CONTRACTING AND PAYMENT FOR
HEALTHCARE SERVICES
Violeta Tylienė
Vilnius
15 September 2016
LEGISLATION REGULATING CONCLUSION OF CONTRACTS FOR THE PROVISION
OF HEALTHCARE SERVICES PAID BY THE CHIF
•
•
•
•
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Law on Health Insurance;
Government Decree which approves the list of criteria of healthcare services
paid from the health insurance fund budget;
Order of the Minister of Health, which approves the procedures for the
conclusion the contracts of territorial health insurance funds (THIFs) and
healthcare providers;
Descriptions approved by orders of the Minister of Health for planning
contractual amounts for the provision of healthcare services;
Order of Director of National Health Insurance Fund, which approves
standard contract terms and conditions of healthcare delivery and payment
of their costs from the healthcare insurance fund budget.
2
LAW ON HEALTH INSURANCE OF THE
REPUBLIC OF LITHUANIA
Article 26. Contracts of the THIFs and healthcare institutions, and THIFs
and pharmacies
The expenditure of healthcare provided to the insured are paid
according to the contracts of the THIFs and healthcare institution
THIFs conclude contracts with state, municipal, and other healthcare
institutions that hold a licence for providing healthcare services or
pharmaceutical activities or that are accredited for this activity and
would like to conclude such contracts.
Clause 8 of article 9
Only those healthcare services shall be paid from the health insurance
fund that are in line with the criteria established by the Government.
DECREE OF THE GOVERNMENT OF THE REPUBLIC OF
LITHUANIA
•
Has established the criteria for the services paid from the CHIF,
for example:
 At least 300 cases of deliveries per year per healthcare
institution;
 The services of inpatient palliative assistance should involve
not more than 9 beds per 100,000 of residents.
•
Has established the criteria for the conclusion of contracts for
the services that were not paid by the CHIF to healthcare
institutions in the current year:
 The contracts my be concluded if the services consumption
rate in the territory of the THIF (district) is at least 10
percent lower than the average of the country.
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CONTRACTING TERMS AND CONDITIONS
5
THE PROCEDURES OF CONCLUSION THE CONTRACTS OF THE THIFs
AND HEALTHCARE PROVIDERS
A healthcare service provider that wishes to conclude a contract for the
upcoming calendar year shall submit a request to a the THIF not later than
before 1 November of the current year
This term shall not be applied if the institution wishes to conclude a contract
or supplement the contract of the current year for the following services:
• For the services of outpatient primary health care, outpatient palliative
assistance, outpatient care at home, care of persons with diabetes
mellitus, services of prosthesis, haemodialysis, and the services foreseen in
preventive programs;
• Day surgery, outpatient surgery, day outpatient treatment, geriatrics, care
and palliative treatment, and observation services (where the healthcare
provider respectively reduce inpatient healthcare delivery case defined in
the contract) ;
• And in some other cases.
THE PROCEDURES FOR CONCLUSION CONTRACTS BETWEEN THIFs
AND HEALTHCARE PROVIDERS
Along with an application, the following should be provided:
• A list of services that healthcare providers are planning to provide;
• A declaration/statement regarding the provision of healthcare
services;
• A copy of civil liability health insurance certificate currently in
force;
• If the institution is willing to provide inpatient healthcare services
of a new profile– a certificate issued by the Ministry of Health to
provide compensatory services of a new profile.
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CONTRACTUAL TERMS
•
Within 10 working days from the day of approval of the budget of the THIF, the
THIF shall dispatch a healthcare provider draft contracts or a note regarding
the refusal to conclude a contract in which it shall indicate the motives of this
decision;
•
Within 10 working days from the day of receiving the draft project, a
healthcare provider shall submit the THIF written proposals and remarks
regarding the draft contract;
•
The contract with the healthcare provider shall be discussed for not longer
than 1 month from the day after healthcare providers receive a draft project;
•
The contract between the THIF and a healthcare provider is considered
signed when one of the copies is returned to the THIF.
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NUMBER OF HEALTH CARE PROVIDERS THAT SIGNED CONTRACTS
IN 2015-2016 AND CONTRACTUAL AMOUNTS (THOUSANDS, EUR)
Total number of health care
providers
787
793
Number of public health care
providers
269
269
Out of them only 24 t tripartite contracts
Number of private health care
providers
Out of them only 50 tripartite contracts
0
100
200
2015 m.
300
400
518
524
500
600
700
800
900
2016 m.
9
CHANGE OF THE NUMBER OF CONTRACTS SIGNED WITH the THIFs (5)
WITH PUBLIC AND PRIVATE HEALTH CARE PROVIDERS IN 2005-2016
NUMBER OF HEALTH CARE PROVIDERS THAT SUBMITTED NEW
REQUESTS TO CONCLUDE CONTRACTS FOR 2016
Form of ownership
Number of bodies
Public health care providers that had
contracts with a the THIF in 2015 but
are planning to provide new services
96
Private establishments that had
contracts with the THIF in 2015 but
are planning to provide new services
69
Public health care providers that did
not have contracts with the THIF until
2016
7
Private establishments that did not
have a contract with a THIF until 2016
54
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PLANNING OF CONTRACTUAL AMOUNTS
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DESCRIPTION OF PLANNING CONTRACTUAL AMOUNTS FOR PRIMARY
OUTPATIENT HEALTHCARE SERVICES (1)
Planned annual amount consists from:
• The sum of the primary outpatient healthcare services (family doctor/team)
(according to the number of the residents registered at a healthcare
institution according to 7 age groups);
• The sum of the primary outpatient dental healthcare services (according to
2 age groups of residents registered at the healthcare institution) (the
number of patients under the age of 18 and the number of patients older
than 18);
• The sum of the primary mental healthcare services according to the number
of residents registered at a healthcare institution;
• The sum for incentive services;
• The sum for good performance results (primary outpatient, primary
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outpatient dental healthcare, primary outpatient mental healthcare).
NUMBER OF CONTRACTS FOR PRIMARY OUTPATIENT
HEALTHCARE SIGNED IN 2016
36.2% from
the number
of all
healthcare
providers
63.8% from
the number of
all healthcare
providers
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DESCRIPTION OF THE PLANNING CONTRACTUAL AMOUNTS FOR
AMBULANCE SERVICES (1)
The annual amount of the emergency medical aid (ambulance)
services consists from:
•
The sum for the services provided by the call centre;
•
The sum for the services provided by the ambulance teams;
• The sum for the patients’ transportation services:
 The sum for the transportation of pregnant women in case of normal or
threatening premature delivery and due to a pathology occurred in the
period after delivery;
 The sum for transportation of patients to the hospital providing the services
of percutaneous coronary intervention in the case of acute myocardial
infarction or to institutions providing interventional radiology services in
the case acute stroke;
•
The funds for good performance results of ambulance services.
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NUMBER OF CONTRACTS REGARDING
AMBULANCE SERVICES SIGNED IN 2016
16
DESCRIPTION OF THE PLANNING CONTRACTUAL AMOUNTS FOR NURSING
AND SUPPORTIVE TREATMENT, PALLIATIVE AID, SERVICES OF NURSING AT
HOME, AND SERVICES OF NURSING PERSONS WITH DIABETES MELLITUS
Contractual amounts for services of inpatient nursing and supportive and
palliative aid treatment, consists from:
• The volume of such services factually provided in the territory of the
municipality;
• The number of the residents registered at the primary outpatient healthcare
providers of the municipality and people older than 65 registered at the
primary outpatient healthcare providers of the municipality;
• The volume of nursing and supportive treatment beds in the municipality (3
nursing beds per 1,000 registered residents);
•The number of beds approved for the inpatient palliative aid approved by the
founder (not more than 9 beds per 100,000 residents (approved in the list of
the Criteria of healthcare services paid from the CHIF)).
CONTRACTS OF THIFs AND HEALTHCARE PROVIDERS
REGARDING NURSING AT HOME SERVICES IN 2015 -2016
V - public
healthcare
providers
P - private
healthcare
providers
V-35
P-52
V-15
P- 22
V-14
P-22
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CONTRACTS BETWEEN THIF AND HEALTHCARE PROVIDERS FOR INPATIENT
NURSING AND SUPPORTIVE TREATMENT SERVICES
IN 2015-2016
Vilnius THIF 2
healthcare
provider private
company
- UAB "GEMMA
sveikatos centras"
- Public provider
“Pal. Kun.
Mykolo Sopočkos
hospisas”
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PLANNING OF CONTRACTUAL AMOUNTS FOR SPECIALIZED OUTPATIENT, AND
INPATIENT HEALTHCARE SERVICES (1)
The contractual amount for each type of specialized services takes into consideration:
• Annual amount allocated by the THIF for reimbursement of these services;
• The values of the consumption indicator of corresponding type of services in
the municipality and in the country;
• Number of residents registered at the primary outpatient healthcare
providers of a certain municipality;
The final annual amount allocated for reimbursement of consultations is divided into
amount allocated for reimbursement of ordinary consultations and amount allocated to
reimburse the cost of consultations with interventions (they are proportionate to the
value of the services provided during the reference period).
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PLANNING OF CONTRACTUAL AMOUNTS FOR SPECIALIZED OUTPATIENT, AND
INPATIENT HEALTHCARE SERVICES (2)
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•
•
•
The annual amount for inpatient active treatment services takes into
consideration:
Hospitalization indicator – 20 cases of hospitalization per 100 residents of
municipality (it is planned to achieve 18 cases of hospitalization by 2020
per 100 residents of the municipality);
The contractual amount of previous reference period;
The number of services which may be provided not only as inpatient
active treatment services, but which can be provided in day hospital or
day surgery and etc.
Annual amounts of active treatment of inpatient delivery, stroke
treatment services, when thrombolysis is applied, stroke treatment, when
invasive thrombectomy is applied, myocardial infarction (in patients with
ST segment elevation) treatment services are planned separately
according to the amounts of the factual costs incurred during the last 12
months.
NUMBER OF HEALTHCARE PROVIDERS PROVIDING
INPATIENT SERVICES IN 2015-2016
* UAB “Kardiolita”
UAB “Socialiniai ir sveikatos projektai”
UAB “Baltijos-Amerikos terapijos ir chirurgijos klinika” contract of 2016 regarding active treatment services signed only
with Kaunas THIF (contractual amount EUR 1,361)
23
NUMBER OF CONTRACTS OF SPECIALIZED OUTPATIENT
CONSULTATION* SERVICES SIGNED IN 2015-2016
•Outpatient specialized healthcare providers (II, III level and prophylactic consultations, additionally paid, human genetics services)
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BASIC PRINCIPLES OF PAYMENT OF INPATIENT AND OUTPATIENT
HEALTHCARE SERVICES (1)
Healthcare services are paid within the scope of contractual amount
according to the amount planned for the reference period, except for:
• Primary healthcare services shall be paid according to the factual
number of patients registered at the healthcare provider during
the reference period;
• Expensive tests and procedures shall be paid according to the
number of tests and procedures provided and the planned amount
in a concrete reference period.
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KEY PRINCIPLES OF PAYMENT OF INPATIENT AND OUTPATIENT
HEALTHCARE SERVICES (1)
Provided outpatient (specialized outpatient, emergency aid, day hospital,
observation, day surgery, observation and outpatient surgery) services
shall be paid within the limits of contractual amount but payment may be
redistributed between the types of these services.
Payment for doctor consultations shall be regulated separately :
If the healthcare provider exceeds the number of consultations agreed in
the contract, the THIFs reimburse 25% of the cost of ordinary consultations
and 70% of the cost of consultations with interventions.
Inpatient services shall be paid according to the contractual amount. The
value of 1 point can not exceed EUR 1.25.
Data of factually provided priority* and inpatient services for 2008-2015 (number
of services, thousand)
*Outpatient specialized, emergency aid, day outpatient services, outpatient surgery, day surgery, observation services
Source: data of information system SVEIDRA
THANK YOU FOR YOUR ATTENTION!