New health rules might be bad medicine

SLOVAK patients will once again have to make an extra stop before they see a cardiologist, neurologist or surgeon. A recent amendment to the law on health care has reinstalled the rule requiring patients to get a referral from their general practitioner before they turn to a specialised doctor.

(Source: Sme - Miroslava Cibulková)

SLOVAK patients will once again have to make an extra stop before they see a cardiologist, neurologist or surgeon. A recent amendment to the law on health care has reinstalled the rule requiring patients to get a referral from their general practitioner before they turn to a specialised doctor.

In a report from September 2007, the Health Ministry argued that the revision is needed to prevent patients from abusing the care that specialists provide. However, critics of the legislation said that the authorities have not properly explained the reasons behind the changes.

As a result of the law, all the care that patients receive should now flow through their general practitioner. But those doctors should still be able to deal with most of their patients’ health problems, the Slovak Society of General Practice says.

The vast majority of all the health problems that patients bring to their doctor are uncomplicated forms of acute and chronic organ diseases, the organisation says.

“A general practitioner should be able to solve approximately 60 to 80 percent of problems at his office using his skills and knowledge,” said society president Peter Lipták. “Patients mostly visit their general practitioners with problems that physicians are well prepared for. They solve them and they do not need to send the patients anywhere.”

Each GP belongs to a network of related specialists and hospitals, where the practitioner sends more complicated cases for consultations or hospitalisation, Lipták said.

“The referral is a communication tool for secondary care,” he told The Slovak Spectator.

The recent steps follow the latest trends and experiences from the most developed health systems in the European Union, he added.

However, the Health Policy Institute argues that the law solves a problem that has not yet been analysed in depth.

“An estimate of the amount of unnecessary examinations by specialists is missing, and it is not guaranteed that after the referral system is installed, this workload will drop,” said Tomáš Szalay, an analyst with the HPI.

The institute says the ministry has failed to provide convincing arguments that would answer two questions: Is the number of health check-ups performed by specialised physicians too high? And is the reason for the problem an overly dense network of specialists?

If part of the workload is caused by medically unnecessary visits to specialists, the solution would be to re-install the fee for trips to the doctor, Szalay said. One of the first moves the new health minister made was to cancel the Sk20 fees that patients had to pay for each visit with a new health concern.

“Paying for their own time while they wait for a referral would cost more for (employed) patients than the cancelled Sk20 fees,” Szalay said. “For those with an average salary of Sk100 per hour, even a 15-minute waiting time is more expensive.”

The HPI also argues that by filling the GP’s office with patients waiting for referrals, the doctor might have less time to devote to each patient, which could threaten the quality of care they provide.

“There might also be a higher risk of infection, waiting in a room filled with people suffering from acute infectious diseases,” Szalay said.

Mixed reviews for health districts

The new legislation also says that district GPs are not allowed to turn away a patient with permanent residence in their district. But patients will still be allowed to choose any doctor they prefer.

The Health Ministry said the rule binding the GP to treat all patients from their districts secures the right of each citizen to accessible health care.

The previous government cancelled the system of health districts and based the system entirely on an agreement between the patient and the physician. The GP also had the option to refuse any patient.

Lipták told The Slovak Spectator that his group is OK with the change.

“It is a reasonable step and it supports changes that head towards building a functional primary health care system,” he said.

General practitioners can provide their patients the best care if they have their social, community and family support systems in the vicinity, said Lipták. And patients gain the most if they can access their physicians without any limitations.

The ideal situation would be if patients from a given neighbourhood went to their district GP, he added.

“The current situation, where patients sometimes travel 50 kilometres to get primary health care when there is a general practitioner in their neighbourhood, cannot be considered a functional primary health care system,” Lipták said.

Now that physicians can no longer refuse patients who live in their district, they might have to drop patients who live farther away if they have too many local patients, he said. The patients who have been travelling to see them will have to find doctors in their own district.

The Health Policy Institute argues that the wording of the law contains some provisions that could potentially be abused.

“The revision that was approved lacks any rules to define health districts,” Szalay said.

The Health Ministry will not define health districts – the regional governments will, and that could create room for abuse or corruption, he added. For example, the regional government could refuse to include a Roma settlement in any of the districts and still not violate any rules.

“The ministry should not have gotten rid of the responsibility for the consequences of installing the health care districts by shifting the whole agenda to the regional governments, without giving them at least a framework regulation,” Szalay said.

“In short, the revisions that were approved do not meet the undoubtedly good intention of guaranteeing the accessibility of health care through the district system.”

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