“In the case of scheduled surgeries, the state funds not 70% of the medical facility costs but 70% of the price as established by the state.”
The governmental team said that the availability of healthcare, namely the Universal Healthcare Programme, is one of their main achievements. On the same programme, the former Minister of Labour, Health and Social Affairs, Zurab Chiaberashvili, spoke about the flaws in the Universal Healthcare Programme. For instance, he reviewed the method of funding scheduled operations and said: “In the case of scheduled surgeries, the state funds not 70% of the medical facility costs but 70% of the price as established by the state. Therefore, if one goes to a high quality, good clinic in which the operation cost may twice exceed the price as established by the state, the price is still 70% of the price as established by the state and, in reality, the co-financing from the state may represent 30 or 40%.”
FactChecktook interest in the principles guiding the finance of scheduled operations within the framework of the Universal Healthcare Programme and verified Zurab Chiaberashvili’s statement.
The implementation of the Universal Healthcare Programme began on 28 February 2013. The second stage of the Universal Healthcare Programme started on 1 July 2013 as the Programme was expanded. The citizens of Georgia who do not possess any other insurance package benefit from the Universal Healthcare Programme.
According to Resolution No. 36, the Universal Healthcare Programme reimburses:
- Scheduled ambulatory service by 70% and the service of a family doctor and basic laboratorial analyses – by 100%;
- Emergency stationary service (limit for a single accident – GEL 15,000. Reimbursed by 70% and sometimes also by 100%);
- Scheduled surgical operations and associated tests (annual limit – GEL 15,000. Reimbursed by 70%);
- Treatment of oncological diseases (annual limit – GEL 12,000. Reimbursed by 80%);
- Childbirth (within GEL 500) and caesarean section (within GEL 800);
- FactCheck has written about the Universal Healthcare Programme before (see the article). In this case, we concentrate upon scheduled surgery operations.
We learned more about scheduled operations from the Universal Healthcare Administration Department. The Ministry has worked out a special formula for calculating the cost of a scheduled operation. The Universal Healthcare Programme funds 70% of this price. Specifically, the cost of scheduled operations is calculated in the following way: (maximal cost - minimal cost)/4 + minimal cost. The minimal cost is added to one-fourth of the difference between the maximal and minimal costs. The limit is 70% of the cost as calculated by the aforementioned formula. In the case if the price in the clinic is lower than the price as determined by the state, then the Ministry covers 70% of the operation costs without any additional calculations.
Let us say, for example, that the lowest price for one particular surgery among the clinics participating in the Universal Healthcare Programme was recorded at Clinic A – GEL 1,000. The highest price for the same surgery was recorded at Clinic B – GEL 1,600. In this case, if the patient undergoes surgery at Clinic A, he will get funding equal to 70% of the clinic price which is GEL 700. Let us see, according to the formula, what percentage of the patient’s surgery cost would be covered if he underwent the surgery at Clinic B: (1,600 – 1,000)/4 + 1000 = 1,150. Thus, he will get funding equal to 70% of GEL 1,150 which is GEL 805.
The clinics participating in the Universal Healthcare Programme are required to publish the respective costs of their medical services as defined by Resolution No. 36. The prices are updated upon a monthly basis and the tariff range (the prices as defined by the Ministry) is revised once per month.
It should also be noted that in order to receive funding for scheduled operations, the users of the Universal Healthcare Programme should address the service centres of the Universal Healthcare Programme. The maximal length of the waiting period is two months.
Conclusion
Within the framework of the Universal Healthcare Programme, the Ministry of Labour, Health and Social Affairs has worked out a special formula for calculating the cost of a certain scheduled operation: (maximal cost - minimal cost)/4 + minimal cost. Scheduled operations receive funding equal to 70% of the cost as calculated by this formula.
In the case if the price of the operation in a clinic is lower than the price as defined by the Ministry of Labour, Health and Social Affairs, the patient receives funding amounting to 70% of the price as defined by the clinic and not by the Ministry.
FactCheck concludes that Zurab Chiaberashvili’s statement: “In the case of scheduled surgeries, the state funds not 70% of the medical facility costs but 70% of the price as established by the state,” is TRUE.
