_________________________________________________________________________
Influence of Reforms on Availability and Quality
of the Czech Health Care
_________________________________________________________________________
Irena Jindrichovska1 and Ivana Funkova2
Abstract:
Health care sector is essentially a very important industry in every developed democratic
country, especially in Europe. This paper concentrates on assessment of the impact of ongoing reforms of Czech health care system on patients. The empirical part of this study
concentrates on the core hospitals providing medical services in every statutory district
across the country. We assess the changes after 2003 when the reform started to be
implemented in practice, and in particular we consider the recent changes in legal status and
ownership of hospitals in 2011. The paper comes to the conclusion that services for
population are reduced and are becoming more costly at the same time. As to the availability
of health care, health care is still available, but the on-going reforms make it less accessible.
We suggest that this result is a combination of bureaucracy and ill-management of the
process.
Keywords: Health care, reform, public sector, privatization, hospitals
JEL classification: I11, I18, H41
1.
Introduction
Health care as part of national economy is one of the most closely monitored followed
sectors. Health issues affect all age groups. Even though the health care is not the only factor
that determines the health of population the availability of drugs and good treatment can
significantly affect the quality of human life.
The health care system in the Czech Republic is the only sphere traditionally dominated by
the state that went through radical reform after the political changes at the end of 1989
(Vyborna, 1994; Uldrichova, 1996; Anderson, 2009). The new health care system is strongly
orientated towards the private provision of health care and is striving to introduce a sense of
personal responsibility of individuals for the status of their health. It is possible to conclude
that this fact is explicable by the strong support and active co-operation of health care
providers in the preparation and realization of health care reform.
Each country has its own specific system of health care with different institutions and
relationships among them. Ideal system does not exist. Although the reform must be based on
the specific situation of the state we can observe similar tendency in all countries. Different
systems are analyzed by international health organizations (Matl et al., 2009).
University of Economics and Management, Nárožní 9a, 150 09 Praha 5, Czech Republic,
e-mail: irena.jindrichovska@seznam.cz
2
University Hospital Motol, V Úvalu 84, 150 06 Praha 5 – Motol, Czech Republic,
e-mail: ivana.funkova@fnmotol.cz
1
In the Czech Republic the new system suffers from the common problem of all health care
systems – the difficulty of controlling increasing costs. The reform of the health care system
contributed to cost increases by imposing an additional administrative cost for the creation of
a system of health insurance companies, by technical mistakes in the system of price
regulation, and by introducing a pure fee-for-service reimbursement system in combination
with of new fee-for- service price list.
Nevertheless the new system is compatible with new market orientation of the whole
economy and did not distort the accessibility or quality of health care in the interim transitory
period. In the future, the Czech health care system will most likely follow the path on which it
has embarked during 1990s. It will concentrate on improvements in the structure of health
insurance and price regulation, and on introducing cost-combating modifications of the feefor-service system (Vyborna, 1994).
All Eastern European countries of post communist block have gone through a period of rapid
and major change in every sector, including health, since the revolutions of 1989. Major
reforms were executed since 1989 and by 1998 the previously centralized, tax-based system
had been transformed into a decentralized and pluralistic social health insurance system with
contractual relationships between purchasers, health insurance funds and health care providers
(Cosoveanu et al., 2009).
In the Czech Republic the healthcare program is based on a model of a welfare state. This
concept is a heritage given by the historical development after the Second World War that
was maintained and developed for several decades until the Velvet Revolution in 1989.
After the 1989 the system has changed. There was not a steady flow of financial resources
directly from the state budget but hospitals and other medical facilities started to be
reimbursed for health care provided by newly established health insurance companies. Stream
of revenues that goes to health care institution is a combination of direct payments and
payments in form of reimbursement by the Ministry of Health established by legislation
(Jindrichovska et al., 2011).
The structure of our paper is as follows: The first part is the introduction and motivation. To
gain some more perspective on this issue the second part provides a short summary of
previous literature. The third part presents brief characteristic of health-care funding in the
Czech Republic and approaches to health care funding in Eastern Europe. The fourth part
characterises changes of the health care system in the Czech Republic and explained recent
changes especially in regional hospitals that serve the widest part of population. The fifth part
presents a discussion of recent development – issues of availability and quality. The last part
provides conclusion and recommendations.
2.
Previous literature
In the Eastern Europe the health care was under the scrutiny several times. The work of
selected authors, which have recently explored this topic, is summarized in the following
table.
2
Table 1. Recent literature on health care in Czech Republic and Eastern Europe
Author(s) (year)
Vyborna, O. (1994)
Uldrichova, V. (1996)
Jevcak, A. (2006)
Anderson, L. S. (2009)
Country
Czech Rep.
Czech Rep.
Slovakia
Czech Rep.
Cosoveanu, G., Dlouhy, M., Czech Rep.,
Hinkov, H. and Cizmarik, P. Slovakia,
(2009)
Romania
and Bulgaria
Matl, O., Pavlokova, K.,
Czech Rep.
Roubal, T. and Vachek, S.
(2009)
Sova, A. (2010)
Czech Rep.
Jindrichovska, I., Peskova,
Czech Rep.
R., Funkova, I. and
Nesladkova, E. (2011)
Research question
The Reform of the Czech Health Care System
Liquidation of state monopoly of Health care
Unpopularity of Health Reforms in Slovakia
Political issues related to the Czech Health
Care Reforms
Mental Health Financing in several East
European countries
Sustainability models of Czech health care
Long term care in the Czech Republic
Efficiency Management of the Czech Health
Care
To ease the classification we have grouped the literature into several blocks.
Goals of Health Care reform
 To summarize the bulk of recent work we start with Vyborna (1994) who claims the
health care system is the only sphere traditionally dominated by the state that went through
radical reform after the political changes at the end of 1989. The following new health care
system is strongly orientated towards the private provision of health care and it is striving to
introduce a sense of personal responsibility in individuals for their own health. Therefore the
strong support and active co-operation of health care providers in preparation and realization
of health care reform is needed for successful end result.
 The reform of the Czech public health system started in 1991. The main goals were the
liquidation of the state's monopoly on health services and creation of non-state health care that
would include private facilities. Another goal was the introduction of multi-resource financing
for health care that respected the principle of social solidarity (Uldrichova, 1996).
International Experience – post socialist block
 Situation in Slovakia was characterized by Jevcak (2006), who claims that although many
painful reforms have been adopted in Slovakia over the last couple of years, the only one,
which is clearly disliked by the public, is the reform of the healthcare system. The reform
introduced profit-making and hard budget constraints into the system in an effort to increase
efficiency. However, up to these days the reform did not significantly increase choice or
responsiveness in insurance coverage and medical treatment.
 Four country characteristic was summarized by Cosoveanu et al. (2009), who assert that
all the four countries have started mayor changes in their systems of purchasing and financing
mental health care. The diversities due to different context as well starting points in the
reforms could be overcome. The information gap identified is a challenge for the countries
(Cosoveanu et al., 2009, p. 1). In the Czech Republic and Slovakia a compulsory public health
3
insurance system replaced the tax-financed system in 1993. In Slovakia, as a part of social
insurance; public health insurance was separated from the social insurance in 1994. Public
health insurance is the major source of health financing in the country; the direct expenditures
of the national and local governments are low, but stable. Altogether, public financing covers
90 percent of health expenditures in the Czech Republic and 80 percent in Slovakia; the share
of private spending is relatively low, but growing (Cosoveanu et al., 2009).
Political issues and sustainability of reforms
 Anderson (2009) characterizes the transition as the fundamentals transformation from
a Soviet-style health system in which the government paid for and provided all healthcare to
citizens free at point of service to a new system with compulsory health insurance provided by
multiple, quasi-private health insurance funds and a mix of public and private providers.
Although costs had been low under the old system, healthcare expenditures rose dramatically
under the new social insurance model and by the mid 1990s the financial sustainability of the
post-communist health system was in question.
 Matl et al. (2009) concentrated on the long term viability of the Czech healthcare system
and models of financial sustainability of Czech healthcare. Their study offers detailed
information about the possibilities and limits of forecasting and predicting revenues and
expenditures of the public healthcare sector.
 Sowa (2010) studied the problem of ageing and explored a question, how to develop an
efficient and sustainable long-term care systems for elderly responsive to needs. This question
is imminent, due to rising demographic pressures and becomes an urgent matter all over the
Europe. Czech Republic is among the countries that have redesigned long-term care system
according the principles of accessibility, quality and fiscal tenacity in the past couple of years.
The reform process was well rooted in the practice of local governments and social sector
empowering institutions that existed before 2006, when the reform was introduced, but were
insufficiently anchored in legal regulations.
Health care quality and efficiency
 Jindrichovska et al. (2011) concentrated on health care efficiency management and
funding in the Czech Republic. In their study they were exploring how both the financial and
non-financial measures operate in two representative Czech university hospitals. The general
recommendations for efficiency improvements in health care sector in the Czech hospitals are
to significantly reduce their costs, with use of outsourcing and lowering costs of medical
materials with the use of auctions. The system of control can be used as a non-financial
indicator, which can serve in evaluation of medical institutions. The system of control which
is used in organisations contributes to reducing inefficiencies and improves quality of
provided medical services and also efficient use and allocation of financial resources
3.
Funding of health care in the Czech Republic
In Czech Republic health insurance funds receive their budgets by directly collecting
contributions from the insured inhabitants. Contribution rates amount to 13.5% of the gross
income, paid by employers and employees in a 9% to 4.5% ratio. Self employed contribute
13.5% from profit. For pensioners, students, children, the state budget allocates a capitation
payment for each non-waged person. About 53% of the population is insured through the
state. There is a yearly minimum and maximum health insurance contribution. There is a risk
4
pooling procedure. The collected contributions are redistributed among funds on the basis of
risk of age groups – there are different weights for different age groups (Cosoveanu, 2009, p. 4).
The health care legislation in the Czech Republic is regulated mainly by the Act No 48/1997,
on Public Health Insurance. This law gives an opportunity to every Czech citizen to use any
medical institution supplying urgent care (emergency and ambulance) or to institution with
a valid contract with Insurance Agency to provide medical treatment. There is an element of
solidarity and equity in the Czech health care. In the Czech Republic the healthcare program
is based on a model of a welfare state. This concept has been inherited from the historical
political development after the Second World War. This system developed for several decades
until the Velvet Revolution in 1989. Both funding and budgeting systems in medical care are
specific due to particularities of the sector. This means that a patient does not pay directly for
medical services provided.
The health care system is set up for the public provision of treatment. Therefore, it has been
very difficult to implement private medical facilities that could by the scope of provided
services be similar to established public hospitals.
The impossibility to compete basically gradually divided the market into services which are
almost exclusively provided by the private clinics (e.g. laser eye surgery, aesthetic surgeries,
assisted reproduction etc.) and the overwhelming majority of the rest of medical services is
provided by public hospitals. Private clinics provide particular medical services, because the
level of reimbursement is making them profitable and these services are almost solely
provided by them. Private medical facilities provide services mostly for direct cash payments.
This system of funding makes them independent on the insurance companies, and thus leaves
them the space for standard non-regulated way of competition. The public hospitals cover all
other types of medical treatments.
Even though the standard of supplied services differs vastly among the public facilities across
the Czech Republic, the providers are basically not allowed to compete. The reimbursement
for particular treatment is specified by the Ministry of Health and it is the same for everybody.
In other words, hospitals always get the same contribution, no matter the quality provided.
This aspect is recently changing with new reforms that bring more concentration in the sector
and closures of regional medical facilities. This is very different from the approach of private
commercial entity and it also partially explains why at the same market there is usually no
space for both public and private medical facilities.
In the Czech Republic the health care expenditures represented about 6.9–7.5 per cent of the
GDP total expenditures in the period from 2004 to 2010. This is comparable to European
standard, as it can be seen in Figure 1. As it concerns the budgeting of individual hospitals
and health care institutions the current reimbursement system in the Czech health care is
unfavourable to the private medical facilities in the sense that the amendments to the contracts
with insurance companies are signed retroactively for the given year.
Funding of health care is provided from two major sources firstly by cost-sharing as part of
health insurance and secondly by direct payments for private health services.
In Czech Republic prior to January 1, 2008:
1. Cost-sharing was a part of public insurance: reference pricing for drugs, some dental
services, and some other really marginal services.
5
2. Direct payments were executed for private services: medical examinations not directly
related to health (e.g. certificates for issue of driving licences, or for life insurance), over-thecounter drugs and some private services (plastic surgery, above-standard dental services etc.)
or any services provided by provider without a contract with the public insurance (which is
rather exceptional).
New payments provisions were introduced in January 1, 2008. Patients pay 30 CZK for each
outpatient visit; they also pay 30 CZK for drug prescription, 60 CZK per inpatient day, and
90 CZK for emergency treatment. This is all added to all payment services that were instituted
prior to January 2008 as mentioned above. There are no differences between physical and
mental health (Cosoveanu et al., 2009, p. 6). Starting December 1, 2011 there was also an
increase of the fee for an overnight stay in hospital to CZK 100 per night.
Figure 1. Health care expense as a percentage of GDP per country
20,0
18,0
16,0
2004
14,0
2005
12,0
2006
10,0
2007
8,0
2008
6,0
2009
4,0
2010
2,0
USA
Turkey
Switzerland
Spain
Sweden
United
Slovakia
Austria
Greece
Poland
Portugal
New
Norway
Netherlands
Mexico
Germany
Hungary
Korea
Luxembourg
Canada
Italy
Japan
Ireland
Iceland
France
Finland
Belgium
Denmark
Czech
Australia
0,0
Proportions of health care expenditures on country GDP (Europe in years 2004–2010),
http://www.oecd.org/els/healthpoliciesanddata/oecdhealthdata2012-frequentlyrequesteddata.htm, cited on 22-082012.
This graph shows the health care expenditures of the Czech Republic in comparison with
OECD countries. The expenses of Czech Republic are reasonably low about 6.9–7.5 per cent
of total GDP in comparison with other developed countries both in and outside Europe.
4.
Changes in the network of district hospitals and impact on health care availability
After 1989 the Czech health care has undergone extensive transformation. Prior to 1989
health care was managed centrally by the state and it was financed from taxes. Subsequently,
the hospitals and equipment was transferred to the public health care system and health
insurance companies have been established to take responsibility for organization and
funding3.
In the Czech Republic all health care facilities initially belonged to state. After 1989, the
introduction of a new system was accomplished and the Regional Institutes of National Health
were abolished and associated equipment in them was transferred under the administration of
3
http://www.uzis.cz/katalog/mimoradne-publikace/vyvoj-zdravotnictvi-ceske-republiky-po-roce-1989,
31-01-2012].
[cited
6
the Ministry of Health. In 1991 the Ministry of Health issued a new the Decree No. 242/1991
Coll., on the system of health care facilities established by district authorities and
municipalities, which governed the decentralization of the district national institutes of health
into smaller, economically separate and distinct legal entities.
In connection with the approval of the new health care system there was an amendment to Act
No. 20/1966 Coll. by the Health Care Act No. 548/1991 Coll. issued in 1991. The Act No.
551/1991 Coll., on the General Health Insurance Company of the Czech Republic established
set up the concept of health insurance and the General Health Insurance Company was
established. In 1992 the Act No. 280/1992 Coll. set up further departmental, professional, and
business health insurance companies. Health insurance market is not regulated by the state,
and at the beginning there was a gradual decline, which caused a collapse of several health
insurance companies. Currently, there are nine well-functioning health insurances on the
Czech market.
The health system that has been in existence since 1996 was funded by performance payment,
which led for chasing points. Since 1997 the funding for health insurance was changed to
capitation payments for physicians and advance payments derived from the previous period in
hospital inpatient care. The performance system remained in power only for outpatient
specialists.
In 1992 the Act No. 160/1992 Coll. was adopted. This has transferred the healthcare into
private health care institutions and privatization of healthcare facilities started. Creating
a network of medical facilities in the territory is subject to Law No. 20/1966 Coll.
about the care and health of people, as amended.
Significant changes occurred in the inpatient care in 2002. Then in accordance with the Act
No. 290/2002 Coll. further transfer of other equipment, rights and obligations of the Czech
Republic to the regions and municipalities was executed. This reorganisation started in 2003,
and a total of 82 hospitals were transferred to regions and municipalities. At that time many
health facilities were running huge debts and regional authorities were faced with the
possibility of failure of medical facilities. At the same tome they had a difficult task to
guarantee health care to the extent and quality that the patient was a Czech patient was
accustomed.
Nowadays, region is the only shareholder in 17 facilities. In 2004, further transfers to regional
and later urban hospitals were executed. In 2005 the parliament managed to push through
a law that does not allow the transfer of governmental organizations and companies. Due to
the gap in the law regions managed to further transform the hospitals. The parliament of the
Czech Republic failed to enforce the law on public or non-profit organizations and law on
university hospitals, which would regulate common workplace learning in teaching hospitals.
This enabled the transfer of certain other things, the rights and obligations of the Czech
Republic to the regions and municipalities, civic associations active in the field of physical
education and sport and related changes and amendments to Act No. 157/2000 Coll., on the
transfer of certain assets, rights and liabilities from the Czech Republic, as amended by Act
No. 10/2001 Coll., and Act No. 20/1966 Coll. on Health Care, as amended. The region was
transferred 1 to 1. In the year 2003 medical institutional care facilities (district hospitals and
other medical institutions) with the exception of state contributory organizations whose
functions founder passes from district offices to the Ministry of Health – Annex 3 cit. law.
7
The health care regional network is regulated by the Act No. 290/2002 Coll., which is
ensuring the availability of outpatient health care, and which is entrusted the jurisdiction of
the regions with regard to the local conditions of the area – population density, transport
services, geographic conditions of the region and its demographic indicator. Creation of the
network of healthcare facilities is also ensured by announcing tenders, where the is director is
region with delegated powers for the purpose of entering into contractual relations for the
provision of health care to non-medical facilities and health insurance companies.
4.1
Current state of Czech regional health care network
For our purposes we have concentrated on district hospitals which form the spinal network of
primary health care in the Czech Republic. Our research sample-population consisted of
63 hospitals.
We have run research on the network of previously district hospitals, tat were subsequently
transferred to regions as of December 1, 2011. The research concerned their activity,
ownership structure and financial results. There were 63 district hospitals under consideration,
out of which 49 hospitals were transferred to regions, either in the form of joint stock
company – plc or contributory organizations (příspěvkové organizace). Three hospitals were
run by municipalities, one hospital was managed by the town and 11 hospitals were run by
other legal persons (jiná právnická osoba – JPO).
Table 2: List of districts and corresponding hospitals
Transfer
Region/district from
Region Central Bohemia
Mladá Boleslav OÚNZ
Mělník
OÚNZ
Kladno
OÚNZ
Rakovník
OÚNZ
Beroun
OÚNZ
Příbram
NsP
Benešov
OÚNZ
Kutná Hora
Kolín
OÚNZ
Nymburk
OÚNZ
Plzeňský Region
Plzeň
KÚNZ
Tachov
N/A
Domažlice
N/A
Klatovy
N/A
Rokycany
N/A
Karlovarský Region
Karlovy Vary
N/A
Sokolov
N/A
Cheb
OÚNZ
Ústecký Region
Děčín
N/A
Ústí nad Labem N/A
Teplice
N/A
New Institution
Form
Founder
Scope
of care
Result in 2010
Klaudiánova hospital
Hospital Mělník
Area hospital Kladno
Masaryk hospital
Hospital Beroun and Hospital
Hořovice
Area hospital Příbram
Hospital Rudolfa and Stefanie
Part of hospital Kolín
Area hospital Kolín
Hospital Nymburk
plc
plc
plc
s.r.o.
Region
JPO
Region
JPO
4
Int.,g.,surg.
4
4
undisclosed
undisclosed
undisclosed
undisclosed
plc
plc
plc
plc
plc
s.r.o.
JPO
Region
Region
Region
Region
JPO
4
4
4
Int.,g.,surg.
4
Int.,g.,surg.
undisclosed
undisclosed
undisclosed
undisclosed
undisclosed
undisclosed
Stodská hospital
NNP Sv. Anna
Domažlická hospital
Klatovská hospital
Rokycanská hospital
plc
s.r.o.
plc
plc
plc
Region
JPO
Region
Region
Region
4
0
4
4
4
profit
undisclosed
undisclosed
undisclosed
loss
Karlovarská regional hospital
Karlovarská regional hospital
Karlovarská regional hospital
plc
plc
plc
Region
Region
Region
4
4
4
loss
loss
loss
Regional healthcare, a.s.
plc
Region
4
profit
8
Most
OÚNZ
Chomutov
OÚNZ
Litoměřice
OÚNZ
Town hospital v Litoměřicích
Louny
OÚNZ
Hospital Louny
South Bohemian Region
Písek
OÚNZ
Hospital Písek
Strakonice
OÚNZ
Hospital Strakonice
Prachatice
OÚNZ
Hospital Prachatice
Český Krumlov N/A
Hospital Český Krumlov
České
Budějovice
OÚNZ
Hospital České Budějovice
Jindřichův
Hradec
OÚNZ
Hospital Jindřichův Hradec
Tábor
OÚNZ
Hospital Tábor
Liberecký Region
Liberec
KÚNZ
Regional hospital Liberec
Česká Lípa
OÚNZ
Hospital with polyclinic
Turnov
OÚNZ
Panochova hospital
Jablonec nad
Nisou
N/A
Hospital Jablonec
Královehradecký Region
Jičín
OÚNZ
Area hospital Jičín
Trutnov
OÚNZ
Area hospital Trutnov
Rychnov nad K. OÚNZ
Area hospital Rychnov n/K.
Náchod
OÚNZ
Hospital Náchod
Pardubický Region
OÚNZ,
Pardubice
KÚNZ
Pardubická regional hospital
formerly
Chrudim
LDN
Chrudimská hospital
Svitavy
OÚNZ
Svitavská hospital
Ústí nad Orlicí
OÚNZ
Orlickoústecká hospital
Region Vysočina
Jihlava
OÚNZ
Hospital Jihlava
Pelhřimov
OÚNZ
Hospital Pelhřimov
Havlíčkův Brod OÚNZ
Hospital Havlíčkův Brod
Žďár nad
Hospital Nové Město na
Sázavou
OÚNZ
Moravě
Třebíč
OÚNZ
Hospital Třebíč
South Moravian Region
Znojmo
OÚNZ
Hospital Znojmo
Břeclav
N/A
Hospital Břeclav
Hodonín
N/A
Hospital TGM Hodonín
Vyškov
N/A
Hospital Vyškov
Blansko
OÚNZ
Hospital Blansko
Zlínský Region
Zlín
KÚNZ
Regional hospital T. Bati
Vsetín
N/A
Vsetínská hospital
Kroměříž
OÚNZ
Kroměřížská hospital
Uh. Hradiště
OÚNZ
Uherskohradištská hospital
Moravian and Silesian Region
Ostrava
OÚNZ
Municipal hospital Ostrava
Hospital and polyclinic
Karviná
OÚNZ
Karviná-Ráj
p.o.
plc
Municipality 4
JOP
LNP
profit
undisclosed
plc
plc
plc
plc
Region
Region
Region
Region
4
4
4
4
profit
profit
profit
loss
plc
Region
4
plc
plc
Region
Region
4
4
profit
Loss in 2009.
2010 missing
profit
plc
plc
s.r.o.
Region
Region
JPO
4
4
int.,g.,surg.
profit
profit
loss
p.o.
Municipality 4
profit
plc
plc
plc
plc
Region
Region
Region
Region
4
4
4
4
undisclosed
undisclosed
undisclosed
undisclosed
plc
Region
4
loss
plc
plc
plc
Region
Region
Region
4
4
4
loss
loss
loss
p.o.
p.o.
p.o.
Region
Region
Region
4
4
4
profit
loss
profit
p.o.
p.o.
Region
Region
4
4
profit
loss
p.o.
p.o.
p.o.
p.o.
p.o.
Region
Region
Region
Region
Town
4
4
4
4
Int.
undisclosed
undisclosed
profit
undisclosed
profit
plc
plc
plc
plc
Region
Region
Region
Region
4
4
4
4
undisclosed
loss
loss
profit
p.o.
Municipality 4
undisclosed
p.o.
Region
undisclosed
4
9
Opava
OÚNZ
Nový Jičín
N/A
Bruntál
OÚNZ
Frýdek Místek
OÚNZ
Olomoucký Region
Prostějov
OÚNZ
Přerov
OÚNZ
Šumperk
N/A
Jeseník new
district
N/A
Sources of data:
ÚZIS.
Legend:
OÚNZ
NsP
s.r.o.
plc
Slezská hospital
p.o.
Lease
from
the
region
Region
4
undisclosed
plc
p.o.
Lease from
the region
AGEL, plc 4
int.,g.,
Agel, JPO
surg..
Region
4
Středomoravská nemocniční
Středomoravská nemocniční
Šumperská hospital
plc
plc
plc
Agel, JPO
Agel, JPO
Agel, JPO
4
4
4
undisclosed
undisclosed
undisclosed
Jasenická hospital
s.r.o.
JPO
4
loss
Hospital s pol. Nový Jičín
Podhorská hospital
Rýmařov,Bruntál
Hospital ve Frýdku-Místku
undisclosed
undisclosed
profit
Own research based on web pages of individual hospitals, districts and regions, and data from
District institute of national health,
KÚNZ Regional institute of national health,
Hospital with Polyclinics
LDN
Hospital for long-term aftercare
Small public limited company
p.o.
Contributory organization
Big public limited company – joint stock company
5. Discussion of the health care quality and availability
5.1
Issues of Availability
In all hospitals under study maintained the core departments, which represent: internal
medicine, surgery, gynaecology, and paediatric departments, Only 5 hospitals did not
maintain the system and have only 3 fields of specialization. From one hospital became
a hospital for aftercare. Previously, the district hospitals were in each district. At present, the
former districts of Prague-East, Pilsen-North, Plzeň-city, Tachov, Louny, Litoměřice, Hradec
Kralové, Brno and Brno-Country are without regional hospitals.
The network structure is based on the benchmarks for Health care facilities of the World
Health Organisation (WHO). The organisation recommends that there should be a hospital
with all basic specializations per each hundred thousand inhabitants. In the Czech Republic
this unit was a district. Hospitals of higher type should concentrate on more complex cases
mainly because of patient’s safety, and also because the physician needs to have appropriate
conditions to be able to provide high quality of complicated treatment.
Czech Government at its meeting on 29 August, 2012 approved the Regulation on driving
distances to a GP, dentist and gynaecologist. Patients should be able to reach their physicians
within a maximum of 35 minutes. Driving time to outpatient care also applies to childcare
practitioner, dentist, gynaecologist and pharmacy. The time limit of 45 minutes will be
available to more specialized care such as surgery, neurology, internal care and orthopaedics.
Even this can lead to further reduction of an access to health care because it can be enforced
by health insurance companies to reduce not only the outpatient departments, but also
hospitals
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5.2
Issues of quality
Quality and safety of hospitals is becoming a hot topic even in facilities managed regionally.
For this reason the coordination groups have been created to promote the accreditation
process awarded by the Joint Accreditation Commission as a measure to reduce costs and at
the same time to improve quality. The accreditation process is a guarantee that a systematic
analysis will be performed in all hospitals. To minimize the risks, that could lead to of any
patients’ damage. Accreditation increases the work safety even for the medical staff and helps
the hospital in concern in orientation in complex system of legislation.
Another positive element of accreditation is that hospitals will be ready to comply with
requirements of health insurance companies which will favour the accredited bodies’ to
unaccredited in payments for rendered services. The accreditation process is a useful tool for
comparison of services provided by individual hospitals During the accreditation process
common quality indicators are established and due to this procedure it will be possible to
compare the individual hospitals and individual results. Hospitals that have been transferred to
regions individual hospitals are preparing to accreditation process or they are already
completed.4
The general health insurance company is also interested in the process, because they negotiate
the contracts with providers, which highlight the need for gradual optimisation of the health
care network and the need for optimising the bed fund. This is done preliminary because of
the need to create financial reserves. According to the strategy5 the assessment of impatient
healthcare facility in its restructuring depends on several criteria, e.g. filling material,
technical and staffing, bed occupancy of at least 75%, the minimum number of five key
performance procedures. And last but not least the quality and efficacy of health care
provided. The main goal of the General insurance company in addition to establish and
guarantee the financial sustainability and improve the quality of health care is to align the
requirements of patients, healthcare insurance providers and health insurance companies. The
General health care insurance company sees this evidence that accredited hospitals are
providing a high standard medical care.
6.
Conclusion
The move from controlled socialist structure to an insurance-based, fee-for-service model has
been institutionalized in a short time. Health care spending increased 50% in 2 years at the
beginning of 1990s. This development now resembles many industrialized nations. Claims for
reimbursements are increasing at a rate of 5% to 7% per quarter. Market incentives have
changed the behaviour within the medical community. Newly privatized physicians generate
greater volume and consume more resources than those continuing as state employees. Policy
issues requiring further evaluation include supply, distribution, and relative valuation of
physician services; clinical resource allocation; and cost containment (Massaro et al., 1994).
In accordance with previous findings (Vyborna, 1994 and Uldrichova, 1996) the new system
suffers from the common problem of all health care systems – the difficulty of controlling
SAK ČR [online]. SAK-standardy-nemocnice-2009.pdf. Dostupný z http://www.sakcr.cz/czmain/dokumenty/akreditace [cit 2012-08-31].
5
SAK ČR [online]. Akreditace zařízení zlepšuje pozici při jednání s VZP. Dostupný z http://www.sakcr.cz/czmain/archiv-aktualit/akreditace-zarizeni-zlepsuje-pozici-pri-jednani-s-vzp-.488/ [cit 2012-08-31].
4
11
increases in costs. The reform of the health care system initially contributed to cost increases
by imposing additional administrative charges associated with the creation of a system of
health insurance companies and by introducing a pure fee-for-service reimbursement system
in combination with an amateur fee for-service Price List. Decentralization of state facilities
has gone extremely quickly. In the future, the Czech health care system will most likely
follow the path on which it has embarked during 1990s. According to Anderson (2009) the
most significant reform was a 1997 temporary bill passed by an interim government. Efforts
to contain healthcare costs through legislative reform proved difficult to achieve. Until 2007,
no other significant healthcare reformed aimed at financing was passed.
Cosoveanu, at al. (2009), have established that in the Czech Republic and Slovakia
a compulsory public health insurance system replaced the tax-financed system in 1993.
Altogether, public financing covers 90 percent of health expenditures in the Czech Republic
and 80 percent in Slovakia; the share of private spending is relatively low, but growing.
In the previous study Jindrichovska et al. (2011) claimed that providing health care is not only
a budgeting question, but it is related to many ethical issues. Up to now, the Czech state and
municipal hospitals were not really forced to be cost effective and to be responsible for their
results. Thus, on a more general level, patients in the Czech Republic need to be aware of the
costs of medical care they receive. As we have learned in the case of Germany, patients
receive a bill summarizing the cost of their treatment. Therefore they have an opportunity to
become cost conscious.
Our current study contributes to the stream of previous literature of transformation of health
care system and health care reforms with providing detailed study of changes in the spinal
network of district hospitals distributed across the Czech Republic. We have found that there
are changes in ownership of hospitals in their structure and expertise. The WHO
recommendations are much looser than the arrangement under the previous Czech system.
To perform a thorough analysis of influence of on –going health care reforms more
quantitative data need to be employed and features of population ageing need to be taken in
consideration. On the other hand the influence of new technologies together with witty cost
conscious management should bring the overall health-care costs to optimal level.
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