3.1 Graphic presentation of the PMG components—PMG service packages

FIGURE 3.1

Graphic presentation of the PMG components—PMG service packages

Program of Medical Guarantees

Primary Health Care

Detailed benefit packages

Affordable

Medicine

Program (list of 264 drugs) • Cardiovascular diseases • Bronchial asthma • Type 2 diabetes Rehabilitation

• Infants born prematurely and/or ill during the first three years of life • Patients with musculoskeletal disorders • Patients with lesions of the nervous system Conditioin specific

Source: World Bank. Note: COVID-19 = coronavirus (pandemic). Palliative care Complex care Outpatient services Hospital care

• Inpatient • Mobile Broad • Chemotherapy • Radiotherapy • Mental health Broad

• Tuberculosis • HIV Conditioin specific • Mammography • Hysteroscopy • Esophagogastro duodenoscopy • Colonoscopy • Cystoscopy • Bronchoscopy • Hemodialysis • All other secondary and tertiary care Specific intervention

Broad • Acute stroke • Acute myocardial infarction • Childbirth • Complex neonatal care Conditioin specific

• Surgical • Nonsurgical Broad

Mobile brigades for COVID-19 testing

2 COVID-19 Packages (hospitalization and salary increase)

COVID-19 packages Emergency care

• All types of services

Broad

Emergency care for patients with COVID-19

level and psychiatric care by mobile interdisciplinary teams—and continued a range of COVID-19 related care, adding vaccinations. The transformation package was discontinued. The Affordable Medicines Program (AMP) (Dostupni Liky), which was part of the PMG-2020, is included in PMG-2021.

The NHSU purchases services from providers using contracts that define service specifications. Each package of care has specific requirements that providers must meet in order to contract with the NHSU. The service specifications are defined by the NHSU through working groups that include Ministry of Health (MoH) representatives, some international partners, service providers, and researchers. The specifications are mainly related to the organization of service provision, key equipment, and personnel of the providers. By defining service specifications, the NHSU is strengthening strategic purchasing. The use of specifications to define the eligibility of providers enables selective contracting of providers that can meet those standards with a view to efficiency and quality improvement.

Any provider can apply to provide any set of service packages—a practice that risks potential inequality in geographical access to services, with overconcentration in some areas and gaps in others. Purchasing rules for 2020 allowed any care provider to apply and sign a contract with the NHSU for one or more packages of service, subject to meeting the eligibility criteria. Contracting was not subject to a master plan for a network of services that would ensure a guaranteed health care supply. In other words, while the NHSU was able to use its contracting and purchasing power to improve the efficiency of contracted providers, it was not able to use contracting to strategically shape the provider network into a more

efficient one. Moreover, contract requirements for specific types of equipment have prompted facilities to invest without the security that they would continue providing such services once the regional masterplans are crystalized.

Figure 3.2 presents the requirements that all contractors have to meet as well as the various service packages they can apply for.

Some packages are defined in more general terms, while others are condition-specific and more detailed. Looking across packages, it can be said that priority services tend to be defined more explicitly. These include acute stroke, acute myocardial infarction, childbirth, and complex neonatal care at the hospital level. A set of six diagnostic services, such as hemodialysis, is also organized into six individual service packages. As discussed elsewhere in this report, the process for defining these priorities is unclear. In contrast, all other types of outpatient specialized care are broadly defined as secondary and tertiary outpatient care and are aggregated into one package. A PHC package has its own definition and an explicit list of services covered at that level of care.

The NHSU purchases services from health care providers using different payment methods. The mix of payment methods used for contracting includes a global budget for the majority of hospital and specialized outpatient care as well as emergency medical services, case-based payments for inpatient priority services, fee-for-service for specific types of diagnostic examinations and types of treatment, and capitation for the PHC package, as shown in table 3.1. In addition, there are some other payments made to providers through the NHSU and financed as part of the PMG package. These payments relate to managing the financial risk associated with health financing reform and the COVID-19 pandemic. The first consists of compensatory lump-sum payments to facilities that experienced a substantial reduction in revenues following the April 2020 payment reform. The second is payments that have been in place since September 2020 to health personnel working in a subset of facilities and who have been paid temporary COVID-related salary top-ups equivalent to 70 percent top-ups for physicians, 50 percent for nurses, and 30 percent for junior medical staff.

In parallel with the rollout of the PMG, the government developed the e-Health system, which has been critical to the service-purchasing function. In April 2018, the government launched Ukraine’s new national health information system, e-Health.1 In the first years of reform (2018–19), e-Health was focused on supporting PMG payments for PHC—enrolling patients, contracting providers, and implementing and monitoring payments (see figure 3.3). It was also used to reimburse pharmacies for the AMP medicines. As the PMG expanded in 2020, the e-Health system was further developed to capture a larger set of providers, and electronic health records and e-Referrals were introduced. E-Health data are also pulled into extensive online dashboards, with PMG purchasing statistics on the NHSU website. Despite technical difficulties caused by, among other things, very tight reform deadlines, the e-Health system provides the NHSU with a wealth of basic PMG purchasing data that can be used not only for contract management and payment but also to monitor the services provided and inform decision-making and policy development in the sector.

In the remainder of this chapter, different types of care covered by the PMG will be discussed in more detail. Key recommendations for the expansion of the PMG package and the purchasing of services covered by the PMG are organized into the following sections: primary care, AMP, and specialized care—inpatient, outpatient, emergency, and hospital care.