Krzysztof Landa, M.D. Additional Health Insurance Business Opportunities in the Polish Healthcare System 2017-03-24 WWW.WATCHHEALTHCARE.EU

Total expenditure on health per capita (USD due to purchasing power parity ) Source: OECD Health Data 2006, (*) OECD Health Data 2008

Total expenditures on healh (private and public) per capita (2007, USD due to PPP) Source: OECD Health Data 2009

Basic Benefit Package This insurance-budgetary model of healthcare funding is regulated by the law on Basic Benefit Package (BBP). The most important changes in regulations were introduced in second half of 2009 – law on BBP. It means that this new law is not mature and there is still a lot of imperfection, divergence, ambiguity what requires constant improvement. 2017-03-24 WWW.WATCHHEALTHCARE.EU

Poland Serbia Drugs - Reimbursement List – A, B, C, D Higly Specialized Procedures Hospital catalogue Chemotherapy regimens catalogue Therapeutic Programms Drugs - Reimbursement List Ambulatory Care Primary Care Prevention Programms Vaccination catalouge Dentistry care Serbia Drugs - Reimbursement List – A, B, C, D Higly Specialized Procedures Dentistry catalouge Prevention Programms Secondary and Tertiary Care Primary Care

Hospital treatment There are three ways of finansing: DRG system Therapeutic programs Services contracted separately Historical budget Limits on health services 2017-03-24 WWW.WATCHHEALTHCARE.EU

What does a decision-maker want to know? Is this technology of proven efficacy (health benefit and its safety profile)? What is the strength of intervention in comparison to optional ones? (which is the most efficacious option and what are the differences) Which is the most cost-effective option and what are the differences? Is coverage of the intervention possible with respect to available resources? What changes should we expect if the technology gets a privileged market position?

The most important requirements of the EU Transparency Directive (89/105/EEC from December, 21st, 1988) Supervision of the court over decisions concerning reimbursement and pricing – i.e. a possibility to appeal from the DECISION Supervision of the court is possible only if appellations to the court are considered according to transparent criteria ensuring high reproducibility! “Each decision on exclusion of a certain category of medicinal products from the national health insurance system must embrase justification based on objective and verifiable criteria and must be published in an appropriate publication.” The course of decision and appellation – decisions within 90 days following submission of the application (in case of a large number of applications additional 60 days – the applicant must be informed) and within another 90 days following appellation

Main advantages of the new law on drug reimbursement in Poland Economic Committee Doubled Transparency Committee Transparent reimbursement criteria RSS (risk sharing schemes, patient access schemes) 2017-03-24 WWW.WATCHHEALTHCARE.EU

Evidence based coverage decision-making – general process

REIMBURSEMENT GOES FIRST IN UTYLITARIAN APPROACH Initial price by manufacturer in dossier and HTA report Pricing Agency Negotiations New price or risk sharing Rejection REIMBURSEMENT GOES FIRST IN UTYLITARIAN APPROACH

Cost per QUALY / cost per LYG 1/ willingness to cover Cost per QUALY / cost per LYG B C A Rwanda Cambodia Serbia Hungary UK Switzerland

Total expenditure on health in Poland [bn, 2007-2011] Public expenditure Private expenditure Total expenditure Source: ppt Jakub Gierczyński 2010 2017-03-24 WWW.WATCHHEALTHCARE.EU

Private expenditure on health care Fees for medical examination Fees for drugs Additional health insurance (lisence fees) Medical subscriptions (co-payment) Bribes to get better or quicker access or any access at all 2017-03-24 WWW.WATCHHEALTHCARE.EU

Private health expenditure In 2009 - 28 bn PLN per year 30% of total medical market in Poland 2017-03-24 WWW.WATCHHEALTHCARE.EU

Out of pocket payments Apart of mandatory health premium Poles spend 30 bn for treatment Including 15 bn PLN for drugs its two times more than in 2007 2017-03-24 WWW.WATCHHEALTHCARE.EU

Supplementary insurance in Poland attain less than PLN 2 Supplementary insurance in Poland attain less than PLN 2.5 billion per year, while the complementary insurance market may reach 15 - 30 billion PLN per year Additional Supplementary (alternative) Substitutional Complementary Allows for leaving the public system Benefits are granted faster, outside the queue, in a higher standard Benefits which are not covered by public insurance or co-payment Public Supplying Insuring Protective Financed directly from taxes, depending on income Financed from contributions, depending on risks Dotations, donations, indirect taxes and other Source: Classification based on a presentation by Xenia Kruszewska, 2010

The DIRECTIVE OF THE EUROPEAN PARLIAMENT AND OF THE COUNCIL The Directive on the application of patients' rights in cross-border healthcare 2017-03-24 WWW.WATCHHEALTHCARE.EU

Council adopts its position on patient's rights in cross-border healthcare The key provisions As a general rule, patients will be allowed to receive healthcare in another member state and be reimbursed up to the level of reimbursement applicable for the same or similar treatment in their national health system if the patients are entitled to this treatment in their country of affiliation. 2017-03-24 WWW.WATCHHEALTHCARE.EU

The key provisions In case of overriding reasons of general interest (such as the risk of seriously undermining the financial balance of a social security system) a member state of affiliation may limit the application of the rules on reimbursement for cross-border healthcare; member states may manage the outgoing flows of patients also by asking a prior authorisation for certain healthcare (those which involve overnight hospital accommodation, require a highly specialised and cost-intensive medical infrastructure or which raise concerns with regard to the quality or safety of the care) or via the application of the "gate-keeping principle", for example by the attending physician. 2017-03-24 WWW.WATCHHEALTHCARE.EU

A cost of an exemplary health service 2017-03-24 WWW.WATCHHEALTHCARE.EU

Pricing – the most important regulatory mechanism of HI „Partially guaranteed” = partially covered BP (theoretically 1-99% co-payment or a HI trully 20-80% copayment or aHI) 100% out of pocket payments or aHI ( „not guaranteed”) >120% BBP regulation by pricing

A + B = ACTUAL NEGATIVE BP „THE MOONS”: Deimos and Phobos Funds from the primary contribution (health premium), tax FIELD B FIELD A BASIC BENEFIT PACKAGE cheap expensive A + B = ACTUAL NEGATIVE BP 2017-03-24 WWW.WATCHHEALTHCARE.EU

Quality of healthcare in Poland „On a national level, there are some countries where citizens are consistently negative about the available healthcare. They feel harm from hospital- or non-hospital care is likely, feel at risk of experiencing adverse events and rate the quality of their national healthcare poorly and worse than other Member States. These countries are Greece,Bulgaria, Hungary, Latvia, Lithuania and Poland”. Report: Patient safety and quality of healthcare, TNS Opinion & Social, European Comission , April 2010 2017-03-24 WWW.WATCHHEALTHCARE.EU

Quality of healthcare in Poland Report: Patient safety and quality of healthcare, TNS Opinion & Social, European Comission , April 2010 2017-03-24 WWW.WATCHHEALTHCARE.EU

HIGHER demand than supply –> QUEUES/ state control

HIGHER demand than supply -> corruption and bribery

HIGHER demand than supply -> PRIVILEGE (using connections)

THE BBP CAN BE PUMPED UP TOO MUCH BUT THE BUDGET IS NOT MADE of RABBER The greater the discrepancy, the more severe pathologies in health care Removal of the causes of the disease, eliminates the symptoms MONEY Form PUBLIC HEALTH PREMIUM BBP

They suffer in silence – they are not organized „THE MOONS”: Deimos and phobos Organized patients $ FIELD B FIELD A They suffer in silence – they are not organized cheap expensive AS SEEN BY THE PATIENT 2017-03-24 WWW.WATCHHEALTHCARE.EU

Access limitations to health care benefits and medical procedures in field A are mainly caused by: Watiting lits Limits / limiting the size of contract concluded with the payer (NHF) → increasing queues and patient selection Lowered (incorrect) price estimations = benefits are not cost- effective for clinic → patient selection stage character of treatment (GP → specialist → diagnostic test → therapy → control visit) Red tape Narrowed/ limited inclusion criteria, e.g. For therapeutic programs Copayment Lack of procedure standard 2017-03-24 WWW.WATCHHEALTHCARE.EU

Icrease health premium or/and higher co-payment How the financial resorces from health premium and BBP can be balanced? Icrease health premium or/and higher co-payment Remove from BBP expensive and not cost-effective health services Enforce additive health insurance (complementary and suplementary insurance) 2017-03-24 www.korektorzdrowia.pl

Co-payment „Trifles”: 3 pln to a visit 10 pln to hospital addmission HIGH POLITICAL RISK BUT NO CURE FOR THE SYSTEM Deductibles (Udział własny) High co-payments 2017-03-24 WWW.WATCHHEALTHCARE.EU

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The project on „100 conferences” „Innovative health technologies in …(specific medical field)…. – assessment of accessibility in Poland” Presentation of therapeutic and diagnostic innovations remining out of BBP in Poland Cooperation with National Consultants and Associations of Specialists E.g. oncology: chemiotherapy (15-16.04.2011), vaccination (May), hematooncology (June) Participants: MDs, Health Insurance, patients’ organizations, media – debates with MoH, NHF, AOTM (AHTAPol) - free participation / www.korektorzdrowia.pl or www.watchhealthcare.eu 2017-03-24 WWW.WATCHHEALTHCARE.EU

SOCIAL AWARENESS CAMPAIGN "INNOVATIONS IN ONCOLOGICAL PHARMACOTHERAPY - HOPES FOR PATIENTS, SOLUTIONS FOR THE SYSTEM" 15-16.04.2011 PARTNERS: Polish Oncology Union (PUO) www.puo.pl Watch Health Care Foundation (WHC) www.krektorzdrowia.pl Business Centre Club (BCC) www.bcc.org.pl  GREEN PR Agency www.greenpr.pl 2017-03-24 WWW.WATCHHEALTHCARE.EU

Program – day 1 2017-03-24 WWW.WATCHHEALTHCARE.EU 11.00-11.15 Przedstawienie Komitetu Naukowego kampanii oraz uczestników debaty – moderator spotkania, red. Krzysztof Michalski 11.15-11.30 Otwarcie debaty przez Minister Zdrowia, Ewę Kopacz 11.30-11.45 Wystąpienie Prezesa Honorowego PUO, prof. Marka Belki 11.45-12.00 Wystąpienie Szefa Zespołu Doradców Strategicznych Prezesa Rady Ministrów dr Michała Boniego 12.00-12.15 Wystąpienie Podsekretarza Stanu Ministerstwa Zdrowia, dr Andrzeja Witolda Włodarczyka 12.15-12.30 Wystąpienie przedstawiciela NFZ 12.30-12.40 Wystąpienie Konsultanta Krajowego w Dziedzinie Onkologii Klinicznej, prof. Macieja Krzakowskiego 12.40-12.50 Wystąpienie Prezesa Fundacji WHC, dr. Krzysztofa Łandy 12.50-13.00 Wystąpienie Prezesa PUO dr. Janusza Medera, 13.00-13.10 Wystąpienie Prezesa AOTM dr Wojciecha Matusewicza 13.10-13.20 Wystąpienie przedstawiciela BCC, Wojciecha Bociańskiego 13.20-13.35 Podsumowanie wystąpień i zaproszenie do dyskusji, dr Krzysztof Łanda 13.35-14.35 Dyskusja z udziałem: pracowników naukowych, etyków, prawników, przedstawicieli branży ubezpieczeniowej, organizacji biznesowych, pacjentów i dziennikarzy. 14.35-15.35 Poczęstunek, czas na rozmowy nieformalne 15.35 Transfer uczestników seminarium do hotelu Fort Piontek w Jabłonnie 19.00 Uroczysta kolacja w Pałacu PAN w Jabłonnie pod Warszawą Program – day 1 2017-03-24 WWW.WATCHHEALTHCARE.EU

10.00-10.30 Powitanie uczestników i przedstawienie założeń kampanii społeczno-edukacyjnej „Liczymy się z naszym zdrowiem” w kontekście innowacyjnych rozwiązań diagnostyczno-terapeutycznych dla onkologii, prof. Tadeusz Pieńkowski (PTBRP), dr Krzysztof Łanda (WHC) i dr Janusz Meder (PUO) 10.30-10.45 Wykład inaugurujący sesje medyczne, prof. Wiesław Jędrzejczak Konsultant Krajowy w Dziedzinie Hematologii 10.45-11.15 Przerwa kawowa 11.15-14.30 Sesje sponsorowane 14.30-14.50 Podsumowanie przedstawionych prezentacji, prof. Wiesław Jędrzejczak 14.50-15.00 Zamknięcie seminarium, dr Krzysztof Łanda, dr Janusz Meder (PUO) 15.00 Lunch 16.00 Transfer na Dworzec Centralny w Warszawie Program – day 2 2017-03-24 WWW.WATCHHEALTHCARE.EU

Partially guaranteed benefits 2017-03-24 WWW.WATCHHEALTHCARE.EU

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Partners of the Foundation 2017-03-24 www.korektorzdrowia.pl

Supporting Institutions 2017-03-24 WWW.WATCHHEALTHCARE.EU

Landa@korektorzdrowia.pl THANK YOU! 2017-03-24 WWW.WATCHHEALTHCARE.EU