Hospitals in Recovery Return to Counties, Followed by Emergency Service Reform

Health Minister Dario Nakić explained what his primary tasks are during his term at the head of the ministry he leads.

As reported by the media, Nakić announced that during his term he will try to increase revenues from supplementary and additional health insurance, resolve the debt problem of 2.5 billion kuna, return hospitals in recovery to their founders, determine which diagnostic procedures are mandatory and which will enter the above-standard that will require additional payment, change the model of contracting health care based on services rendered, reform public procurement, resolve the problem of the professional collective agreement for doctors, and enable the continuation of the emergency helicopter medical service project relying on its own resources.

The government has begun working on the budget for this year; will you manage to ensure that the total funds of 22 billion kuna for the health system are not reduced, and does HZZO remain an off-budget fund?

I certainly want that; I think it would be good for it to remain at last year’s level, but given that we are on the brink of excessive deficit, I think it will be difficult. I have contacted the Minister of Finance, and I believe that HZZO will remain outside the treasury, as that was a good move, but we will have to find a way to develop supplementary and additional insurance, which will primarily serve to increase revenues in basic insurance. We need to see what the possibilities are for using EU funds and health tourism, but it is difficult to expect that revenues can be increased at that level this year. Therefore, in response to the question of whether patient rights will change, I answer – yes, they will change, I hope for the better, because if we secure more money for the health system, we will be able to purchase new equipment, and with the increase in quality, we will provide better service.

The health budget has been suffering for years also because the state does not cover the costs of health care for retirees, the unemployed, etc., so last year only 2.4 billion of a total of 4.8 billion was paid. How to solve this problem?

That is a part we will have to discuss. We have nothing to discuss about contributions because they are collected from salaries, but our goal should be to finance the health system as little as possible from the State Treasury and to try to enable it to finance itself more or less with reduced expenses and increased revenues. For example, you have a drop in revenues from supplementary insurance, while at the same time there is an increase in private insurance companies dealing with supplementary insurance, so we need to work on HZZO’s revenues from supplementary insurance to avoid the situation where private insurers take the healthier population, leaving HZZO with the sicker one.

Will you change the current price of the supplementary insurance policy of 70 kuna, and what exactly do you mean when you say that services that fall under the above-standard will be charged?

The supplementary insurance policy will not be changed for now. Professional medical societies will determine through guidelines which diagnostic procedures are mandatory for each diagnosis and which fall under the above-standard and will need to be paid extra. This will also apply to certain orthopedic aids. For example, if someone wants to have a titanium hip implanted instead of a steel one during hip surgery, they will have to pay extra for that.

Usually, with the arrival of a new health minister, we always talk about inherited debts and “skeletons in the closet”; what did your predecessor leave you?

It is always customary for us that when you take office, you attack the one who was before you. I will not do that and will say that the former minister Siniša Varga warned me about several things upon my takeover. The health system had a deficit of 2.8 billion kuna after the recovery; last year it was reduced by about 300 million kuna and now amounts to about 2.5 billion kuna. This debt was created by stimulating consumption in healthcare through a new way of contracting and paying for services rendered. I will not blame anyone; we will see what the real situation is when all reports arrive at HZZO. I believe that our path is not a new recovery of the system because we will gain nothing from that, and all the holes from which it leaked will remain. We will have to work on reducing the debt to ensure that the health system is financially stable. The first measure where we plan to achieve savings will be the reform of emergency medical services. In the Unified Emergency Hospital Admissions (OHBP), about 50 percent of patients come without a referral, emergency patients whose lives are at risk wait for hours, and all this is an additional financial burden. We will have to find a way to financially disincentivize the arrival of such patients to OHBP because they should, above all, go to their family medicine doctor or to out-of-hospital emergency services. That is why I requested a report on the work of OHBP for December and January, to see what the average waiting time is and how long the longest wait was for admission.

You announced the return of hospitals in recovery to their founders – the counties; will you return them with newly created debts?

Hospitals have created a new debt of about 1.5 billion kuna after recovery. Undoubtedly, the counties will not agree to have hospitals returned to them with debts, as the state took them to settle debts. We will need to find a good way and talk to the founders about how to resolve this. Our goal will be to return those debts in the next period, and local government will take greater responsibility for the operations of those hospitals. The recovery was a bad project because new debts were created again. I regret that the public did not rise more strongly when the recovery managers were appointed without a competition, plan, and work program. This is unacceptable in a democratic world. Regarding appointments, I intend to go a step further. Until now, the directors of clinical institutions whose founder is the state were appointed by ministers, and I believe that this should remain only for one health institution, which will be a national institution for the implementation of the most complex forms of health care. I think that all other clinical institutions should be transferred under the jurisdiction of local government.

There are many such institutions in Zagreb; do you think the City would be interested in this given the enormous financial burden?

I think this needs to be discussed with the City. If we have one state, how many state institutions should there be in one state? One. And Sveti Duh is a clinical hospital and is owned by Zagreb, while KBC Sestre milosrdnice and KB Dubrava cannot. How is that? The system is not well set up.

Will you change the new model of contracting health care based on services rendered, thanks to which 20 hospitals ended last year in the black?

We will change it because, as I said, this model has only encouraged consumption. At the same time, we will not return exclusively to the limit model because that would again disincentivize people in the system, which is not good. Currently, we have 80 percent fixed financing and 20 percent variable, but I think we will reduce that part. Rockefeller once said that the demand for everything that is free is unlimited, but healthcare is not free. The goal is to reach a diagnosis and subsequent treatment with as few tests and additional procedures as possible, not to do everything, including unnecessary tests, just to bill more and thus get more money.

Speaking about changes in healthcare, Prime Minister Orešković particularly emphasized the reform of public procurement and increasing the efficiency of administration. What does that specifically mean?

Through unified public procurement, good moves have been made because lower prices have been achieved, and we intend to continue in the segment that was good, especially with medicines. When it comes to equipment procurement, the question is whether we should have a centralized procurement method or centralized reference prices. I am more inclined to the latter, so that when you procure a device in Dubrovnik, you know that it is procured under exactly specified conditions and that you cannot buy it for 10 million if it costs 7.5 million. Regarding administration, in some institutions, the ratio of healthcare to non-healthcare staff is good, while in others it is not. It should also be seen whether, in the age of informatization, it is possible to do some jobs from one place for multiple institutions, at the county or regional level. This is difficult to achieve because not all hospitals are at the same level of informatization, but that is the direction we should go.

What is your stance on the relationship between public and private healthcare, which has been much discussed in the past period?

We will take care of preserving the public healthcare system. We have nothing against private institutions; they are our competition and an incentive to raise quality as we compete for a certain part of the market. I think patients should be allowed, if they cannot obtain a certain diagnostic procedure in a reasonable time in the institution where they are registered on the waiting list, to have that service done in another hospital, including a private institution, for the same price. Until yesterday, it was claimed that everything in healthcare was perfect and that the waiting list could be reduced; you just need to pick up the phone, call five hospitals, and schedule an MRI. People are signing up for tests in December in January. I will insist that professional medical societies create guidelines and procedures on medically acceptable waiting times for tests for specific diagnoses, and that they be key for waiting lists.

Will you continue with the implementation of the National Hospital Plan, which was unanimously supported in the Parliament?

It is incredible that foreign experts were paid to create a plan when it was clear to us what needed to be done. We will no longer pay anyone for that; we will reorganize the hospital system ourselves, which we plan for next year. The master plan has good ideas, such as functional merging and developing day hospitals, but they need to be elaborated and clearly defined. For example, to develop day hospitals and for the system to function, we need to have a well-developed home care service. Functional merging of hospitals makes sense, but at the regional level with a national center above that. Merging hospitals that are close together – yes, but in such a way that one develops one segment, and the other some other segment of healthcare instead of having a dispersion of people. We also have only the outlines of a palliative care system, so we will need to redefine it.

How do you evaluate the functioning of primary care, and should the concession system be introduced at the level of the entire activity?

We will return primary care to its place, so that doctors start doing what is actually in their job description. In large cities, doctors administer more due to the large number of patients than they examine people. The system has been built so that the patient is removed from the family doctor, as the system of white referrals has allowed you to go to the emergency hospital admission without having to go to your doctor. When it comes to concessions, if we give all practices to concessions, I ask who will then take, for example, the clinic in Donji Lapac? Those patients will never have healthcare like patients in Zagreb, Osijek, or Zadar, but let’s help them have at least a better one. Doctors are leaving for larger centers, so 100 percent concessioning is not possible, but it can be discussed whether 20, 30, or 50 percent of practices should remain at health centers.

How do you plan to conclude a professional collective agreement with the Croatian Medical Union (HLS) when the Law on the Representativeness of Unions does not allow it, which provides for the conclusion of collective agreements only for activities?

You have seen the reactions of the public to the departure of doctors. Whether 300 or 400 have left is hard to say because it is difficult to get real numbers. I must talk to HLS, respect it, and ask for understanding because it is unlikely that we will have money for a 6 percent salary increase if it is determined that GDP in Croatia has grown by two percent in two quarters. I need their understanding and help to create normal working conditions. I do not think this is directed against anyone else. Some people leave for existential reasons, but a large part of them leave because they cannot realize themselves in the profession, due to overload and inability to advance. Many are afraid of various attacks, whether someone will sue them… I cannot bring a professional collective agreement contrary to the law, but laws are passed by the Croatian Parliament, proposed by the Government, so they are not something that cannot be changed. I will talk to all unions, but I think that the professions that carry the greatest weight in the system are doctors, nurses, and other healthcare personnel.

Before the appointment of the new Government, the pilot project of the Emergency Helicopter Medical Service was completed, the abolition of which provoked public reactions. Will you re-establish it?

I welcome the project as an idea, but the pilot project was flawed and had too many illogicalities for me to say: “Yes, this is it.” I saw the contract and read that these helicopters could not fly in bad weather, that they only fly during the day, and can only carry patients who weigh less than 95 kilograms, and Croatia is, unfortunately, the fifth in Europe in terms of obesity. The price of the contract for four months was more than 10 million kuna, and one new helicopter costs 28 to 30 million kuna. In one year, for which we had to pay the service to the Italian company, we could have bought one new helicopter. It is normal that I first talk to the Ministry of Defense and the Ministry of the Interior to see what our options are. I do not want to prejudge, but allow me to try to do something to keep taxpayers’ money in Croatia.