The health care services contracting process

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

Abstract

The Regulation analyzed hereby is based on the Law of 27 August 2004 on health services financed from public funds and Regulation of 11 June 2004 with particular scope of the Ministry of Health activity. It introduces general conditions of contracts. It bounces legally from 10 October 2005. Due to the Regulation all parties of contracts have to adapt all contracts accepted before the date of this regulation entry into force.

Purpose of health policy or idea

From the very starting point of health care reform in Poland the process of health care services contracting was an important issue and after quite a long time of subsequent reforms it still causes problems. At the beginning the main question was how Sickness Funds as payers could keep theirs freedom and relatively independent position but, at the same time, provide the same level of health care services. On one hand they should have kind of a contracting freedom margin (questionable was how wide and in what scope of matters) but, on the other hand, all insured (beneficiaries) should get the same quality and the same quantity of health services. Briefly speaking it was a dilemma of equality in health care service access and the competency of Sickness Funds. Differences between contracts and growing imbalance between SF incomes had lead to the introduction of standardized, general conditions of health services contracting and "equalization mechanism" introduced on the basis of adequate regulation of the Ministry of Health. After the "second wave" of health care reform, National Health Fund (its units) have to standardize the contracts conditions due to the general conditions introduced in quite new regulation of the Ministry of Heath - regulation from 6 October 2005 on the general conditions of health services providing contracts. Therefore, NHF and health services providers have to adapt all contracts to the new conditions set in the regulation.

Main points

Main objectives

The act outlined the main terms (legal definitions) and the conditions of the contracting (general conditions bouncing all health care services providers and payers (local units of NHF). Firstly the regulation states main steps, principles and rules of the contracting procedure and clearly defines the subject of such contracts (there are 13 issues - types of health care mentioned). Secondly it regulates and defines providers liability, conditions of health care services realization, methods (ways) of health care financing,  contractual indemnities. Finally it provides the health care services contracting rules: settlements of disputes in a conciliatory way.

Type of incentives

Regulation provides only one financial incentive based on contractual indemnities (contractual fines). As a whole it is a  tool given by  the Minister of Health for payers and providers aiming to introduce more unified and clear contracting conditions - equal in terms of general conditions and as such being a fundamental mechanism of equal access to health services.

Groups affected

Health care providers, The local units of National Health Fund., Patients

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

This policy was introduced as an idea of improvement of accessibility and equity of health care services provided to insurees. It was implemented in a form of executive legislation, as a mechanism incorporated in Ministry of Health competencies. Such  instruments are quite often criticized for interfering into rules of competency by establishing rules that not let parties of contracts  for freely arranged (and economically profitable) conditions of contracts. Of course it is not possible - in such construction of the whole health care system - to make it free to the same or similar extend as in case of  another services on a free market. The process of control and supervision is strongly needed and the regulation itself introduces criteria for such process. As it was mentioned the regulation creates an executive legislation for equalization of access and  it also creates the conditions for functioning of health care services providers - in a sense of establishing fundamental conditions for contracting process. The public opinion (the patients) will be dependent either on a scale of the perceived improvement within the activity of the service providers or on a shortage of it (the quality and quantity of contracted services).The patients are mostly interested not in a systemic changes but rather in a quality improvement. They also expect that the form of the services will significantly improve.

Political and economic background

The Minister of Health is responsible (on the basis of the Regulation of 11 June 2004 (by the Prime Minister) on particular scope of the Ministry of Health activity[1] for determining general conditions of health services contracting. It should be understood as a requirement of rational management. Government tries to remove existing differences in access to health services arising from not sufficiently unified main terms, definitions and conditions of contracts. All problems started in Sickness Funds contracts (at that time they were able to set contracts conditions individually and they often did not reveale signed contracts even for the purpose of research or surveys provided by universities or other research bodies). Better control over the process of health services contracting and in this way over service financing should actually influence in a direct way the access to services (also in terms of medical quality and more rational money spending).

In such context the main object of the act results in control of health care services contracting process, unification of main conditions of contracts and also unification of standards (in a sense of quality and quantity). The regulation is also directly connected with the previous executive legislation of the Ministry of Health from 18 April 2005 on the schedule of negotiation process for the general conditions for health services providing contracts project. The schedule was issued in a form of appendix to the regulation. It determined the negotiation procedure and requirements, as well as defined interested parties:

President of National Health Fund (plays the leading role), National Physician Chamber, National Nurses and Midwifes Chamber, Organisations of representatives of providers defined by the Law from 27th August 2004 on health care services financed from public finances as negotiating parties.
[1] Dz.u. nr 134, poz. 1439) (Journal of Laws no 134, clause 1439.

Change of government

The parliamentary election that took place in last September 2005 created quite new and different situation also in the field of health care sector. Due to the election program the new government is going to introduce fundamental changes; the health serv

Complies with

General requirement of rational management and equalization of contract conditions (in a view of equal access) as well as requirement of disclosure (transparency) of public finances management.

Change based on an overall national health policy statement

Statement Title: National Health Plan 2004-2013 (Ministry of Health, Warsaw 2003r.) ? as general call for rational management (and equal access).

Purpose and process analysis

Current Process Stages

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

Origins of health policy idea

This regulation follows earlier regulations but it widens its scope, it is aimed in amending and updating a prior enactment and can be seen as a next step in reform (more precise conditions and more strict rules of health services contracting put in more formal and systematic way). The driving forces of this policy is the Ministry of Health and NHF - both interested in unification of health services contracting conditions in a view to comply with provisions of law of 27th of August 2004 on the heath care services publicly financed.

Initiators of idea/main actors

• Regierung: The government (the Ministry of Health) was interested in improving a previous general condition of health services contracting and also in making the control of the process more strict. The rules introduced in this regulation are very important for the process of equal access and quality of health care services. It belongs to the Ministry of Health competencies that are realized in a form of an executive legislation derived from law of 27 August 2004 on the heath care services publicly financed). Also the president of NHF is directly engaged in the process of negotiations influencing the draft of the regulation project very strongly.

Approach of idea

The approach of the idea is described as:
renewed: From the time of the ?first reform? that occurred to introduce some important differences in contracting process (Sickens Funds were accused of to much independence that lead to unclear situation (contract conditions kept secretly) and as a result to the
amended: New regulation became the following step in the long process of unification of health care services contracting rules - it started at the time of Sickness Funs activity as payers and resulted after very wide and sharp critics concerning rules of heal

Stakeholder positions

The  health care provider position is not clear: They support the idea of equal rules in case of payment but they do not accept some of the conditions that are set for the provision of health services. It is a bit difficult to describe the position of the local units of NHF towards the idea: On the one hand they would rather prefer a more independent position in creating contracts conditions (in practice it means they would prefer the situation that they can offer the lowest price for the service and very often low quality) but, on the other hand, the NHF (centre) is interested at most in controlling the local units and this is one of the possible instruments. Patients would prefer the clear situation: They expect that they can get the same kind of health services  (in terms of quality) as the rest of insured. In practice they have no real means of pressure for establishing general conditions for health services contracting process, so their position and influence for this process (establishing contracting conditions) is very weak. The Ministry of Health - realised (in the form of executive legislation) the main aim of  the law cited above.

Actors and positions

Regierung
Health care providers.	sehr unterstützend		stark dagegen
The local units of National Health Fund.	sehr unterstützend		stark dagegen
Patients.	sehr unterstützend		stark dagegen

Influences in policy making and legislation

The issue of contracting conditions is not a legislative process involving the parliament. The regulation itself is only an executive act issued by the Ministry of Health. It belongs to the scope of ministerial competences and as such it is not "included" in the process of parliamentary control. It is difficult to say how far the content of actually binding regulation will be changed in near future - to comment it is necessary to wait for the new government first proposals and changes.

Legislative outcome

success

Actors and influence

Regierung
Health care providers.	sehr groß		kein
The local units of National Health Fund.	sehr groß		kein
Patients.	sehr groß		kein

Positions and Influences at a glance

Adoption and implementation

By the implementation of the described policy the regional units of NHF and providers, as parts of health care services contracts,  will be directly affected. They both will have to comply with the set of contracting rules. Services providers of course will have to comply with conditions stated for health care services providing. Patients will be also directly affected due to the regulation's influence on quality and quantity of contracted services.

In the adoption process the regional units of NHF will be most involved, because they have to organize the whole process of contracting health services - from offer to signing of the contract by providers.

To achieve the policy purpose of this regulation a rule of transparency should be respected. The implementation cannot be evaluated at the moment, as it was pointed out before. Real results of the implementation can be evaluated after the new contracts assignment, but only in case if the system will not be changed by the new government.

The regulation bounces legally all parties of contracts on health services financing. The NHF units, having more clear positions due to the regulation could have the opportunity to create more standardized conditions of  health services contracting (that was a main aim of the centralization of the financing system policy and later reform). The radical improvement in equalization of services quality and access might be achieved only due to the unification of health care services contracting process.

Monitoring and evaluation

Generally, the regulation meets the requirements for the general conditions of  health care services contracting - taking into account more general aim of the last health care reform that is unification and harmonization of services.  The results, monitoring and evaluation process however cannot be described at the moment, it is necessary to wait until the next year (renewing of contracts and assignment of the new contracts). As it was pointed out before, in case of fundamental changes in the system, to observe potentially introduced changes in the sphere of health care services contracting process -and especially general conditions of contracting - conclusions depend on undertaken by the new government policy and reforms derived from it.

Expected outcome

It can be expected that the general conditions for health care services contracting would be kept due to the fact that they introduce a more unified situation - but only in case when the present system would be kept. It is difficult to foresee the real outcomes because of possible change from insurance into budgetary financing system especially when the situation of unstable policy at the government level does not let to formulate an assured and reasonable conclusion on unexpected and undesirable effects. If one can expect basic, fundamental changes, they would be probably undertaken in a slow, step by step,  process, and the effects can be positive in a sense of accessibility and equity improvement.

Impact of this policy

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

Offered by the regulation and derived from its provisions results could be  directly transferred on health care services provision. The impact may be directly seen for below reasons:

1. Quality of health care possible  improvement;
2. Equity of health care possible improvement;
3. Cost-efficiency possible  improvement. 

References

Sources of Information

• Rozporz¹dzenie Prezesa Rady Ministrów a dnia 11 czerwca 2004r. w sprawie  szczegó³owego zakresu dzia³ania Ministra Zdrowia -Dz.U. Nr 134, poz.1439 (Prime Minister Regulation from 11th of June 2004 on particular scope of the Ministry of Health  competencies, Journal of Law no 134, clause1439), 
• Ustawa z dnia 27 sierpnia 2004r. o œwiadczeniach opieki zdrowotnej finansowanych ze œrodków publicznych  - Dz. U. Nr 210, poz.21350 (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).
• Rozporz¹dzenie Ministra Zdrowia  z dnia 6 paŸdziernika  2005r. w sprawie ogólnych warunków umów o udzielanie œwiadczeñ opieki zdrowotnej - Dz.U.05.197, poz. 1643  (Ministry of Health  regulation  from 6th October 2005 on general conditions for health care services providing contracts, Journal of Law no 05.197, clause 1643)
• Rozporz¹dzenie Ministra Zdrowia  z dnia 18 kwietnia 2005r. w sprawie regulaminu negocjacji dotycz¹cych projektu ogólnych warunków umów o udzielanie œwiadczeñ opieki zdrowotnej- Dz.U.2005 nr68, poz. 608, (Ministry of Health  regulation  from 18th  April 2005 on negotiation rules on the project for general conditions for health care services providing contracts, Journal of Law no 68, clause 1643)

Reform formerly reported in

National Health Fund: The Next Step to Reform Process Stages: Umsetzung, Gesetzgebung

Author/s and/or contributors to this survey

Anna Mokrzycka

Empfohlene Zitierweise für diesen Online-Artikel:

Anna Mokrzycka. "The health care services contracting process". Health Policy Monitor, October 2005. Available at http://www.hpm.org/survey/pl/a6/1