A severe cyberattack occurred in France hitting the University Hospital in Rouen. All information systems were blocked to maintain patient safety and privacy. What we all dreaded is now a terrible reality. At a time of major digital transformation, revolutionizing healthcare delivery, each weakness appears to be a step backwards. No firewalls are entirely effective against malware and/or ransomware.

Cybersecurity has become a top priority in information security risk management in hospitals. This issue will be discussed during UEHP next Workshop which will be held in Brussels on the 22 January 2020 in collaboration with our Partner SHAM and with the participation of European Experts coming from the biggest European Private Hospitals Groups.

The situation is critical, and safety must be guaranteed in our everyday work. An efficient hospital must be safe. UEHP supports all initiatives and training useful to healthcare professionals. We know that the new DGSANTE Commissioner Stella Kyriakides will be at work soon, initiating a new deal with all Health stakeholders for the future in Europe. We hope for a positive approach embracing innovative proposals by the private sector we represent.

The first morning of meetings was dedicated to the presentation of the National Health System (Serviço Nacional de Saúde) by the Secretary General of the Association of Hospital Managers (APAH - Associação Portuguesa de Administradores Hospitalares).

In this sense, it was clarified how Portugal, a country that has about 10 million inhabitants, features a universal healthcare service (Beveridge model), which is for the most part free. It was introduced in 1979, and is financed through a social security system consisting mainly of indirect taxes (60%), for the benefit of the entire population. The amount allocated to support healthcare is approximately 2.75% of gross income, of which 0.8% is paid by the worker, and 1.95% by the employer.

A substantial part of the population then integrates its public coverage with a private expenditure component or with professional insurance schemes. In particular, about 10% of the population participates in supplementary healthcare funds, about 5% resorts to out-of-pocket spending and a further slice of the population, equal to about 25%, benefits from supplementary healthcare coverage from insurance companies and other private healthcare "subsystems" financed by contributions from employers and users. In 2015, public health expenditure amounted to 8.9% of GDP and 71% of total healthcare expenditure, while private spending corresponded to around 29% of the total expenditure.

The ways in which healthcare expenditure is financed have witnessed great changes over the years. In this regard, it is important to remember that with the introduction of the DRGs and the cataloging of health services, starting in 1984, a process of managing hospital costs began which led to the abandonment of the criterion of financing the hospitals based on global budgets, adjusted from year to year and, starting in 1990, saw the introduction, first, of a financing criterion based on historical expenditure and then, starting in 2002, of the contract budget criterion assigned according to prospective activity and according to the DRGs.

Currently, the subdivision of the budget allocated to the healthcare sector starts with the central government making an allocation to the Ministry of Health. The latter allocates the said budget among the various regions which, in turn, then divide the amount received among the healthcare and assistance facilities on the basis of the agreements stipulated. Alongside of the public component, there is an active private, profit-oriented sector, whose activities are largely subsidized by the National Health System through agreements that are stipulated to deal with the emergency of the waiting lists and, therefore, to provide citizens with healthcare services within the time limits required by national legislation.

With this mechanism, about one-third of the financial resources of the National Health System are directed to the private sector.

The country's continental hospital network is divided into 68 groupings of healthcare centers (ACES - Agrupamentos de Centros de Saúde) organized in 5 regional health authorities (ARS - Administração Regional de Saúde) which are entrusted with the task of managing the healthcare system on a regional level and, more precisely:

1. coordinate, guide and evaluate the implementation of national health policy;
2. implement and verify the provision of healthcare services by primary care centers and hospitals;
3. coordinate the provision of healthcare services with the private sector and other non-profit organizations;
4. monitor the quality of the healthcare services provided.

The administration of individual hospitals, on the other hand, falls under the authority of the respective executive branches. The exception to this are the autonomous regions of the Azores and Madeira which enjoy greater managerial autonomy of healthcare services, though remaining under the control of the central government.

Therefore, it is a national health service that is regulated, programmed and managed at the central level, which means, however, that the control and coordination of service provision and territorial assistance are delegated to the regional level. In this regard, it is possible to identify the organizational methods and the roles of the different operators active in the local area for each level of care.

Primary care, fully covered by the public sector, is provided through the USF (Unidades de Saúde Familiares), established in 2006 as functional units of the ACES (Agrupamentos de Centros de Saúde). In 2015, 289 USFs were active in the country: multi-disciplinary teams with functional and technical autonomy composed of general practitioners and nurses, who provide primary care on the basis of a contractual framework stipulated with the regional health administration, with the objectives of accessibility, effectiveness, efficiency and quality. Remuneration of the USFs involves a mixed composition of budgets and incentives linked to the achievement of set objectives. In this sense, the role played by the USFs, which currently assist 52% of the population, in taking charge of chronic patients is becoming increasingly important.

Acute care is provided in hospitals. There are five categories of hospitals in Portugal:

1. Hospitais EPE (Empresas Publicas Empresariais): entirely publicly funded hospital facilities subject to direct control by the Ministry of Finance and Health.
2. Hospitais SPA (Sector Público Administrativo): public hospitals subject to supervision and monitoring by the Ministry of Health, managed with a business approach and an organizational structure that is divided into management and cost centers.
3. Hospitals based on public-private partnerships. This category of facilities stems from the need to find resources for the sustainability and improvement of the National Health System. It is interesting to note that, since the early 2000s, the Portuguese health sector has been a pioneer in creating a highly regulated legal framework in the field of public-private partnerships (PPPs). Under the guidance of the Ministry of Health, interventions were undertaken to renew and reorganize the Serviço Nacional de Saúde network, which led to the establishment of partnerships aimed at promoting innovative ways of sharing healthcare risk, starting with new private management experiences for public facilities and the participation of the private sector in all phases of the commissioning of a hospital: planning, construction, financing and management of hospital units of the National Health System. Although the investment and operation of these units are private, access to clinical services is the same as that available for other hospital units in the public sector: users therefore retain the rights and duties envisaged for accessing the National Health Service. As regards the Property Management Authority, payments by the State are based on the clinical production actually carried out by the main lines of activity (e.g. inpatient and outpatient consultations) and on the availability of the Emergency Service. In turn, the remuneration of the building management body is based on the availability of the infrastructure and the support services provided.
4. Public hospitals managed by non-profit organizations.
5. Private for-profit and non-profit hospitals.

The Serviço Nacional de Saúde therefore integrates all healthcare services that can be provided in the State: from prevention to diagnosis, from therapy to medical and social rehabilitation. In this regard, Portugal's healthcare policy, with the aim of responding to an ever-increasing demand for health and reducing the occurrence of acute events, and with the consequent overcrowding of Emergency Rooms, is moving to increase prevention activities and take care of patients at the primary care level.

In addition to this, the demographic trend of the population, with an increasing number of elderly and chronic patients, is leading to the creation of solutions for taking charge of these categories of "fragile subjects" that is witnessing an increasingly active role of the private and the social sector, with a view to full integration and support to the public provider. With the intent, therefore, to reorganize assistance on the basis of integrated networks of hospital services for acute care, intermediate facilities and territorial services for chronic illness, rehabilitation and non-self-sufficiency, private operators are taking on an increasingly important role in the panorama of Portugal's healthcare services. This is being achieved thanks to the healthcare policies of a State that allows the complementarity and coordination of functions/services with the public sector and uses the benefits in terms of operational efficiencies, clinical outcomes and speed of response to the citizens' healthcare demand with a flexible supply system and in line with the needs expressed by the territory.

In 2017 the principles of hospital financing were changed in Poland. In October, the Ministry of Health introduced a healthcare reform that led to the constitution of a “Hospital Network”, gathering 594 hospitals financed by public funds in the form of a lump sum. Among the 594 hopitals, 78 are non-public entities and 31 of them are private hospitals, affiliated to the Polish Association of Private Hospitals (OSSP, UEHP member). The requirements to be part of the “Hospital Network” (have specific types of wards and/or an emergency service) led automatically to the exclusion of many private hospitals (small, single specialty units…)

Hospitals included in the network have guaranteed access to public financing in the form of a lump sum payment for a four-year period, which allows more stable long-term projections. Hospitals that were not included in the Network (355 entities including 339 non-public Hospitals) can apply for contracts via tenders announced by the National Health Fund, in order to obtain income from public funds (7% of NHF budget).

According to a study on Health Policy "Poland is characterized by the overcapacity of the hospital sector, which is accompanied by deficits in out-patient care provision. Although the hospital network regulation provided financial incentives for hospitals to shift from in- to out-patient services, the new system did not include one-day procedures, which continued to be contracted separately (outside the network) … One of the major controversies concerning the reform’s design and implementation is the lack of any quality of care, health outcomes, and/or efficiency measures in the network inclusion criteria."

In 2019 the Polish Association of Private Hospitals (OSSP) together with the European Association of Private Hospitals (UEHP) started negotiations with international certification companies aimed at the implementation of uniform quality standards for the private hospital sector in the European Union.

According to the statistics of the Ministry of Health, in 2017 there were 930 hospitals in Poland (public : 58%, private : 38%). Private hospitals associated with the Polish Association of Private Hospitals (OSSP) represented about 5% of all hospital beds in Poland (18% of the total number of hospitals). OSSP private hospitals employed approximately 13% of doctors and 7% of nurses and midwifes.

The hospital sector is shrinking. This unfavourable phenomenon is confirmed by a decreasing occupancy rate of hospital beds : 51.3% in 2017 versus 65.8% in public hospitals (77 % in average in the EU). Nevertheless, the Polish private hospital sector has the infrastructure, medical equipment and qualified medical personnel to accommodate up to 20% more patients. OSSP private hospitals who participated in a survey confirmed that the average usage of some medical equipment reached 70% only.

In 2017 OSSP private hospitals treated approximately 5% of all patients within planned hospitalisation and 7% of all patients within one-day hospitalisation. The highest increase in the number of patients admitted by OSSP private hospitals was noticed in the area of one-day hospitalisation, where over 3 times more patients were admitted. It correlated with the decrease in the number of hospital beds and shorter in-hospital stays.

The value of contract with the National Health Fund (NHF) has a significant impact on the revenues of all hospitals including private hospitals. In 2017, OSSP private hospitals received from the NHF contracts 59% of their revenue vs 36% from paid medical services. Since October 2017 with the introduction of the Hospital Network, not all hospitals have a financing guarantee from the NHF. 81% of non-public hospitals are excluded from the programme. From a financial point of view, this reform leads to a reorganisation of medical activities, especially in private hospitals.

Despite the new regulation, 70% of OSSP private hospitals closed 2017 with a profit (versus 45% in 2016). The structure of revenues of OSSP private hospitals over the past few years confirms the development of the sector. Private hospitals gradually increase the scale of their operations. The sector is also being consolidated by large entities such as EMC, Lux-Med. or American Heart of Poland (AHP).

Moreover, those companies are selling healthcare provided by public medical establishments, which is against the law, as they are offering healthcare British citizens are already entitled to and for which they bear none of the costs.

This prevents those tourists from accessing with their travel health insurance Spanish private hospitals and clinics, which in some cases might prevent them from receiving adequate treatment.

Those British insurers are also committing a possible fraud against British travellers who believe that their medical care abroad is covered for all types of healthcare institutions.

Travel insurance policies require British tourists to have a European Health Insurance Card, so they can be transferred to a public healthcare organisation. When tourists enter a private hospital or clinic, they either bear the cost for private medical services or consult their insurance company, which immediately refers them to public hospitals, alleging that the private healthcare system in Spain is deficient. This is completely untrue, given the high level of international scope of Spanish private health care. The real goal of these practices of attempting to discredit Spanish private medical healthcare is to avoid meeting their responsibilities as insurers.

This situation places the health of British travellers at serious risk, the insurers forcing private hospitals to refer them to a public hospital as soon as possible, sometimes even in cases where a transfer compromises the patient's health.

These practices mean high costs both for the Spanish National Health System (the SNS), which must handle a greater volume of patients, including those who, in theory, could have been treated in private hospitals, and for the British National Health Service (NHS) which must cover the costs of treatments at Spanish public healthcare facilities.

However, it is the Spanish private medical healthcare sector which is most affected if a foreign patient with such an insurance is treated or admitted. Private hospitals are subjected to medical costs, which can be very high on some occasions, and which are neither borne by the patient nor by the insurer. In addition, the private facility is often unfairly requested to pay the cost for transferring the patient and any subsequent healthcare service provided at the public hospital.

ASPE calls for an end to these abusive practices, which affect patients, public and private healthcare systems. ASPE demands that these insurance firms provide consumers with clear information about the coverage included in their travel insurance policies; it is calling for users to sign a specific document regarding the healthcare assistance service and is asking for clear information so that patients, if they decide to go to a private healthcare establishment, know they have to bear the costs of the healthcare service.

Among other actions, ASPE intends to file a second complaint with the European Commission, for fraudulent use of the European Health Insurance Card (EHIC). In addition, for months, ASPE has contacted different British authorities to inform them of this situation, the illegal enrichment achieved by these insurance companies and the violation of the rights of their citizens.

Within Spain, ASPE requested support from the central government and regional governments to curb this practice. In addition, during the summer a communication campaign has been carried out to defend the Spanish private healthcare from the defamatory tactics used by these insurers with citizens of the United Kingdom. Private institutions have disseminated this information widely to British travelers.

To this end, ASPE has released a dedicated booklet, so that affected patients know their rights. It is distributed by its member institutions, especially in touristic areas. ASPE also launched a website, www.safetraveltospain.com, where travelers can find more detailed information.

Finally, ASPE is considering taking legal actions to prevent Spanish state authorities from passing the costs of transfers and/or medical treatments to private healthcare insitutions.

The Alianza de la Sanidad Privada Española (ASPE) is the business association for the Spanish private healthcare sector. ASPE brings together nearly 600 private healthcare organisations and represents more than 75% of hospital centres. The main aim of the association is to defend, represent and foster the common objectives of its members, to promote the private medical healthcare sector and to offer services and activities which are of use and interest for private healthcare organisations. https://aspesanidadprivada.es/