The rules for financing the health service within the framework of outpatient specialist care has been created to motivate specialists to diagnose and treat patients instead of referring them for hospital treatment.
Before, the specialist had a fixed rate for a medical consultation. The current settlement system provides that the appraisal of the appointment depends on the actions taken by the doctor during that time, e.g. a test referral.
Appraisal of the consultation by NFZ
The current system of financing outpatient specialist care has been in force since the middle of 2011.
The National Health Fund has set categories of consultation and the tests referred for which a certain number of points is given. Moreover, each point has a fixed rate.
As NFZ press office states, the average price of a point in outpatient specialist care amounts to approx. PLN 9.
In case of the number of points for a consultation with a specialist within outpatient specialist care (OSC), the rule is simple, as the Fund explains:
- Specialist consultation (without test referrals): 3.5 points (approx. PLN 35)
- Specialist consultation + referral for tests: from 5 to 52 points, depending on the type and number of tests);
- Comprehensive consultation (the first appointment comprehensively assessing the patient’s state of health): from 6 points (without test referrals) to 26 (depending on the tests referred);
- Post-hospitalisation consultation (consultation conducted in a hospital outpatients’ clinic within a period of 30 days from the end of the hospital treatment): 4 points;
Such principles are the basis for appraising consultations by a specialist, such as cardiologist, endocrinologist, orthopaedist, ophthalmologist or pulmonologist.
“The more test referrals the more cost-inducing the service, the higher the appraisal" NFZ emphasises. Whereas a specialist consultation without referral is 3.5 points, i.e. approx. PLN 35.
Motivation as the core of financing the OSC system
Such an OSC-financing system was introduced in order for doctors, instead of sending patients to the hospital for diagnosis, to refer for a test in an outpatients’ clinic. Hospitalisation is much more expensive than doing the test or diagnosis in the outpatients’ clinic.
NFZ aims to move more and more services which are being done as part of hospitalisation to OSC operatories. The Fund is changing, i.a., their appraisals of these services which may be performed in the outpatients’ clinic, so that service providers do not find it “more profitable" to perform them within hospitalisation.
OSC services financed by NFZ may be implemented only by centres and practices which have signed an agreement with the Fund.
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