primary health care in poland - amazon web...
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Primary Health Care in
Poland
Slawomir Chlabicz
Department of Family Medicine
and Community Nursing
Medical University of Bialystok
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Basic facts
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• The largest country in central and eastern Europe
• Population - 38.2 million
• Area - 312 685 square kilometres
Poland – basic facts
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Poland – short history
• 1569-1795 Polish-Lithuanian
Commonwealth
• 1795-1918 Partitions
• 1918-1939 Independence
• 1945-1989 Part of Soviet bloc
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• Healthcare largely financed from government
resources
• No market economy
• Healthcare workers – salaried employees
Poland
Previous healthcare model
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Based on Soviet system
Polyclinic with
Paediatrician
Internist
Gynaecologist
Dentist
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• The concept of a family physician or general practitioner did
not exist
• Primary care undervalued
• Narrow specialties dominated the system
• Primary care not an academic discipline
Primary health care before 1991
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• The introduction of compulsory health insurance
(9% of gross income)
• Development of the private sector in ambulatory
and primary health care
• The strengthening of primary care
Health care reform 1997-1999
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• 9.0% of the base (almost all the income of an insured
person)
• contributions calculated, collected and transferred by payers
(by employers or institutions responsible for providing
benefits)
• all social groups practically covered
• unemployed contributions covered from budget
Mandatory health insurance
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Workforce
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Pediatrician Internist Gynaecologist
Family physician
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How do you become a FP in
Poland
• Residency training (4 years)
• Retraining (previously for 6 months for
established prinmary care physicians)
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• Medical specialist training -“residency”
financed from the state budget via the
Minister of Health
• Training 4 years
• 2 months – family medicine
• 24 months hospital and specialist
outpatient
• 22 months – family medicine
• 44 days of courses
Training of family physicians
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• Broad curriculum
Rotate through internal medicine,
obstetrics, gynecology, surgery,
emergency medicine, critical care, and
psychiatry as well as other medical and
surgical subspecialties
• Includes training in both hospital and
primary care
How to become FP
Training in Family Medicine
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Types of doctors in PHC in
Poland
1. Residency trained FP (certified)
2. Retrained Paediatricians and Internists (certified)
3. Pediatricians and Internists without FM
certificates
Some competent in care of children and adults
Some competent only in children or adults
Some competent mostly in one age group but ready
to see adults/children if necessary
Gynaecology part of FM residency training but not
practiced by FP
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• 1994 – first exam for specialization in
family medicine held
• MCQ-Warsaw
• Oral exams in regional centers
Exams
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Number of residents in FM
• 200 graduates in Medical University of
Bialystok
• Around 12 (6%) start FM residency every
year
• Target for UK – 50%
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• Primary care mostly based on private
medical practices and private health care
institutions (contract with NHF)
• Usually practices run by a group of 1-3
doctors
• They may employ other doctors (not
partners)
• Everybody is entitled to open a practice
and apply for a contract
Primary care ownership
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Family practice team
• Family physician
• Family nurse (capitation fee)
• Community midwife (capitation fee)
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• Departments of Family Medicine in all
Medical Universities in Poland
• Family medicine obligatory in
undregraduate curriculum (105 teaching
hours)
Changes in education
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Activities
Books
Journals
Guidelines
Congresses
CME
3 organizations
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Financing
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Mandatory health insurance - the major source
of financing
Complementary sources
• Private medicine (not financed by NHF) large part of
healtcare services
• (pay as you go, or prepaid monthly schemes individually ot by
employer)
Financing Health reform 1997-1999
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• health insurance contributions directly linked to personal
income tax
• can be regarded as a “quasi-tax”
• lack of a defined upper limit
• no relation between health risk and the insurance
contribution
• you get the same irrespectively what you pay
Insurance or tax?
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• The National Health Fund (NHF) with its regional branches
administers the health insurance scheme
• The NHF has the responsibility for planning and
purchasing public financed health services
Organization
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• Contracts for health services can be made only with service
providers who meet the requirements laid down in the law along
with specific requirements defined by the National Health Fund.
• The NHF contracts for the delivery of
health services are concluded through a competition for public
funds
Market in healthcare
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• Financing per capita on the basis of patient lists
(capitation fee)
• A basic rate is adopted and differentiated by age for three
age groups (0–6 years, 7–19, 20-39, 40-64 years, 65
years and older)
20-39 – 140 PLN/year
0-6 x2
7-19 x1,2
20-39 x1
40-65 x1,1
>65 x2
Primary care financing
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Capitation fee
0-6 years – 11,7 zł x 2 = 23,4 zł;
7-19 years – 11,7 zł x 1,2 = 14,4
20-39 11,7 zl x 1 11,7
40-65 years – 11,7 zł x 1,1 12,9 zł
Over 65 – 11,7 x 2= 23,4 zł
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• Rent for the premises
• Salaries of employees (receptionist,
cleaner)
• Cost of tests (laboratory, microbiology, x-
ray, ultrasound)
• Accounatancy
• Cost of equipment
• TAX
• Physician’s income
Capitation fee
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In a family physician’s practice there are
1750 persons,
• 250 children up to 6 years,
• 300 people 7–19 years,
• 200 people 20-39 years,
• 600 people 20–65 years,
• 400 persons over 65 years
Example
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Money
0-6 yrs– 250 x 23,4 zł = 5850 zł
7-19 yrs– 300 x 14,4 zł = 4320 zł
20-39 yrs– 200 x 11,7 zł = 2340 zł
40-64 yrs 600 x 12,9 zł = 7740 zł
Over 65 yrs– 400 x 23,4 zł = 9360 zł
29610 zł – 7400 EURO
INCOME- 5000 EURO?
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• The level of the basic rate is a problem
• In 2004 the rate remained at the 2003 level, whereas
physicians were required to provide, additionally, 24-hour
health care services
• mass protest of primary health care physicians
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2015 again
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Many Poles left without medical care as health
minister clashes with protesting doctors
January 7, 2015
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Organization of work and
scope of services
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Exclusions
Very low threshhold for referral
• STD
• Obst and Gyn
• Psychiatrist
• HIV
• Oncology
• Tbc
Family physician as a gate-keper
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Family physician
Patient’s expectations Free choice of physician
Capitation
Family physician
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• Active list –each patient has to choose his
primary care physician and sign the
Decalaration of Choice
• Free choice
• Max. number of patients 2500/physician
• FP work with list of patients
• Patient records obligatory by law
Patients’ list
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• Care of the newborn
• Care of children
• Screening (children, adults)
• Immunizations
• Chronic and acute diseases
Scope of services
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• Open 8 am-6 pm on weekdays
• Office visits and house-calls doctor, nurse,
midwife)
• Appointements personally and by phone
Organization
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Chronic diseases
• Ability to diagnose and follow-up common
chronic conditions
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Chronic diseases
Tests (+) Tests (-)
Thyroid
TSH,ft4,ft3, ultrasound Antibodies
Diabetes
Glucose, eGFR, oral glucose
test, HBa1C
Microalbuminuria,
Albumin/creatinin ratio
Prostate
PSA, prostate ultrosound
COPD/Asthma
Spirometry IgE. Skin tests
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Chronic diseases
Tests (+) Tests (-)
Osteoporosis
- Densitometry
Gastrointestinal
Gastroscopy, colonoscopy Tests for coeliac disease
Cardiology
ECG, BP Holter RR, Holter,
Echocardiography, BNP,
exercise test
Haematology
FBC, Fe, TIBC B12, folic acid
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Chronic diseases
Tests (+) Tests (-)
Angiology
D-dimers, Doppler
ultrasound
Allergy
FBC Total IgE, Skinprick tests
Oncology
CXR, endoscopy, ultrasound,
FBC, FOB
No tumour markers
Rheumathology
Rheumatic factor, CRP, x-
rays
autoantibodies, anti-CCP
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Cooperation with other healthcare
providers
• Generally poor
• Some referrals answered by specialists
but low quality
• Many pts instead of being consulted
overtaken by specialist care
• Waiting lists for outpatient specialist
services!!!
• The Ministry of Health attempts to address
those problems with rather poor outcomes
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For physicians
• Family medicine – academic discipline
• Training of family physicians designed for primary care
needs
• Private ownership of practices
• Freedom (you are your own boss)
• better income
For Patients
• Free choice of physician
• Open and easy access to primary care
• Much better premises
Achievements
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• For the NHF (the payer)
• Rigid budget for primary care (no risk of
increased costs)
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• Free choice illusional in small towns
• The system encourages to refer to other
sectors even simple cases
• Waiting lists!!!
• AandE overburden
• No data on quality of care of individual
doctors
Disadvantages
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• Nurse of long term home care
• Home hospice
New developments – home care
(paid by NHF)
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• only one payer in the system – NHF –
monopolist position
• No co-payment on the patient side
(unlimited demand for health care
services)
• Many consult unecessarily
• Incentives not to investigate at primary
care level
Problems with the current system
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