Journal of Health Policy,
Insurance and Management

Polityka Zdrowotna


Polityka Zdrowotna Journal of Health Policy, Insurance and Management IX 2011

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Conceptual approaches to formation of new preventive strategy in public health – discussion of the article*



Vitaly F. Moskalenko, National Academy of Medical Science and Bogomolets

National Medical University of Kiev (Ukraine)


Public health services systems in the global market have serious problems and difficulties associated with stability of their functioning and resource, including financial security. Therefore, efforts to shape perfection of systems of public health services, formation of bases of the future adequate model are aimed at a number of strategic documents of World Health Organization (WHO), resolutions of sessions of Executive Committee of the World Assembly of public health services.

It is known that the theory of risk factors is the heart of prevention concepts formation. The considerable attention paid to risk factors is connected with polyaetiological origin of many diseases. There is a possibility of using risk factors knowledge in practice for prevention, diseases prediction, diseases features and diagnostic process. The World Health Organization defines the leading health risk factors. For developing countries they are poverty, low weight, unsafe water, poor sanitary-and-hygienic conditions, unsafe sex, iron deficiency anaemia, smoke from solid fuels burning in premises. For economically developed countries the risk factors are high blood pressure, increased cholesterol content in blood, tobacco consumption, abuse of alcohol, obesity and low physical activity.

WHO recommends governments, Ministries of Health to occupy the leading role in developing of strategies of risk factors prevention to support scientific researches, to improve monitoring systems and to expand access to the global information. It is necessary for public health services systems to provide the holistic approach to service, including promotion to population health improvement, prevention and integrated programs of illnesses struggle. The most important aspect of the public health services policy is to concentrate on formation and development of integral communities, systematic work with all sectors on purpose of health risk factors negative influence decrease, development of the sanitary potential in certain living conditions, establishments, institutions and organizations in the field of culture, education, industry, etc., providing conditions for all community members to realize their potential.

Słowa kluczowe :

zdrowie publiczne, czynniki ryzyka, programy profilaktyczne

public health services, risk factors, preventive programs

Management of change in health care and health insurance – in light of the doctrine of common sense



Romuald Holly, Uniwersytet Medyczny w Łodzi, Szkoła Główna Handlowa,

Krajowy Instytut Ubezpieczeń


The present paper discusses change management in health care – the subject of change, the possible ways and limitations of stimulating change, as well as the principles and criteria for the determination of socially desirable directions of change, its course and effects. The author makes the assumption that the main cause of the impasse in health care change management is the progressing intransparency of such values and notions as equality, justice and social solidarity, which should constitute the foundations of every health care system. Under the circumstances, in the way of substituting such foundations, the author proposes that the algorithm of the health care system model should adopt assumptions derived from the general systems theory and the theory of risk management, including risk sharing and risk adjustment. However, to build an overarching algorithm for the creation of a universal model of a health care system based both on market mechanisms (to ensure high efficiency) and on the humanist values of solidarity, justice and equality, it seems necessary to embrace the concept of insurance and insurance-related methods of neutralizing the risks of loss of health. Therefore, the first step in designing or restructuring a health care system should be in-depth analysis of the opportunities following from the comprehensive inclusion of health insurance in the system, as well as the related benefits and threats for different groups of stakeholders: on the one hand, for society, the state, the current state authorities, the public administration, the health care system itself, particular socio-demographic groups and individual citizens, and, on the other hand, for the suppliers: health care providers, the pharmaceutical industry, private insurers, and social animators of civic solidarity. The author shows that the approach he offers will make it possible to substantially rationalize health care management, even despite the absence of the aforementioned foundations. Otherwise change management in health care will continue to be limited to continuous renovations and repairs of the system in line with the effects of the ongoing changes or, at most, such management will involve ex post adaptation of the existing health care system to unplanned developments. Rational and active management should consist of responsible stimulation of the change process in the direction determined by socially desirable objectives. The reform (and, subsequently, restructuring) of the health care system may thus become one of the areas, and also tools, of responsible and efficient change management, not only in the field of health care, but throughout the social protection system.

Słowa kluczowe :

zarządzanie zmianą społeczną, system ochrony zdrowia, polityka zdrowotna, ubezpieczenie zdrowotne

management of social change, health care system, health policy, health insurance

The government’s package of health care bills – the next stage of health care reform in Poland



Aneta Mrózek, Aleksandra Dąbek, Ministerstwo Zdrowia, Departament Nauki i Szkolnictwa Wyższego


In the middle of the last year, the Minister of Health began working on a second package of ten bills introducing broad and innovative changes to the currently existing system of health care in the Republic of Poland. The planned changes concern the education of physicians and dentists, drug reimbursement, patients” rights protection, pharmaceutical law, the transformation of health care facilities into commercial companies, the computerization of health care, the separation of the registration of medicinal products from reimbursement, and changes to the legal status of the Office for Registration of Medicinal Products, Medical Devices and Biocidal Products. Such wide-ranging reforms in the field of health care are aimed at enhancing the financial condition of hospitals, improving the system of medical services provision to citizens, increasing accessibility to health services, introducing fixed prices and margins on reimbursed drugs and adjusting Polish medical care to the European Union standards. The Ministry of Health intends to address the above-mentioned objectives when the package of bills enters into force.

The Act on the reimbursement of drugs, foodstuffs intended for particular nutrition purposes and medicinal devices involves a reduction in the prices of reimbursed products (creating the possibility of increasing the availability of new drug therapies), a decrease in patient co-payments, the suppression of pathological phenomena in the marketing of reimbursed drugs, the introduction of clear and transparent rules of operation and competition for the reimbursed product market, the rationalization of the National Health Fund’s spending on reimbursed products, fixing funds for the drug reimbursement system at a constant percentage rate and tying them to growth by establishing a total reimbursement budget of up to 17% of the total public funds allocated to guaranteed benefits, developing precise decision-making criteria for reimbursement, for the determination of sales prices and reimbursement eligibility levels, for the creation of limit groups and for the removal of drugs from reimbursement lists as well as changing and systematizing the procedures for entering drugs in reimbursement lists.

The Act on the Office for Registration of Medicinal Products, Medical Devices and Biocidal Products concerns the definition of the tasks of the President of the Office and is a consequence of the proposal to separate registration from reimbursement of medicinal products.

The Act on medical activities sets out principles for the therapeutic exercise of treatment activities, the principles of operation for entities carrying out medical activities, the principles for keeping a register of health care facilities, and the standards for personnel working time and for the supervision of health care facilities. The solutions included in the Act on medical activities are to lay the groundwork for transforming the existing health care facilities into operators with balanced budgets as well as enforcing the founding bodies” liabilities for the financial obligations of the health care facilities.

The Act amending the Act on Patients ”Rights and Patients” Rights Ombudsman includes a revision of regulations concerning procedures for awarding damages for medical malpractice or violation of patients” rights. The act is meant to make it easier to obtain damages for medical malpractice and to give patients the possibility to get compensation for injuries sustained in the therapeutic process out of court, without having to prove the guilt of the health care personnel.

The Act amending the Act on the physician’s and dentist’s professions relates to changes in the education system for physicians and dentists as well as modifies the requirements for medical studies, and in particular it eliminates postgraduate internships and national medical examinations. The essence of the bill is to revise the education system for doctors and dentists so as to shorten the process of postgraduate education. First of all, this will involve the elimination of postgraduate internships and changes in the previously conducted medical and dental examinations.

This aim will be achieved by changing the system of medical education, in particular by focusing on practical preparation for the physician’s and dentist’s professions. The Act on the system of health care computerization defines the organization and operating principles of an IT system in health care for processing the data necessary to implement the state health policy, improve the quality and accessibility of health care benefits and fund health care. The act creates a fair system of health care information that will enable the collection, processing and archiving of data. The proposed solution will reduce the information gap in the health care sector by streamlining the existing system of collecting, processing and using information.

Słowa kluczowe :

podmiot leczniczy, działalność lecznicza, reforma służby zdrowia, informatyzacja, LEK, LDEK, prawa pacjenta, dodatkowe ubezpieczenie zdrowotne, zdarzenie medyczne, lekarz dentysta, staż podyplomowy

legislative acts, government bills, Ministry of Health, National Health Fund

The legal and economic situation of pharmacies in the light of new rules for reimbursement



Eugeniusz Jarosik, Grzegorz Kucharewicz, Naczelna Izba Aptekarska


The rising prices of innovative medicines, the development of new drug therapies, the ageing of society, the increasingly limited public resources for medications, and abuses in the trade of reimbursed drugs – these tendencies affecting the contemporary pharmaceutical market have forced the government, with the Minister of Health as an initiator and coordinator, to adopt a new drug policy. The aim of the policy is to reform the reimbursement system so that it comes in line with the country’s overall economic situation, and also to ensure wide public access to reimbursed medicinal products.

The extent and total costs of drug reimbursement in generally available pharmacies are vital tools which regulate the accessibility of medicinal products. In 2010, the National Health Fund (NHF) spent over PLN 8.53 billion on reimbursement. In Poland, reimbursement costs have been gradually rising over the years, which stems from advances in medicine (more and more patients are diagnosed and undergo treatment), as well as from aggressive advertising campaigns launched by large companies in the pharmacy market. The increase of drug reimbursement costs from PLN 5.18 billion in 2001 to PLN 8.21 billion in 2009 cannot be explained on medical grounds, or by the overall deterioration of the public health.

The new regulations concerning the pharmaceutical market included in the Act on the reimbursement of drugs, foodstuffs intended for particular nutrition purposes and medicinal devices of 12th May 2011, which will come into force on 1st January 2012, will have a profound effect on pharmacies – their activity as well as legal and economic situation. The pharmaceutical authorities see some of the ideas stipulated in the Act as an introduction to a comprehensive reform of the pharmacy market. These ideas include introducing fixed official sales prices and fixed official wholesale and retail margins on reimbursed drugs, foodstuffs intended for particular nutrition purposes and medicinal devices, a ban on the advertising of pharmacies and their activities, and a ban on any form of incentives for publicly funded medicinal products.

The Reimbursement Act is aimed at accelerating the reform of the Polish pharmacy market. It is the first step of the long-heralded amendment to the Pharmaceutical Law of 6th September 2001.

The pharmaceutical authorities demand that the aforementioned law allow only a certified pharmacist to run a pharmacy (the so-called “pharmacies for pharmacists” rule). They also stress the necessity to define geographic and demographic criteria for issuing permits to open new pharmacies. All of the stipulations pronounced by the Polish pharmacists are in accordance with EU regulations, which was confirmed by the European Court of Justice.

Słowa kluczowe :

ustawa o refundacji leków, środków spożywczych specjalnego przeznaczenia żywieniowego oraz wyrobów medycznych, sztywne ceny zbytu, sztywne marże hurtowe i detaliczne, zakaz reklamy aptek i ich działalności, umowa na realizację recept

Act on the reimbursement of drugs, foodstuffs intended for particular nutrition purposes and medicinal devices, fixed official sales prices, fixed official wholesale and retail margins, ban on advertising of pharmacies and their activities, pharmacy contracts for reimbursed drugs

Restructuring and functioning of independent public health care providers (SPZOZs) on the basis of the Medical Activity Act: Between the Scylla of legal regulations and the Charybdis of economic inefficiency



Grzegorz Mączyński, Krajowy Instytut Ubezpieczeń, Kancelaria Adwokacka Grzegorz Mączyński


The new Medical Activity Act of 15 April 2011, which recently entered into force, introduces new legal regulations in Poland in the field of establishing, transforming and operating health care providers. The previous Health Care Provider Act was criticized especially for its provisions concerning one particular type of health care providers, namely, independent public health care providers (SPZOZs). These providers were obliged to carry out public and political goals while complying with certain legal requirements, such us ensuring the continuity of health care services for the citizens, which should be provided in line with economic efficiency. SPZOZs were widely regarded as economically inefficient and as a politically and legally petrified organizational form. With the new legal tools and solutions, it should be easier to satisfy the legal requirements of SPZOZ functioning and restructuring. Unfortunately, the systemic issue of economic inefficiency of SPZOZs has yet to be resolved, which significantly increases the political and economic risks for the managers of health care providers and for the local policy-makers.

Słowa kluczowe :

działalność lecznicza, jednostka ochrony zdrowia, szpitale, restrukturyzacja, przekształcenie, jednostka samorządu terytorialnego

medical activity, health care provider, hospital, restructuring, transformation, local self-government unit

Adjusting the State Emergency Medical Service to Changes in the Polish Health Care System



Robert Gałązkowski, Lotnicze Pogotowie Ratunkowe

Janusz Kleinrok, Aneta Mrózek, Ministerstwo Zdrowia


In Poland, the emergency medical system is an organization that was formed in order to improve the effectiveness of providing urgent medical care to persons who find themselves in life-threatening situations. In order to accomplish this objective, the National Emergency Medicine Act was adopted to guide the establishment of such a system, provide for methods of its financing and describe units within the system with specific tasks to fulfill. The creation of such a system will also result in the regulation of the standards of teaching and providing first aid. The model of emergency medicine that Poland has embraced fills gaps in the functioning of urgent medical care through shortening of emergency medical response time. The act also defines the competence and tasks of the administration, which includes the creation of the system and its ongoing supervision, entrusted to the Minister of Health and province administration. The system in the provinces functions on the basis of a plan prepared by their governors, which still needs to gain approval from the Minister of Health. All the actions taken by the State in order to ensure the smooth operation of the system cover many areas, including: ensuring the financing of the system, training of medical personnel for the system, creating investment programs needed to build the system (hospital emergency departments, trauma centers, ambulances and rescue helicopters, rescue emergency notification system). The system as a “living organism” requires observation and possibly further necessary legal and organizational changes aimed at bridging gaps and adapting the functioning of the system to the changing reality.

Słowa kluczowe :

ratownictwo medyczne, finansowanie ratownictwa medycznego, ratowanie życia, personel medyczny

emergency medicine, medical finance, lifesaving, medical personnel

Procedures and extent of drug reimbursement in the Polish health care system



Leszek Michalczyk, Uniwersytet Jagielloński


The aim of the paper is to demonstrate the fact that the rapid decrease in the funds allocated by the National Health Fund (NFZ) to drug reimbursement is a direct violation of the constitution, and specifically of the regulations concerning popular access to health care services. In this respect, the paper adopts the WHO’s definition that medicines are accessible if at least 60% of their costs are reimbursed.

If the reimbursement rate is lower, accessibility is out of the question and, consequently, the Polish constitutional regulations are not met. Health care services may be of two kinds: (1) clinical or (2) “home”. In the second case, health care services entail the purchase of medicines prescribed by primary care physicians or medical specialists. If such pharmaceuticals are too expensive for the end recipient, this either means that the provider of medical insurance defaults on its statutory obligations, or the behavior of doctors, acting as „sales representatives” of pharmaceutical companies, is irresponsible and unethical. Meanwhile, the nominal increase in expenditures on drug reimbursement by the NFZ has not even been proportional to the rate of the NFZ’s revenues (except for two years out of the 10-year period under analysis). This is all the more unethical as non-clinical treatment concerns for the most part elderly people, whose financial contribution to the health care system has been, naturally, the most considerable.


Słowa kluczowe :

rynek farmaceutyczny, dostępność leków, wydatki gospodarstw domowych, wydatki NFZ

pharmaceutical market, availability of medicines, household expenditure, National Health Fund expenditure




Dariusz Timler, Uniwersytet Medyczny w Łodzi


Director’s regulations are a very popular hospital management tool used in Poland. This study evaluates the use of Director’s Regulation no. 58/2009 at Copernicus 89 Are directors regulations a useful tool in hospital management? AIM: This present study, which is devoted to Director’s Regulation no. 58/2009, addresses the following questions: Is it a useful tool in hospital management?and Is it effective as a stand-alone tool?.

METHODS: Out of 444 doctors working at Copernicus Memorial Hospital in Lodz, Poland, 103 were tested with an anonymous test prepared by the author of this paper. Only 9 out of the 103 doctors (8.7%) passed the test. Only 2 out of the 10 questions were answered correctly by more than 70% of the tested physicians. There is a huge gap between expectations and reality. The data indicate a problem as they show that director’s regulations are not effective as a stand-alone management tool.

Therefore, it is recommended that mandatory training and a test review should follow director’s regulations to successfully achieve maximum performance and provide better management outcomes.

Słowa kluczowe :

Risk Adjustment as a principle and a tool of the social change in Health Care System – from “passive” to “active” adjustment – discussion of the article*



Romuald Holly, Uniwersytet Medyczny w Łodzi, Szkoła Główna Handlowa, Krajowy Instytut Ubezpieczeń

Kai Michelsen, Maastricht University, International Health Institute (Netherlands)


Risk Adjustment is a promising approach to handle some of the major challenges of current health policies. They can be used to create transparency for the assessment of the quality of health services between health service providers (including decisions about the allocation of resources), or as a basis for a need orientated reallocation of resources between third party payers.

While the potential advantages of Risk Adjustments are acknowledged, a couple of challenges stimulate an ongoing debate about the further development of Risk Adjustments.

This article addresses the meanings of the term, summarizes discussion about opportunities and challenges, and develops some ideas for further research activities. The recommendations are based on three major assumptions: A) It is possible and beneficial to cooperate in the development of an “algorithm of algorithms”. B) A generic Risk Adjustment system has to be adapted towards the specific situation of health systems. C) While differences between “old” EU Member States and “new” EU Member States as well as challenges to organize policy transfers and policy learning have to be taken into account, mutual learning is possible and beneficial – for the Member States and in the process of European integration. The assumptions like these make possible to understand and use Risk Adjustment algorithms as the leading principles and ways of improving Health Care Systems both in “old” and “new” EU Member States according to the same universal, politically neutral rules and methods. The attempt proposed in the article make also possible to treat Risk Adjustment methods as a set of instruments useful to implant such ideas like Convergence of European Health Care Systems, Open Method of Coordination as well as helpful tool to inculcate the new Directive on Patient mobility.

Słowa kluczowe :

Risk Adjustment, selekcja ryzyka, alokacja zasobów, systemy ochrony zdrowia, polityka zdrowotna, algorytmy Risk Adjustment

Risk Adjustment, risk selection, allocation of resources, health systems, health policy, Risk Adjustment algorithms

The concept and methods of Risk Adjustment in selected European Countries and in Poland



Cezary Głogowski, Krajowy Instytut Ubezpieczeń


The collected data have confirmed the importance of the ongoing discussion in Poland about the need to implement reforms of the health care system. The results of objective rankings clearly show that in practice the low level of financing very clearly translates into health outcomes, although the relatively high scores in rankings for particular therapeutic areas except oncology should also be emphasised.

In contrast to objective measures, consumer perception of the quality of health care in Poland is very pessimistic. Poland ranks very low, far behind the Czech Republic, Slovakia and Hungary. Analysis made it possible to select a group of countries of a similar population size as Poland which hold the leading positions in reports and rankings prepared by some international institutions listed in the paper. These countries include the Netherlands, France, Germany, Switzerland and Belgium. What all of them have in common is the operation of competitive payers which manage public funds for health care and the use of risk adjustment methodology in the allocation of funds to individual payers. An analysis of financial and health indicators supported by a literature review confirmed that a risk adjustment method can be useful in an insurance model in which insurance premiums are the primary source of funding for services.  Risk adjustment enhances rational and just allocation of financial resources by reflecting individual risks, and reduces the undesirable effect of adverse selection. It seems that the key to successful reform in Poland is to increase financial resources in health care to counter the growing imbalance between the burdens resulting from rising health costs and an ageing population, but only with a parallel implementation of processes to increase the efficiency of their use. Analysis of the data collected in the study shows that a centralized system, organized, managed and financed by the state, is outperformed by the Bismarck model in this respect. Competition among payers obtaining funds from health contributions or public charges seems to be the most effective factor increasing the efficiency of the funds invested.

Słowa kluczowe :

zdrowie publiczne, Risk Adjustment, efektywność, jakość, finansowanie

public health, reform, Risk Adjustment, effectiveness, quality, funding

Statistical and economic Risk Adjustment methods for measuring the quality of hospitals – discussion of the article*



Alexander C. Tsai, Harvard University (USA)

 John F. P. Bridges, Johns Hopkins Bloomberg School of Public Health (USA)


The past two decades have witnessed an expansion in efforts to publicly disseminate data on hospital performance based on comparisons of risk-adjusted outcomes for the purpose of affecting reimbursement or patient choice. While much is known about which risk factors should be adjusted for, less is known about the appropriate statistical methods that should be used in deriving such quality measures.

We discuss the literature on profiling and Risk Adjustment, with an emphasis on recent econometric and statistical methods, highlighting key assumptions involved in the various analytical techniques. Particularly problematic for the traditional methods of analysis are inadequate sample sizes and unobserved severity of illness. We illustrate how these issues affected recent public profiling initiatives and highlight how recent contributions from the econometric and statistical literature may be helpful in ameliorating these problems.

Słowa kluczowe :

metody ważenia ryzyka, jakość opieki zdrowotnej

Risk Adjustment methods, health care quality

Risk Adjustment in the German health insurance system – Does the risk compensation system leave incentives for risk selection? – discussion of the article*



Anna Drabik, Markus Lungen, Stephanie Stock, University Hospital of Cologne (Germany)


Germany’s Statutory Health Insurance (SHI) more or less dates back to the late 19th century when Chancellor Bismarck implemented a forerunner of the present system to combat social unrest. Without any doubt, this was a great achievement for the social welfare state in Germany, of which the SHI is one pillar – and the SHI has proved to be remarkably stable ever since, both against reform efforts and social change.1

In the beginning, the SHI system was not designed to foster competition. Rather, sickness funds, as health insurance corporations are called under the SHI, were forced to contract and act uniformly to ensure equity and to maximize market power. This was necessary as e. g. in the middle of the 20th century there were still more than 1,800 sickness funds – many of them operating only regionally. 2 Also, the cost-containment policies which remained in place until the mid-1970s did not encourage competition. Not until the early 1990s did the political will change and the implementation of competitive elements into the SHI was seen as a way to raise efficiency potentials.3,4,5,6,7

This was the result of a general shift in the social climate favoring deregulation, questioning the effectiveness of top-down cost containment regulations and a raising societal debate over unequal options in choosing and switching sickness funds. As a consequence, the Health Care Structure Act was passed in December 1992, and almost all mandatorily insured individuals, including blue- and white collar workers, were given the same right to choose a sickness fund in order to promote competition among sickness funds.8,9,10 From then on, sickness funds could be switched on a yearly basis with three months” notice starting in 1997. To provide all sickness funds with a level basis for competition, a risk compensation system (RCS) was implemented two years before free choice of sickness funds was granted.11 Thus, the implementation of open enrollment in Germany was the aggregate result of the concern to provide equity of choice for all mandatorily insured individuals and the hope to improve efficiency within the system by strengthening competition. With time, the discussion concerning the RCS evolved to transforming the RCS, and to linking the risk compensation system to incentives for sickness funds to manage care and to implement a fully morbidity adjusted RCS while providing sickness funds with increasing leeway to compete with each other. Therefore, further refinement of the RCS has been on the political agenda ever since its implementation in 1994, leading to various expert reports and evaluations of the functioning of the RCS and its role in leaving incentives for risk selection.12

In this article, we focus on the latest health care reform refining the RCS and present an empirical analysis of its effects on risk selection for sickness funds.


Słowa kluczowe :

: ustawowe ubezpieczenia zdrowotne, ochrona zdrowia, wyrównanie ryzyka, dostosowawcza korekta ryzyka

statutory Health Insurance, health care, risk compensation system, Risk Adjustment

Application of data warehouse for Risk Adjustment algorithms – discussion of the article*



Petre Iltchev, Uniwersytet Medyczny w Łodzi


The main objective of this paper is to present a framework for designing a research data warehouse to analyse Risk Adjustment algorithms. The framework provides a methodological foundation for a systems approach to analysing Risk Adjustment models. The data warehouse will store data from many insurers, sickness funds and other source systems, and will offer a foundation for modelling and multidimensional analysis of Risk Adjustment algorithms.

Słowa kluczowe :

hurtownie danych, algorytmy korekcji ryzyka, modelowanie ubezpieczeń zdrowotnych

data warehouse, Risk Adjustment algorithms analysis, modelling health insurance

Current and future use of Risk Adjustment in the U. S. – discussion of the article*



John Bertko, Brookings Institution (USA)


The United States has extensive experience with Risk Adjustment systems for the Medicare and Medicaid public insurance programs and many lessons have been learned. With health care reform, there will be a great challenge to “get it right” for a very large new population (perhaps more than 70 million people) in order to make insurance offerings more transparent on price and quality. To the extent that Risk Adjustment assists with achieving this objective, the USA may attain its twin goals of near-universal coverage at a more acceptable cost.

Słowa kluczowe :

regulacja, korekta ryzyka, ustawa o ochronie pacjenta i zapewnienie przystępnej opieki, systemy zdrowotnych ubezpieczeń, Medicare, Medicaid

Risk Adjustment, Patient Protection and Affordable Care Act (PPACA), health insurance systems, Medicare, Medicaid

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