers are included in the national register of private health care providers which is located at the Ministry of Health (data for physicians, dentists and pharmacists are assured by the respective professional chambers). Some services, namely pathology and forensic medicine, public health and transfusion and transplantation services are specifically excluded from private provision. Those providers that wish for their services to be reimbursed by the compulsory health insurance have to obtain a concession. This is granted by the municipalities in the cases of primary health care and by the Ministry of Health in all other cases. Concessions were granted for an unlimited period of time, which caused serious problems in those cases where problems occurred.

The new policy should enable a more precise conclusion of a concession contract, based on time limit imposed by the act. It should normally be no shorter than 7 years and it should not exceed 25 years, in exceptional cases, where significant infrastructural investments have occurred, it could be extended for an additional period of 12 years. Another novelty is that concessions would be tendered and not awarded based on a list of candidates, served on a 'first come-first take' basis. There could be then also competition on conditions and, possibly, also on prices. The concession contract is now specified in precise details as experience showed there were a lot of unclear situations created by the former regulation. The termination of practice is also more clearly specified and a possibility for any type of entity to establish health care providers.

An important second part of the same act is dedicated to the 'free medical specialist', which is a legal entity that would introduce a special status of a self-employed physician, who could practice based on contracts concluded with different providers, which would be the only holders of contract with the compulsory health insurance. Status of the free medical specialist would be granted by the Medical Chamber of Slovenia.

Main points

Main objectives

The proposed legal act is supposed to:

1. regulate the process of granting concessions to private providers
2. better define the contractual relationship between the Ministry of Health cf. municipality and the private provider
3. introduce a structured and transparent tendering process for posts offered to private practitioners
4. introduce the concept of a free medical specialist as a self-employed medical practitioner who enters in contractual relationship with those providers who need his/her/their services and have the funds necessary to pay for them (out of the compulsory health insurance through the Health Insurance Institute of Slovenia)

The new solutions are supposed to better structure the process of granting concessions, make it more transparent and verifiable, contain costs through a controlled competition expected for the posts tendered, enhance other possibilities of contractual relationships of medical specialists who wish to work in a more independent position (but not as a private entity). The present trend of single-handed (or small) medical practices posed several questions on their stability and safety and on the problems of selectively accepting only those patients who fit into their capacities and facilities. A standard (hospital) environment should provide a typical, controlled and sustainable setting for practice of these specialists.  

Type of incentives

The act proposes solutions, which in itself should provide incentives and motivation for a move in the direction of a more competitive provider market with a greater flexibility and diversity of contractual relationships with different types of providers. It will lead (at least transiently) to a greater number of providers, though it is expected that the interest for single handed practices would be replaced by free medical specialists.

Groups affected

medical specialists, public providers of health care (public health care centers, hospitals), compulsory health insurance

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

Political and economic background

Two important processes were guiding the presently proposed changes. On the one hand and most importantly, there was a significant change in the political direction in 2004. The coalition elected in that year is of centre-right and has consistently defended a stronger move into a more diversified and privatized market in health care. On the other hand, there was the need, following the EU regulations to organize tendering of health care providers in a structured manner that would comply with the rules and regulations of a regulated market. One of the problems of the proposed legislative solution is that it is motivated politically and not grounded in a longer-term document, such as a health strategy or a national health plan, which would have its own targets and goals, offering the possibility of evaluating the impact of such measures. Therefore, the future act is no more precise in its ambitions or goals as the present one as it does not imply what would the 'final state' be, putting a lot of pressure and stress on the public providers of health care and all involved in securing a continued health care delivery. However, it is true that these aims are described in the government's general strategy on economic and social reforms (2) where privatization is presented as one of the options in enhancing efficiency and effectiveness in health care.

Change of government

More impact and importance given to privatization in all aspects of social services, in particular in health care, also through a stronger role of the medical profession.

Complies with

EU regulations

tendering processes of allocating public funds

Change based on an overall national health policy statement

Measure 67: Increasing the efficiency of health care providers

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 was originated within the political setting and within the chambers and associations representing medical, dental and pharmacy professionals. The main purpose of the renewed system of granting concessions for private provision of health care is a more transparent process through the introduction of tenders, increasing the competition among providers, regulating the area of free medical specialists and complying with the regulation on tendering publicly financed services within the EU. The Ministry of Health would like to have a stricter control over the granting of concessions and will therefore have the right to overturn a decision taken at the municipality level in those cases when the estimate will lead to limited rights of the plaintiff (i.e. of the future or potential concessionairy). Free medical specialists would be enabled through this act. The driving forces behind both changes are the current governing political parties and health professionals, especially those most interested in private practice - physicians, dentists, pharmacists. The new act should enable more interested in moving into private practice to do so with fewer administrative obstacles they used to face when making the applications in the past. 

The proposal is based on the experience of several other countries in the part which regulates the granting and tendering of concessions. In the part where the free medical specialists are introduced, the examples are taken from the Dutch, Canadian and German experiences. Regulating concessions actually amends the existing solutions and makes it somewhat more transparent, but at the same time more open to broadening the base for private practice. Free medical specialists are a new concept to Slovenia and have not existed before.  

Initiators of idea/main actors

• Regierung

Approach of idea

The approach of the idea is described as:
renewed: solutions based on examples from other countries, mainly the Netherlands, Canada, Germany

Innovation or pilot project

Pilot project - Individual medical specialists were granted 'test' statuses as free medical specialists.

Stakeholder positions

The main opposition to this idea comes from the following stakeholders:

1. the opposition political parties
2. the public providers of health care, especially primary health care centers
3. the Movement for public delivery of health care, organized as an NGO with around 70,000 listed supporters (3)
4. a part of health professionals opposed to extending private practice
5. a certain number of municipalities, especially in the cities

Opponents comment that the act opens the door to an indiscriminate privatization of larger scale proportions with benefits only for the private providers and for those patients who would be able of paying additional costs incurred due to price and cost pressures derived from the private provision of health care. They estimate that the share of copayment transfers through supplementary insurance may increase, especially for laboratory tests and some procedures where cost shifting could be possible (or through the development of parallel markets). Public providers of health care consider this act as a step in the direction of putting them in a further uncertain position about their future and about the future of their services with difficulties in workforce planning. Municipalities object to the solution where the Ministry of Health would have the right to overturn the decision previously taken by the municipality in the legal process of considering the application for a private practitioners post.

Medical specialists, especially those employed in the biggest hospitals, see the establishment of the free medical specialist as an option of keeping their tight connections with the present employer (and the probable future client), contrary to the present solution where they had to opt out from the system if they wanted to become independent. It would probably be possible to keep free specialists in teaching positions, much better than with the total separation into a fully developed single-handed private practice. There is strong alliance between the official political setting and the health professionals, especially physicians on this topic.

Actors and positions

Regierung
medical specialists	sehr unterstützend		stark dagegen
health insurance	sehr unterstützend		stark dagegen
left-wing political parties	sehr unterstützend		stark dagegen
consumers' association	sehr unterstützend		stark dagegen

Influences in policy making and legislation

The act is now under consideration in an extended public debate which is to end by the end of this month. Afterwards it will be presented to the government for approval of the final text which will be drafted and sent to the parliament for the first phase of the adoption process.

Legislative outcome

pending

Actors and influence

Regierung
medical specialists	sehr groß		kein
health insurance	sehr groß		kein
left-wing political parties	sehr groß		kein
consumers' association	sehr groß		kein

Positions and Influences at a glance

Adoption and implementation

This act will be intensely scrutinised and examined to every nitty-gritty detail by almost all relevant stakeholders in health care. On the one hand there is the 'proposing side' with the Ministry of Health and the Government and the organized health professionals and, possibly, also the Health Insurance Institute as a relatively neutral party; on the other hand, we have the opposition, which presides over the Parliamentary Committee on Health, the Movement for public delivery of health care (3), which is actively against privatization in health care and, finally, there are a mixed group of opposing stakeholders, ranging from trade unions to some health care experts who are sceptical about the positive outcomes of the process enacted through this particular act.

Expected outcome

Impact of this policy

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

References

Reform formerly reported in

Introduction of independent medical specialists Process Stages: Idee

Privatization of health care in Slovenia Process Stages: Strategiepapier, Idee

Author/s and/or contributors to this survey

Albreht, Tit

Empfohlene Zitierweise für diesen Online-Artikel:

Albreht, Tit. "The act on concessions and free specialists". Health Policy Monitor, April 2007. Available at http://www.hpm.org/survey/si/a9/2