The beginning of medical reform has no end: what else needs to be considered in it

The country urgently needed health care reform. It can be successfully launched only by a large team, including the Ministry of Health of Ukraine, legislators, experts, and the public.

After long, exhausting discussions on June 8, Parliament finally supported in the first reading the draft law "On state financial guarantees for the provision of medical services and medicines."

However, for the law to work after final adoption, it is necessary to take into account all the constructive recommendations as much as possible.

Thus, the reform will indeed have a chance of implementation and will not be bombarded with "dozens" of laws with conceptual changes and amendments already in the first year after adoption.

Let's try to understand what reform proposes and what for its successful implementation is still not enough.

Purchase of medical services

The first fundamental difference between the proposed model and the one currently in force in Ukraine is the change in the budget allocation system.

Now, finance for medicine is being distributed from the state budget between local budgets through a system of subventions in accordance with the population of the administrative-territorial unit and the adjustment coefficients that take into account the differences in the cost of providing medical care.

Instead, the new mechanism provides for the payment of medical assistance directly upon the fact of its provision.

To do this, a guaranteed package of medical assistance will be defined, as well as tariffs for assessing the cost of such aid, and preliminary agreements with medical institutions on the possible volume of procurement of services.

Consequently, after providing patients with assistance, medical institutions will receive money for them from the state budget.

The manager of state funds, in this case, it is about the equivalent of more than USD 2 billion, will be a specially created body of executive power – the National Health Service (NHSU).

Talks about the need for the formation of such an organ have been going on for several years, and its necessity was argued to make the medical institutions less dependent on the profile ministry.

However, after the adoption of the law on autonomation, medical institutions will become almost completely independent of the department.

Another argument – the need to reduce the corruption component of public procurement – does not look very convincing, because the creation of new bureaucratic structures has never contributed to overcoming corruption.

However, the Ministry of Health of Ukraine assured that the formation of NHSU does not carry high corruption risks, since this body will be controlled by such controlling bodies as the Accounting Chamber of Ukraine, Audit Office, and also National Anti-Corruption Bureau of Ukraine and National Agency on Corruption Prevention.

Unfortunately, the mentioned entities will be able to identify corruption after the fact. Fuses regarding the corruption must be the involvement in the procurement process of various participants in this process – professional associations of health workers, patient organizations and the public in the regions.

Introduction of co-payment for medical services

The second novelty of the medical reform is the introduction of a "co-payment" for the provision of medical care.

If the draft law will be voted on in the second reading, then it will oblige Ukrainians to pay part of the cost of treatment independently.

That is, the logic is following: the state honestly informs the population how much funding it can guarantee for each type of diseases and that part of the funds for which the state has no resources, the patients pay themselves.

This will happen not hidden, like today, but openly, transparently and officially through the cashier.

In fact, the MOH team "went to storm" the obsolete postulates of the Constitution of Ukraine, which guarantees free treatment in state and municipal institutions, but in fact, no one receives such treatment.

The Ministry of Health assures that co-payment from citizens will be small. Although everyone has his own dimension of big and small.

The expediency of the complete abolition of subventions

A new mechanism for allocating public finances for medicine provides for the complete abolition of state subventions.

However, whether such cancellation sufficiently substantiated? In particular, regarding primary, palliative care, child care, childbirth, and pregnancy?

One of the main arguments for switching to the principle of post-payment for medical services is that, supposedly, the state pays today not for the service itself, but for walls, batteries, and beds.

Although in fact about 80% of the subvention is spent specifically on the wages of health workers and less than 10% on utility payments.

At the same time, the system of subventions ensures that medical institutions have the necessary staff of doctors and nurses, as well as light, hot and cold water and warmth in winter. After all, the state must provide one-hundred-percent guarantees for the year ahead for the provision of primary medical care, medical care for children and palliative patients, as well as for delivery and support of pregnancy.

Regardless of whether people get sick or not, today the state cares about providing the necessary funding for medical care for these categories of the population.

The current procedure for calculating subventions is based on estimating the number of people in the above categories. The approach proposed by the Ministry of Health in the calculations cannot fundamentally change anything.

Do officials of the new body will have some other indicators, other than estimating the size of the population within the specified contingents, as this is taken into account in determining the subvention.

Calculation of the amount of funds that should be allocated will not change. Only the sign will change – the purchase of services.

The positive is very illusory, and the negative is obvious – for the new body there will be a need to recruit new officials with high salaries, and besides, if the current procedure for calculating the size of the subvention does not work, there is a factor of subjective error: and suddenly this official is missing something, or another region will not receive sufficient funding.

A new approach should be at the first stage of reform when concluding contracts at the primary level.

Over time, contracts with secondary and tertiary hospitals are planned, which, according to the plans of the Ministry of Health, should streamline the networks of medical institutions – noncompetitive ones will be redeveloped for the real needs of the population (rehabilitation centers, hospices, day hospitals, etc.).

It is also necessary to work out the mechanism of procurement of medical services. After all, if the principle of the preliminary conclusion of contracts for the purchase of services within the borders of each region is declared, it is necessary to determine somehow how many services for each type of disease for a particular region need to be purchased.

Do we have enough instruments for carrying out these calculations?

In addition, to buy something you need to know the value of the goods, in this case, services. For such calculations, the special method for identifying tariffs is needed. It is being developed for many years, but still ineffectually.  This is the problem that can and must be solved preventively – before the law comes into force.

Also, you need to find the answer to the question – in which institutions you should purchase the mentioned services?

How to determine which hospital how many operations within a certain need for these operations should or can do because it will depend on how much each of them specifically receives money. That is, there is also a need for a methodology for determining the viability of each medical institution.

In this situation, private hospitals will have a better chance, with, as a rule, better equipment, nd personnel. It is to private institutions that the lion's share of state funding will probably be paid.

Moreover, finally, how the work will be paid in practice, even if there is a contract with the institution where these services were ordered.

The hospital will not be able to refuse the patient when he appeals for treatment, even if such treatment goes beyond the amount of contractual cases for this particular hospital.

Really in this situation, each time you need to apply to a newly created body and wait for an answer before you go to the operating table?

It is unlikely that this body will be able, in a constant mode, to effectively perform the function of a large cash register for the whole country.

This is a collision that also needs to be resolved – to provide for a transitional mechanism that will allow institutions and doctors to get their livelihoods in the form of an advance payment in advance, while the cash-on-delivery mechanism starts functioning normally.

In addition, the algorithms for coordinating the provision of medical services over the limits and the receipt of funds on the principle of payment should be very clearly prescribed not only procedurally, but also in time.

Financing of diagnostics

Of the draft law adopted in the first reading, it is not entirely clear how the medical care for patients will be financed at the stage of diagnosis.

Diagnostics is today the most problematic part of our medicine.The diagnostic system is scattered across all levels. At the primary level in the clinic, the family doctor prescribes the patient to do tests, ECG, X-ray.

After the start of the reform, all these procedures should be guaranteed by the state, although the quality of laboratories at this level is not always high and there are not enough specialists. If according to the results of the diagnosis, the patient was referred to the hospital, then there he undergoes repeated diagnostics twice, first before hospitalisation, and then again in the course of treatment.

However, there is no guarantee that after the reform of medicine, diagnostics at the secondary level will be financed by the state, it is possible that Ukrainians will be paid for it in the co-payment framework.

If there is a serious illness, the patient will also have a hospital of the higher tertiary level, where he will for the fourth time carry out diagnostic procedures, which he will be forced to pay in part.

So, each of the four stages of diagnosis requires not small funds: both from the state, and from the patient.

Therefore, in this case, it would be more appropriate to allocate subventions for the establishment of special treatment and counselling centres with high-level equipment and qualified personnel. Such centres could diagnose all patients, and they would accumulate funds allocated for the study of patients' health status.

Medicaid to vulnerable groups of the population

Another difficult question is the provision of medical and social assistance to vulnerable groups of the population, in particular, needy, elderly, chronic patients.

These categories periodically "lie down" in a district or city hospital for routine maintenance of a supporting type.

In the new mechanism, the guarantee that such medical and social assistance will be procured for public funds is practically minimal. However, the mentioned categories of the population do not have the means on co-payments.

New approaches actually cut these categories from medical care, leaving only social care. Fortunately, the Ministry of Health promises to provide mechanisms that will allow treatment of the needy.

The issue of providing social and medical assistance, including a harmonious combination of medical care and social care as a result of the reform, can worsen.

Medical institutions will not have the means to do this, and social institutions are actually deprived of the possibility of providing even basic medical care - vaccinations, droppers, massages, not to mention surgical intervention and prescribing, since medical institutions can medically enforce such assistance.

Not to get a sharp aggravation of social tension, it is necessary either to seek legislative decisions on the creation of a new organizational and legal model of social and medical assistance, or for some time not to give up the budgetary financing of such assistance at the level of district hospitals, primarily through the mechanism of subventions.

The solution of this issue is not in the competence of the Ministry of Health and the Ministry of Social Policy – you need to make the necessary changes in the legislation.

By the way, in developed countries, a large segment of the market is occupied by institutions of the medical and social profile – the so-called "nursing centres" and hospitals for social care. It is this model that should be prescribed in the current legislation, at the next stages of medical reform.

Restrictions on the purchase of medical and social assistance, including in terms of planned treatment, as well as secondary care at the local level, will immediately entail two problems for the local authorities: how to help people who are ill and do not have money for treatment and how to maintain medical facilities, will receive budgetary financing?

As a result, social tension will grow, as people will be forced to co-finance treatment for the last "penny" for themselves, and the local authorities will not be able to close medical facilities because of a constitutional ban.

Compulsory health insurance

Such a simple scheme of financial guarantees in the form of two sources: the state budget and the patient's pocket, which is proposed in the framework of the reform, hardly corresponds to the current socio-economic status of society, because of the poverty of the population.

Therefore, all the more pressing is the introduction of compulsory health insurance, which will attract additional sources of funding to medicine.

The introduction of compulsory health insurance would cover a significant portion of the financing that should occur under the new reform projects at the expense of citizens.

In general, the Ministry of Health does not oppose the introduction of compulsory health insurance and can support legislative initiatives that have already been introduced to parliament in the long term.

However, the logic of medical reform is such that it is advisable to introduce insurance right now when co-payments for medical services are being introduced.This would greatly strengthen the position of the reformers and would make it less problematic to introduce a co-payment mechanism, replacing it largely with insurance payments.

In many countries where successful medicine functions, this compulsory insurance does not replace or cancel budget financing, both sources complement each other.

The advantage of health insurance is that everyone makes contributions, and payment goes only for the sick, whereas with co-payment each one is left with the illness one on one.

In this case, unlike budget financing, money is not channelled in the form of budgetary allocations to medical institutions, but payments are made only upon the occurrence of insured events.

Starting compulsory health insurance is necessary from complex, high-cost diseases, primarily where surgical interventions and complex treatment are needed.

Unfortunately, in the draft law adopted in the first reading, there are no talks on compulsory medical insurance.

Medical subsidies

The next fuse can be the introduction of a medical subsidy, which is being practised in many developed countries of the world.

It is good that the Ministry takes this into account and assures that such subsidies will be introduced for especially poor categories of the population, and special programs that will help with co-payment.

Although to date, such mechanisms have not yet been developed and are not reflected in this draft law.

Recall that the basis for granting subsidies should be the patient's low level of income that is, income below the set limit.

In addition, a list of nosological conditions, indications, symptoms, syndromes, types of medical care, under which a subsidy is assigned, should be determined.

The decision to grant subsidies should be made by the local government body if there are relevant documents.

Doctor's personal responsibility

The medical reform proposed in the draft law is based on the traditional agreement between Ukraine and the medical institution for Ukraine.

Today, a medical institution, not a doctor, is responsible for the patient, receives funding and distributes it. The doctor is an employee of the institution and does not influence decision-making on many issues.

However, it is the doctor who must decide on the patient's future route, bear personal responsibility, including in court, for possible mistakes, and receive financing.

An institution for a doctor is more a place to work, a material base, and the patient will have a real right to choose a doctor, not an institution.

Therefore, it is necessary to make changes and prescribe the personal responsibility of the doctor in the current legislation.

The shift of emphasis from a medical institution to a doctor will allow building a perfect mechanism for distributing tasks and meeting the existing needs for the provision of medical services.

As a result, a more effective funding mechanism will arise, based on real contracts between the doctor and the patient, targeted budgetary allocations, a rational combination of budget guarantees and a fee-based approach.

However, for this purpose, the legislation should provide for mandatory individual licensing of each doctor for the right to conduct medical practice, the right to participate in the purchase of a guaranteed package.

It is also possible to use the so-called "brigade" principle of work when the doctor hires assistants, junior medical staff, anesthesiologists and chooses a medical institution as the place of treatment.

The Ministry of Health supports the strengthening of the responsibility of the doctor.

In particular, the patient can complain to the National Health Service. However, given the seriousness of the issue, it must definitely be resolved more radically.

To start reforming in this part is necessary with a clear delineation of the functions and powers that must be fulfilled:
A) Attending physician,
B) Chief physician,
C) Manager – the head of the medical institution in case he is not the chief doctor,
D) Supervisory Board,
E) Representatives of a local government or authority responsible for medical care.

Only if every participant in the medical service process clearly understands both their authority and their responsibility, the reforms will get their real performers.

(The article was published on the Ukrainska Pravda: Zhytia on July 6, 2017)