W tym artykule postaramy zmierzyć się z liczbami dotyczącymi pacjentów korzystających z leczenia za granicą na podstawie Dyrektywy Transgranicznej.

Wydatki publicznych systemów zdrowotnych (NHS i NFZ) na refundację kosztów leczenia za granicą

W tym artykule postaramy zmierzyć się z liczbami dotyczącymi pacjentów korzystających z leczenia za granicą na podstawie Dyrektywy Transgranicznej.

 

Zadanie to jest o tyle trudne, że dostępne analizy przekrojowe dotyczące stosowania Dyrektywy Transgranicznej w krajach UE dotyczą jedynie pierwszych dwóch lat po wdrożeniu Dyrektywy.  Niemniej jednak, zebrany przez nas materiał z rozproszonych źródeł, pokazuje trendy i obraz skali, jak również ciekawe przewidywania co do skutków wdrożenia Dyrektywy, między innymi dla krajowych systemów zdrowotnych i ich budżetów.

 

Zaczynając od podsumowania można powiedzieć, że po 4 latach funkcjonowania Dyrektywy, w praktyce, skala wydatków na leczenie za granicą tą drogą oraz poziom refundacji jest skrajnie rozbieżny od pierwotnych przewidywań, wieszczących nieuniknioną zapaść systemu finansowania leczenia krajowego.

 

Polacy najbardziej zainteresowani Dyrektywą

 

Niekwestionowanym liderem w zakresie skali zainteresowania medycyną transgraniczną jak i realizowanych w praktyce procedur medycznych za granicą jest ….. Polska. To z niej w roku 2017 wyjechało na leczenie ponad  15 tys. Osób.

 

Podana wyżej liczba znacząco blednie w porównaniu do liczebności Polskiej populacji oraz wielkości kolejek w NFZ. Również z perspektywy budżetu, wyniki nijak mają się do pierwotnych założeń. Nakłady na leczenie za granicą i jego refundację to poniżej 0,05% udziału w łącznym budżecie NFZ oraz poniżej 3% przewidywanej i zatwierdzonej części budżetu przeznaczonego na refundację kosztów  leczenia za granicą.

 

Sytuacja w innych krajach UE – ze szczególnym wzdględnieniem UK

W zakresie promowania i popierania rozwiązań objętych Dyrektywą przodują kraje, które upatrują w niej możliwość poprawy sytuacji zdrowotnej swoich obywateli, nie stawiając żadnych barier i ograniczeń przed Pacjentami zainteresowanymi takim leczeniem. Jako liderów wsparcia dyrektywy warto tu wymienić Szwecję, Norwegię, Czechy, Holandię i Estonię.

 

Wielka Brytania stara się dorównać kroku liderom i zauważalne jest coraz bardziej przychylne traktowanie Pacjentów zainteresowanych leczeniem za granicą i ich postulatów refundacyjnych.

 

Na rynku brytyjskim, udział wydatków mieszkańców zjednoczonego królestwa na leczenie za granicą jest  również niezauważalny w skali budżetu NHS.

 

Zakładając 5 krotny wzrost od 2015 r (bazując na trendzie zauważalnym w Polsce – choć to bardzo mało prawdopodobne) udział kosztów leczenia za granicą refundowanych z NHS zgodnie z przepisami Dyrektywy wyniósłby w roku 2017 niespełna 0,005% łącznego budżetu – czyli 5/100000.

 

W budżecie NHS na rok 2017 (150 mld EUR) ekstrapolowane wydatki na refundację leczenia za granicą na kwotę ok 8 mln EUR są kroplą w oceanie – i dla porównania, stanowią 10 krotnie mniejszy udział w budżecie, niż udział refundacji uzyskiwanych w Polsce w budżecie NFZ (głównie z tytułu leczenia zaćmy za granicą).  

 

Oznacza to, że wprowadzanie sztucznych barier w dostępie do tego leczenia i zawracanie tego budżetu na rynek krajowy nie rozwiązuje żadnych problemów.

 

Co więcej, kraje przodujące we wdrożeniu i popularyzacji przepisów Dyrektywy wśród swoich obywateli dostrzegły, że leczenie uzyskiwane tą drogą jest po pierwsze tańsze, po drugie szybsze niż leczenie gwarantowane na własnym rynku, a dla części ich obywateli pochodzących z innych krajów UE leczenie w ich krajach rodzimych jest po prostu bardziej naturalne w języku ojczystym, w znanym środowisku i ze wsparciem części rodziny.    

 

Na przykładzie poniższego porównania danych dotyczących systemu zdrowotnego UK i Polski (przez zestawienie nakładów na zdrowie) można wskazać co jest motorem wspierającym rozwój leczenia za granicą z perspektywy państw starej Unii.

 

Dane za rok 2016 UK Polska UK / PL
Liczba ludności 65 383 000    37 967 000      1,7
GDP (mln EUR)   2 395 801       425 980 5,6   
GDP / per capita (EUR)        36 643         11 220 3,3   
Budżet na leczenie w powszechnym systemie zdrowotnym NHS/NFZ (mln EUR)       150 600         16 900   8,9
Udział kosztów leczenia w publicznym systemie w GDP       6,3%         4,0%   1,6
Udział wydatków na zdrowie (w tym prywatnych) ogółem w GDP      9,7%         6,4%   1,5
Udział wydatków niepublicznych na zdrowie w GDP     3,4%         2,4%   1,4
Koszty leczenia statystycznego obywatela                                              w systemie publicznym (EUR / rok)        2 303           445   5,2
Koszty leczenia szpitalnego ogółem                                      (mln EUR / rok 2015)       106 486         9 728  10,9   
Koszt leczenia szpitalnego                                                 statystycznego obywatela (EUR / rok 2015) 1 629 256    6,4
Dane na podstawie danych Eurostat

 

Wydatki na zdrowie, zarówno ogółem, jak i wydatki finansowane z systemów publicznych, w przeliczeniu na mieszkańca, obecnie są w UK ponad 5-krotnie wyższe niż w Polsce. Z jednej strony wynika to z wyższego udziału tych wydatków w PKB  – odpowiednio 9,7% w UK na tle 6,4% udziału w Polsce ( patrz dodatkowo na wykres „Wydatki bieżące na ochronę zdrowia w należących do OECD krajach europejskich w 2016 jako % PKB”) oraz ponad 3-krotnie wyższego PKB na mieszkańca.

 

Biorąc taki limit pod uwagę jasnym jest, że zachowując zasadę refundacji do niższej z kwot (tzn. refundacja ma miejsce do granicy wyceny leczenia w Anglii, a jeśli cena jest niższa, niż wycena NHS, zwracana jest mniejsza z kwot), realizacja takich świadczeń za granicą jest tańsza dla systemu i finalnego płatnika.

 

Skala oszczędności w rozliczeniach między systemami publicznymi na przykładzie porodów

 

Skala „oszczędności” w rozliczeniach między systemami publicznymi – w ramach ścieżki S2 sięgać może 5 krotności ceny płaconej względem lokalny poziom kontraktacji czego doskonałym przykładem mogą być porody (w ścieżce S2, NHS rozlicza się bezpośrednio w NFZ – ścieżka ta obejmuje jedynie leczenie w publicznych placówkach) .

 

Z obserwacji i praktyki wynika, że istotny odsetek kobiet pochodzenia polskiego mieszkających na stałe w UK rodzi swoje dzieci w polskich szpitalach w systemie publicznym w ramach ścieżki S2 – za co NHS płaci na rzecz NFZ stawkę w kwocie ok 1750 zł / poród (w przypadku porodu bez komplikacji). Analogiczną stawką finansującą poród w brytyjskim szpitalu jest stawka 5 krotnie wyższa wynosząca ok 1820 GBP stanowiąca też limit refundacji przy wyborze ścieżki objętej Dyrektywą. To samo dotyczy innych procedur operacyjnych czy leczniczych.

 

Dyrektywa i leczenie w prywatnych szpitalach za granicą

 

Trochę inaczej rzecz się ma wybierając Dyrektywę i segment prywatnych szpitali w takich krajach jak Polska. Wskazana w tabeli 6 krotna różnica w kosztach leczenia szpitalnego na 1 obywatela na rok w systemach publicznych oczywiście niwelowana jest różnicą cen w systemach publicznym i prywatnym w Polsce. Niemniej jednak, z dużą dozą prawdopodobieństwa i w oparciu o dotychczasową praktykę można stwierdzić, że gross zabiegów operacyjnych w systemie prywatnym mieści się odnośnie komercyjnej ceny w limicie NHS.

 

Oczywiście nie można generalizować, bo w Polsce praktykują również lekarze o światowej renomie i kompetencjach, u których leczenie wykraczać może ponad budżet określony przez NHS – w takim przypadku świadomy wybór takiego ośrodka czy lekarza oznaczać będzie istotne zmniejszenie komercyjnej ceny o dostępną refundację. Koszty operacji aż do granicy refundacji pokryte będą przez NHS, a reszta kosztów jest współfinansowana przez pacjenta.  

 

Sytuacja z perspektywy gospodarki

 

Jeśli założymy, że wśród osób dorosłych w wieku produktywnym choroba osłabia lub eliminuje zdolności do pracy i efektywność, pochłania koszty związane z leczeniem w tym te niemierzalne związane z opieką, zmniejszonymi dochodami wynikającymi z absencji chorobowych czy generuje obciążenia związane choćby z brakiem pełnej satysfakcji życiowej to można bronić tezy, że choroby w tej grupie powinny być skutecznie leczone tak szybko jak to możliwe.

 

Na przykładzie systemu zdrowotnego i statystyk polskich mających analogie w innych systemach zdrowotnych w tym w UK, można stwierdzić, że nakłady na zdrowie w grupie wiekowej 20-60 lat osób pracujących stanowią mniej niż połowę wartości odprowadzanych przez tę grupę składek zdrowotnych. Nadwyżka składek od tej grupy stanowi źródło pokrycia nakładów na zdrowie dzieci, bezrobotnych i osób na zasiłkach oraz seniorów, dla których z kolei składki zdrowotne od ich emerytur i rent pokrywają tylko nieco ponad połowę kosztów leczenia tej grupy.

 

Powyższe oznacza, że ze względów czysto ekonomicznych i gospodarczych, z perspektywy gospodarki brytyjskiej, grupa polskich emigrantów na wyspach brytyjskich stanowiąca trzon młodej części społeczeństwa UK (dominanta wieku 30-35 lat) powinna być beneficjentem dobrej, szybkiej i skutecznej opieki medycznej, bo po prostu to się opłaca!

 

Jeśli polscy emigranci zdecydowaliby się na leczenie w Polsce ścieżką S2 (gdzie NHS rozlicza się bezpośrednio z NFZ), oznaczałoby to wydłużenie i tak napiętych do granic możliwości kolejek do specjalistów czy na zabiegi operacyjne przynosząc iluzoryczne wpływy gotówkowe według 5 krotnie niższych niż na wyspach stawek.

 

Leczenie w szpitalach prywatnych omija natomiast ograniczenia związane z kolejkami czy nieadekwatną wyceną wysoko jakościowych świadczeń i realizowane jest przy zachowaniu zbilansowanego interesu każdej ze stron w postaci lepszej jakościowo opieki nad Pacjentami niż oferuje system publiczny za istotnie wyższą stawkę niemniej mieszczącą się w granicach ustanowionych przepisami Dyrektywy.

 

Jego obecna skala jest minimalna niemniej zachowując zrównoważony interes każdej ze stron ma szansę na dalszy rozwój.

Co ciekawe i ważne, w Polsce – oraz w innych krajach UE – prawa do możliwości wykorzystania dobrodziejstwa Dyrektywy Transgranicznej strzegą instytucje publiczne – polecamy tu lekturze zarówno raporty Najwyższej Izby Kontroli:  

– Informacja prasowa o wynikach kontroli NIK korzystanie Polskich obywateli z prawa do leczenia za granicą w ramach Dyrektywy transgranicznej:

https://www.nik.gov.pl/aktualnosci/nik-o-leczeniu-za-granica.html

– Prezentacja pokazująca korzystanie Polskich obywateli z prawa do leczenia za granicą w ramach Dyrektywy transgranicznej:

https://www.nik.gov.pl/plik/id,14895,vp,17364.pdf

 

jak i stanowisko rzecznika Prawa Pacjenta w zakresie praw Pacjenta w transgranicznej opiece zdrowotnej:

http://www.rpp.gov.pl/dla-pacjenta/transgraniczna-opieka-zdrowotna/

Podobne działania w zakresie rzetelnej informacji na temat funkcjonowania Dyrektywy można znaleźć na oficjalnych stronach Komisji Europejskiej i rządowych czy oficjalnych stronach publicznych systemów zdrowotnych w krajach UE.

 

W przypadku UK prawa pacjentów szczegółowo opisane są na stronach NHS:

https://www.nhs.uk/NHSEngland/Healthcareabroad/plannedtreatment/Pages/Introduction.aspx

 

oraz powołanego przepisami Dyrektywy Krajowego Punktu Kontaktowego w sprawie leczenia

transgranicznego w UK:

https://www.nhs.uk/NHSEngland/Healthcareabroad/national-contact-point/Pages/uk-national-contact-point.aspx

Zauważyć można również gdzieniegdzie działania nastawione na popularyzację przepisów i praw Pacjentów wynikających z rozwiązań objętych Dyrektywą szczególnie – co po części wynika z oswojenia tematu oraz pierwszych oznak pozytywnego wpływu takich rozwiązań na dobrostan zdrowotny obywateli UE.

 

Powyższe zdecydowanie przeczy postrzeganiu takich rozwiązań w tym działalności Med4EU jako działalności „na pograniczu legalności” czy „wątpliwej etycznie

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