Primary health care in Slovenia: Alternative payment models as a possible opportunity for further integration of health care

Abstract

Since 1926, the primary health care system in Slovenia has been developing on its own successful path, which has from the very beginning included some elements of integrated care. Despite the continuous changes that occurred in the last 30 years in Slovenia (population 2 million), it is still based on primary Health centers (HC) complemented by primary and secondary level privately owned solo practices. The legislation describes HCs as health units owned by one or more municipalities that provide basic health care in the area of one or more of them. In contrast, regional hospitals and tertiary clinics are mostly owned by the state. HCs have by now developed into comprehensive multidisciplinary centers of primary health care supposed to serve an average of 50,000 people, depending on the geographical and demographic circumstances. According to the Health Care Act, HCs must provide medical and dental care, pediatric and gynecological specialist services, emergency medical assistance, outpatient services, physiotherapy, laboratory and other diagnostics, as well as health prevention and education in their geographical areas. Many HCs have established mental health centers, children's mental health centers and health promotion centers. HCs must provide an ambulance service if it is not organized in a hospital. As a rule, above activities take place in the same physical location, which makes the use of health services very easy for the local population. The primary level also includes pharmacies, which are often located in or near the HCs.
 In every HC family medicine teams include a specialist, an intermediate nurse and a part-time graduate nurse, who actively takes care of preventive examinations of the target population of patients (that is, for people over 30 years old) and for the comprehensive treatment of patients with chronic non-communicable diseases. Family medicine teams are supposed to treat adult patients with efficient and comprehensive care using the dispensary method of work.
 The Health Insurance Institute of Slovenia finances the activity of HCs with capitation fees (75%) and with fees for services (25%). The activity of acute hospitals, on the other hand, is financed mostly by the DRG system. There are no bundled payments or global payments, although there are efforts to start the implementation of payments based on outcomes of care. 
 As a rule, HCs in Slovenia guarantee services and their providers to patients in one physical location. However, health care can still be considered as hyper-fragmented. In particular, the information support available is not developed enough. The patients’ documents are only partly stored in electronic form without any horizontal or vertical connection between them. There are no electronic health records. The organization and geographical spread of the HCs represent an excellent opportunity for the integration of care, which should be encouraged by payment models such as bundled payments and global payments with population management.