Jasna Radić

Murgić Murgić

Sunčica Rogan

Zvonko Kusić

English

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Acta Clin Croat,  Vol. 48,  No. 3,  2009 121Acta Clin Croat 2010; 49:121-123 NewsSYMPOSIUM ON THE EXPERIENCESIN THE IMPLEMENTATION OF HEALTHCARE REFORM IN CROATIATh e symposium with international participa-tion entitled Experiences in the Implementation of Healthcare Reform in the Republic of Croatia took place on October 27-29, 2009 at Plitvice Lakes. Th e Symposium was organized by the Ministry of Health and Social Welfare of the Republic of Croatia and Andrija Štampar School of Public Health, School of Medicine, University of Zagreb, under the personal auspices of Jadranka Kosor, Prime Minister. Th e plan of implementation and results acquired to date in healthcare reform in the Republic of Croatia were presented at the conference, with special reference to the novel concept of healthcare fi nancing, the role and responsibilities of local government and self-govern-ment, reform of the primary and hospital healthcare system, reform of emergency medical service, and role of education and training of healthcare workers.In Croatia, healthcare reform that involves the overall healthcare system with all its segments has been in eff ect since 2008. Th e concept and objective set by Darko Milinović, MD, Minister of Health and Social Welfare, as the reform initiator and his team, is to bring the patient-insuree in the center of service, to improve the population health, the level of health-care and healthcare indicators, and to upgrade the healthcare system. Th e fi nancial healthcare indicators recorded in mid-2008 made healthcare reform abso-lutely necessary.In his reform program, Minister of Health and Social Welfare describes the reform objectives as follows: to achieve fi xed healthcare allocations from the budget for the next three years; to ensure social sensitivity, accessibility and solidarity; to fi nd new fi nancing sources; to enable reduction in the rate of contribution for healthcare in order to stimulate the national economy competitiveness; to abolish the mo-nopoly of the Croatian Institute of Health Insurance (CIHI); and to contribute to the reinforcement of in-dividual responsibility, decentralization and fi ghting corruption.A considerable part of the Symposium program was dedicated to the reform of hospital healthcare, with the introductory lecture on this topic held by academician Zvonko Kusić as head of the Task Force for Monitoring Healthcare Reform in Hospital and Specialist-Consultation Healthcare (Task Force). Academician Zvonko Kusić is head of the University Department of Oncology and Nuclear Medicine, Ses-tre milosrdnice University Hospital in Zagreb and has great experience at leading positions in healthcare sys-tem as Director of Sestre milosrdnice University Hos-pital for several years, Vice-President of the National Health Council of the Republic of Croatia, and mem-ber or head of many commissions and councils. Be-sides academician Kusić, members of the Task Force were: Head Doctor Marcel Majsec, MD, MS; Profes-sor Herman Haller, MD, PhD; Professor Vlado Jukić, MD, PhD; Velibor Drakulić, MD; Mirela Crničić, MBA; and Dario Nakić, MD. Th e Task Force held a number of sessions and was in charge of monitoring the course of reform in hospital healthcare.At the beginning of his presentation, academician Kusić gave a survey of diffi  culties found in the health-care system before the reform was launched. First of all, there were no multiple sources of healthcare system fi nancing, along with a very high level of payroll allo-cation of as much as 15 percent, which was the highest rate in Europe. In addition, a great deal of insurees did not pay their contribution for health insurance, thus the debt grew at a rate of 2 billion HRK per year. In the public, healthcare system was perceived as a corrupted setting, while being burdened with the lack of physicians (in part due to the decreased popularity of the profession and their drain to other, better paid services), lack of hospital standardization, inappro-priate or nonexistent computerization, and unsound Book Acta 1-2010.indb   121 14.6.2010   9:23:13Vlasta Vuković et al. Gabapentin in the prophylaxis of cluster headache: an observational open label study122 Acta Clin Croat,  Vol. 49,  No. 1,  2010relations between primary healthcare and specialist-consultation healthcare. He gave an overview of the hospital fi nancing pattern, showing that hospital lim-its in the 2008-2009 period were at fi rst increased and then reduced, however, recession was met in relatively good conditions owing to the increased hospital bud-gets. Th e main changes in the model of hospital system fi nancing referred to the new method of accounting and paying treatment costs through the introduction of the Croatian version of the internationally relevant Diagnosis Related Groups (DRG) system, in Croatia named Diagnostic Th erapeutic Groups (DTG); chang-es in the method of payment for intensive treatment through the introduction of the SAPS II score; and introduction of the new system of accounting patient payment. DRG as a valid method of hospital service accounting was introduced at the beginning of 2009, with the aim to stimulate and reward effi  cient hospital work; to ensure equity for all hospitals and patients; to reach equal footing on determining hospital limits; to stimulate hospitals to reduce expenditures but not on the account of patients and effi  cacious treatment; easier management and cost control; transparency on making contracts on healthcare; hospital stay reduction; stimu-lating day hospitals; and introduction of high-quality hospital computerization. DRG system includes and enables development of clinical protocols and guide-lines, control of hospital admission justifi ability and proper planning of discharge from the hospital. DRG system implies a number of fi nancial risks in case of misunderstanding, but also a more effi  cient internal and external control and introduction of hospital cat-egorization. Th e introduction of DRG system resulted in some favorable indicators such as reduced treatment time, increased patient turnover, integration of medi-cal procedures and fi nancial indicators, increased mean cost of treatment and cost of treatment per day, how-ever, still at a relatively low index of case complexity (probably due to inadequate coding); to say the truth, in the conditions of recession, the presented fi nancial gain cannot result in increased hospital budgets. Academi-cian Kusić referred to diffi  culties encountered in DRG implementation, such as incompleteness of the system, its relying on the physicians’ responsibility, DRG cod-ing and fi lling out is not administrative but medical task, some diagnoses are missing in the system, one-day hospitalization, patient transfer from one hospital to another, etc.After long time, hospital revenues increased with the introduction of the new system of patient payments through additional insurance and cash payments.Reduction of waiting lists for diagnostic and op-erative procedures through introduction of the Na-tional Waiting Lists and hospital units for central pa-tient appointments was one of the major goals of the reform. Th is step was expected to upgrade the qual-ity and accessibility of healthcare, transparency and reduction of waiting lists, while the pilot project of patient appointment for hospital procedures from pri-mary healthcare facilities has been under way. Since the introduction of the National Waiting List, wait-ing lists have been reduced by 30%-50% by patient referral to other institutions and stimulation of shift work and weekend work (greatest reductions were re-corded in the waiting lists for computed tomography, magnetic resonance imaging, heart ultrasonography, and hip arthroplasty); waiting lists for the most com-mon operative procedures are shorter than those in industrialized West European countries. Th e project of central appointment has pointed to some diffi  cul-ties, especially in terms of inadequate hospital com-puterization, which requires considerable fi nancial resources, the need of uniform software for central appointments at the national level, and the need of networking all healthcare institutions in Croatia. In addition, there are problems related to the lack of professionals and premises; patient failure to present for appointed examination, thus leaving the appoint-ment unutilized; increase in the requests for diagnos-tic procedures; and excessive patient pressure for ex-aminations and treatment at large centers (university hospitals and university hospital centers), which has resulted in paradoxical increase in waiting lists. Considering waiting lists, there is enough room for additional improvements. Computerization of the healthcare system should be completed and the project of e-appointments should be introduced, where family physician will make electronic appointments for diag-nostic and therapeutic procedures for his patients. Th e role of family physician should be reinforced and addi-tionally motivated, providing them with a higher level of independence, in order for ever more patients to be taken due care at family physician offi  ces, without the need to go to hospitals for (unnecessary) special-ist examinations and procedures. Numerous analyses have shown the accessibility of specialist healthcare Book Acta 1-2010.indb   122 14.6.2010   9:23:13Acta Clin Croat,  Vol. 49,  No. 1,  2010 123Vlasta Vuković et al. Gabapentin in the prophylaxis of cluster headache: an observational open label studyto be too broad and primary care physicians have the key role in solving this problem. Many examinations are unnecessary and unjustifi ed, or are unnecessarily repeated, thus posing great fi nancial burden upon the system. In order to rationalize diagnostic procedures, it is necessary to establish and use the guidelines and protocols set by professional medical societies for the diagnosis of the currently most common diseases.Another step to improve the healthcare system was the foundation of the Agency for Quality and Accreditation in Healthcare (Agency). Upgrading the quality and accessibility of healthcare at the resources available is the best support to the healthcare reform. Th e main objectives of the Agency are development of national standards in the diagnosis and treatment, and hospital evaluation through categorization and accreditations. Accreditations will be allocated for a 4-year period and will stimulate additional contracts (revenues) with insurance companies. Th e whole pro-cedure and process should lead to improved patient safety and healthcare quality. Th e Agency will have a department for development and assessment of healthcare technologies, which will be in charge of following the development of medical technology and its clinical use in the national conditions. It is well known that the continuous increase in the price of medical technology, i.e. novel diagnostic and thera-peutic devices, cannot be covered through payroll al-locations for healthcare even by high-industrialized countries.Th e international tenders for very expensive drugs have signifi cantly improved (rationalized) the system of purchase and utilization of this group of drugs. Th e list of these drugs includes drugs used in the treat-ment of some malignant, neurologic, infectious and genetic diseases. Successful healthcare reform defi nitely requires updating of medical equipment, which is necessary for high-quality diagnosis and therapy. Th erefore, purchase of capital equipment is under way, for the fi rst time at the national level.In spite of the sophisticated and modern equip-ment, healthcare system relies on manpower. Great steps forward have also been made in this segment, e.g., compulsory payment of trainees and approving specifi c residencies-sub residencies. It is known that the number of physicians per the population of Croatia is too low according to the European Union criteria, while the age structure of the specialists is very unfa-vorable. In order to overcome these problems, many residencies have been approved. Yet, many fi elds suf-fer from the lack of specialists, such as pediatrics, gy-necology, anesthesiology, surgery, internal medicine, etc. Th e popularity of medical profession among the young has declined due to negative social atmosphere, unfavorable attitudes of the public and mass media towards physicians, and inadequate payment for the very responsible job. It has resulted in rather low in-terest for the demanding medical profession among the young and generally reduced interest in the pro-fession.In conclusion, academician Kusić emphasized that, despite global recession and its impact on local circumstances, and organizational diffi  culties, there were some favorable indicators of the hospital system reform. Th ere are challenges to manage in terms of maintaining fi nancial stability of the system in the conditions of increased costs of treatment and gross national product decrease, medical equipment updat-ing, retaining high-quality professionals within the national healthcare system, and implementation of complete system computerization. He also pointed to the importance of fostering initial enthusiasm in the face of diffi  culties that cannot be avoided in the process of settling such a large system as healthcare system.Besides Croatian professionals involved in the planning and implementation of the healthcare re-form, participation of renowned international guests, health ministers of the neighboring countries and rep-resentatives of respective international organizations, contributed greatly to the importance of the Sympo-sium. Health ministers from the following countries were present at the Symposium: Slovenia, Austria, Hungary, Bosnia and Herzegovina, Serbia, Macedo-nia, Albania and Montenegro, and representatives of the World Health Organization and World Bank.All the respectful guests took part in the panel discussion on the topic of maintaining healthcare quality in the time of crisis and experiencing crisis as a problem or challenge for healthcare system, having additionally enriched the quality of the Symposium.Jure Murgić, Jasna Radić,Sunčica Rogan, Zvonko KusićBook Acta 1-2010.indb   123 14.6.2010   9:23:14

Symposium on the Experiences in the Implementation of Healthcare Reform in Croatia

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