Doctors: Changes in financing will worsen access to care. National Health Fund: No such risk
- - This is a step back and a waste of a huge effort - family doctors comment on the change in the rules for financing coordinators in primary care.
- Starting in October, smaller clinics with fewer than 1,000 patients will receive approximately 2,700 PLN for coordinator salaries. The current 7,700 PLN flat-rate monthly payment will be replaced by a rate of approximately 0.83 PLN per patient. Doctors believe this will force them to limit or withdraw from the new model of care.
- The National Health Fund points out that the lump sum for coordination was supposed to be a temporary solution from the beginning (initially it was agreed that it would be paid for 12 months, then this period was extended) and representatives from the Zielona Góra Agreement knew about it
The regulation issued by the President of the National Health Fund (NFZ) a few days ago regarding the conditions for concluding and implementing contracts for the provision of healthcare services, such as primary care, has sparked controversy in the community. Primary care physicians (PCPs) warn that the new regulations will significantly limit access to coordinated care, especially in small towns where large medical centers are lacking.
The regulation will change the rules for financing coordinators in primary care clinics that provide coordinated care. They are responsible for organizing visits, monitoring test results, explaining medical recommendations, and overseeing subsequent stages of patient diagnosis and treatment.
Primary healthcare facilities that have decided to expand their operations to include coordinated care have previously received an additional lump sum of PLN 7,700 per month for hiring a coordinator. Following the changes, this allowance will be available only for six months to facilities implementing the new care model and with up to 5,000 registered patients. The Fund will pay the remaining facilities a rate of approximately PLN 0.83 per patient.
"This is a step backward and a waste of the enormous efforts of family doctors, who have demonstrated that coordinated care works and delivers real results. Instead of strengthening what has improved patient access to tests and shortened waiting times, the National Health Fund is making a decision that will set the system back by years. This is the destruction of well-functioning care and the shattering of the foundations of the healthcare system," Jacek Krajewski, president of the Zielona Góra Agreement Federation, commented in an official statement.
In an interview with Medycyna Praktyczna, the head of the organization calculated that for a medium-sized medical practice with 5,000 patients, the changes will mean funding of 4,000-4,500 PLN per month. Smaller practices with fewer than 1,000 patients will receive only about 2,700 PLN for coordinator salaries, he indicated, which is less than the current minimum wage.
Krajewski points out that clinics won't be able to find anyone to work with this amount, not even part-time. Further fueling the controversy is the fact that the changes weren't consulted with the medical community.
After publishing the order, the National Health Fund issued an official statement explaining that by leaving PLN 7,700 for entities entering Coordinated Care, it "maintains the incentive nature of the lump sum for the coordinator." In an interview with Rynek Zdrowia, Paweł Florek , director of the Social Communication and Promotion Office at the National Health Fund Headquarters, explained that the lump sum for coordination was intended from the outset as a temporary solution (initially, it was agreed that it would be paid for 12 months, then this period was extended), and representatives from the Zielona Góra Agreement were aware of this.
"The supplement was intended to motivate and support additional facilities that were joining coordinated care. To strengthen Coordinated Care, Filip Nowak, president of the National Health Fund, extended its validity, but it was clear from the outset that this was not a permanent solution. Therefore, it's hardly surprising," Florek emphasizes.
He also reminds us that starting in October, a monthly lump sum will be paid to primary healthcare facilities that opt into coordinated care. "Therefore, we maintain our primary goal of further motivating the development of coordinated care," he adds.
He also claims that he informed the Primary Healthcare Team at the Ministry of Health about the update of the current method of financing the tasks of the National Health Fund coordinator.
"The accusation that the new primary healthcare institution (POZ) regulation was not consulted in the context of coordinated care is misplaced, as the effective date of the allowance for coordinator tasks – September 30th – results from the regulations in force before that regulation. We agreed on this with the primary healthcare community. Despite this, we have put forward a proposal that provides POZs with additional funds for coordinator tasks and continues to provide the allowance (PLN 7,700) for those POZs that decide to participate in coordination."
On the other hand, if it weren't for our proposal, the coordinator's allowance would have ended at the end of September. However, that didn't happen," he emphasizes.
According to the National Health Fund, entities should pay coordinators' salaries from their own budget. "The primary source of financing for coordinator tasks is the capitation rate. This is stipulated in the current regulation. The rate is paid regardless of whether the primary healthcare facility is part of coordinated care or not. In the case of a primary healthcare facility that provides coordinated care, the capitation rate for coordinator tasks is 25% higher, " explains Paweł Florek.
He also reminds us that until now, this rate was only calculated for adult patients registered with primary care, but starting in October, the Fund will expand it to include the pediatric population. "This is a major and important change. The rate is calculated for all patients registered with primary care, not just those using services under coordinated care," the NFZ representative points out.
He announces that the National Health Fund (NFZ) is aiming to fund services for patients, not full-time positions. "This is important, especially since there are cases where no or only a few services were provided as part of coordinated care, and at the same time, the primary care facility received a lump sum for the coordinator," he points out.
He also emphasizes that primary healthcare centers are not obliged to employ a separate person for the position of coordinator, and his duties can equally well be performed by staff already working in the clinic.
"The information we're receiving indicates that these tasks are often performed by people working in registration," Florek maintains. "Therefore, relating coordination funds to the minimum wage is completely inappropriate in this situation," he adds.
In an interview with mp.pl, Jacek Krajewski disagreed with the National Health Fund's rhetoric that it was clear from the outset that the lump sum would be temporary. "I participated in the talks in October 2022, and it was very clearly stated that the lump sum is the amount the Fund allocates to the development of coordinated care, and that after some time, there will be another meeting during which we will assess how it is working and decide how this model should continue. There was no question of unilaterally introducing a change to the procedure or abruptly changing the terms of our contracts," he said.
According to the doctor, large healthcare providers will be able to cope with the change in coordinator financing, unlike small providers, for whom the elimination of the lump sum will be particularly painful. "I fear that patients under the care of such practices will quickly feel the negative consequences of the Fund's decision," he said.
"Clinics will be forced to limit the scope of coordinated care. If a doctor believes that all the effort put into it ultimately results in a loss, he won't act to the detriment of the company. He will limit the scope of coordination or withdraw from it, focusing on fulfilling the contract," he explained.
However, in the opinion of the National Health Fund, these concerns are unfounded.
"There's no risk that clinics will abandon coordinated care, especially since the majority of National Health Fund (NFZ) funding for coordinated care goes towards tests and consultations. The coordinator's additional support was intended for the period when the facility's coordinated care was launched, when fewer patients were involved in the coordination process – and we are maintaining this support," assures Paweł Florek.
Currently, over 48% of primary health care facilities in Poland coordinate this, which – as the Zielona Góra Agreement argues – actually shortens queues, improves access to diagnostic tests, and supports the treatment of chronically ill patients.
A year ago, the National Health Fund (NFZ) paid over PLN 546 million to primary healthcare facilities under its coordinated care budget. In the first quarter of this year alone, coordination costs the Fund PLN 148.2 million. A total of 20.6 million patients registered with primary healthcare (60%) are covered by this program.
Adoption of the new patient care model is voluntary for primary care providers. It provides comprehensive treatment for patients with diabetes, hypertension, heart failure, asthma, chronic ischemic heart disease, atrial fibrillation, chronic obstructive pulmonary disease, hypothyroidism, prediabetes, and chronic kidney disease.
Coordinating clinics perform a wider range of diagnostic tests (including tests in the field of cardiology, such as echocardiography, stress ECG, Holter ECG, Doppler ultrasound of the carotid arteries and lower limb vessels, as well as tests in the field of endocrinology, such as antithyroid antibodies and fine-needle aspiration biopsy).
Patients enrolled in the program are required to undergo a comprehensive visit once a year, during which the doctor develops a personalized, 12-month treatment plan for the patient. Each patient is also assigned a coordinator who manages their appointments and tests, ensuring patient attendance. Primary care physicians, in turn, can consult with other specialists instead of sending their patients to a specialist clinic.
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