Macedonia: It is time to introduce minimal co-payment at the visit to GP 

Under the conservative estimates the expenses of one primary health care organization consisted of team of doctor and nurse are around 92 000 denars (1500 Euro) 92000;

Majority of the general practitioners earn less compared to their colleagues employed in the public (state) health sector;

There is need to revisit the capitation formula and to assess the possibility to introduce minimal co-payment at the visits to GP’s;

(28 June 2012) - Introduction of capitation as a new way of payment for the primary health care doctors in the Republic of Macedonia was one of the most politically courageous reform step that was ever implemented in the process of transition and transformation of the Macedonian health system. In short period of four months from September to December 31st 2006 the whole process of privatization of the primary health care was completed and doctors previously paid by fixed and guaranteed salary, shift to receive income according to the number of patients enrolled at their lists. Introduction of capitation at the outskirts was followed by dilemmas how much general practitioners in fact earn. To ones, their income was overvalued; to others it was low and not realistic. Although the value of the capitation point has not been changed over the past 10 years, the dilemma if the GP’s earn “too much” still exists. conducted survey among GP’s who work in the Republic of Macedonia to estimate how much they earn, compared to the expenses they have.

Our survey suggests that one team in the primary health care sector, consisted of GP and medical nurse on average has around 92 000 denars monthly expenses. This calculation does not incorporate variable expenses that are much different between the providers. The GP’s or chosen doctors – who undoubtedly belong to the group of entrepreneurs have real expenses for the investment in their facilities, and are under constant pressure of sanctions by which health authorities (Health Insurance Fund) monitor their work. Ideally, if one Primary Health Care Provider comes under the estimated monthly income of capitation according to our calculations of 111 972 denars or 1820 Euro (1 euro = 61.5 denars) and if there are no other additional expenses such as sanctions, loans, etc., the provider may have at its disposal maximum of 20 000 denars for development, investments and other activities. This estimates are under the condition salaries to remain 20 000 denars (325 euro) net for the doctor, and 14 000 (225 euro) net for the nurses. These salaries are lower than the existing salaries of doctors and medical nurse employed in the public sector.

Main complains of the doctors in relation to their income are: the value of the capitation point, delay in payment of the capitation, weighty administrative procedures, and frequent visits of patients even when this is not needed.

GP’s testimonies: 

I work everything, but not as a doctor and I do not feel like a doctor. Patients tell me what therapy I should give them. I need to serve then and to listen what they want, to pleased then because this is written in the contract with the Health Insurance Fund. My examination of the patient in fact is paper work, typing in the computer, and explaining to patients the roles set by the Fund. I get impression that the patients are in deception they receive quality health care services..

I seat all day at my computer and I just print some new reports, schedules, passes”

We are overburdened with administration, and to follow the administrative changes reduce our possibilities to follow the medical updates. It takes two weeks just to learn the Role book for sick leave."

If earlier prior the privatization the doctors who were employed in the public (state) sector, have no worries about how much are the monthly bills for electricity, water, heating, telephone, accountant, printers, tonners and so on, now they recalculate each denar. If earlier, the expenses were common and paid by the “state”, now the expenses are private and the doctors who work in the primary health care pay with their own money. This transformation in the approach towards the work, ownership and doctor-patient relationship, from state owned, towards private sector is the essence and main advantage of the privatization. But to maintain and develop this benefit it is necessary to stimulate and upgrade it constantly by the health authorities. Our survey showed that the GP’s have much more obligations, duties and constant need to balance between income and expenses in their work. This aspect of work is still beyond the scope of the doctors employed in the public sector.

Capitation as reform and way of payment for the primary health care doctors in Macedonia has accomplished most of its initial goals. But, ten years after its implementation there is a need to revisit the existing model and to explore and identify alternatives for its improvement and further development. There are many models where capitation is combined with small copayment at the visit to doctors. The current situation emphasize the need to come up with detailed analysis and simulations of various models of copayment at primary level. It is proved that current model generates many unnecessary visits to GP’s what can be seen by the average number of daily visits by patients as reported by the doctors. Introduction of small copayment at the visit to GP will prevent unnecessary visits, it would increase the quality of the service due to the decreased workload of the doctors, and it would open the possibilities to employ new doctors and medical nurses at the primary health care level. There should be safety nets for certain groups of patients who would be excluded of copayment.

There is need to come up with appropriate balance between the needs of the doctors for decent income, less administration, and the patients expectation for free and high quality health care. The success of the capitation and primary health care reforms should be appropriately awarded by the health authorities. Introduction of copayment at the primary health level is bold and political not popular move, but it seems necessary for further development of the primary health care reforms. The success of the primary health care reforms should serve as example and motivation of the state employed doctors, where reforms have not yet started, or they are not yet completed.

Healthgrouper is web based platform for communication between doctors and offers the patients complete information about doctors and healthcare providers in the Bakans. Healthgrouper conducts surveys in all countries where it is active, in order to make comparative analyses of the conditions in the health systems in the region and improve the quality of healthcare. The results of the surveys are published in the media and available on the following link. Healthgrouper is a registered trademark in the EU Countries.