The description of the health care delivery and financing mechanisms

In Poland DRG system (called Jednorodne Grupy Pacjentów) was implemented in 2008. At the same time, financial products “ambulatory DRG” (defined by procedures) were implemented in ambulatory settings (the same no matter the type of specialists). For both types of healthcare services financing was limited to the contract level (defined for each clinic/out-patient specialist). In 2015 the reform called “hospital network” was implemented. Hospitals listed in the hospital network and belonging to "hospital" ambulatory settings receive a global budget one for all outpatient and inpatient clinics) based on services performed one year before (DRG plays as points and is used to settle a budget for next year). The "satellite" ambulatory providers (not being part of any hospital listed in the hospital network system) and hospitals not included in the hospital network system are still financed with an ambulatory/hospital DRG up to a limit defined separately for each type of outpatient/inpatient clinic. As a result, the ophthalmological cases are financed with two different regimes (i.e. DRG used as a payment method or as a point system) depending on being or not on “hospital network” lists. Above it, there are some exceptions–services that are financed by DRG on a fee-for-service basis (i.e. without any limits for providers). These are for example child delivery and cataracts. There is no co-payment for healthcare services in the Polish healthcare system. If a patient wants a higher quality treatment or device, he must cover the whole cost of treatment.

Since 1993 in Hungary the basis of payment mechanism the NHIF has applied the DRGs-based payment scheme (the Hungarian version is Homogén Betegségcsoport: HBCs) both for in-patient and one-day surgery care. For each DRGs, there is a special weight number that expresses the relative cost level as compared to the national average, and it is multiplied by the national equal base rate. For outpatient care since 1993, it has been used the so-called German score system based on the detailed list of activities calculated in scores (points), each activity code has a fixed number of points. Both the ambulance scores (HUF/point) value and the DRGs base rate are predetermined as a national equal tariff announced by the Ministry that is responsible for the Health Affairs (MoH). The MoH announced different ministerial orders that regulate the detailed list of financed out-patient ophthalmology services, including diagnostic examinations (e.g. OTC) and treatment technologies and in-patient services, short-term care distinguishing twenty-five different DRGs (mainly surgeries). In Hungary, in the compulsory health insurance scheme there is no generic co-payment system, just for the pharmaceutical for ophthalmic treatment, the patients have to contribute 10%, 20%, and 45% of the total price. During the COVID-19 pandemic, the abovementioned performance-based payment system was temporarily suspended, but since the 1^st of February 2023. The former system was applied again with smaller modifications in the codes and tariffs it is true for the formerly successful cataract waiting list reduction programme that was launched again.

Four periods of changes in the financing mechanisms of the health care system in Ukraine can be identified. The first period took place until 2018 when the financing of the treatment of all ophthalmological cases in the public sector was conducted according to the fixed budget method. The second period began in 2018 and lasted until the first quarter of 2020—the reform of the health care system in Ukraine began. New payment mechanisms were introduced at the level of primary medical care using the capitation method, and the hospital and outpatient sectors, which provided specialized care to the country’s population, were financed based on a fixed budget. The third period began in 2020 and is characterized by the fact that the financing reform was extended to secondary outpatient and inpatient care. Surgical treatments of patients with ophthalmological cases were included in the package of medical guarantees "Surgery for adults and children in hospital". The fourth period started in 2021 when the principles of financing by diagnostic and related groups (DRGs) began to be applied, and reforming according to this method of payment is still taking place. In 2022, ophthalmological cases will be included in the package of medical guarantees "Surgery for adults and children within one-day hospitalization".

It is very difficult to compare the prices of healthcare services between Hungary and Poland, as they differ between countries by ICD-10 (disease types) and/or ICD-9 codes even if they are defined by DRGs. In Ukraine, healthcare services only started to be determined by DRGs in 2021, i.e. specialized medical services were paid according to the global budget, considering adjustment factors. From 2022, payment for healthcare services is conducted as a combination of the global budget and the global rate and payment for a treated case of DRGs (S3 Table).

The descriptions of the health care delivery and financing ophthalmology services in Hungary and Poland have led us to the conclusion that there are significant differences across these countries. The differences exist although both countries have implemented DRG-based systems for hospital care for a long time. The comparison of practices in each country allowed us to identify these differences and define good practices in treatments for cataract, glaucoma, AMD, DME, cornea transplantations, and vitrectomy. As was found in the summary report, there is no good practice in financing leading to increase access to all services in ophthalmology and financial incentives differ not only across countries but also across diseases [7].

Identification of practices of health care services and financing of ophthalmology

Cataract is and will continue to be, the most frequent treatment provided in ophthalmology care. As our populations are aging, ensuring access to treat the problem of visual impairment when needed will become essential. The major difference identified during our research pertains to the treatment scheme. In Hungary cataract surgeries can be financed within the ambulatory care, while in Poland only in hospital care. This now contributes ’only’ to the higher costs of care, as the mechanism of a financial penalty (a 10% decrease in DRG price) in the case of one-day treatments lower than 80% leads to a sharp increase in short hospitalizations. With 98% of daily cases (Zdrowe dane. Choroby narządu wzroku), Poland does not differ much from the ambulatory treatment scheme provided in Hungary.

The main barrier to access treatment is also limited (put by third-party payers on healthcare providers) in financing the number of cataract surgeries. No limits on volumes introduced in Poland in 2018 allowed to treat patients without unnecessary delay. Together with separating the payment for qualification visits (with specific medical criteria for cataract surgery) it increased in number of treatments (S4 Table) and reducing significantly the waiting time for treatment (from 489 days in 2016 to month to 127 days in 2020 in Poland; Zdrowe dane. Choroby narządu wzroku). The average waiting time for cataract surgery was 104 days in 2014 and 39 days in 2019 after a few years of a conscious continuous waiting time reduction program organized and financed by the NHIF in Hungary [24].

The second disease that was explored by the project team members in each country was glaucoma. During our team discussions and interviews with healthcare providers, we discovered that glaucoma is mostly treated with the use of pharmacotherapy. Therefore, ensuring access to many medicines that correspond to the wide variety of clinical conditions of patients diagnosed with glaucoma was crucial. The wide list of reimbursed drugs allows matching the treatment with health needs while being affordable for patients. According to a Polish medical doctor who works in an ambulatory care facility with the public-payer contract and private facilities: There is great access to modern drug treatments, with huge public funding, especially in the age group 75+ (P2).

For glaucoma and vitrectomy also, financial limits were released in Poland for ambulatory as well as for surgical care. During interviews, they were pointed out as “a wish good practice” (Distinguishing the consultation- qualification for treatment, cataract surgery, and follow-up consultation was the key to providing access with the right financing, including removing the limits for financing surgeries. There is no data about waiting time for glaucoma treatment. There are waiting lists for vitrectomy. These procedures probably require removing limits too. (…) Removing limitations in financing medical procedures in ophthalmology could help to increase access to services. (P3). The requirements and proper financing would have to be adjusted to move more treatments to 1-day hospitalizations. Cataract, glaucoma, and vitrectomy could be mostly conducted during the 1day stay (P5).

AMD was another disease that was analysed. Increasing access to health care can be achieved by adjusting the financial product to the complexity of the procedure. The greatest shift in volumes was observed in Poland, where in 2018 introduction of the so-called “drug programme” allowed the gradual transition from inpatient hospitalizations to outpatient care (from 9,790 in 2015 to 27,787 in 2020, Zdrowe dane. Choroby narządu wzroku). It [the program] is one of the few things that works. It is an example of how the pricing influences the market: the better pricing pushed providers to buy medical equipment and equipment allowed to diagnose the patients and this resulted in higher access to treatment (P6). In Hungary this programme is defined as an ambulatory treatment provided by the hospital so it realised capacity resources in hospitals leading to a sharp increase in the number of people treated (from 4,500 in 2014 to 19,300 in 2019 in Hungary’s NHIF financial database), the payment method was the same than for cataracts a special DRGs code was set up exactly for AMD neovascularisation for relatively low tariffs (RW: 0,15122), appr. 80 EUR/case without volume limit for the hospitals.

When analysing the financial mechanism for treatment for DME, wide coverage of diagnostics in Hungary stood up as good practice both increasing access and quality of care respectively (The diabetic ambulance service (the network of diabetic care centres) itself are quite well organized, who are already diagnosed can receive appropriate care, yearly control of the typical complications (among them the blindness), however, it should be recommendable to launch further national early detection campaign of DME (P9). Regarding DME following diagnostic services are financed: detailed anamnesis and basic examination: eye movement examination, digital eye pressure estimation, slit lamp examination, a subjective determination of refraction, ophthalmoscopy, blood pressure, blood lipids, gonioscopy, fluorescein angiography, OCT optical coherence tomography. A good practice influences many treatments in financing healthcare services, where it is possible, in outpatient care. In Poland, the introduction of a so-called drug programme for DME as outpatient treatment (realized by high-quality hospitals) lead to allow to help these patients most efficiently (..)the program is developing, and more and more patients are being treated so access to care is improving (P4).

Highly complicated and relatively low frequency realized procedures should be subject to centralisation (i.e. performed only in a high-quality health centre). In ophthalmology, such procedure is cornea transplantations. Acquiring organs, tissues, and cells for these procedures are the top barriers to access. Functioning tissue banks organising a sufficient number of transplants is the key to covering the demand for treatment. The other thing is payment mechanisms. If the cost of the cornea is the same for all providers DRG must cover the whole cost of the cornea and the cost of the medical procedure, as in Hungary (The DRGs on cornea transplant cover the following interventions and activities: costs of extraction of donor cornea, detailed anamnesis and basic examination: eye movement examination, digital eye pressure estimation, slit-lamp examination, subjective determination of refraction, ophthalmoscopy (P10). In Poland, there are tissue banks financed from public sources (i.e. the cornea is given for free to the provider) and tissue banks that do not receive public financing, so the cost of the cornea has to be covered by a healthcare provider. Separating the payments for cornea from the payments for transplantations was an important step towards increasing access to this service by covering costs for those health providers that procure cornea from commercial cell and tissue banks if they do not receive cornea from the public ones. Such financial incentives were implemented in Poland. We should conduct about five thousand surgeries per year, we do about 1200. The longer patients wait, the more invasive transplantation, hence more complications, and higher costs for everyone. There are mechanisms to gather cornea and incentives for gathering cornea (P4).

Financing schemes can also influence the quality of treatment. In this type of action, some incentives were identified the same for several types of ophthalmological diseases. The most common were procedures to centralise care in high-quality healthcare centres. This was a case for special glaucoma surgery and vitrectomy in Hungary (provided by the four Medical Universities, and in some other county hospitals), AMD and DME in Poland (separate contracts for hospitals performing certain conditions), and cornea transplant in Hungary and Poland. (For some procedures, like for glaucoma, it would be good to have centralization, for those that are rather rare, not in thousands, so that we have highly specialized centres to deal with these rare or more complicated cases. [corneal transplantation] It should not be centralized because we need too many transplantations (P4). Several factors would be highlighted for the concentration of special and very expensive treatments and surgeries: the composition of the team, the improving organizational culture, and team building, the learning curve of physicians, and economies of scale all can contribute to a better cost-effectiveness and higher outcome (P9).

For cataract treatment, it was stated that mechanisms ensuring flexibility of payment are good practices for increasing better access to treatment as they are the best way of matching patient needs (The ideal patient pathway: to detect the problem at a lower level, in any secondary care provider let’s be in a smaller city, county hospital, or University Clinic outpatient department. After receiving the referral to the surgery centre the patient must be diagnosed, and examined to the patient should be thoroughly, to decide about the best available and appropriate lens, soon there be a discussion and agreement with the patient about the best option and its financing if it needs additional private payment (co-payment) (P8). In both analysed countries we found some mechanisms of that kind. In Poland, the price for DRG groups is adjusted by a factor of 1.25 when using toric lenses or iridial lenses (implemented in 2018). This 25% additional payment is aimed at covering the difference in costs between “classic” lenses (covered in DRG price) and toric/iridial ones. In Hungary, there has been introduced a new DRG group (since 2014) dedicated only to the costs of surgery. Hospital material, hotel costs, and human resource costs are reimbursed by the public third-party payer (NHIF), while the cost of a new lens implant is paid directly by the patient. So, the patient can choose between a whole public payment (cost of the lens included in DRG price) or part public payment (cos of the lens is covered by out-of-pocket payment).

Quality indicators measured while providing healthcare services and making them publicly available result in better healthcare outcomes. In Poland, such indicators were added to the DRG scheme. When reporting cataract DRG healthcare providers are obligated to report an assessment of surgeries. Three indicators are reported with DRG (to each patient case): posterior capsule rupture, endophthalmitis, and change in visual acuity. Especially vision impairment measurement (before and after) surgery appeared to be a patient-choice sensitive indicator.

Also, the definition of financial products can influence the treatment quality. The most important practices identified by our research team were payment for each injection separately and financial products for evaluation of achieved outcomes. Payment for each injection imposes elasticity for treatment conditions for each patient. It is implemented in Poland and Hungary for AMD and in Poland for DME. The change in financing with the fee-for-service payments in 2021 can contribute to greater flexibility in adjusting the treatment scheme to patients’ needs and coverage of providers’ costs linked to the treatment. It also enables greater monitoring and keeping up with the clinical excellence guidelines. In Poland, the quality of care was also assured via new financial products to cover the cost of evaluation of achieved health outcomes during a follow-up consultation after the end of treatment.

Good practices in financing ophthalmology care to be proposed for implementation in Ukraine

The analysis of good practices of Poland and Hungary and the expert opinion of ophthalmologist-surgeons, representatives of the National Health Service as a purchaser of services, and the heads of health care facilities from the public sector in Ukraine showed that the best practice for Ukraine among those proposed by this study, which can be implemented into routine practice at the moment, is separate payment for lenses for the treatment of cataracts. Experts consider separate payment or even co-payment for standard or more individual (rare) lenses as good practice to adopt. The Programme of Medical Guarantees covers most costs, including diagnostics, consumables, surgery, and basic lenses. One of the experts noted the following: These are very rare lenses, so only co-payment or even full payment for lenses because the state cannot cover all lenses, especially such individual ones (P11). The plans for 2023–2024 include a review of pricing and allocation of individual services or medical products for which the patient will have to pay separately: Right now, we are preparing a more detailed list, which will, as it were, break down the general services to understand that we cannot now fully pay for Programme of the Medical Guarantees. These services will be included in a separate Cabinet of Ministries Decree, which will be supplemented with a list of paid services. It will be clearly understood what the state pays for and what it absolutely does not cover by state budget (P14).

The proposed practices for cataract, which relate to financing under the DRG, quality indicators for DRG, and limits, were classified as good practices and partially supported by Ukrainian experts, since the financing under the DRG is only being implemented in Ukraine, it is difficult for experts to predict what changes will happen soon since these processes depend on the adoption of relevant legislation and the introduction of relevant changes in financing system. Thus, it was difficult for the experts to answer about good practices such as a decrease in DRG payment in case of a low share of one-day treatment, because two funding mechanisms are currently being implemented, one-day treatment under the Programme of Medical Guarantees, and the DRG financing system: Currently, all ophthalmology is carried out in outpatient settings, or it is 1-day surgery. In rare cases, the patient may be hospitalized (P12). Experts do not know how the healthcare system will be related to DGR soon.

However, different package prices for three lens types as a good practice for cataract was not supported by experts: Due to the high specificity, a very small percentage of toric and aniridia lenses are used, some fractions of a percent, so no, it is better to cover average used lenses. The specificity of lenses for these patients is very high, there are very few of them…These lenses are very specific, sometimes even individual, and their production can be more expensive than the expected social result, so I don’t think that covering from the budget is appropriate to these types of lenses (P13).

Unequivocal support from the ophthalmological community was received for the good practice of Poland and Hungary in the maximum expansion of the National list of medications (both original medicines and generics) for the treatment of glaucoma. Experts from Ukraine also consider that it is necessary to expand the "Affordable Medicines" reimbursement program and add absolutely all medicines of various classes used for the treatment of glaucoma (P13). This is justified by the fact that glaucoma as a disease has a significant burden on the state because if it is detected or started treatment too late, it can lead to absolute blindness, and therefore increase the level of disability from glaucoma (P12). The experts supported a good practice as wide coverage of diagnostics for DME and ADM: Screening programs are needed, because these are the diseases that, in suppressed stages, can carry a social burden for the state and increase disability due to blindness (P14). ‘There is no systematic screening of the early stage of AMD. Early diagnosis and early treatment would result in a better outcome (P9). Overall, it can be said that in Hungary there is no national protocol for the organization of early detection and effective treatment of AMD among the rapidly aging population. It was also said that primary care prevention in ophthalmology is usually more expensive than treatment; it is very expensive to cover from the state budget, but screening programs are possible to implement (P10). AMD and DME screening programs are needed because these diseases can carry a social burden for the state and increase disability due to blindness. International standards of treatment are supported in the country, including following the rules of primary diagnosis, but perhaps the government and the Ministry of Health should pay more attention to screenings (P15).

Financial products for evaluation of achieved outcomes and payment for each injection, including the biological treatment anti-VEGF, separately were recognized as good AMD and DME practices that should be implemented in Ukraine after the adoption of necessary legislation. Experts noted that medications for the treatment of AMD and DME are expensive, so none of them are sure whether patients will be able to cover all injections out of pocket, and whether the state budget can cover everything. Perhaps it is worth periodically launching local state programs, within which such medicines would be purchased in regions or state clinics with the highest demand (P14). Also, it is necessary “to expand the state list of medicines due to their high cost to increase access to services (P12). As a result, the implementation of this good practice should be postponed.

Cornea transplantation is currently not included in a separate package of the Programme of Medical Guarantees, because such surgery is still very difficult to cover fully (P15). However, it is conducted within the "Surgery for adults and children in hospital" package, as it is a high-tech surgery. This package covers all examinations, surgery, and partial consumables. Transplantation in Ukraine is already performed only in specialized centres, particularly in Dnipro, Odesa, and Kyiv, and it cannot be otherwise, because the patient must be prepared by all standards (P15). Experts found the functioning of tissue banks and separate payments for procedures and cornea as a good practice, but at the legislative level, there is currently no permission to take corneas from commercial cells and tissue banks. There is permission both to use only state banks, but the quality of the cornea is not high (P13), and to conduct transplantation from a posthumous donor. Of course, functioning tissue banks to have sufficient transplants is a good practice, but Ukraine must first develop a legislative framework and all the conditions for conducting high-quality corneal transplantation (P12). Some experts said that there is support for implementing a separate package of medical guarantees for transplants, but the circumstances in Ukraine currently do not provide a clear framework for realization.

The system of providing medical services is currently constructed in Ukraine in such a way that surgery for almost all nosologies is performed at the inpatient level or as a one-day hospitalization. Therefore, experts from Ukraine did not support dedicated centres for surgeries of all nosologies as a good practice to be implemented in Ukraine. To implement such a practice, it is necessary to change the approach and system from the legislative level, which is currently difficult and almost impossible in the current conditions.

During the interviews with experts, it was revealed that it would be a good practice for Ukraine to perform vitrectomy surgery in specialized institutions to increase quality, which also provides greater opportunities. At the same time, experts doubted that such good practice will improve the quality of vitrectomy services in Ukraine. It is commented by the following: This is a good practice, but in our country, everything is regulated by certain laws and decrees (P12). Implementing these good practices requires significant legal work upfront.