11.1. The health care system

The Lithuanian health system is principally funded through SHI, through the compulsory health insurance fund, administered by the National Health Insurance Fund (NHIF), an agency under the auspices of the Ministry of Health. Statutory insurance accounted, in 2012, for 60.1% of total health expenditure, complemented by tax revenue (10.7%) and OOP payments (28.5%) (WHO, 2014). In 2012, health expenditure constituted 6.7% of GDP.

The NHIF is responsible for overall compulsory health insurance fund performance, as well as for the procurement of medicines and other medical supplies. The health care system covers all public providers including those working under contracts with five NHIF regional branches (Murauskiene et al., 2013). The state budget contributes more than 30% of the NHIF’s total revenue to cover certain population groups.

Overarching health policies are set by Parliament, with the Health Committee and National Health Council in an advisory function, and government, while the Ministry of Health is responsible for the general supervision of the health care system. It shares responsibility for operating two major university hospitals and after the abolishment of the regional (county) level of the public administration system from July 2010 the ministry is in charge of health care provision in about 20 health care institutions. Since 2003, gradual reorganization of the public health care facilities network is under way, with its goal to achieve safer, efficient and more cost-effective care through the prioritization of family and specialist outpatient care, and the optimization of inpatient care (Republic of Lithuania, 2009). A new stage of the network consolidation has recently been declared: it is planned that in 2013–2016 functional clusters will be piloted and implemented starting from prioritized cancer, heart and cerebrovascular diseases, injuries, child diseases managing models (Ministry of Health of the Republic of Lithuania, 2014).

Access to health care is guaranteed for the vast majority of residents. Joining the state health insurance scheme is mandatory for the working population. Children, recipients of social assistance, the unemployed, and patients with certain diseases (about 60% of the population) are insured by the state. The insured population is eligible to receive all publicly financed health care services. Co-payments for medicines present the major share (approximately 75%) of private health care expenditure. Emergency care is free of charge.

Sixty local governments are responsible for the organization of primary care. The primary care system in Lithuania comprises family physicians, community mental health centres, ambulance units and nursing hospitals. These are typically financed as non-profit-making foundations. Staff are usually salaried and employed by health care institutions. Family physicians act as gatekeepers to specialist care provided in outpatient and inpatient care facilities. The private sector comprises mostly small dental practices and other outpatient facilities; it employs about 10% of physicians and 60% of dentists. Municipalities are also responsible for organizing and financing social care services. Social care policies are developed and overseen by the Ministry of Social Security and Labour.

Primary care providers are paid through capitation, calculated on the basis of the number and age structure of the enrolled population, with additional payment for people living in rural areas and incentive payments for certain listed services and performance. Outpatient specialist care providers are paid on a fee-for-service basis; payment for secondary and tertiary specialist care is uniform throughout the country. Providers are paid according to the actual volume of health services provided, according to the terms and conditions set by their contracts with the NHIF branches. Currently, AR-DRG (Australian Refined DRG) v6 is under implementation in Lithuanian hospitals.

11.2. Approaches to chronic disease management

As indicated in the preceding section, there is growing interest in a more systematic approach to chronic disease management, emphasizing coordination and integration in particular. Experience so far can be broadly distinguished into approaches to improve intersectoral collaboration and the systematic use of clinical guidelines. Recently, policy initiatives to establish health care clusters addressed an issue of better coordination of health care delivery.

11.3. A patient journey

This section describes the journey of two hypothetical typical patients with co-morbid chronic disease in the Lithuanian health care system.

(A) A 54-year-old woman with type 2 diabetes and COPD who has a leg ulcer and moderate retinopathy. The patient is also slightly overweight (BMI of 27). She has been unemployed for three years and receives social assistance benefits; she lives on her own.

(B) A 76-year-old retired engineer with chronic heart failure, severe asthma and high blood pressure. He lives with his 73-year-old wife who cares for him, while herself suffering from arthritis. They live on the third floor in a housing block and are increasingly housebound due to their illness. They are determined to remain independent; their grandson, who lives nearby, does the daily shopping for them.

Both cases would be ‘managed’ by the family physician, community nurse and community social worker. Typically, patients will be pre-diagnosed by their family physician and referred to the specialist for confirmation of the final diagnosis and the development of a treatment plan. The family physician will remain the main contact for the patient, supervising management by following the defined treatment scheme. In case of the women with type 2 diabetes, the family physician will monitor the course of the condition and she would consult with the nurse on her diet.

In both cases, where complications arise, the patient might be referred to specialists at secondary or tertiary health care level. Depending on severity, they might be admitted to nursing homes for a maximum four months per year, which will be covered by the NHIF. They can also access medical nursing care at home free of charge.

Medication is accessible and usually reimbursed by the NHIF. Access to self-management support is limited and at present accessible through selected active patient organizations only, such as the diabetes association or the patients’ nephrological association; there are also cancer patients’ organizations.

Again depending on the severity of their conditions, the patients described here may be considered as unfit to work, following assessment of their capacity to work, and may qualify to receive disability pension or, alternatively, social assistance. The patient in case A could also claim for some social services paid from the local budget, while the patient in case B likely receives retirement pension.

Any person, including the two examples considered here, who are in need of permanent or nursing care may qualify for additional benefits, for example, payments to buy additional social services or, less frequent, payments to the main caregiver where she/he receives care in their home, for example the wife of the person in case B. Institutional long-term care is co-financed on the basis of means-testing.

11.4. Summary and conclusion

There is growing interest in developing a more systematic approach to the management of chronic disease in Lithuania. Although there is no documented explicit strategy to that effect, the National Health Council, an independent advisory body reporting to parliament, has expressed commitment to promoting more coordinated care. Ongoing health care reform efforts are set towards the implementation of a strategic direction for health promotion, disease prevention and the reduction of morbidity and mortality overall. A range of initiatives are being implemented, principally organized around intersectoral collaboration and the systematic use of clinical guidelines, with primary care in the form of family medicine viewed as the cornerstone for enabling structured chronic disease management. Newly implemented health care policy initiatives focus on establishing health care clusters.