**2. Structure**

#### **2.1 Financing**

The financial and economic crisis starting in 2008 significantly affected Slovenia. The crisis resulted in a severe economic contraction of 7.8% of real gross domestic product (GDP) in 2009 in comparison to 4.4% across the EU28. After 2013, GDP grew continuously. According to Eurostat database, Slovenia's GDP increased for 47.1% in a period 2005–2017; in 2017 reached 43 billion EUR. In comparison, in the same period GDP of EU countries increased for 32.6%.

Total health expenditures (THE) as a percentage of GDP have been increasing steadily since 2000. In 2000 they amounted to 7.8%, and then increased to 8.8% in 2013 and start decreasing thereafter, reaching 8.21% of GDP in 2019. The main explanation for the decrease was the strong growth of GDP after 2013, which was not followed with the comparable growth of THE.

Three main sources of financing the healthcare system are compulsory health insurance, transfers from the central and local budgets, voluntary complementary health insurance and out-of-pocket expenditures paid directly by the citizens. Compulsory health insurance is carried out by a single payer Health Insurance Institute of Slovenia (HIIS) and represents the main public sources of financing; it accounted for 66% of THE in 2019. Complementary health insurance premiums (13.5% of THE) and out-of-pocket payments (13.6%) represent the main private sources of funding.

Public health expenditures as a share of THE have decreased slowly; they ranged between 70 and 74%, reaching 71.8% in 2019. The most important part of public health expenditures is compulsory health insurance, representing between 91 and 96%.

Consequently, there has been an increase in private health expenditure. The slow increase started in 2000 where they amounted to 27.1% of THE, and then reached as high as 28.9% in 2014 and 29% in 2018. In 2019, they amounted to 28.2% [1].

OOP payments as % of THE do not have a clear trend and have been relatively stable amounting to around 12% between 2000 and 2019. In 2018, they amounted to 11.9% [2].

The role of complementary health insurance has been unclear and source of numerous debates as it acts as co-insurance, covering share of each healthcare

*Structure, Processes and Results in Healthcare System in Slovenia DOI: http://dx.doi.org/10.5772/intechopen.98608*

service in the basic benefit package. Although this makes the basic benefit package largely undefined (as almost each healthcare service from the package is partially covered also from complementary insurance) and causes inefficiencies in the healthcare system, complementary health insurance acted as a protection in economic downturns. In recession, the share of coverage from complementary insurance increased for many healthcare services, enabling complementary insurance to act without loss; the consequences are of course higher premiums for complementary insurance causing higher inequities as the premiums are in absolute terms and equal for all [3]. These inequities, however, have largely been counteracted with a measure introduced in 2012, when the automatic coverage of claims by socially vulnerable are directly covered by central budget [4].

#### **2.2 Payment mechanisms**

The total budget for health services is divided among the providers through the negotiation process with main stakeholders, being Health Insurance Institute of Slovenia on behalf of the patients, Ministry of Health on behalf of the Government and the providers of healthcare services. When the allocation of the funds is agreed, the defined models are applied for fund allocation. This procedure clearly defines provider budgets as well as the healthcare services they have to provide and which will be paid for by compulsory health insurance. In contrast, there are no predefined limits for private health expenditure. The general agreement with special agreements for different groups of healthcare providers are the key products of the first phase of contracting processes, which create the fundament for direct contracting negotiations between the Health Insurance Institute of Slovenia and each provider.

The second stage of purchasing of health services involves Health Insurance Institute of Slovenia and the specific provider within the public healthcare network. Definition of the general agreement includes special agreements for various groups of healthcare providers, on basis of which the contracts between the Health Insurance Institute of Slovenia and each provider are concluded. The contracts specify the type and volume of services, but also the prices, methods of payments and other important elements, such as supervision and quality monitoring. With the exception of some of the programs (outpatient care, surgeries, dialysis services and the transplantation program), the reimbursement of provided services is prospectively defined and capped in way that healthcare services exceeding the negotiated amount are not paid by the Health Insurance Institute of Slovenia. If a provider produces fewer services than determined by the contract, he is reimbursed according to the actually provided services. Voluntary health insurance companies do not participate in the negotiation process to define the general agreement and special agreements for different groups of healthcare providers, but are mandated to reimburse the total value of the provided health services covered by complementary health insurance according to the annual plan negotiated in the general agreement. The relative value of voluntary health insurance coverage for different health services is defined by law.

Payment mechanisms used in Slovenia differ according to the health service category. In primary health care, a combination of capitation and fee-for-service is used. The planned income of the family medicine in the amount of 132,000 EUR at the annual level is divided into the capitation income (approximately 50%) and fee-for-service income (approximately 50%).

The capitation income is defined according to the number and age structure of the registered persons. Doctors with an above-average number of registered persons (more than 29,231 capitation coefficients per year) receive more funds than family physicians with a below average number of persons registered. Capitation is paid in a flat rate.

The other half of the income - the service part - depends on the services provided. Although the program of services is planned (27,488 coefficients per family physician per year), however, in order to obtain the whole service part of the revenue, it is sufficient to perform half of the planned services (13,000 coefficients). The acute care services (coefficients – relative prices) are listed in a catalog. One coefficient is worth around 2.5 EUR, depending on the value of the total annual budget for family physicians [5].

Outpatient care is paid on a fee-for-service basis. The payment is based on the planned (and realized) number of "points", which historically reflect the estimated costs of the provided services. Each specialty has a defined set of services (short visit, expanded visit, ultrasound etc.) and each service is assigned a cost weight expressed in the number of points. These points reflect the labor costs (medical doctor specialist, nurse, administrative and laboratory staff), material costs, depreciation, and a separate informatization costs.

Acute inpatient care is paid on DRG basis and non-acute inpatient care on bed day of stay.

### **2.3 Network of providers**

The Slovene healthcare system remains relatively centralized, as the responsibilities of municipalities have not been fully implemented. The Ministry of Health has the task of planning healthcare ensuring equal access to healthcare services and equal patient rights for all citizens. All administrative and regulatory functions of the system are managed at the national level, whereas municipalities have a task to execute the policies and strategies in the area. Compulsory health insurance is centrally managed and administered by Health Insurance Institute of Slovenia. The professional chambers and organizations also operate at the state level or through their regional branches. Municipalities seem to be making limited use of autonomy they gained to plan health services. Consequently, the de facto devolution in planning primary health care from the central government to local communities has not yet occurred.

Primary care falls under the jurisdiction of municipalities, which are responsible for health policy development at the local level. Municipalities are the owners of the community-level primary health care centers that occur all over the country. Primary health care centers are established and owned by municipalities, which are responsible for their functioning and for ensuring sufficient funds for the maintenances of the centers. All employees receive their salary in line with the general contract, which is valid for all employees in the public sector. Primary health care centers provide emergency medical aid, GP/family medicine, and healthcare for women, children and teenagers, community nursing, laboratory and other diagnostic facilities, preventive and curative dental care for children and adults, physiotherapy and ambulance services. Primary care practitioners in Slovenia include family physicians, pediatricians, gynecologists, community nurses, midwives, dentists, pharmacists, therapists, psychologists or psychiatrists and other profiles necessary to deliver care. Family physicians and nurses are the initial contact with patients, who are in need of care. Community nurses support the patients through health promotion and prevention activities, curative, long-term and palliative care. Patients are entitled to select their own physician from among the physicians operating at the primary health care level (i.e. in primary health care centers). Slovenia operates a typical gatekeeping system, and patients need a referral from their family

#### *Structure, Processes and Results in Healthcare System in Slovenia DOI: http://dx.doi.org/10.5772/intechopen.98608*

physician to be treated by a specialist. International organizations (such as the WHO and the World Bank) have played a key role in establishing a family medicine model based on the English and Dutch models. The International Survey on the Benefits of Primary Health Care "Monitoring Primary Health Care" assessed 77 indicators for 2009 and 2010 and included, among others, the areas of governance, staff development, accessibility, continuity, coordination and scope. Indicators for Slovenia show that primary health care is very good and better than in neighboring countries [6].

A total of 30 public and private hospitals provide care in Slovenia. There are 10 general hospitals, 2 university hospitals, 5 mental health hospitals and 13 specialized hospitals (3 of them are private). Upon the referral by family physician, the patients can freely choose their secondary care provider. Most of outpatient care and inpatient care is offered in the hospitals. Most of the hospitals are public owned by the state. They are non-profit organizations. Private hospitals, on the other hand, are profit organizations, privately owned. They can receive concession from the Ministry of Health and can make a contracts with the Health Insurance Institute of Slovenia, who would pay them for the care provided. Tertiary care is provided by University Medical Centers located in Ljubljana and Maribor, the Institute of Oncology, the University Clinic of Respiratory and Allergic Diseases Golnik, the Psychiatric Clinic Ljubljana and the University Rehabilitation Institute [7].

According to the number of beds for acute treatment per 1,000 inhabitants, Slovenia has been close to EU-15 average since the early 1990s, in contrast to the countries of Central and Eastern Europe, which have drastically reduced the number of beds. The number of acute hospital beds and the average length of stay have decreased since the early 2000s. Such a development is due to many factors: the introduction of new payment systems, (e.g. bed-days payment was replaced by Diagnosis-Related Groups (DRG) payment in inpatient care); during the economic crisis the prices of healthcare services were reduced; and there was a significant increase in the provision of day care (from 11.1% of all hospital cases in 2005 to 30% in 2013). The number of beds is currently similar to the EU average and the average length of stay is low at 6.8 days. Still, bed occupancy rates are below the EU average, indicating an overextended network at the secondary level. The data would require urgent strategic measures to streamline the network, subspecialize and connect operators [7].

With regard to the number of days in acute treatment, the number of dismissals and the number of outpatient visits, Slovenia does not deviate from the EU-15 average. Slovenia has the lowest number of private beds for acute treatment per 1,000 inhabitants in the EU28.

Outpatient specialist services are paid on a fee-for-service basis, whereas inpatient care is covered (in theory) by fixed allocations and DRG. In practice, however, hospitals are still financed according to historical volumes, meaning that they are not really limited by the DRG-based budget limit. Although the primary care system is strong, particularly since 2011 when the government upgraded family medicine practices and increased the emphasis on prevention and care coordination, service organization and delivery overall are highly fragmented. Waiting lists represent the biggest challenge, and they have translated into an elevated unmet need due to waiting. Share of people reporting unmet needs was higher than EU average according to Eurostat data: 3.5% of people in 2017 and 2.9% of people in 2019 reported unmet needs [8]. The large increase of unmet needs in 2017 is not due to sudden change, but rather to a change in question supporting the calculation of the unmet needs indicator. Presumably, the unmet needs were higher than reported already before 2017.

#### **2.4 Human resources**

Despite a steady increase in the number of physicians, partly driven by migration from neighboring countries, Slovenia has one of the lowest physician densities in the EU. In 2018, Slovenia ranked a modest 17th among the twenty-one Member States with 326 physicians per 100,000. In terms of the numbers of nurses (383 per 100,000) medical technician (645 per 100,000) and graduate midwife, Slovenia ranked in the first third among the EU countries and in terms of the number of dentists (72.5 per 100,000 inhabitants) just below the EU average. There are high geographical variations among the number of medical staff: while the number of physicians is highest in Central Slovenia statistical region (463 per 100,000), it is lowest in the Coastal-Karst region (136 per 100,000) [9].

In 2020, the number of general practitioners and pediatricians still lagged behind most EU countries, leading to problems of access and over-referrals to specialist care in some parts of the country. Nurse density was slightly above the EU average. Slovenia tried to solve the lack of medical doctors by opening second medical faculty Maribor in 2003. Also, provision has been made for foreign doctors to practice in Slovenia. Still, the issue of lack of physician has not been solved, especially in some defined specializations, such as primary care and anesthesiology. Due to these difficulties, the question of task-shifting has been analyzed and the scope of practice for community nurses has been widened to optimize patient-centered care. The model practices were introduced, described in the processes, unfortunately the evaluation of their introduction has never been conducted.

#### **2.5 Health information structure**

According to the Digital Economy and Society Index (DESI), Slovenia performs very well. More specifically, it ranks very high in the use of provision of access to open data and e-health services (it ranks 6 among EU members) and in the area of electronic prescriptions (number 3 among EU member states). Electronic prescriptions are used by 98% by all family physicians [10]. The e-prescription system has improved interoperability and transparency. The e-registry of patient data and patient summaries the registry of healthcare providers, e-referral system and the e-booking system are implemented. zVem patient portal, which enables patients to see their own medical data is active and used. The current epidemics further increased the use of the implemented solutions, especially zVem portal, which is used for vaccination applications, alongside other lists.
