Author: Dr. Hab. Dorota Maśniak
Assisting in the fulfillment of wishes is necessary, and wishes for health are among those whose realization largely depends on decisions made by ourselves and entities responsible for the functioning of healthcare. It is a good time for planning. Healthcare should be associated with actions that protect our health, rather than fighting disease. In such efforts, allies are needed, solutions that support the challenging relationship between the patient and the doctor. The near future will show how helpful coordinated care will be in this regard.
Prepared Patient before a Visit to the Clinic
The philosophy of approaching the patient is changing. Currently, the patient visits the clinic when they feel they have a health need. Coordinated care reverses the situation. The coordinator assesses the patient’s health needs and, importantly for the entire healthcare system, rationalizes them. Health services are planned in advance. A healthcare plan is created, and its implementation is overseen by the coordinator.
Coordinated care has been in operation since October 1, 2021, and is gradually evolving. Primary healthcare facilities (PHC) can apply to the National Health Fund (NFZ) for an additional payment for the coordinator’s work. In the initial stage, the scope of their duties was limited to encouraging patients to participate in preventive programs. For example, in a medical facility, a list of individuals eligible for a specific program or health intervention is generated, and the coordinator’s role is to recruit patients. This includes inviting patients to the program, providing information about the program, and guiding patients on how to prepare for it. This approach provides an opportunity to promote preventive programs among patients, such as the Cardiovascular Disease Prevention Program, whose implementation level in the population is still low.
Holistic Coordinated Action of the Family Doctor
The introduction of coordinated care in a given clinic is still voluntary. From October 1, 2022, facilities can apply to the NFZ to expand the scope of services and enter into relevant agreements. The goal is to strengthen the family doctor and, consequently, relieve specialist doctors. Emphasis is placed on the diagnosis and treatment of the most common chronic diseases. In medically justified situations, the family doctor can prescribe tests that were previously reserved for specialists.
The selection of conditions covered by coordinated care is dictated by the frequency of occurrences. As part of a comprehensive individual consultation, a treatment plan can be established for patients diagnosed with diseases in the fields of cardiology, diabetology, pulmonary diseases, endocrinology, and, from December, nephrology. Importantly, the family doctor can order a thyroid function test, EKG, or heart ultrasound. The patient does not need to obtain a referral to a cardiology clinic. Based on the results, the doctor decides whether the patient can be under their care or if a referral to a specialist is required. Most patients will not need this because they are not so seriously ill as to require outpatient specialist care.
Treatment is based on an Individual Medical Care Plan, which considers not only conducting tests but also consultations between the family doctor and the specialist. It also includes additional consultations, for example, with a dietitian in the case of diagnosing diabetes. Each clinic that has joined coordinated care must offer dietitian consultations.
The coordinator is intended to support the patient-doctor relationship. This role can be fulfilled by a clinic employee. Their role is to assist the patient in implementing the treatment plan. The coordinator supports the patient, registers prescribed tests, and reminds them of appointments.
Barriers to the Development of Coordinated Care
It is estimated that around 30% of PHC clinics currently provide coordinated care. The most common problem is the availability of family doctors to specialists in a specific field, as the NFZ requires a specific specialist to be identified on the day of signing the coordinated care agreement. This touches on the issue of funding. Given the current valuations of healthcare services in some regions, it is difficult to recruit specialists.
The expansion of the family doctor’s competencies is not accompanied by appropriate remuneration. The lack of motivating elements for them to provide coordinated care is another problem. The same applies to assigning the role of coordinator to employees or hiring coordinators.
Coordinated Care and Private Health Insurance
Coordinated care is a guaranteed service within primary healthcare and is funded by the National Health Fund. Therefore, it is available to all patients, regardless of whether they have private health insurance.
In light of the barriers mentioned above, private health insurance can provide significant financial support for the development of coordinated care. Serving as a source of healthcare funding enables and improves access to specialists. It provides real financial relief for both primary and specialist healthcare and reduces waiting times for appointments.
On the other hand, the shift from “referral-based” to coordinated medicine poses a challenge for insurers in creating insurance conditions that are adequate to complement the universal healthcare system and serve as an effective source of funding.
The shift from treating diseases to health prevention aligns with the current trend of emphasizing the preventive function of insurance.
The author of the text is Dr. Hab. Dorota Maśniak, a professor at the University of Gdańsk.
She is currently also a member of:
The Management Committee of the Polish branch of the Association Internationale de Droit des Assurances (AIDA),
The Advisory Scientific Committee for the Financial Ombudsman for the term 2023-2026,
and the Program Board of Insurance Law.
