4. Paying for services
Adequate funding for health is important to manage the excess demands on the health system. This section considers how countries are PAYING FOR COVID-19 SERVICES. Health financing describes how much is spent on health and the distribution of health spending across different service areas. The section also describes who is covered for COVID-19 testing and treatment, whether there are any notable gaps (in population coverage and service coverage), and how much people pay (if at all) for those services out-of-pocket.
4.1 Health financing
MEASURES INTRODUCED IN 2020
To address the COVID-19 outbreak, additional funds have been injected into the health care system from both public and private sources. As a part of the anti-crisis package, the government has announced that it will allocate additional PLN 7.5 billion to the health care sector to finance current activities (health care services and medical products) as well as investment (e.g. in infrastructure or digitalization). Since May, the Ministry of Health has been publishing the information on all purchased products and non-medical services related to COVID-19. By September 21st, the value of purchases amounted to over PLN 1.3 billion. The Ministry of Health confirmed that some of these products (e.g. masks) were purchased at inflated prices and did not meet the required standards.
Central government is responsible for financing health care services to counteract COVID-19 and is the main source of funds. Funds are transferred (based on a monthly report) to the National Health Fund (NHF), which in turn uses them to pay for health services. The payments are made based on reports and bills submitted by providers to the NHF outside the usual contracts for providing health care services. Only providers included in the list of providers dedicated to performing services related to COVID-19, are entitled to receive these dedicated funds. By end-June, the NHF paid nearly PLN 1.3 billion to providers.
In order to pay for services related to COVID-19, the NHF has established a catalogue of services it finances and their prices. According to the catalogue, providers are paid both for assuring readiness to provide services and for the actual provision of services. Over time, the catalogue has been updated to reflect the emerging needs of the population and the changes in the organization of care for COVID-19 patients (e.g. implementing three-stage hospital security system, involving GPs in managing cases, see Section 2.1. and 3.2). Originally, it included six items such as hospitalization, hospitalization in an intensive care unit (ICU), isolation in a designated facility, transport, readiness to provide hospitalization, and readiness to provide transport. This list has been gradually extended to 38 items currently (end of October), with some items split into more detailed procedures and with additional procedures added. The added services are related to:
· Performing diagnostic test for SARS-CoV-2 among patients and medical staff of hospitals (including hospitals which are not specifically dedicated to COVID-19 patients) and readiness to provide tests;
· Taking biological samples for testing and readiness to take samples;
· Teleconsultations with a physician or nurse;
· Physician consultation provided at SARS-CoV-2 infected patient home;
· Emergency dental services (and readiness to provide them) for patients with SARS-CoV-2 infection or suspected to be infected;
· Pre-triage of people with suspected SARS-CoV-2 infection;
· Dialysis for patients with SARS-CoV-2 infection or suspected to be infected.
At the same time, the prices of services in the catalogue have been adjusted to reflect providers’ cost. For example, the payment for RT-PCR molecular test has been reduced from PLN 450 (ca EUR 100) to PLN 280 PLN (ca EUR 60) following the recommendation of the national health technology assessment (HTA) agency (the Agency for Health Technology Assessment and Tariff System). This however raised criticism by the National Council of Laboratory Diagnosticians.
Additional funds for health care services have been released by the NHF to cover extra costs without reducing regular payments to hospitals due to cancellations of services not related to COVID-19. During the first months of pandemic, hospitals that provided care within so-called hospital network still received their ‘usual’ funding (a lump sum payment which has been increased by 5% at the beginning of the year) regardless of the payments for services related to COVID-19. However, there are reports that the regular lump sum payments for some hospitals, which are involved in fighting the COVID-19 pandemic but recorded a financial surplus, have been reduced. Inpatient and outpatient health care providers delivering services outside the network, in the period March-August, could also apply to receive payment for contracted services (in monthly instalments) regardless of whether they had been provided, assuming that these services would be provided later in the year. To secure financial liquidity of hospitals, payments for provided services were made faster and more frequently.
The NHF has also devoted additional resources to certain outpatient specialist services, tele-consultations, and helplines for patients.
From April till September, healthcare employees who were in contact with COVID-19 patients (or persons with a suspected coronavirus infection) were prohibited from working in more than one place. To compensate them for the loss of income due to this restriction, the Minister of Health instructed the NHF to provide them with monthly cash benefits equal to 80% of their lost salary or 50% of salary received at the place where the employee continue to work, but not more than PLN 10 000. The benefits were financed from the Ministry of Health budget. The monthly cost of this compensation has been estimated at PLN 100-150 million (See Section 2.2 on Workforce).
Since July, the NHF has been paying all contracted providers additional 3% of their bill, which is intended to cover the cost of an elevated sanitary regime, i.e. organization and provision of services in safe conditions, including purchasing PPE. These resources come from the state budget.
Provincial self-governments (voivodeship), which are the owners of some health care providers, support their facilities by providing funds, mostly to purchase medical equipment or personal protection equipment (see also Section 2.1). Public funds are also used to finance research and development activities related to COVID-19. The National Centre for Research and Development supported by EU funds has devoted PLN 300 million (about EUR 66 million) for this purpose.
Private funds also play a role in the fight against the COVID-19 pandemic in Poland. Fund raising and donations by firms has become popular to support individual health care facilities and to address their shortages (see also Section 2.1). Additionally, external sources of funds to support health care are significant: Poland is one of the largest beneficiaries of EU funds allocated to addressing COVID-19.
Ustawa z dnia 2 marca 2020r.o szczególnych rozwiązaniach związanych z zapobieganiem, przeciwdziałaniem i zwalczaniem COVID-19, innych chorób zakaźnych oraz wywołanych nimi sytuacji kryzysowych.
Rozporządzenie Ministra Zdrowia z dnia 12 marca 2020 r. w sprawie sposobu i trybu finansowania z budżetu państwa świadczeń opieki zdrowotnej wykonywanych w związku z przeciwdziałaniem COVID-19.
Rozporządzenie Ministra Zdrowia z dnia 15 kwietnia 2020 r. zmieniające rozporządzenie w sprawie ogólnych warunków umów o udzielanie świadczeń opieki zdrowotnej.
Rozporządzenie Ministra Zdrowia z dnia 17 października 2020 r. w sprawie zmiany rozporządzenia zmieniającego rozporządzenie w sprawie ogólnych warunków umów o udzielanie świadczeń opieki zdrowotnej.
Zarządzenie Nr 32/2020/DSOZ 08-03-2020 w sprawie zasad sprawozdawania oraz warunków rozliczania świadczeń opieki zdrowotnej związanych z zapobieganiem, przeciwdziałaniem i zwalczaniem COVID-19 (tekst ujednolicony z dnia 01.07.2020).
Zarządzenie Nr 104/2020/DSOZ 08-07-2020 zmieniające zarządzenie w sprawie zasad sprawozdawania oraz warunków rozliczania świadczeń opieki zdrowotnej związanych z zapobieganiem, przeciwdziałaniem i zwalczaniem COVID-19.
Zarządzenie Nr 146/2020/DSOZ 25-09-2020 zmieniające zarządzenie w sprawie zasad sprawozdawania oraz warunków rozliczania świadczeń opieki zdrowotnej związanych z zapobieganiem, przeciwdziałaniem i zwalczaniem COVID-19.
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https://www.politykazdrowotna.com/56317,prezes-nfz-dla-polityki-zdrowotnej-min-o-budzecie-funduszu-w-zwiazku-z-epidemia-koronawirusa [access online 03.05.2020]
http://bipold.aotm.gov.pl/index.php/zlecenia-mz-2020/939-materialy-2020/6714-94-2020-zlc, [access online: 04.05.2020].
https://www.rp.pl/Zadania/305189994-Niedzielski-Za-wczesnie-na-decyzje-jak-rozliczyc-Covid-19.html [access online 1.06.2020]
https://www.gov.pl/web/zdrowie/covid---ewidencja-zakupow [access online 4.10.2020]
https://www.gazetaprawna.pl/artykuly/1477255,szumowski-wyjasnienia-maseczki-wywiad.html [access online 1.06.2020]
https://www.nfz.gov.pl/aktualnosci/aktualnosci-centrali/dodatkowe-wynagrodzenie-dla-personelu-medycznego-za-prace-w-jednym-miejscu,7721.html [access online 1.06.2020]
https://pulsmedycyny.pl/nfz-bedzie-dodatkowe-finansowanie-placowek-medycznych-996240 [access online 13.07.2020]
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In September, the pre-COVID-19 rules on payment were restored, and payments are again made only for health care services that have been provided. In October, new regulations were introduced, again securing regular NHF funding for health care providers that were made to discontinue or limit provision of services due to the pandemic, regardless of whether services were provided or not. At the same time, health care providers have been offered the possibility to apply for an extension of the billing period by 6 months (until June 30th, 2021) to enable them to provide all contracted services and receive full payment.
After the restriction on working in more than one place was lifted in September, the cash benefit equal to 50% of salary (capped at PLN 10 000) was granted to all medical professionals involved in care for COVID-19 patients working in COVID-19 hospitals. By a decision of the Ministry of Health, this benefit was increased to 100% of salary (capped at PLN 15 000) starting 1st November. At the same time, the beneficiary group was extended to include health professionals providing transport and working in laboratories. Before that, only those delegated by voivode to work with COVID-19 patients had received a double salary.
The frequent updates of COVID-19 service catalogue have been continued. The catalogue now includes 51 items. The amendments implemented in November and at the beginning of December were related to the changes in financing of temporary field hospitals. As many beds in these hospitals remain unoccupied, the NHF limited the number of beds for which a fee for readiness will be paid. Since family physicians are now involved in antigen testing, a suitable payment was also established. Other changes in the catalogue are due to changes in the organizational of care for COVID-19 patients (implementing Home Medical Care Programme) and organization of isolation facilities. Furthermore, the HTA agency has issued the recommendation on the pricing of SARS-CoV-2 immunization. Health care providers will receive from PLN 61.24 to PLN 95.70 for every vaccinated person.
MEASURES IMPLEMENTED IN 2021
Payments for providing SARS-CoV-2 immunizations have been included in the NHF’s catalogue of COVID-19 services. Payments were set following the HTA recommendations. They are differentiated based on where the immunization is administered (at a health care facility or at a patient’s home):
• Vaccination in a health care facility: PLN 61.24
• Vaccination at a patient's place of residence: PLN 141
• Vaccination at a patient's place of residence with more than 5 patients staying at one address: PLN 73.19 per patient.
Other amendments to the catalogue of COVID-19 services, which now includes 57 items, were made to address changing health needs of the population and changes in provision of services. These changes include introduction of payments for mobile extracorporeal membrane oxygenation (ECMO) teams for SARS-CoV-2 infected patients with respiratory and heart failure, as well as for infected patients requiring haemodialysis.
Zarządzenie Nr 19/2021/DSOZ 27-01-2021 zmieniające zarządzenie w sprawie zasad sprawozdawania oraz warunków rozliczania świadczeń opieki zdrowotnej związanych z zapobieganiem, przeciwdziałaniem i zwalczaniem COVID-19.