You are reading a sample from Vizita – Martin Čaban’s newsletter full of observations about the Czech healthcare system and its influence on politics. If Vizita interests you, be sure to subscribe!
As is known, the reimbursement decree is a document by which the Ministry of Health determines the distribution of money from public health insurance among health care providers. In recent years, however, it has increasingly become a symbol of the gradual, creeping shift of the Czech healthcare system from a pluralistic model with several competing health insurance companies towards a centralized system of “state healthcare”, as we know it at best from Great Britain, at worst from the days of the communist regime.
The shift is insidious mainly because neither the current nor any previous political set had state healthcare as its officially declared political goal. On the contrary, when past ministers of health were forced to think about the overall functioning of the health system, they always swore by a plural insurance model. At the same time, however, they pampered the institution of the reimbursement decree, which in the current concept places virtually unlimited power in the hands of the Ministry of Health in the distribution of money.
The theory is that the reimbursement decree “just” copies and summarizes the agreements between insurance companies and care providers in individual segments into a single document that will govern the flow of money in health care in the coming year. And only in cases where no agreement is reached, the Ministry will determine the payment authoritatively.
But the practice has been completely different for many years. The so-called conciliation procedure between insurance companies and providers has a rather formal character, agreements in essential segments occur rather rarely, and interest groups representing individual segments of care devote more energy to subsequent lobbying at the ministry than to conciliation procedures with insurance companies.
In addition, the Ministry has a tendency to correct even successfully concluded agreements. There is always a reason: Political pressure to increase doctors’ remuneration, the need to divide the covid remuneration, the need to compensate doctors for the lack of care due to the pandemic, the need to compensate for high inflation… all this and much more were and are the reasons why the idea that the central political an order is a better solution than a price agreement between the insurance company and the provider.
The result, especially in the last four years, was that the ministry ordered health insurance companies to spend more on care than they collected on health insurance. According to the reimbursement decree, the management of public health insurance is supposed to be in deficit next year as well, by roughly nine billion crowns.
Last week, a seminar was held at the Institute of National Economy of the Academy of Sciences dedicated to the reimbursement decree. The current concept was defended by Tomáš Troch, the director of the ministerial department of price regulation and payment, with considerable personal bravery, given the audience’s mood. He very convincingly described the role of the document, its development and functions. He openly stated that the deficit management ordered by insurance companies for the next year is the result of a political balance, according to which “affordability of care is a bigger problem than the financial strength or sustainability of the system”.
Among other things, director Troch stated: “If we had better control over the activities of health insurance companies, perhaps the mandate of the reimbursement decree would not be so strong.”
This was a very important sentence, at which numerous representatives of health insurance companies in the audience frowned in displeasure. It is heading towards the essence of the contradiction in which the Czech healthcare system has been operating since the 1990s. Indeed, while almost all health ministers cursed the health insurance “market” and the need for a pluralistic system, none of them ever proposed a viable model for the division of competences and control of health insurance companies that would respect their public and self-governing status.
With the honorable exception of Tomáš Julínek, who planned the instrument for the supervision of health insurance, but failed to implement it.
However, the absence of clearly defined competences and responsibilities of insurance companies did not prevent politicians across the spectrum from burdening health insurance companies with various obligations. For example, to ensure local and temporal availability of care for patients. Insurance companies are required by law to do this, but in fact they have no tools to do so. And when they don’t, because they don’t have the tools, there’s no one to reprimand them, punish them, or make amends.
At the same time as ignoring the role of insurance companies, there was even obsessive pampering of the reimbursement decree. It gradually developed into a document for the chosen ones. The decree for next year has a nice 186 pages. Without wanting to underestimate the abilities of my readers in any way, I dare to make one guess: For the vast majority of the public (including the author of Vizita), this is a completely incomprehensible document. When interpreting it, it is necessary to rely on a much more humanely written explanatory report.
After all, even health care insiders admit that in every insurance company and in every large medical facility there is one, at most two people who really understand the reimbursement decree as a legal document and can really read it.
It is the long-term contradiction between the endless sophistication of the document that serves as a central decision on the distribution of money and the unwillingness or inability to define the role, competence and responsibility of health insurance companies that is at the root of what I call the creeping shift to state healthcare.
The solution is not easy and will be politically demanding. And not in sight. Although Minister Vlastimil Válek is preparing a kind of amendment to the law on public health insurance, which is surrounded by a lot of secrecy, according to the available information, it should not involve any deep systemic changes.
The Healthcare 2030+ initiative, which came up with the concept of healthcare reforms that would fulfill the original intention of a pluralistic insurance system, remains chaste on campus for understandable reasons (the mentioned seminar with Director Troch was part of it).
Meanwhile, healthcare is systemically corroding from within. The economy of health insurance companies is falling into problems. After all, the ministry expects two insurance companies to run into financial difficulties in the next year or the year after. The problems that just come to the surface, whether it is excessive overtime work, problems with the availability of certain services or the remuneration of doctors, are solved by the ministry by pouring in money – through a reimbursement decree.
And insurance companies continue to function as flow heaters of money, including those funds that actually do not even flow into them, only the ministry orders them to be heated and issued.
Sooner or later this machine will retire. Nothing can prevent this other than the willingness to think systematically about the deeper settings of the system. And politically decide what type of health care we want – state or self-governing-public. Doing one and pretending to do the other is inefficient, expensive, and ultimately backfires on both health professionals and patients.
You will find much more in the full issue of the Vizita newsletter, including interesting reading tips from other media. If you want to receive the entire Visit every other Tuesday directly to your e-mail box, sign up for the subscription.