(source: SME - Marko Erd)
The absence of regulation, accompanied with the omnipresent conflict of interest, distorts the financial relations between health insurers and hospitals in Slovakia. This leads, among other things, to hospitals being financed mainly by the state-owned insurer Všeobecná zdravotná poisťovňa (VšZP).
The insurance company Dôvera owned by Penta Investments Limited pays the least per unit of output - we first reported on this during my time at the Health Care Surveillance Authority (hereafter “HCSA”, Úrad pre dohľad and zdravotnou starostlivosťou) in 2022. Back then, the payment deficit for this insurance company amounted to more than EUR 40 million for hospitals alone (see also official graph below).
(source: UDZS (Health Care Surveillance Authority in Slovakia))
In 2023, things did not get better with Dôvera, despite the fact that it wept in the media all year that it was generating losses because "there is not enough money in the healthcare sector", which is not true. The total amount of resources flowing into the healthcare sector is comparable to countries of similar economic strength to Slovakia, however, it is not reflected adequately in the quality of health care and citizen satisfaction.
At the end of 2023, private health insurers reported a profit of about EUR 20 million; the figures of Dôvera for 2024 are similar. The calculus is simple - to benefit from public resources through "our hospitals" or through "our insurance company", while the weak state remains silent.
In the pursuit of profit, predatory capital likes to invest in local elites; financially, this continues to pay off enven though since 1 January 2023, the health insurance company profits have been capped. For some elites, all they need in return is a crunchy image in the related News and Media Holding (NMH) group also owned by Penta Investments Limited and invitations to related panels at conferences.
But sometimes the elites go off the rail, as in the case of Marián Petko, who has been President of the Slovak Association of Hospitals (hereafter “Association”) for more than 20 years.
Non-transparent negotiations under the Association’s cover
In 2022, during my time at the HCSA, we began focusing on these practices. We set up an analytical unit and looked closely at the mechanisms of price negotiation in inpatient health care.
It was mainly the Association that surprisingly resisted transparent remuneration based on quality and performance in negotiations with both the HCSA and the Ministry of Health, while the representatives of state hospitals mostly sat quietly in the corner.
As a newcomer to the negotiations, I was unbiased, I openly asked why the insurance companies and the Ministry of Health were negotiating only with the Association, headed by Marián Petko, and not directly with the individual shareholder representatives, headed by the directors of Penta and Agel hospitals, so that the negotiations would be transparent. This would also consider the actual performance of hospitals controlled by Penta, minimise the risk of bundled ownership abuse (major health insurance and hospitals with the same owner). I have not received a satisfactory answer.
More or less, everyone referred to the fact that this is a 'historical approach to negotiating contracts' and that in Slovakia, budget discussions are conducted in terms of the percentage increase in payments compared to the previous year and not whether the payments as a whole are fair and how they take account of the actual performance of hospitals.
Anecdotally, the sector talks about better and worse paid unions and hospitals, depending on who is behind them. I wrote about this in more detail last summer. One consequence of this is, among other things, the continued indebtedness of state hospitals.
Despite HCSA's findings of unfair funding for 2022, the Association claimed early the following year that "representatives of health insurers, in negotiations with Association members, reaffirmed a claim of EUR 238 million. However, the Association is concerned that if these promises are not promptly turned into reality, there will be a real threat to social reconciliation".
At the time, the package was for district hospitals alone, with a total value of around EUR 400 million.
It was not only the media narratives that were aggressive, in fact, there was a dictate of the Association. No one objected to this except the HCSA, however, its competences were insufficient. It looked like everyone was in agreement, the insurers and the Ministry, and that this was a long-standing system in which two powerful financial groups dictate terms, and the rest of the sector stands by silently.
Among non-state institutions, only the Doctors' Trade Union Association (Lekárske odborové združenie) has openly supported the HCSA in its quest for transparency; thanks to their efforts, a commitment to launch DRGs as a reimbursement mechanism was included for the first time in a memorandum with the government in October 2022.
When the President of the Association Petko was convicted in late 2022 in the first instance by the Specialized Criminal Court (Špecializovaný trestný súd) for corruption at the Bardejov hospital, of which he is the director, it was again only the HCSA that tried to publicly appeal to the Association and its members to take action.
Instead of self-reflection, the Association's Petko-Petko Doctor duo sued the HCSA and surprisingly obtained court action in 2023, after which the Communication Department had to withdraw the appeal from HCSA's website.
It seemed inconceivable to me that such a person would negotiate the redistribution of hundreds of millions of euros on behalf of the private sector. Recently, the final verdict was published by the Supreme Court, which convicted the Association’s President of accepting bribes.
Marián Petko has served as President of the Association for more than 20 years. According to information released last month, he only suspended his function despite enormous pressure, and the Association expressed its support for him despite the conviction.
During his absence, the Association will be represented by its long-time first vice-president Igor Pramuk, who works for Penta and is at the same time the state's nominee at the Bardejov hospital – he sees no problem with this conflict of interest.
Bojnice hospital worth following
The first to react on social networks last week was the director of Bojnice hospital: 'As of yesterday, Wednesday 12 March 2025, our Bojnice hospital is not a member of the Slovak Association of Hospitals. We found out that if we had set payments for inpatient care last year as Association’s private hospital members, we would have had about EUR 5 million more income in 2024. And that's just the difference in the largest insurance company and only for inpatient care."
He added that from now on they will negotiate directly with the insurance companies.
This is the right step to follow, and it takes courage in our health care system. Encouraging is the silence of the two biggest players, Penta and Agel, whose possible cartel in inpatient health care has long been given the acronym Pentagel in the backrooms.
Although the cooperation of these two oligopoly-dominating players occasionally escalates into a competitive struggle, they eventually divide up their territories rationally, with most puppet directors of state hospitals waiting resignedly to see what deal the private hospitals, covered by Association and Marian Petko, negotiate.
Should the Bojnice hospital be followed by others, it could mark a major turning point in favour of a fairer distribution of resources.
The king in the redistribution of money to district hospitals in recent years has clearly been Agel, but the clear winner in the chase for profits over the last 20 years is the Penta group. Especially thanks to its globally unique cross-ownership of the insurance company Dôvera, which controls and also dominates (through the same shareholder) the network of polyclinics and hospitals Penta Hospitals, as well as the most profitable part of the pharmacy Dr. Max, the operation of which as such is also controversial from the point of view of competition.
What the Antimonopoly Office investigates
Competition between businesses is supposed to reduce costs and improve the quality of products and services, and in the healthcare sector, it should improve healthcare. However, it appears to be the other way around. It is a fact that competition in inpatient healthcare is illusory; in fact, the Association has not even tried to pretend it.
According to a press release, the Slovak Antimonopoly Office initiated administrative proceedings on 7 February 2025 regarding a possible cartel agreement between entrepreneurs in the provision of inpatient health care.
The move is the result of an investigation in which the Antimonopoly Office carried out unannounced inspections last year and obtained documents and information indicating that four entrepreneurs operating in the sector cooperated in setting prices, coordinated in negotiations with health insurers and exchanged sensitive commercial information.
Last October, the daily SME reported that hospital managers had had their mobile phones and computers taken away and the Antimonopoly Office raided hospitals of the Association, as it suspected the hospital networks of a cartel, although Penta and Agel deny this. As usually, they consider any thereto related questions to be a defamation of their reputation.
In this context, it tastes bittersweet that they did not consider the retention of the convicted Marián Petko as the President of the Association to be a problem, or that they simply cannot solve it.
Although the initiation of administrative proceedings does not mean that the entrepreneurs have violated competition rules, nor does it prejudge the conclusions that the Antimonopoly Office may reach in its decision, it is very likely that the way in which the Association covered up unfair agreements of several players in the sector may play a significant role in this investigation.
As the Antimonopoly Office does not provide any further information on the case at this stage of the proceedings, we must be patient.
If such an agreement is proven, the company may be fined up to ten per cent of the turnover for the preceding closed accounting period. But, more importantly, there would be new pressure for a fundamental reform of economic relations in the Slovak healthcare sector.
The author, Renáta Bláhová, is the former Chair of the Health Care Surveillance Authority.
