The Universal Healthcare Programme attracts substantial criticism – sometimes it is justified, at other times less so. However, there has been a lack of detailed reviews and reports containing evidence-based and substantiated discussions of the issues surrounding the programme. In October-December 2021, two non-governmental organisations conducted a study that examined the attitudes of different stakeholders towards the existing service tariffs under the Universal Healthcare Programme (UHP) as well as the ongoing pricing process. The aim of the study was to gather evidence and describe the problems related specifically to UHP tariffs. The study was conducted using a mixed methodology consisting of desk research, qualitative research, and quantitative research.
Below we will share several important findings of this study that we would like to see discussed in front of a wider audience.
The process of determining the costs of medical services under the Universal Healthcare Programme is not transparent. Specifically, different respondent groups have different views regarding the transparency of the process: State employees believe that the pricing policy has been transparent and that providers have been involved in the pricing process. In turn, providers and public health experts state that while there has been some communication with stakeholders, the pricing decisions have been made unilaterally by the ministry based primarily on the programme’s budget. More importantly, the ministry has never employed an official pricing methodology. Some experts believe that the decision-makers have avoided setting a clear methodology that would place the pricing process within a certain framework and limit the ministry’s room for manoeuvre in case of unforeseen challenges.
Prices have essentially remained unchanged since 2013. Providers openly state that the current low prices threaten the financial sustainability of medical institutions and the quality of their services. In truth, the prices put in place in 2013 are inadequately low. Since then, a number of changes have been made in an attempt to further lower prices, with particular focus on the Ordinance of the Government of Georgia N520 from 2019 and its subsequent negative impact.
It may seem that these problems do not concern ordinary Georgian citizens, but in the long term, they will affect the quality of medical services provided to patients. The planning process for each and every issue must take the best interests of patients into account. Despite increased state spending on healthcare, Georgians still pay a large share of their medical expenses out of their own pocket. The percentage of patients who are pushed into poverty by high medical bills is growing. All respondents stated that buying medicine constitutes the most serious financial burden for patients. The government does not normally regulate or control service prices. It is therefore difficult for patients to know exactly what they are paying for, often leaving them confused.
There are also conflicting attitudes towards Ordinance N520. Most private providers and experts insist that the fixed tariffs proposed by the government for certain intensive therapy services and cardiac surgery in 2019 only served one purpose, namely, to reduce budget spending. Other risks, such as service quality and the financial sustainability of hospitals, were not considered. On the other hand, ministry employees believe that the initial dissatisfaction of providers with Ordinance N520 has already subsided and that the sector is constructively working with the ministry on a pricing policy that will gradually be implemented in other fields as well.
There is also a lack of clarity regarding the introduction of diagnosis-related groups (DRGs). According to the Ministry of Health, gradual implementation of DRGs has already started, while experts are complaining about delays in this process. Moreover, the ministry’s decisions regarding the need and the timeline for wide implementation of the DRG system are currently unclear.
The study also shows that inadequate tariffs may create negative stimuli among private providers. Notably, none of the respondents opposes the pricing process, but providers and experts want the process to be transparent and involve all stakeholders. Most providers and experts believe that the pricing process should not focus blindly on reducing tariffs. Instead, there should be a rational evaluation of quality medical services with a clearly defined pricing tool.
During the survey, respondents expressed several views in the form of recommendations that are summarised below. Further details can be viewed in the report itself.
- Implement the recommendations issued by local and international experts simultaneously and promptly;
- Continue implementing planned strategies in the following areas: a) Devising a uniform pricing policy; b) Implementing the DRG system; c) Selective contracting; d) Implementing the primary healthcare reform guide;
- Devise long-term policies for healthcare;
- Review the UHP design: What types of services will be funded by the government, to what extent, and through which copayment system for different sections of the population;
- The programme design should encourage, rather than prevent beneficiaries from purchasing insurance packages;
- Replace the programme administrators and introduce a level of intermediaries who will be responsible for service utilisation management (independent third parties or people acting on behalf of insurance companies);
- Improve UHP management, quality control and monitoring; devise relevant and specific KPIs for evaluating (among others) the effectiveness of primary healthcare; analyse ambulatory care sensitive conditions (ACSCs);
- Analyse the outcomes and forecasts related to Ordinance N520 and revise them accordingly;
- Settle on an official pricing methodology; • Give patients the right to choose (balance billing) under the condition that the state will set the upper price limit on services by codes;
- Use the state negotiating authority to purchase expensive medical equipment and optimise costs through consolidated tenders;
- Manage human resources and find the right balance between the services of expensive doctors and medium-level medical personnel.
We believe that the information gathered from the survey and the recommendations voiced by stakeholders will act as a catalyst for an open dialogue that will help improve public and private partnerships. Only a transparent and inclusive process of policy dialogue and decision-making can find common ground in the interests of the population, the state, and the private sector, as well as realise the country’s aspirations for universal healthcare through rational, evidence-based, and balanced policy changes.
