Healthcare spending review II Final report October 2019 This project has been supported by the European Social Fund One of the tasks of the Value for Money project is a spending review of public administration. This paper is created by the Ministry of Finance of the Slovak Republic and the Ministry of Health of the Slovak Republic and is an evaluation of healthcare expenses under a resolution of the Slovak government No. 202/2018, task B.6. The evaluation was prepared by Štefan Kišš, Lucia Grajcarová, Daniel Kozák, Adam Marek and Kristína Královičová from the Value for Money Division and Martin Smatana, Michal Štofko, Michaela Laktišová and Ján Dudek from the Institute of Health Policies of the Ministry of Health of the Slovak Republic. Chapters 2.2 and 4.6 were prepared by Miriama Letovanec and Daniela Potočňáková from the Implementation Unit of the Government Office of the Slovak Republic. Acknowledgements We would like to thank the official reviewers Zuzana Baťová (ŠÚKL), Michaela Černenko (IFP MF SR) and Tomáš Szalay (HPI), also our colleagues from the Budgetary Policy Section of the Ministry of Finance, Alexandra Bražinová (Faculty of Medicine of the Comenius University), Jozef Hašto (Teaching Hospital in Trnava), Ľubomíra Izáková (SPsS SLS, University Hospital in Bratislava), Jana Ježíková (Bratislava Self- governing Region), League for Mental Health, Zita Michlerová (SPS), Jozef Šuvada (Ministry of Health of the SR), Tomáš Tesař (Faculty of Pharmacy of the Comenius University) and Katarína Harrison Tvarožková (Royal London Hospital), as well as all participants of the workshop that as part of the review process, for their valuable insights and comments during the preparation of this report. The responsibility for mistakes and omissions lies with the authors. Table of contents List of tables and graphs .................................................................................................................................... 5 Introduction and summary .................................................................................................................................. 9 1 Outcomes and goals ................................................................................................................................ 13 2 Expenditures ............................................................................................................................................ 15 2.1 Expenses by area of healthcare ...................................................................................................... 17 2.2 Out-of-pocket payments for healthcare ........................................................................................... 17 3 Budget ..................................................................................................................................................... 20 3.1 No-policy-change expenses ............................................................................................................ 22 3.2 Policy-change expenses ................................................................................................................. 23 3.3 Cost-saving policy measures .......................................................................................................... 26 3.4 Expenses beyond PHI..................................................................................................................... 31 3.5 Unquantified measures and structural measures ............................................................................ 32 3.6 Better budgeting .............................................................................................................................. 33 3.7 Budget and actual expenses in 2019 .............................................................................................. 37 4 Inpatient care ........................................................................................................................................... 39 4.1 Inpatient care expenditure ............................................................................................................... 39 4.2 Quality, accessibility and effectiveness of inpatient care ................................................................ 40 4.3 Inpatient care reform – Hospital network stratification .................................................................... 40 4.4 Management of the largest hospitals .............................................................................................. 44 4.5 System of DRG reimbursements .................................................................................................... 47 4.6 Optimisation of selected operational (non-medical) expenses ........................................................ 49 4.7 Reimbursements from health insurance companies ....................................................................... 51 5 Outpatient Care ....................................................................................................................................... 52 5.1 Outpatient care expenditure ............................................................................................................ 52 5.2 Effectiveness and quality of outpatient care .................................................................................... 52 5.3 Effective primary care ..................................................................................................................... 56 5.4 One-day healthcare......................................................................................................................... 60 Additional funding of inpatient and outpatient care ...................................................................................... 62 6 Drug policy ............................................................................................................................................... 63 6.1 Total consumption of pharmaceuticals ............................................................................................ 64 6.2 Prices and reimbursement of pharmaceuticals ............................................................................... 67 6.3 Cost-effectiveness of pharmaceuticals ........................................................................................... 73 6.4 Redundant out-of-pocket payments ................................................................................................ 77 7 Common examination and treatment units .............................................................................................. 79 7.1 Laboratory examinations ................................................................................................................. 79 7.2 CT and MRI examinations ............................................................................................................... 80 8 Medical devices ....................................................................................................................................... 83 9 Special medical material .......................................................................................................................... 84 10 Waiting for healthcare .............................................................................................................................. 85 11 Staff ......................................................................................................................................................... 87 11.1 Staff remuneration........................................................................................................................... 87 11.2 Staff numbers .................................................................................................................................. 89 11.3 Increasing the attractiveness of general medicine and profession of nurses .................................. 91 11.4 Competences, staff mix................................................................................................................... 92 11.5 Remuneration mechanisms ............................................................................................................ 93 12 Standard diagnostic and treatment procedures ....................................................................................... 95 12.1 Case study – Procedures in mother and child care ......................................................................... 95 12.2 Inappropriate procedures before childbirth ..................................................................................... 97 12.3 During childbirth .............................................................................................................................. 97 12.4 After childbirth ................................................................................................................................. 99 13 Healthcare systems ............................................................................................................................... 100 13.1 Resources in healthcare ............................................................................................................... 101 13.2 Resource management ................................................................................................................. 102 13.3 Health system regulation ..............................................................................................................