Doctors clash with the National Health Fund over healthcare agreement
At the end of 2005, the situation for public healthcare patients remained uncertain as the conflict escalated between the National Health Fund and the employer organisation of general practitioners (GPs) over the Zielona Góra Agreement. The agreement covers the primary medical care contracts for 2006. The GPs' organisation boycotted rate proposals by the National Health Fund, arguing that they were too low. In the case of the contracts not being signed, GPs would have kept their practices closed from 1 January 2006 onwards. Although the conflict was diffused, it is far from being resolved, as the affair is not an isolated case.
This feature examines the reform process of the Polish healthcare system over the past seven years, focusing on the primary healthcare services sector and the problems brought about by the reform process. Regular conflicts between the state and medical practitioners in the primary care sector led to the establishment of a strong employer organisation in this sector, the Federation of Health Protection Employer Unions (Federacja Zwiazków Pracodawców Ochrony Zdrowia Porozumienie Zielonogórskie, PZ).
National Health Insurance Act
The Zielona Góra Agreement is drawn up by the Federation of Health Protection Employer Unions (Federacja Zwiazków Pracodawców Ochrony Zdrowia Porozumienie Zielonogórskie, PZ), which covers general practitioners (GPs) and represents their collective interests. It is named after a town in south-west Poland, Zielona Góra, where a group of GPs, who provided healthcare services in five administrative regions in Poland (voivodeships), first established the agreement in August 2003. Later on, unions from further three voivodeships joined the organisation and became party to the agreement. Currently, PZ comprises 16 regional unions from all over the country, assembling 15,000 members. The agreement signatories decided to launch common initiatives aimed at protecting the interests of GPs, particularly with regard to public healthcare funds.
Decentralisation of the healthcare system
Over the past seven years, the public healthcare system in Poland and its funding have been subject to radical change. Until 1999, healthcare services were controlled and funded by central government. On 1 January 1999, the centre-right government brought in the National Healthcare Insurance Act. This Act envisaged a shift from a centrally-controlled, budget-based system to a decentralised insurance-based system, operating through multiple regional funds and a special fund with nation-wide coverage (covering employees from the defense, interior, justice and railway sectors). At the same time, the government launched a reform of the local administration that resulted in the creation of 16 new and bigger regional administrations (voivodeships). With this decentralisation, the health insurance funds were placed at regional level and given autonomy. As a result, the conditions were set for private sector service provision: medical practitioners in private practices concluded contracts with the regional health insurance funds - institutions based on the German model (and referring to Polish pre-War tradition) - to provide medical services funded by insurance contributions. This new health insurance system was oriented towards primary care services and thus strengthened the role of GPs as gatekeepers. Specialist treatment is only provided on the basis of a referral from a GP.
The National Healthcare Insurance Act generated widespread criticism, as, for example, it did not cover secondary health provisions sufficiently. Most medical practitioners agreed that the reform required more consultation on their part. As the leftist opposition condemned the Act leading to the set-up of the health insurance funds, it was not surprising that, in autumn 2001, when they came to power, they announced further radical changes of the Polish healthcare system, including the closure of the health insurance funds. The funding of healthcare was centralised again. The National Health Fund (Narodowy Fundusz Zdrowia, NFZ) (close to the British model) was established at the beginning of 2003, and the independent health insurance funds were transformed into regional branches of the NFZ, reporting to it as well. It can be argued that the reorganisations of the healthcare system, which were implemented within such a short period of time, certainly did not improve its functioning.
Insufficient financial resources
Insufficient financial resources represented the main difficulty in changing the funding of the healthcare system in 1999. Furthermore, changing rates of health insurance contributions as well as discrepancy between the proposals on target rates weakened the financial support of the reformed healthcare service. The revenue from contributions, which originally amounted to 7.5% of a person’s income, appeared to be insufficient (as health insurance funds pointed out), from 2001 onwards, the contributions were set to increase by 0.25 percentage points per year. In 2002, however, contributions remained the same, but raised again by 0.25 percentage points in 2003 (up to 8%), although this time contributions were not tax-deductible. Up to 2005, health insurance contributions gradually increased, reaching 8.5% of a person’s income after the deduction of social insurance contributions.
Establishment of the Zielona Góra Agreement
The lack of financial resources led to unsatisfactory contract rates between primary healthcare providers (outpatient healthcare units and GPs) and the NFZ. This became a characteristic feature of the healthcare system in Poland and subject of a prolonged dispute, flaring up anew each year, between the interested parties. In general, GPs claimed that the rates proposed by the NFZ were too low, and the conflict allowed for legitimised negotiation and became an instrument of financial management in the healthcare service.
PZ is the result of an initiative by a group of GPs, aimed at creating a forum which would offer them support in contract negotiations with the NFZ. According to the signatories of the Zielona Góra Agreement, one of the reasons why they opted for this agreement was related to their worry that a centralised funding system of the healthcare service would negatively affect the position of practitioners from the provinces in their negotiations with the central office. Thus, the agreement was to play the role of a powerful lobby.
Continuing protests in the healthcare sector
At the end of 2003 and the beginning of 2004, Poland witnessed a period of protests in the healthcare services sector. Trade unions claimed a rise in healthcare expenditures while boycotting a government proposal to privatise hospitals. Nurses also joined the nationwide protests since the 2001 public health care reform and the cutting of funds going into this sector had resulted in a deterioration of their economic condition. Under pressure, the government passed an act, Act 203, stipulating a pay rise for public healthcare providers without, however, ensuring the necessary funding. Moreover, PZ decided not to participate in the NFZ open tender procedures for the year 2004, arguing that the contract terms offered by the fund were unsatisfactory, as they extended GPs’ duties but failed to increase their rates. Several months of negotiations between the general practitioners’ federation, PZ, and NFZ representatives did not lead to a settlement in 2003. After practitioners affiliated to PZ kept their practices closed at the beginning of 2004, the federation and the NFZ agreed on a compromise which resulted in contract conclusion between the National Health Fund and the GPs. However, PZ expressed no reservations regarding NFZ contract proposals for the year 2005.
Conflict over a new bill on general contract terms
In August 2005, the Minister of Health submitted a bill on the General Terms of Contracts determining the provision of primary healthcare services. PZ categorically contested the new bill, claiming that GPs as primary healthcare providers would become dependant of the NFZ, giving indirectly their consent to all future NFZ proposals irrespective of their contents. Practitioners also stressed that the bill does not leave any room for negotiation between the interested parties.
In October, PZ put forward a motion to the Minister of Health requesting a change of the general contract terms for 2006 and an immediate annulment of a regulation on the professional and sanitary requirements imposed on the premises and equipment of healthcare units (Zaklady Opieki Zdrowotnej, ZOZ). Both binding regulations were considered too rigorous. Although the parliamentary and presidential elections brought about a new government, negotiations between PZ and the newly appointed Health Minister did not resolve the situation.
Partial compromise between the state and healthcare providers
Towards the end of 2005, the tension increased as both parties toughened their positions. PZ affiliated GPs demanded a monthly rate of six Polish zloty (PLN) per patient, whereas the National Health Fund (NFZ) proposed a rate of five zloty. As the negotiations ended in a stalemate, PZ doctors announced that they would keep their practices closed after the New Year. In response, the Minister of Internal Affairs issued a warning that they might bear criminal liability, or even be called up for the army for a period of three months. The Minister of Health tried to tone down the conflict by appealing to the federation’s practitioners, and the NFZ attempted to soothe anxious public opinion, assuring that a contingency plan was in place. However, no special preventive measures were necessary as negotiations on New Year’s Eve ended in a partial compromise and some medical practices opened at the beginning of 2006. Finally, on 10 January, PZ accepted an offer of the Minister of Health, announcing the allocation of an additional PLN 240 million to the primary healthcare services. The NFZ should receive the funding this year due to an upturn in the economy. However, the enforcement of obligations as announced by the Minister may be difficult, and the only immediate profit for GPs is a higher monthly rate per patient by PLN 0.05.
Healthcare funding in 2007
Looking at the experience of the past years, it seems as if compromises reached under pressure are somewhat shaky. Are public healthcare patients doomed to relive a similar scenario in the second half of 2006? There is no clear answer to this question as forecasts on GPs’ behaviour are only speculative. There is no information available on the NFZ financial plan and on contract proposals for primary healthcare services for 2007. Moreover, much depends on whether or not and to what extent the Minister’s announced increase in NFZ funding will become reality. An increase of healthcare expenditures announced by the Minister of Health and expected for several months is now a long-term process and there is no chance of any noticeable improvement this year.
Since its establishment in 2003, the Federation of Health Protection Employer Unions, PZ, has become a powerful lobby in the primary healthcare services sector. In both cases of open confrontation between PZ and NFZ in 2003, the GPs’ organisation managed to force through its claims. With the emergence of the federation, which can be considered as a logical consequence of the healthcare reforms, labour relations in the primary care sector have changed significantly. PZ constitutes an important actor operating alongside trade unions, fully aware of its interests and strengths. In the continuing sage of conflicts waged by the GP lobby on the one hand and by the government and the public insurer (NFZ) on the other, it is important not to lose sight of the interests and welfare of the patients who seem to be treated in a somewhat instrumental way by both parties during their dispute.
Jan Czarzasty, Institute of Public Affairs (Instytut Spraw Publicznych, ISP), Poland