(EN) General Strategic Plan for the 2013-2015 Term

Strategic Measures for Business Improvement

1.  Fund's General Strategic Plan for the 2013-2015 Term

• provide comprehensive solidary health care available to everyone,
• enhance patient rights and involve their representatives in decisions concerning investment of resources, subject to maximum focus on vulnerable members of society,
• simplify the system by reducing it to an appropriate population, geographic size and needs,
• remove employment barriers in the real sector,
• brand CHIF as a trusted public institution,rationalize the scope of basic insurance, implement additional services in supplemental insurance and introduce health savings as supplemental insurance (so-called 3^rd pillar),
• introduce solidarity model 4: the irresponsible with the responsible,
• introduce a management model that will integrate the national health insurance system in the health care system, vertically and horizontally connected for the purpose of increasing availability,
• develop a secure and high-quality integrated information and communication health care system based on international standards,
• develop a system of trust and partnerships with contractual health care organizations, whose work will be evaluated according to key performance indicators (KPI) and quality indicators,
• financially consolidate the system to for long-term independent viability without relying on the national budget,
• enhance the transparency and publicity of operation by disclosing all decisions and contracts on the portal,
• become involved in European integrations, utilize EU funds, accept and spread best practices and make the system globally recognizable,
• prepare the system for future health care challenges resulting from migrations and ageing of the population and ongoing increase in chronic noninfectious diseases.

 

2. Projects for improving the efficiency of business processes within the Fund

2.1. Planned reorganization The reorganization of the Croatian Health Insurance Fund represents a sort of a reform in the operation and responsibilities of the Fund with respect to defining its internal organization with a new number and arrangement of its organizational units and redefined scope of operation, the method of managing such units, the approximate number of employees necessary to carry out its responsibilities, and other issues relating to its business processes. Particular focus should be put on the list of business processes to establish adequate control and provide a basis for coordinating the practices and actions across the Fund i.e. on the entire territory of the Republic of Croatia. The reform of the internal organization by downsizing certain organizational units and reducing them to a regional level will raise the issue of the necessary number of Fund’s sites, which would ultimately result in decreased operating costs. Such reorganization also includes the process of issuing certain documents through the Fund’s Managing Council, namely the Rules for Fund’s Internal Organization and Job Systematization Rules, which will ultimately result in amendments to its Statute as a decrease in the number of assistant directors is also envisaged. The Croatian Health Insurance Fund is a public institution established under the Mandatory Health Insurance Act for the purpose of providing mandatory health insurance and performing other activities according to the regulations defining CHIF’s operation. Fund’s activities include provision of mandatory health insurance, including rights deriving from occupational injuries and diseases, supplemental and additional health insurance, and the right to time and financial benefits under the Maternal and Parental Benefits Act, as well as activities relating to Croatia’s accession to the European Union. The mandatory health insurance rights include the right to health care and the right to financial benefits. CHIF’s rights, obligations and responsibilities are defined by the Mandatory Health Insurance Act and CHIF’s Statute. On analysis of the present situation, CHIF was found to perform its registered activities i.e. ensuring availability of insured persons’ rights, in its central unit and its area organizational units organized through 20 area offices in the county centers of the Republic of Croatia. 91 branches of area offices were established for the purpose of performing particular activities (+2 remote offices). The provision of mandatory health insurance includes: developing and enhancing health care, providing technical assistance in the exercise of rights and protecting the interests of insured persons, planning and collecting mandatory health insurance funds and paying for services (especially in case of occupational injuries or diseases) provided by contractual health care institutions and contractual private health care professionals, and participating in proposing the scope of health care rights within mandatory health insurance. The proposed organogram is attached hereto.

2.2. Strategic plan to increase efficiency Based on the information received from CHIF’s organizational units, a strategic plan to increase efficiency may be formulated as follows:

A.  Establish an integral office operating system, which must include digital archives. Establishing an integral office operating system primarily includes the required organizational changes to be formally defined in the Office Operations Guidelines. After that, consistent and complete implementation of everything set forth in the guidelines must be ensured. This in particular applies to the following areas:

• consistent use and, if necessary, expansion of an office information system,
• recording all outgoing written documents,
• dispatching all outgoing written documents,
• using an electronic delivery book for internal deliveries – terminate the internal delivery book in paper format,
• consistently define filing of Area Office cases at sites outside Zagreb, as an integral part of CHIF’s office operations,
• establish an integral archiving function including digital archives to reduce the volume of archival materials,
• begin to implement digital archives in the form of a Contract Digital Archives Pilot Project,
• ensure the required human, organizational and technological resources for digital archives purposes,
• where necessary, increase administrative resources by outsourcing them,
• ensure physical space to store archival materials.

B. Analysis and cataloging of business processes. Analysis and cataloging of business processes is a condition precedent not only to the functioning of office operations, but all other processes as well. The analysis to be performed across CHIF must establish the following elements for each process:

• process flow,
• process status,
• process participants,
• types of documents used in the process, their attributes and statuses.

C.  Employee training. Ongoing training of employees must be ensured and appropriate plans need to be developed for such purpose in the following two segments:

• professional training in the area of:
  • office operations and archiving,
  • general procurement, including public procurement as a formal and legal framework,
  • all other technical areas relevant to the operation and successful functioning of CHIF.
  • IT training
• It is necessary to reduce the costs of training for particular IT systems, whether those already procured or those to be procured, which are necessary for efficient functioning of CHIFx.

D. Fulfill all conditions precedent to successful application of the Fiscal Responsibility Act. In practice, this implies successfully performing all obligations within the scope of work of junior management levels and each level up to the top level of CHIF. This segment is particularly relevant to consistent office operations with respect to material and technical activities, resulting in a final document accompanied by all necessary attachments, which will as such be ready to be signed by the Director. The efficiency of internal controls needs to be enhanced for the purpose of obtaining unconditional State Audit findings.

E. Establish an internal procurement system Establish an integral procurement system (public procurement is merely a formal legal framework) including all stages of procurement – development of a procurement plan, its amendments, monitoring its implementation, and disclosing the procurement plan and registry of contracts. The following should be focused on:

• implement strict control of issuing all order forms under contracts and trivial order forms through the existing procurement information system – discontinue manual completion of order forms on pads,
• monitor the implementation of the procurement plan on an ongoing basis,
• monitor procurement procedures on an ongoing basis,
• monitor contract performance on an ongoing basis,
• duly disclose the procurement plan,
• duly disclose the registry of contracts,
• ensure upgrades of the procurement information system to comply with the new Public Procurement Act in force since the early 2012 and aligning with the budget.

F.  Establish secondary records in CHIF and interoperability with records in other TDUs (State Administrative Authorities) The establishment of secondary records necessary for efficient functioning of CHIF includes:

• establishing and informatization of records and charges with noncurrent assets and small inventory,
• establishing and informatization of travel order records, including all phases of their processing and alignment with the budget,
• establishing and informatization of fleet using records (to include records of using ENC, fuel consumption, etc.) and alignment with the travel order records. Technologically enhance these records by using currently available GPS technology installed in vehicles for precise monitoring of all relevant parameters of their use, thus controlling fuel consumption and expenses of using private vehicles for business purposes,
• establishing interoperability with all registries within the health care system (Croatian National Institute of Public Health, Ministry of Health, etc.),
• close alignment with the eCroatia Administration within the Ministry of Administration for the purpose of providing interoperability with public registries (of births, deaths, etc.) and the PIN system.

G.  Advance and improve the HR management function Successful operation of the management function in accordance with the regulations, but certainly in accordance with CHIF’s present and future needs, requires:

• prioritizing activities,
• forwarding a circular notice to all organizational units of CHIF requiring that they comply with all time limits with respect to requests received,
• informatization of the procedure for registering employees sent for professional training seminars outside the Center, so that the information in the registration may be immediately used as a record of attending a seminars,
• making the circulation of requests during processing easier and formatting it.

 

2.3. Development and eHealth projects Through a series of projects, CHIF implements a comprehensive informatization program for the purpose of making the operation of the health care system more efficient. It is an absolute must to implement informatization within the health care system according to the common objectives and the common objective of the overall state administration in accordance with the strategy for the development of Croatian Government’s information and communication system.

A systematically planned and methodologically implemented system prevents the risk of uncontrolled numbers of mutually unrelated parts of the information system (IT equipment, applications and contracts), which inevitably results in excessive spending of funds.

Information systems, whether computerized or in paper format, are essential for effective and efficient operation of health care institutions. Historically, not much attention has been paid to the comprehensiveness and systematization of medical documentation in the Republic of Croatia. Rationality of large IT projects in health care may be explained by two sets of arguments: the need to transform health care projects into information relevant to making key public health decisions and implementing measures in the area of health care economics, and systematic cost monitoring, establishing the potential of rationalization with respect to spending in health care, without reducing the health care levels (funding may be reduced by an estimated 20-30%), and the need to increase system transparency and adjust to the applicable EU standards. An integrated health care system should ultimately have two sets of economic and health care functionalities: creating a centralized public health information system that will allow access to the processes of generating health care spending on a PZZ (health care provider) level, which could be used as a basis for making health economic decisions and implementing the relevant measures and enabling informatization and automation of the process of creating and monitoring the consolidated health care budget including CHIF’s and hospital system’s budgets, and consolidated financial statements of all parties involved in the health care system.

 

Action plan

• conduct a due diligence process, reengineer business processes, and review the coverage of business processes with information and communication solutions, horizontally and vertically across the system. Such business process reengineering is planned  within the BPR process and implies obtaining a loan from the World Bank,
• modernize the predefined functional architecture (2003) and the strategic plan for the development of the information and communication system for the next 4-year period,
• reorganize the IT departments in all system participants (take advantage of all knowledge experience and skills possessed by all capable people within the system),
• coordinate the standards, processes and methodologies (MDD,
• ISO 27001),
• develop a secure high-quality integrated information and communication health care system for the purpose of:
  • centralizing and aligning all parts of the system,
  • allowing collection and exchange of information by and between system participants (eScheduling, eChart),
  • improve support to business processes,• ensure system supervision,
  • improve the system for supporting decision making by health care managing bodies,
  • ensure savings.
  • provide funding to invest in ICT (national budget, EU funds, World Bank) by training and coordinating teams for preparing project proposals and project management.

The information and communication system should ensure long-term functioning and be set up flexibly enough to remain efficient despite all future changes in CHIF’s organization, the health care system, state administration, labor regulations, the environment and Croatia’s accession to the European Union.

 

2.4. Quality management The limit for an acceptable error is dropping in the present highly competitive and changing market. Precise planning for the future is necessary for survival and success and preparations for the future are becoming crucial. Ongoing planning, measuring, assessing and improving of processes, the system and performance are key activities within an organization. With systematic planning and execution, the efforts will yield the intended results.

In the 1980s, when competition became fierce, many corporations across the world started using quality systems, not only in production activities, but also in all other principal and supporting business processes within an organization. Quality management has achieved impressive results in industrial sectors in terms of production process management, customer satisfaction and profitability. The following question arose: is a quality management system applicable to health care? Are insurers, hospitals, healthcare centers, etc. managed according to high-quality proven methods able to achieve new levels of performance, patient and business partner satisfaction, safety, clinical efficiency and cost-effectiveness? Are health care organizations, burdened by complaints of excessive operating costs, variable performance and treatment methods not based on scientific evidence, able to find at least one promising solution to their problems? While answering this question, CHIF will implement its internal Ongoing Quality Improvement Plan project, where Total Quality Management is used as a fundamental management model.

As an organization aiming to provide a high-quality health care service, we must continuously measure, assess and improve our processes in accordance with our role in society.

We believe errors in processes within CHIF are a result of problems already present in the system. Achieving any actual improvement in quality requires thorough knowledge and supervision of the processes based on information derived from systematic process monitoring. In our quality system, improvement is part of each employee’s job. The ultimate responsibility of the Director is determined by the Managing Council. At the same time, joint and several manager liability, as well as statutory regulations and professional codes, are an incorporated human part of the ongoing improvement process. It is clear that the improvement and error prevention measures increase the performance of the processes that previously led to poor results, but it is interesting to observe that the processes that were well managed and performed well in the past are also improving. Our plan will result in a comprehensive organization management system based on a quality management model as a single unit and functions involving all organizational units.

The following information will be used for performance measuring:

• design and assessment of new processes,
• assessment of performance against the basic purpose of each process,
• performance level and stability of important existing processes,
• identification of areas for possible improvement of existing processes defined as a change process achieved by improving the results.

Collected information should also include standards for both processes and results. Collection of information will be based on: the needs and expectations of insured persons and business partners, and the degree reached with respect to such needs and expectations, patient care, efficiency, relevant dimensions and performance of processes and/or results, including clinical and non-clinical elements.

 

Performance assessment In the course of evaluating and validating the processes within CHIF, the analyzed performance factors include efficiency, availability, continuity, safety, respect and care as acceptable standards for the assessment of specific processes. To face this challenges, as already mentioned, our first and foremost principle will be multidisciplinary teamwork. Each team member must be capable of participating in comprehensive identification and resolution of problems. CHIF wants to see each person as part of one or several processes. Each employee’s task is to join his/her coworkers in a process, to add value to the process and to deliver such more valuable task to the next employee in the process. To ensure coordination between units and enable consultation, all organizational unit managers are required to submit quarterly and monthly reports on performance improvements, including initiation of discussion of the findings and future plans for quality and efficiency improvements in their respective areas. The Assistant to the Director of CHIF in charge of the quality system will collect information from organizational unit managers and committees and regularly present it to the management.

Table 1:  SWOT analysis

CHIF’s internal organization and business processes

 

Positive

---

Strengths (S)

• stable business structure
• wide network of regional and branch offices
• complete IT networking system
• many different educational profiles and interests
• sense of loyalty to the company
• people with years-long experience and knowledge
• young people wanting education and professional advancemement
• good relations within individual units (community)
• possibility of fluctuation and job change (Zagreb)
• possibility of internal education

Opportunities (O)

• operation’s restructuring (functional division instead of hierarchical division)
• change of the CHIF’s image (perception) in public
• use of EU funds for education
• use of EU funds for unification and operation’s functional integration (new building?) of the Directorate and the Regional Office Zagreb

 

Negative

---

Weaknesses (W)

• hierarchical vertical structure without cooperation between units (sectors)
• animosities among units (and departments) – who is more important, who works more, whose job is harder
• lack of understanding between units (do not have a common language)
• each unit works for itself and not with the joint objective and interest
• lack of communication (horizontal and vertical)
• slow information flow
• competences overlapping
• lack of internal procedures
• reactive, instead of proactive, action to changes
• employees are lulled into their workplace’s safety
• lack of motivation and indifference
• point of action cannot be seen (vision and mission)
• lack of systematic human resources development (HR)
• lack of the HR Department’s capacity to take over an active role in HR development

Threats (T)

• CHIF’s negative perception in public (negative image)
• excessive influence of the Ministry of Health in the operation of individual units
• frequent changes of regulations
• inability to reward good employees due to legal obstacles
• reduced funding for employees in the Budget
• legal obstacles for new recruitment
• inability to recruit a specific personnel (especially the medical)

It is also to our credit that, gradually, every employee becomes a defender of quality. All of them are willing to contribute to the improvement of the system that is created by them and they constantly move their target limits to keep the continuity of the quality system. The quality management model is described in the diagram (attachment).

 

2.5. New models of health care contracting

Current situation Health care contracting is a procedure in which the funds invested in health care provision are directly linked with the expected result. The main instrument by which, through contracting, the desired effects are achieved is the method of financing (paying) health services and control mechanisms of the health services provision. The method of health services financing influences the motivation of health care providers and patterns of their behavior because all payment methods tend to increase payment units and reduce the cost per payment unit. At this moment there are several methods of health care financing in the Republic of Croatia, depending on the level of health care and activity. Primary health care is paid by the amount per the insured person/per capita, by a standard team and by means of diagnostic-therapeutic groups procedures, while in general family medicine and dental health care additional resources can be obtained by the participation in the work of a general/dental medicine centre and by implementing preventive programs contracted with a health centre. Outpatient specialist-consultative health care is paid in compliance with the List of diagnostic-therapeutic procedures in health activities (Blue Book) and in compliance with diagnostic-therapeutic procedures (DTP). Hospital health care is paid per diagnostic-therapeutic groups (DTS) and per the price of hospital treatment day (DHT) for stationary treatment, and in compliance with the List of diagnostic-therapeutic procedures in health activities (Blue Book) and in compliance with diagnostic-therapeutic procedures (DTP) for specialist-consultative health care.

Disadvantages of existing models and proposals for the contracting model improvement according to health care levels

Primary health care (.elementary 4 activities) - selected physicians

The general family medicine, health care of pre-school children, health care of women and dental health care (polyvalent), in which selected physicians are contracted, are paid by the combination of the amount per insured person (capitation) making up 80% of possible revenues, by means of diagnostic-therapeutic procedures (up to 10% team value) and participation in general/dental medicine centres (do 10% team value).

The amount realized by a general/family medicine team, based on the amount per insured person (capitation), for an average (standard) team or a larger (1,700 insured persons or more) is already due to its own value insufficient not to stimulate physicians for additional performance of diagnostic-therapeutic procedures for the purpose of increasing revenues. On the other hand, the list of diagnostic-therapeutic procedures based on which additional funds can be gained is relatively short (47), and they cannot be carried out by all of them as they have no available equipment (ECG device, ultrasound device). Furthermore, preventive programs, which were supposed to be designed by counties, are missing and preventive procedures are left to be carried out by individuals (depending on their time and affinities, without special valuation).

The control of general/family medicine teams’ operation boils down to controlling of sick-leaves and prescription drugs issuing, in compliance with the guidelines, as well as charging for procedures that were not supposed to be charged, without the real effects control and quality control of the provided health care.

New model of contracting (financing) of the primary health care

In the part referring to selected physicians, the new financing model shall include several segments:

• fixed amount for the team, which enables the team’s existence in the Public Health Service Network (cold standby operation),
• funds based on committed insured persons (capitation), whereby that amount shall be lower than today (since it is not the basic source of funding) and in order to stimulate the performance of diagnostic-therapeutic groups and preventive procedures,
• funds based on provision of diagnostic-therapeutic groups procedures (or the price times service), whereby the scope of services shall be greater (more procedures), but some procedures shall be limited, not to perform only some procedures, while some procedures (the performance of which wants to be especially stimulated) shall be unlimited (delimited),funds for performance of preventive procedures, whereby the group of preventive measures shall be established of which some shall be compulsory and some optional, i.e. selected physicians shall according to their affinities, additional education finished or population taken care by them, chose which preventive activities they shall perform. Preventive activities shall be paid only in case when the intended coverage of population is achieved (e.g. it is not paid if the covered target population is lower than 60%),
• additional funds based on quality indicators, i.e. key performance indicators (KPI) to be determined in cooperation with the profession,
• stimulation of group practice, in the way that additional funds shall be allocated to the teams grouped in group practice. Group practices may be formed of physicians of the same or various activities, (advantage of group practices is the complete care for insured persons and joint use of medical equipment, for example ultrasound device. Group practices of the same activity continuously take care of insured persons for a full working day),
• additional funds shall not be automatically allocated to the teams not having many insured persons due to their location is specific areas (islands, areas of special state concern), but they shall have to (in cooperation with a health care unit) design and carry out health care programs that shall be specially paid per performance.

Control of operation of primary health care teams shall be focused on effects control because the performed also impacts the amount of funds to be paid to the teams (paying for performance). In view of this, the control shall be primarily based on pre-established reports that shall be generated from so called G2 (Gx) system, but shall be easily verifiable by the Fund’s authorized person in order not to abuse the system.

Quality control shall be integral part of primary health care control, which shall primarily involve the application of health service quality standards established for this level of health care.

Hospital health care with specialist-consultative health care

Hospital budgets or maximum amounts for funding the implementation for health care from compulsory health insurance are based on so called historical data or historical budgets as far back as to 1997, when they were first introduced and are, depending on available funds from the State Budget, linearly increased/reduced with slight deviations of individual hospitals without clear criteria.

• At the same time, these budgets are justified by personal invoices, first through the List of diagnostic-therapeutic procedures in health activities (Blue Book), then with the Blue Book through the payment per therapeutic procedure (PPTP) and as of 1 January 2009, acute treatment exclusively through diagnostic-therapeutic groups (DTS), and chronic treatment through day of hospital treatment (DHT).

In order to justify their budgets and achieve even greater ones, the hospitals within the DTS system, and even before that through the Blue Book and PPTP, have been artificially increasing their budgets by exceeding the threshold price. On the other hand, what happens is that hospitals for chronic diseases and the ones for medical rehabilitation treatment, due to the high level of DHTL, know in advance that they cannot achieve the budget i.e. that they would exceed the budget.

Paying the same price for the same treatment to all hospitals seems fair, but the inequality occurs due to the fact that hospitals have different operating costs (cold standby operation) and the real cost per patient is higher. In addition, the number of procedures that are purchased is not fixed and hospitals, when it comes to so called cold procedures, can focus on the ones that make more money and spend less resources.

New model of contracting (financing) of hospital health care

Maximum funds of hospital health institutions shall be based on several criteria (similar as the primary health care teams), but the payment itself shall be executed depending on the case and performance indicators:

• basis for the calculation of maximum funds:
  • fixed amount, given the cold standby operating costs
  • amount per insured person (capitation), given the gravitating number of insured persons in a specific county, and in the counties with several hospitals given the gravitating number of insured persons in a specific hospital,
  • amount for specified cold procedures related to long waiting lists (hip endoprosthesis implant, knee endoprosthesis implant, cataract surgery, arthroscopy and similar),whereby hospitals shall be able in the contracting process individually propose  the procedures of interest, which shall be specially monitored and paid,
  • amount for specialist-consultative health care, given the offered activities and foreseen number of procedures in these activities.
• basis for payment and reduction of funds:
  • personal accounts for hospital and specialist-consultative health care, whereby the value of DTS shall be significantly reduced for acute treatment and differentiated given the complexity of individual procedures (revision of DTS system),
  • amount for capitations shall be reduced if the hospital does not provide for the target share of population in the care from its county,
  • amount for performance of contracted cold procedures shall be reduced if the contracted number of procedures is not achieved,

• amount for specialist-consultative health care shall be reduced if the target number of procedures is not carried out.
• basis for the funds increase:
  •  key performance indicators (KPI) as a measure of quality control, such as:

a. length of bed-rest for specific procedure,

b. ratio change of patients handled through the daily hospital in relation to patients resting in bed,

c. consumption on medical consumables and implants as well on drugs for individual DTS group (savings indicators)

d. number of re-hospitalizations,

e. reduction of waiting list length for determined procedures,

f. attracting patients from its own county (increase of patient number from its own county that are treated in the county  hospital, and reduction of departures to other counties) shall be the basis for hospitals benefiting, i.e. funds increase.

In addition to above stated payment models, hospital category shall also be one of the criteria in funds allocation, so that hospital of the same category would have approximately the same revenues. It is expected that the same level of health care in hospitals of the same category requires approximately same resources, given the health issues taken care of. Therefore the implementation monitoring shall also be focused on hospitals comparison according to ca­tegories.

Control of hospitals operation shall be focused on performance control as the payment of hospitals shall depend on it, and special attention shall be focused on the control of length of waiting for the first specialist examination and for specific diagnostic and therapeutic procedures (CT, MR, heart ultrasound, ergometry, Holter monitor, mammography, breast ultrasound, gastroscopy, colonoscopy...). The control of hospitals operation shall also include the control of primary health care operation and control of operation in a specific area – by means of the number of emergency checkups in specialist-consultative health care and admittance in hospital health care and ratio of selected physicians’ referral slips and specialists’ (internal) referral slips.

 

Quality control of hospital health institutions

Shall be focused on the control of establishing the quality control system in hospitals, as well as monitoring of internationally known and recognized quality indicators of hospital health care that are easily collected and are comparable (e.g. optimum use of resources – number of patients in a time unit, per physician or per bed time for individual diagnostic/therapeutic procedure, beds occupancy, rational (efficiently) use of funds – average treatment costs of specific cases, share of a simple in relation to several days-long surgery, hospital infections – consumption of reserve antibiotics...).

Hospitals shall be enabled to check their position in relation to other hospitals, which shall stimulate them to improve the quality of provided health care and consequently to improve the quality of the entire health system.

 

(Re)organization of hospital health system

The analysis of previously stated indicators, gravitation of insured persons to hospital health institutions especially in relation to hospital categories, i.e. use of resources, shall be the basis to measure hospitals efficiency and profitability in given circumstances. This may lead to the reorganization of hospital health system, in terms of further centralization of hospitals, in order to reduce operating costs, but also in order to improve health care quality.

At the same time, changes are expected in the way that specialist physicians of one hospital (of a specific, most frequently surgery specialty) in which too low volume of surgeries are performed to be able to achieve excellence (skill and quality) in their activity and that at the same time present a bottleneck for certain procedures, are moved to other hospital health institution, in which they can perform several surgeries, whereby the skill and excellence are achieved and bottlenecks for certain procedures are simultaneously reduced. In addition, by performing several procedures in one institution, due to economies of scope, costs per a single procedure shall be reduced.

 

Regionalization of health care

At this moment, health care is organized according to the county-based territorial organization at all levels and in all activities (primary and secondary health care). Only the tertiary level (clinical institutions) is formed regionally and there are five clinical hospital centers, of which two are in Zagreb, so that it can be said that in relation to clinical hospital centers in the Republic of Croatia there are four health regions. However, activities are not equally developed in all clinical hospital centers.

In contrast, all counties with their county hospitals operate independently without special cooperation. In addition to hospitals, each county also has its public heath institutes, significant for monitoring of the population’s state of health, health statistics, but also of microbiological activity. Public heath institutes are completely independent institutions and are not responsible to the Croatian Institute for Public Health. In individual counties, microbiological activity is carried out both in the Croatian Institute for Public Health and in a hospital.

• In this way, with such fragmentation and lack of cooperation between health institutions, costs of health care and increased and it is necessary to regionalize the health system for the two basic reasons:
  • integrated patient care
  • reduction of health care costs.

Integrated patient care implies that it is known in the system, starting from the primary contact physician, where a patient goes and to which health institution s/he belongs, instead of letting it to his or her personal ability to handle the system. Health care costs reduction is achieved by functional organization of activities on a regional level and by the consolidation of medical material purchase.

 

2.6. Financial consolidation of the system

Liabilities of health institutions and the CHIF were reviewed as of 31.12. 2011, in relation to the application of the Time for Performance of Pecuniary Obligations Act. Health institutions present their liabilities according to contractual payment terms to suppliers. The CHIF negotiates payment terms with health services providers for the services of insured person treatment and other rights resulting from the Compulsory Health Insurance Act. The total liabilities of all health institutions as of 31.12.2011 were HRK 5,055,984,429 (state-owned institutions, owned by the city or county).

Total liabilities of hospital health institutions as on 31.12.2011 are HRK 4,227,839,947. Liabilities exceeding 60 days are HRK 2,546,882,348.

The CHIF’s liabilities towards contracted partners, exceeding 60 days are HRK 1,539,489,564. According to the interview, the Ministry of Finance would provide the funds to cover liabilities exceeding 60 days from 2011, whereby the payment deadlines in 2012 would be brought to the set limits, i.e. the deadline for its implementation is by 30.10. 2012.

 

Table 2: Liabilities of health institutions

Tables present the plan of system consolidation and the financial plan and projections