Managing health care is like pulling a short quilt. Head of the Polska 2050 medical team: Let’s focus on quality

Katarzyna Pinkosz, Wprost: For now, there are not many people willing to become the Minister of Health. Would you like to become one?

Prof. Urszula Demkow: In the current situation, it would be a difficult decision, because the state of state finances is not good, so there are no prospects for improving the financing of health care, and this is necessary. Insufficient financing of the system will be the basic problem of every health minister. The money in the health care system today is insufficient. Managing health care today is about pulling the quilt over and over again – when you want to give to some, you have to take from others.

However, Poland 2050 has a very broad health program. If it were implemented, what would the effects be? Will life expectancy in Poland increase? We live shorter than Western Europeans…

I will say this: if we do not introduce radical changes, the life expectancy of Poles will not increase, and will probably decrease. The health care system is not stable, it must be changed and adapted to new needs, new technologies and a changing world.

If we do not transform the system, it becomes more and more distant from reality and, above all, from the needs of patients. It’s as if we were swimming against the current: when we stop rowing, we start going backwards. The health care system must be flexible and requires constant reconstruction, not only administration.

What changes are most important to bring life expectancy in Poland to par with other countries?

The greatest impact on extending the life of Poles would have an emphasis on public health: therefore, all preventive, preventive and patient education activities are important.

So: prevention comes first?

Absolutely yes, but public health programs have been a low priority until now; I am afraid that due to lack of finances they will remain undervalued. Health improvements associated with the widespread implementation of good public health programs take several years, and health care management in recent years has consisted mainly of ad hoc measures and “putting out fires.” There were no long-term reform programs for the system based on demographic indicators or detailed analyses. This is greatly missed. A cross-party consensus would be needed to develop the basic directions of the health care system for at least two terms of parliament. It is also important that subsequent governments, at least in general terms, continue the policies of their predecessors, because health is equally important for all citizens, regardless of the political option that is in power.

It is important to plan long-term and monitor the effects of the changes introduced, also using various forecasts, because in 10 years we will be a completely different society, and on the other hand, completely new methods of diagnosis and treatment, new technologies will be available. It is also a truism to say that society is aging and fewer and fewer new citizens are being born. We are facing a demographic catastrophe that the health care system, but also the state as a whole, must cope with. There are also differences in health needs between regions of the country, large cities are younger than villages and small towns, which are being depopulated. It is therefore very important to use the tool of reliable maps of health needs to make health care decisions in various regions of the country.

Is it worth continuing the actions initiated by the last health ministers?

Two actions are worth pursuing. The first is digitalization in medicine. During the COVID-19 pandemic, digitalization has accelerated greatly, but there is still a lot to do. An example are tools for assessing cost accounting in health care. Just a few years ago, medical procedures were valued on a discretionary basis: e.g., cardiology procedures were overestimated, and pediatric procedures were underestimated. That is why cardiology developed throughout Poland, and, for example, no private pediatric hospital was established. The Act on standard cost accounting came into force only two years ago, and this is the first step towards making the costs of services more realistic – we will learn the real valuation of the costs of individual medical services. It is necessary to make valuations more realistic and introduce algorithms that take into account inflation and salary increases, because rising salary costs lead to hospitals becoming indebted. A basket of guaranteed benefits is also very necessary. A well-developed basket is a basic condition for system stability. Today we do not know what procedures each citizen is entitled to as part of the health insurance premium paid. The constitutional provision is interpreted that everyone is entitled to everything under health insurance. However, this is fiction and leads to pathologies such as queues and limits. The lack of clearly formulated basket procedures primarily affects the poorest people who are unable to meet their health needs in the non-public sector.

And the second point that is worth continuing from the actions of the last health ministers?

Coordinated care. Previously, there was a great lack of continuity of patient care. The patient remained very lost in the health care system. When he received a referral from a primary care physician, he waited in line to see a specialist or sought help in overloaded emergency departments. Ultimately, he sought help from the private sector. The poorest were waiting for help, or their health was deteriorating so dramatically that they were hospitalized with very advanced disease.

Coordinated care is a good direction. It’s still in its infancy, but it’s worth developing. As Poland 2050, we have created the concept of the so-called responsible doctor.

That is? Who would be the “responsible physician”?

A primary care physician who would open an “umbrella” over the patient and guide him through the system, regardless of whether the patient needs specialist care or is to be admitted to hospital. Additionally, the coordinator could greatly support the responsible doctor in administrative tasks: supporting the patient in his journey through the system to obtain comprehensive assistance, including rehabilitation and dietary advice.

Our most important demand, however, is to change the way we think about the shape of the health care system and change its basic paradigm from paying for treatment to paying for cure, i.e. for the quality of services. We want the most important parameter assessed to be the health value, i.e. the quality of services, and not the performance of a given procedure. This is consistent with the concept of a value-based health care system, where the actual patient will be at the center and the payer will pay for the health effect. Today, the National Health Fund pays mainly for procedures: for the fact that the patient was in hospital and was treated. However, he may end up in hospital again or die the next day. Example: the patient had a stroke, was admitted to hospital, received treatment, the vessel was unblocked, but the patient is bedridden and requires rehabilitation. The hospital discharges him home, and further care is the responsibility of the family. If she can afford rehabilitation, the patient will be improved, but if not, he will remain disabled. So this is a waste of money previously spent on saving his life.

Such comprehensive programs have already been partially implemented – an example is the program for COPD patients in Gdańsk, run by Prof. Jassem: patients received comprehensive help; Thanks to this, the number of subsequent COPD exacerbations decreased and patients returned to the hospital less often. The program received an international award; it turns out that in health care we can be solution leaders.

Currently, value-based healthcare is already being implemented in several entities, to great benefit for patients and savings for the entire system. Our task will be to transform the system so that this model becomes common.

But is more money needed for health care?

Yes, it is necessary, but it is also important how they are allocated. Since we do not have enough funds, it is necessary to spend them very effectively. We must try to reduce waste at all costs. Both coordinated care and focus on quality allow you to save money spent in the system. Savings will also be brought by the so-called inverting the pyramid of benefits, i.e. moving health services to a lower level. In other words, transferring some specialist services to the primary care level and transferring some hospital services to the AOS level. Hospital care is the most expensive, so it is not rational to lift limits on inpatient treatment, but to leave only patients in the hospital who cannot be diagnosed and treated on an outpatient basis. It is therefore necessary to change the catalog of hospital services and transfer a number of services to a lower level.

Very often, the patient is admitted to hospital, e.g. for tests, although they can be performed on an outpatient basis. However, this is not done because outpatient procedures are poorly priced; and it is more “profitable” to hospitalize the patient. The result is ineffective use of public funds and queues of people in need who have to be treated in hospitals. Unfortunately, hospital directors are forced to engage in such practices because they are held accountable for the hospital’s financial results

What if there are no reforms?

Health is the foundation; If it is not given the right priority, it will have a negative impact on all sectors, especially the economy. No government will raise the retirement age today; so the only thing left to do is to encourage citizens to work longer. The poor health of citizens will make it impossible to continue working after reaching the lowest retirement age in Europe. The pension system will collapse, the economy will slow down, GDP will fall.

Everyone will have to use the public health care system at some point; Anyone can faint on the street and need to be taken by ambulance to the nearest hospital. Anyone can become seriously ill and not be able to afford the catastrophic costs of care in the private sector. Therefore, the entire system must function efficiently. For all of us.

Prof. Ph.D. n. med. Urszula Demkow is an immunologist, head of the Department of Laboratory Diagnostics and Clinical Immunology of Developmental Age at the Medical University of Warsaw. She is also a member of the Committee of Immunology and Etiology of Human Infections of the Polish Academy of Sciences and the head of Szymon Hołownia’s Polish 2050 medical team.