15/2016 Sb.
FIND
The Constitutional Court
On behalf of the Republic of
The Constitutional Court ruled under SP. zn. PL. ÚS 5/15 on 8. December 2015
the plenary consisting of Chairman Paul Rychetského and judges Louis David,
Jaroslav Fenyka, Jan Filip, Jaromir Jirsy, Vladimir Crust, Tomas
Too, Jan Musil, Vladimir Sládečka, Radovan Suchánka (judge
the Rapporteur), Catherine Šimáčkové, Vojtěch Šimíčka, Milady Tomková, and
Jiří Zemánek proposal for a group of 17 senators, for which this is Senator
Ing. František Bradac, represented by Mgr. Peter Short, lawyer
based in Ostrava-Moravská Ostrava, Hrabákova 1861/1, on the abolition of
Decree of the Ministry of health no. 324/2014 Coll., on the establishment of
point, the amount of the reimbursement paid services and regulatory limits for the year 2015,
Alternatively, on the withdrawal of its section 4, paragraph 4. 1 in the words "up to 12", point 3
part A of the annex No 1 and its annexes 12 and 13, with the participation of
The Ministry of health as a party, and a group of 16
the senators, for which this is Senator RNDr. Jitka Seitlová, as
intervention management,
as follows:
The proposal is rejected.
Justification:
(I).
The subject of the proceedings
1. On 5 July 2004. February 2015 was the Constitutional Court delivered a proposal from a group of 17
the senators (hereinafter referred to as "the applicant"), for which this is Senator Ing.
František bradac, the annulment of the Decree No. 324/2014 Coll., laying down
point values, the amount of the reimbursement paid services and regulatory limits for the year
2015 (hereinafter referred to as "úhradová" or "the contested Decree Decree"),
eventually the cancellation only under section 3 and annex No. 1. According to the
the appellant is the Decree contrary to do business according to the article. 26
paragraph. 1 of the Charter of fundamental rights and freedoms ("the Charter"), as well as
the principle of equality under article. 1 of the Charter and the principle of legality according to art. 2
paragraph. 3 of the Charter, as insufficiently takes into account the financial requirements
providers of health services in geographically and demographically
less-favoured areas. Instead, the effects of the winding-up act against them,
thus indirectly threatens the realization of the right to health under article. 31
Of the Charter. The cancellation of the contested Decree is proposed with effect from 30 April 2006.
September 2015, saying that the case should be dealt with on a priority basis. If
However, the Constitutional Court annulled only that provision, he should do so already
with effect from 30 April 2006. from 1 June 2015.
2. in the course of the proceedings on the application of the claimant, the Constitutional Court received a proposal from the
a group of 16 senators (hereinafter ' the intervener '), for which it is
RNDr. Jitka Seitlová Senator. This proposal was made to repeal section 4 of the
paragraph. 1 in the words "up to 12" and annexes 12 and 13 of the reimbursement of the order,
setting the transition coefficients that reflect the year-to-policyholders
changes in the number of insured persons of the individual health insurance by region
to 1. January two calendar years. According to the intervener
their use in calculating the total amount of remittances, which was
the provider shall be entitled for the paid service, resulting in unfair
setting the terms of the purchase of these services, the health insurance companies. In
as a result, namely the increase or decrease in the sole
Depending on the number of insured health insurance in the region, without
It takes into account whether this change reflected to the extent provided by
health services. This fact should result in non-compliance
These provisions, with the right to do business under art. 26 paragraph 2. 1 of the Charter,
the right to a fair remuneration for the work referred to in article. 28 of the Charter, the right to
free health care from public health insurance under art.
31 of the Charter and the principle of equality under article. 1 of the Charter.
3. the procedure for the latter proposal was originally kept under SP. zn.
PL. ÚS, resolution 19/15 of 26 May. August 2015 (all in this award
the cited decision of the Constitutional Court are publicly available on
http://nalus.usoud.cz), however, there has been a refusal because of
lis pendens pursuant to § 35 para. 2 Act No. 182/1993 Coll., on the constitutional
the Court. The Constitutional Court the question of the conformity of certain provisions of
the contested Decree, whose annulment was the nature of the rejected proposal,
He had to deal with in the earlier proceedings initiated on the proposal of the applicant, and even from
the perspective of the argument then referred to a group of Senators [cf. findings from
27 June 2002. November 2012, SP. zn. PL. ÚS 1/12 (N 195/67 SbNU 333; 437/2012
SB.), section 5]. This group has received in this proceeding, the position of the next
of the participant.
II.
Summary of the proposal of the applicant
4. As mentioned above, the proposal of the applicant to cancel reimbursement
the Decree as a whole, or for annulment of point 3 of section A of the annex
# 1, is justified by reference to its negative impact on the economy
health service providers who carry out their activities in
geographically and demographically disadvantaged areas. An example of one
of them, which is in the draft of this impact is illustrated in detail, it is
trading company JESENICKÁ HOSPITAL, spol. s r. o., company registration No.: 47973972,
based in Jeseník, Lipovská 103, which is the sole provider of
comprehensive inpatient health care on the territory of the District of Jeseník. The position of the
This hospital is based on the claimant has several peculiarities. With
due to its location and availability can realistically provide health
services only to persons usually resident in its catchment area, which
is located on the border of the Czech Republic with the Republic of Poland, and from the
the rest of the territory of the Czech Republic is separated from the Massif
Hrubý Jeseník. It is a region that is characterized by negative
demographic and social developments (e.g., a decrease in the number of inhabitants,
high levels of unemployment or below-average real and nominal
wage earners). These facts preclude referred to the hospital's own
activities has increased the population, which provides health services. In
the case of citizens of the Polish Republic prevents the flatbed delivery of health
services share complications of cross-border health care.
5. In 1994, when the privatisation of that hospital, had her
a legitimate expectation that the licensee will be able to provide health services
to the extent and at prices that this hospital to cover the legitimate
the cost of its activities and make a reasonable profit. The reality is
However, such that as the management company JESENÍK
HOSPITAL, spol. s r.o. is realized completely in accordance with the relevant
the legislation each year occurs as a result of the decree to the reimbursement
its agregátnímu damage. Reimbursement of the decree for the years 2011, 2012 and
2013 resulted in damage in the amount of CZK 100 044 071
reimbursement of the decree for the year 2014 again this damage was at the time of
the proposal estimated in the amount of Czk 18 151 239. The management of this hospital is
influenced by other unilateral decisions state that it
they have, in practice, significant negative effects. It's all about human resources
expenses that are affected by Government Regulation No. 561/2006 Coll., on salary
the proportions of employees in public services and administration, as
amended. Although this legislation lays down the amount of salaries only
for healthcare workers, hospitals, which are příspěvkovými
organizations of the State or territorial self-governing units, with regard to the
the number of workers in respect of which directly apply, however,
result in an adjustment of the wage conditions of employees and in subjects that
they are not bound. The appellant this regulation distorts the labour market
in the entire segment of the medical staff. Just in case the said
hospital staff costs represent approximately up to 63.4% of its
of the total turnover.
6. However, the situation is a commercial company JESENICKÁ HOSPITAL, spol.
s r. o. unique to a certain extent, the applicant appears to be highly
likely that in a similar situation are other providers
health services on other peripheral areas of the United States.
The contested Decree is unconstitutional in its opinion no longer because
that those providers does not provide income equal to at least the
justified by the costs to them effectively transfers the responsibility for
ensuring health care, which would properly should be borne by the State. The concerned
the provider presents two options. Either terminates the provision of the
health services at all, or is limited to a profitable activity, or
the sale proceeds to the hospital as a whole. Whether you are choosing to
However, in both cases without adequate economic compensation
significantly reduced return on the initial investment. The rapporteur believes
that impact justifies the conclusion about the violations of the rights of the
providers of health services and their associates to do business according to the article.
26 paragraph 2. 1 of the Charter. At the same time telling us about a flagrant threat to the rights of
the population of some areas on the free health care from the public
health insurance under art. 31 of the Charter. For example, if in the
Jeseník district was under the influence of a "settlement of the decree to limit some of the
inpatient expertise, for its inhabitants, this would mean that the nearest
available inpatient care should be given to them in the device
Remote for approximately 80 minutes by car (70 km), and only in the
the case of optimal weather and traffic conditions.
7. the applicant stresses that, with regard to the total amount of financial
resources in the public health insurance system, which in 2013
amounted to nearly 230 billion. CZK, to address the situation of the concerned
providers would have to increase their resources. In the case referred
the hospital if it were a million units a year. The omission of
different objective conditions under which the individual providers
offer health services, based in his opinion, a violation of the principle of
equality under article. 1 of the Charter. The shortcomings as a whole is supported by the
that to the issue of reimbursement of the decree did not occur in accordance with the legal
the authorization contained in § 17 paragraph 2. 5 of Act No. 48/1997 Coll., on public
health insurance and amending and supplementing certain related
laws (hereinafter referred to as the "law on public health insurance"), as amended by
amended. The Ministry of health it was duty bound to
issue in this wording, in accordance with the laws and
the public interest. But in that case the case proven to be not,
Therefore it was released also in breach of article. 2 (2). 3 of the Charter.
In conclusion of its application the applicant notes that the repeal of the Ordinance should
has created a space for its more comprehensive treatment, which could better
reflect the constitutional rights of citizens and individual providers
health services. This is due to the fact that, in her case, cannot be
trivially to point out a single or only some of its provisions, which
cancellation would lead to the Elimination of these shortcomings. Repeal of section 3, part A
Annex No. 1 to the tender notice, however, the Elimination of at least the largest
weakness of the applicable legislation.
III.
Summary of the proposal the intervener
8. proposal of intervention is directed only against certain provisions of the
reimbursement of the order, and that other than the plaintiff relied on the reasons.
Specifically, it called into question the constitutionality of the coefficients of the transition
insured persons, set out as an index of changes in the number of insured persons, the competent
health insurance companies in the region, where health services are provided, in
the period between 1. and 1 January 2015. January 2014 (abbreviated Kpp14; Annex No.
12 to the contested Decree), and between 1. and 1 January 2015. January 2013
(abbreviated Kpp13; Annex 13 to the contested Decree). Referred to
the coefficients shall be used when calculating whether the total lump-sum
reimbursement to providers of inpatient care, and the first of them even in the calculation of
the maximum total reimbursement to providers of outpatient care. Depending
on whether their value is greater or less than 1, it will either
increase or decrease the level of remuneration, or to increase or decrease the
limit. Their current settings in case of general health
insurance companies in the Czech Republic as the most important health insurance provider
the country, however, has the effect that with the exception of the city of Prague, where are the
these coefficients higher than 1, occurs in other States to reduce the
the amount of the reimbursement, without having fully compensated this decrease by increasing payments
from other health insurance companies. Their share of the share
each of the providers is not large enough.
9. The basic problem of the coefficients sees the intervener
in the fact that their value is based on exclusively from the decline or increase of
the insured individual insurance undertakings, i.e. in regions. from just movement
(migration) of insured persons. At the same time is of no account at all of the actual proportion of
those policy holders of individual insurance companies, which were given care in the
specific hospitals, nor do the structure of the population of
health or of age. For example. for migration policy holders to
Prague can be assumed to be there for work, mainly younger moved
and healthier policyholders, while in regions where such insured persons
diminished, increased the share of insured persons and older nemocnějších. Yet he was
increased remittance factor just for the city of Prague. In this context,
the intervener refers to the data of the Association of Czech and Moravian
hospitals, which shows that it has already closed 1. in the quarter of 2015
compared to 1. quarter of 2014 the evolution in the number of treated policyholders
fundamentally departs from the coefficients of the transition policy holders as
laid down in the Ordinance of the reimbursement. A similar development can be expected in the
other quarters. Therefore, the coefficients allocated do not correspond
the actual volume of medical care to be provided at individual hospitals.
For almost 67% of the hospitals are thus provided for changes in the number of insured persons
lower than the actual number of treated policyholders. It is not yet
not unusual, that even though the development in the number of treated insured persons in the
the hospital is growing, the Decree provided for the coefficients of the result in that
the remuneration for the higher volume of provided care option reduces. Their
settings for each county is either incorrect, or is based on the
the fact that they do not have with the immediate provision of health care
direct link (e.g. search for the retroactive adjustments of final and preliminary
monthly payments to suit the health insurers). The method of calculation
the relevant factors and evidence in addition to him were never
made available, and under each of the present version of the reimbursement
the decree is their value was different. The intervener therefore disputes the
not only the way of developing the relevant coefficients, but also their
the legitimacy, rationality, appropriateness, necessity and effect.
10. In the opinion of the intervener cannot transition coefficients
the insured, as are set in the contested Decree, stand or from the
point of purchase request setting fair conditions of health
the service, which is apparent from the constitutionally guaranteed rights to conduct business and operate
other economic activities referred to in article. 26 paragraph 2. 1 of the Charter, whether it's
about price or equal status of health insurance companies and hospitals. Any
distortion of free competition between the providers of health services are
by them, rather than due to the adequately compensated. In this respect, the proposal
points out that these coefficients will be applied only in relation to the bed
or outpatient care, and not to many times more sector
external providers of outpatient services. The hospital, which provide
the same outpatient services such as external private ambulance, are so against
discriminated against them. In addition, the following coefficients withheld payment of the
for out-patient emergency services provided by the only exceptions today
in hospitals, as well as remuneration for the extensive preventive screening and
other programs the Department of health, to which they are insured
invited health insurance companies.
11. The coefficients of the gradient is alleged against the unconstitutionality of the insured and of the
in terms of other fundamental rights. The intervener points out
discrimination of the individual insured persons or entire groups, in
their right to free health care from public health
the insurance referred to in article. 31 of the Charter. Their unequal status is based on the
belonging to a health insurance company and it's associated coefficient in the
the appropriate region. Seemingly small differences between the reimbursement provided for
each of the insured person on the order of a few percent can u
more serious diagnoses include tens of thousands of dollars, as a result of
which may affect the willingness of certain hospitals to provide particular
intensive care. The coefficients of the touching and the rights
workers on fair compensation for the work referred to in article. 28 of the Charter.
Government Regulation No. 561/2006 Coll., as amended by Government Decree No. 303/2014
Coll., increased wage rates in health care by 5%, i.e. by the amount
the coverage requires an increase in payments to hospitals by at least 3%. On this
in so doing, had to increase in view of the shortage of nurses and doctors respond
even the hospital, to which this regulation does not apply directly. Úhradová
the Decree provides for an increase in nominal terms while the lump-sum payments for hospital bed
care and limits to cover outpatient care for 3%, this increase, however, in
Depending on the region and the health insurance at the same time variously reduces the
by means of the coefficients of the transition policy holders. To raise the necessary
to increase salaries and wages so thanks to these rates reached more than
half of the hospitals.
12. Given the fact they have to testify about the fact that the contested provisions
reimbursement of the Decree, which provide for the applicability of the coefficients of the transition
the insured, should be assessed in the context of the test of reasonableness and
of proportionality. In the opinion of the intervener cannot reach
the conclusion that the public interest in the issue of this order in the form could
outweigh the public interest in the stability of the network of hospitals, as well as the above
effects in terms of the principle of equality under article. 1 of the Charter or above
of fundamental rights. That the adopted solution was not necessary, says i
the original proposal for reimbursement by the Ministry decree that the use of
the relevant factors podmiňoval the fact that the result does not
reduction in the amount of the remuneration to the individual providers of health services under the
the border of 103%. This solution while not enforced or lack of
of funds on accounts of health insurance companies, as their
balances amounted to 31. December 2014, over 15 billion. And on 31 March 2002.
December 2015 shall assume a total of EUR 10.4 billion. CZK. In both
cases as to the amounts that far exceed the financial entitlements
arising from the reimbursement of guaranteed minimal increase of 103%.
13. The imperfections of the current system of redistribution of the premium selection
between health insurance companies cannot in the long term replace to a large
extent artificial redistribution of costs of health insurance between
providers and at the expense of part of them. The objective of this compensation may be
achieved by other means, which would be more friendly to the above
constitutional rights. Although the intervener acknowledges that no rights or
the constitutional principles of the respective coefficients were not affected enough to
they are full of distortion or deterioration, for several years, however, in
as a result they sub intrusion and crushing.
To cancel their edits finding of the Constitutional Court could this
the trend to prevent not only in relation to the year 2015, but also for the following
period. It comes in its own way of excess provisions, which are not with
other provisions of the settlement Decree is consistent enough to make them
It was not possible to cancel alone, i.e. without changing the meaning of the other it
provided for the parameters.
IV.
Course of the proceedings before the Constitutional Court
14. The Constitutional Court pursuant to § 69 para. 1 and 3 of Act No. 182/1993 Coll., on the
The Constitutional Court, the Ministry of health (both proposals as well as
"the Ministry") as a party to the proceedings and, Furthermore, the Ombudsman,
who is authorised to enter into a control, such as its intervener.
IV./a
Representation of the Ministry of health
15. The Ministry of health is gradually expressed to both proposals, and
that memorandums of 16 June. March 2015 and 13. October 2015, signed
Minister of health. Svatopluk Seas, MBA.
16. On the proposal of the applicant States that the Ministry itself úhradová
Decree law do business according to art. 26 paragraph 2. 1 of the Charter immediately
without prejudice. In no way does not regulate the conditions under which you can get permission to
provision of health services, nor prevent their providers of these
services offered, whether for services paid or unpaid from the public
health insurance. This Ordinance only provides for the General characters
all selected and predefined categories, the amount of remittances point values
covered services and regulatory restrictions. In each category is the remuneration for the
provided by the health service established as well and are providers of
This point of view in a flat position, and none of them is discriminated against.
The Ministry stresses that the providers of health services as
businesses cannot base its business on the fact that will be completely without
known risks of public health insurance. System of this
insurance has limited resources and cannot be run out and bring to
the collapse of the unjustified and unfair payments. Such a status would
no doubt led to the infringement of article 81(1). 31 of the Charter, that the existence of the system
public health insurance specifically calculated.
17. Non-compliance of the Decree, the Ministry does not see any reimbursement nor with the right to
free health care under art. 31 of the Charter. Providers
health services may exclude its application by health
insurance company conclude an individual agreement on the method of payment, amount of payment and
regulatory restrictions, which may be accented and
geography, population, or other specifics related to the area
health services are provided. In this context cannot be
overlook that, according to § 46 para. 1 of the law on public health
insurance health insurance are required to ensure the provision of
covered services to their affiliated persons, including their regional and time
availability. They do so just by providers, with
which have concluded contract for the provision and payment of these services.
In conclusion, their answer to the notice of the applicant adds that the Ministry
the contested Decree has been issued contrary to the authority pursuant to § 17 para.
5 of the Act on public health insurance. A proposal for its abolition would be
Therefore, should be rejected. If, however, the Constitutional Court came to a different
the conclusion should at the same time decide to delay the enforcement of its
the award so that it can be prepared a new proposal for reimbursement of the Decree
containing a different way of determining the payments.
18. as regards the proposal of intervention, the Ministry, in the first
a number have expressed to the reasons for the use of the coefficients of the transition
policy holders. In the year 2015, as well as in previous years, are
the hospital paid for by form of the global flat-rate scheme, which means that from
health insurance companies receive a percentage of the remuneration is always
the previous year (in 2015 it is 103% payment in 2014), if
produce a similar production, IE. the number of hospitalizations, as in the reference
year. The total amount of remittances is, however, also been modified with regard to changes
the number of insured persons according to the individual insurance companies and regions. This is because the
the assumption that the loss of the insured persons for health insurance means
reduction of the total resources for the care of the insured person, while the remaining
the arrival of new policyholders their increase. Comparison of their number to 1.
January, again based on the fact that the policyholder may change his insurance company only
Once a year, just at that date. Otherwise, it is during the year their number in
virtually constant and changes occur only as a result of the death, the birth of
or leaving the insured abroad. The coefficients shall take into account the fact
that in the course of displacement occurs, the insured persons between the region of
because of changes in their residence.
19. changes in the number of insured persons Nepřihlédnutí, according to the Ministry, should
the effect of unequal status among health insurance companies, which would
had to pay to hospitals payments at the same level as in the previous
years, however, each a different number of policyholders. Health
the insured's insurance company, which has gained new would be paid to hospitals
less money per patient than in the past years, while
the insurance company from which the insured person go, would have had to pay more. It,
that such a situation arose in the past, is ultimately one of the reasons
for that today in general health insurance company of the United States shall be borne by
higher payments to hospitals than other insurance companies. Non-application of the coefficients
transition policy holders could also lead to a decrease in payments to individual
hospitals. According to the settings above the lump-sum payments for
bed care would, in fact, while the insurance company that she was paid by the clients
hospitals the same total amount of money, while the insurance company clients
they left, it would be able to pay less, depending on whether their
the departure is not so large that the hospitals make it impossible to fulfill the condition
recognition of a similar volume of production as in the reference year in which they are
still had enough. The coefficients of and in these cases, through the
reduction objectives enable you to maintain the same level of providers
payment, even though it would otherwise because of the decline in production was reduced.
20. Calculation of the coefficients is, of course, more,
However, the Ministry placed emphasis on the determination of the ratio of the number of insured persons
the insurance undertaking in the region of 1. January 2014 and 1. January 2015.
This calculation procedure is trivial, verifiable and transparent. Dear
factor used for example. in the settlement decree for 2014, which
transitioning clients weighted according to their predicted cost, can
on the contrary, only specify an order of magnitude more complex and ambiguous manner and without
the existence of a generally accepted methodology. For the problematic can be marked and
alternative factors, which reflect changes in the number of real
treated patients, since their number to the beginning of the year would not be possible to
Figure. At the same time would reduce the certainty of the Ordinances, planning capacity
health insurance companies and the Ministry's ability to predict future costs
segment and with the financial stability of the system. Last but not least is
should be noted and the risk behavior of the hospitals that could
prefer treatment in terms of the need for care or morbidity of less
challenging the policy holders or hospitalisation in cases
that would make it possible to deal with on an outpatient basis. Determination of coefficients according to
individual regions (and not nationwide or by individual municipalities)
the Ministry considers it appropriate to attain the objective factors for the
prediction of how it changes the representation of the clients of insurance companies at the level of
individual hospitals. In this regard, allows consideration of reasonable
travel insured for health care.
21. Each subarea objections intervention Ministry
It notes that if the increase in payments does not compensate for other insurance companies
the decline in remittances general health insurance company in the Czech Republic, then this is the
due to the fact that, currently, this insurance pays for one
the insured more than other insurance companies. Such a State could be
the result of the massive outflow of its policyholders in the past, which is not yet
Member of its flat-rate payments. In its essence, so today
occurs to remedy the situation. The Ministry does not agree or criticised
breach of the principle of equality and non-discrimination. A segment of the ambulance
hospitals and their essence is the acute in-patient care
very different from the ambulance outside the hospital, which is manifested in their
different úhradovém mechanism. In hospital out-patient clinics can be more difficult to
to distinguish individual expertise. A similar regulation as in
mimonemocničních out-patient clinics (that is, the regulation on the uniquely treated
the insured person) is not possible because of the interconnection with acute in-patient care, when
There is the possibility of part of the production to perform outpatient and inpatient
on the contrary. The difference is then given and in the formation of network providers. In the case of
the transition between the edge of the policyholders are in regions with higher
concentrations of insured persons will increase and concentration of outpatient providers,
but not the concentration of hospitals. They will only increase the volume of
care, which is then reflected by coefficients
transition policy holders. These coefficients so the ambulance outside hospital
they are not needed.
22. According to the Ministry The coefficients have no any impact on
the implementation of patients ' rights to free health care under art. 31
Of the Charter, or on their access to it, nor is it do not discriminate on the basis of
membership of a health insurance company. Health insurance companies have
the obligation to ensure its local affiliated persons and time availability of care. (I)
If reimbursement mechanisms in the decree were not suitable for reimbursement
a particular contractual relationship, the insurance company and the provider always option is
agree individually so as not to put at risk the availability of medical
care for patients. Then you cannot regard the allegation of violations of the rights of
to obtain an equitable remuneration referred to in article. 28 of the Charter. According to the expert
bodies (the working team of the Council of economic and social agreement), it is sufficient
for the increase of tariff salaries of health care professionals about the 5% increase of payments of 2.1%.
The increase of payments in the amount of 3%, though multiplied by (and possibly even reduced)
the relevant coefficient will be always higher and it will be sufficient to
cover the increased staff costs.
23. In conclusion, his second observations the Ministry stated that the way
the calculation of the coefficients, as well as the need for their use is described in detail
in the relevant explanatory memorandum. Different calculation factors in individual
versions of the reimbursement of the Decree was the result of a later correction of the relevant
data from the central register of insured persons, or whether or not changes to the way
the calculation. For all these reasons, and taking into account the arguments put forward
the intervener should be the design of the claimant is dismissed.
IV./b
The Ombudsman's communication
24. On 19 December. February 2015, the Constitutional Court received communication from the Public
Ombudsman Mgr. Čtk, Ph.d., that does not enter into this
control. Substantively identical communication from her, the Constitutional Court received and 16 December.
September 2015, who responded to a proposal for intervention. The delivery of
This proposal she began again period pursuant to § 69 para. 3
the law on the Constitutional Court, which could enter into the control.
IV./c
A replica of the applicant and the intervener
25. The Constitutional Court has sent to the applicant and to the adjacent to the participant the amount of the
referred to the observations relating to their proposals for the case on
they wanted to respond within a specified period. He took advantage of this option only
the petitioner.
26. the applicant in its reply of 4 June. November 2015, stressed that
Decree Law úhradová his business clearly touches, and repeatedly
He pointed out a case study related to the business of the company
JESENICKÁ HOSPITAL, spol. s r. o. from that it follows that a provider of acute
inpatient health care in a geographically and demographically disadvantaged territories
does not the current settings of the reimbursement of the Decree, the possibility to profit.
On the basis of the calculated payment for provided health services
It does not cover even basic costs of this care. The State, on the one
the side has allowed the business even in such a disadvantaged territories where there is a
a real risk of a threat to or breach of the availability of health care as
such, on the other hand, however, for it established the conditions that
de facto exclude his sense. Nezohledněním these details on the reimbursement
the Decree occurs in unequal and less favourable position concerned
providers compared with providers in other areas.
27. According to the Decree of the applicant does not provide the Úhradová concerned
sufficient providers are entitled to compensation. The possibility of individual
the arrangement with the health insurance company that depends exclusively on her will,
the relevant guarantee or system solution of the problem definitely be considered
You cannot. If in so doing, the practical application of the Decree, which, moreover, reimbursement
at the time of the approval of the design of health insurance plan clearly
exceeds the guideline indicators leads to the drawing of all planned resources
then health insurance lose permissions reasons with the provider
Another method of payment.
IV./d
Oral proceedings
28. Within the meaning of section 44 of the Act on the Constitutional Court, the Constitutional Court decided in the case
without holding an oral hearing, as was to be expected from him for more
clarification of the matter.
In the.
An assessment of the conditions of the proposal
29. The Constitutional Court notes that it is competent to judge the proposal on
the cancellation of the contested decree or any of its provisions, and that the proposals
the applicant and the intervener meets all statutory
formal requirements and have been submitted by persons authorised to do so [section 64
paragraph. 2 (a). (b)) of the Act on the Constitutional Court]. At the same time does not find it any of the
reasons of inadmissibility of the proposal of the applicant, or to halt the proceedings for
it. Are therefore met the conditions for substantive assessment of
the perspective of the argument put forward in the two proposals.
Vi.
The assessment of whether the Decree was issued on the basis and within the limits of the law
30. in accordance with § 68 para. 2 of the Act on the Constitutional Court, the Constitutional Court
first dealt with the question of whether the contested Decree was adopted and published
constitutionally Conformal manner and within the limits of the Constitution laid down the competence.
31. The provisions of article. paragraph 79. 3 of the Constitution of the United States confers on the
the ministries and other administrative authorities with the power to issue a contract or
the legislation, to whose implementation may, however, occur only on the basis and in
the limits of the law, if they are authorised to do so by law. That provision is
should be interpreted restrictively, in the sense that such a mandate must be
specific, unambiguous and clear [cf. findings dated June 21, 2000 sp.
Zn. PL. ÚS 3/2000 (N 93/18 SbNU 287; 231/2000 Coll.)]. If so
is, the Constitutional Court examines whether legislation was podzákonný released
public body authorized to do so and within the limits of its competence, i.e. whether the
shall exercise this power was moving within the limits and on the basis of the law, and
not outside the law. Basically the point is that in the case where the
under the law, be X, this prescription has provided that Y should be, but that has
be X 1, x 2, x 3. Of the enabling provisions must be evident at the same time will
the legislature to modify the above the legal standard. Even in this case, however,
podzákonný law shall not interfere in the affairs which the regulation
may occur only by law (i.e. for which applies the so-called reservation)
[cf. e.g. find dated 18 August 2004, SP. zn. PL. ÚS 7/03 (N 113/34
SbNU 165; 512/2004 Sb.) or the discovery of 25 June. March 2014, SP. zn. PL.
TC 43/13 (N 39/72 SbNU 439; 77/2014 Sb.)].
32. The mandate of the Ministry of health to issue a decree
provides the value of the item, the amount of the reimbursement paid services and regulatory
restrictions, it follows from section 17(2). 5 of the Act on public health insurance.
This provision assumes that its release will be preceded by
conciliation of the representatives of the Czech general health insurance company
States and other health insurance companies and representatives of the competent
professional associations as representatives of the providers
providers, which shall be convened by the Ministry. If the result of this
the management agreement on these parameters, the Ministry will issue her as
a decree. However, if the content of the agreement was in conflict with the law
legislation or public interest in the meaning of § 17 para. 2 of the law on
public health insurance means the interest in quality assurance and
the availability of paid services, the operation of the health care system and its
stability within the financial possibilities of the public health system
insurance, or would the agreement was not reached until 120 days before the end
the calendar year, shall issue a decree the Ministry of value
point, the amount of the reimbursement paid services and regulatory restrictions on the following
calendar year separately.
33. In view of the mandate contained in § 17 paragraph 2. 5 of the Act on public
health insurance in the case of the contested Decree is clear that was
issued by a public authority so authorised. From the observations of the applicant,
the intervener and of the Ministry are also served, in accordance
with this provision, as well as the conciliation took place, albeit in
It occurred to early agreement only in respect of some of the segments
health care [on the question of the importance of the conciliation procedure for the use of
mandate, and any binding agreement. find SP. zn. PL. ÚS 6/07
of 9 June. 2.2010 (N 20/56 SbNU 207; 66/2010 Sb.), section 77]. It remains to
Add to this that the contested Decree was duly published in the statute book,
specifically, in its amount of 129, which was circulated on 23 December 2005. December 2014.
For its adoption and the publication had constitutionally Conformal manner.
34. The Constitutional Court did not find no reason in denying that the
the release of the contested Decree was within the limits of legal authorization. In this
regard, considers it sufficient to refer to the more detailed justification for
This question in the award, which was canceled by a decree for the year úhradová
2013 [from 22 October 2013, SP. zn. PL. ÚS 19/13 (N 178/71 SbNU
105; 396/2013), paragraphs 41 to 43]. That conclusion is doing nothing does not change
nor is the claim of the applicant that the deviation from the limits of due
the non-compliance of the decree with the public interest reimbursement, therefore it cannot be
treat, or for existing in accordance with art. 2 (2). 3 of the Charter. From the contents of
This claim is clear, that this is in essence a summary of its
arguments of the parties to the conflict of this order with some constitutionally guaranteed
fundamental rights, the Constitutional Court dealing in other
sections of this report.
VII.
Summary of the contents of the infected parts of the Decree
35. the Charter in its article. 31 guarantees citizens the right to free
health care and medical equipment on the basis of public health
insurance. While this provision requires that the conditions, IE. in particular, the
the extent to which citizens will be able under such constitutional conditions
access to health care and medical equipment, provides only
the legislature, however, cannot be interpreted as meaning that it would be for his
account apparently did not generate no limits [cf. the finding dated April 23, 2008, SP. zn.
PL. ÚS 2/08 (N 73/49 SbNU 85; 166/2008 Coll.), paragraphs 52 to 56]. I eat
adopted legislation must primarily enable the actual implementation
This right, therefore, to maintain its essence and purpose (article 4, paragraph 4,
Of the Charter). If, as a result of the creation of the conditions for
equal access to health care, then this results in touch
only the life and health of those who would otherwise not be able to be enforced. The resulting
the State would have made his doubts about whether the State is at all able to
live up to one of their core responsibilities, which follows from article. 1 sentence
the first of the Charter and is implicitly represented also by enshrining social rights in
The Charter, therefore, the obligation to ensure conditions for a decent life for all
of its citizens.
36. In order to ensure equal access to health care is also used for more
the request directly resulting from the article. 31 of the Charter, which is the existence of a system
public health insurance. Adoption of amendments to the
ensure, as well as its effective implementation, it is the duty of the State, and in
in particular the authorities of legislative and executive power. The Foundation of
the legal definition of this system is the law on public
health insurance, which regulates legal relations between health
insurance companies, their insured persons and providers of health care services for
the purpose of the realization of the constitutionally guaranteed right to free health care.
Úhradová Decree, on the basis of § 17 para. 5 of the Act on public
health insurance is issued by the Ministry of health for
the following calendar year, then the legal supplements. Provides for the
I mean, how will it be the amount of the reimbursement to which a particular
the claim against the health insurance providers for paid services
in accordance with their legal or contractual obligations to provide their
insurance policy holders. Its content is actually price regulation. Although
each provider may agree on a different health insurance
How to determine the amount of reimbursement, and thus in relation to their mutual legal
relationships need not apply "settlement Decree, in general terms,
This Decree significantly complement the conditions for doing business in
the provision of health services. For this reason, it can be
consider also the legal arrangements in relation to these
providers to define the legal framework applicable to the implementation of their
the rights to conduct business according to the article. 26 paragraph 2. 1 of the Charter.
37. The Constitutional Court does not see any reason at this point for more detailed
a summary of the entire contents of the contested Decree. Having regard to the arguments put forward
the applicant and the intervener considers it sufficient approach
the content of those parts which are contaminated by any Petite
the applicant or the intervener seeks the cancellation or
some other content-related provisions. In this way, you can
While admitting the relevance of particular § 4 paragraph 2. 1 the contested Decree and further
points 3.5 and 5.10 part and its annexes 1 and its annexes 12 and 13.
38. the provisions of point 3 of section A of Annex No. 1 of the contested Decree, whose
the cancellation of the appellant suggested, provides that the remuneration for its care, i.e.
remuneration for provided and paid for by the health insurance company recognized by the service,
that the provider has provided to the insured person during the hospitalizations terminated in
the year 2015 shall be in the form of flat-rate case. The method of calculation
the total lump-sum payment, which he paid in the course of a
a claim against a health insurance company, is expressed in this provision
the formula, the individual variables are closer defined verbally.
Total flat-rate remuneration is calculated from an individual lump sum payment,
which consists of the product of the following elements. First and foremost is the sum
total flat-rate remuneration for services, as defined in the same manner provided by
During hospitalizations completed in 2014, and regulatory charges
acute in-patient care, which were selected by the provider in 2014.
The sum of the amounts thus designated is then multiplied by the coefficient 1.03,
expressing an increase in remittances by 3%, as well as the coefficient of the transition
insured persons Kpp14, contained in annex 12 to the reimbursement that Decree
changes in the number of insured persons reflects the health insurance companies in the region
the provision of paid services between 1. and 1 January 2015. January 2014.
Depending on whether the coefficient is higher or lower than 1, occurs on the
the basis of it to increase or decrease an individual lump sum payment.
39. the total lump-sum payment shall be determined by the individual thus calculated
the flat-rate payment, however, may be lower when the number of cases
hospital admissions of completed in the period 2015 does not reach
at least 96% percent of the number of cases, hospitalizations terminated in
2013. This percentage value is in the case of each provider is multiplied by the
the coefficient of the transition policy holders Kpp13, contained in annex 13,
changes in the number of insured persons reflects the health insurance companies in the region
the provision of paid services between 1. and 1 January 2015. January 2013.
Depending on whether the coefficient is higher or lower than 1, so
increases or decreases the bounds of the drop in the production of this provider, when you
that does not, proportioned to reduce an individual lump sum payment.
From the amounts thus calculated will eventually be deducted the total value of the requested
extramural care cases hospital admissions by the provider
declared and recognized health insurance company, which were completed in
the period. Extramural care means care related to
the insured's hospitalisation in the provider that the provider's
requested, and which is insured at the time of hospitalization in the provider
granted to other provider that charges a health insurance company.
The resulting amount after deduction of the total lump-sum payment is.
40. The basic principle of calculation can therefore be summed up so that
the flat-rate remuneration, to which a provider bed care claim
against health insurance for her paid services provided during the
hospital admissions of completed in 2015, is determined from the amount representing the
a fixed remuneration, to which he was entitled for the same services provided by
During hospitalizations completed in 2014, plus 3%. The amount of the
However, it may also be proportionally increased or reduced having regard to the changes
the number of insured persons the competent insurance companies in the region, with
may be reduced proportionally, even if a more pronounced decrease in the number of cases
hospitalizations compared to 2013.
41. the provisions of section 4, paragraph 4. 1 reimbursement of the Decree, whose annulment
suggested by the intervener, worded as follows:
"§ 4
(1) for the paid services provided by providers of inpatient care, with
except for covered services provided by providers of subsequent bed
care, providers of long-term care beds and special providers
bed care, the point value, the amount of the reimbursement paid services and regulatory
limit fixed in annexes no. 1, 9, 10, 12 to 14 of this Ordinance. "
Design intervention for its part defined the words "12
up to "that express reference to annex No. 12 and 13 of this Decree as to the
the relevant section to determine the amount of reimbursement the covered services
supplied by providers bed care. This annex lays down the
the transition coefficients of insured persons, which is used to calculate the payments on
that arise in the course of the year 2015 against health providers
the insurance company paid the claim for the service. Both consist of tables,
in which they are by region and health insurance listed indexes changes
the number of its policy holders in the period between 1. and 1 January 2015. January 2014
(abbreviated Kpp14; Appendix 12 to the contested Decree), and between 1. January
2015 and 1. January 2013 (abbreviated Kpp13; annex 13 to the contested
the Decree). For the calculation of the coefficient is always
provided for at the same time for the County in which the provider provides health
services, and health insurance, which the insured person was the beneficiary. In
now operates in the Czech Republic seven health insurance companies, which
are general health insurance company of the United States, military health
the insurance company of the Czech Republic, Czech industrial health insurance company,
Specialist health insurance of employees of banks, insurance companies and
construction, health insurance, health insurance company Škoda
the Ministry of Interior of the Czech Republic and Guarded the brethren,
health insurance company.
42. the value of the coefficient of the transition of the insured depending on the Kpp14
specific health insurance company and region ranges from 0.951 to
1,073, in the case of general health insurance company in the Czech Republic is
so in between to 0.982 on 992. The value of the coefficient of transition
insured persons Kpp13 ranges from 1.182 to 0.955 and in the case of
General health insurance company United States ranging from 0.930 to
1,008. Both coefficients have been calculated for this insurance as higher than
1 just for the city of Prague, in other cases their value
lower.
43. Although the intervener proposes only parts of section 4, paragraph 4.
1 reimbursement rules and its annexes 12 and 13, not to be overlooked, that the
the coefficients of the transition policy holders and the reference to that annex in
reimbursement notice contained in other places. These coefficients are
in fact apply when calculating the total lump-sum payment providers
inpatient care, which is contained in section 3.5 of Annex No. 1, and
the maximum total reimbursement to providers of outpatient care that is
contained in section 5.10 of part A of annex 1. The essence of the first calculation was
unloaded in detail above (see paragraphs 38 to 40). The maximum total remuneration
providers of outpatient care for the paid services provided in
the period of 2015 is again calculated from the total amount of remuneration
rendered in 2014, which for this purpose shall be multiplied by 1.03 value
(i.e., increased by 3%) and the coefficient of changes in the number of insured persons share Kpp14.
In this case, it is not a fixed remuneration, but about the level of remuneration, offers
calculated in accordance with point values depending on the amount of carried out
performances.
44. the assessment of the coefficients of the transition policy holders in terms of their
the alleged unconstitutionality assumes their importance for clarification
the calculation of the amount of the reimbursement to which a eligible providers. It has already been
stated that these coefficients depending on whether their value
higher or lower than 1, increase or decrease the total fixed remuneration
providers of inpatient care, and the maximum total reimbursement to providers
out-patient care. However, if the total income of these providers
public health insurance, that is made up of the sum of the payments to which the
they are entitled to all health insurers. Thus, although they may
the transition coefficients lead to reduced reimbursement of insured persons from the side of one
health insurance companies, in the case of other health insurance companies may be
on the contrary. However, the overall impact of their use shall be of the
sum of the individual point of view neutral payments. To their amount are always
reflect the increase or decrease of insured persons in the county where the health
the service is provided. The current amount of the payments made by each
insurance companies may be in addition (and according to the observations of the Ministry also is)
historically set differently, which means that certain health
the insurance company paid for a comparable range provided by health
services, on average, a higher amount than any other insurance company. Therefore, you cannot
eliminate the use of these factors occur in a particular
the provider to the total amount of the payments to which he is entitled,
Despite retaining the same range will not be provided by the health
services as in the previous year increased by 3%, but the amount is lower,
or that it will not be increased at all or will even be reduced.
45. The reason for which the Ministry of zakomponovalo the coefficients referred to in
reimbursement of the order, according to the Constitutional Court can be found in the request
adjustment or settlement of expenditure of individual health insurance with
the changes in the number of their policyholders. This is because these changes affect the
the amount that you will have individual health insurance
the choice of insurance available for payment of health services
your insurance policy holders. Using the coefficients so's purpose is mainly
a fairer or more even distribution of health expenditures
insurance between the health insurance company.
VIII.
The assessment of the contested decree law do business according to the article. 26
paragraph. 1 of the Charter
46. the proposals of the applicant and the intervener challenge the constitutionality of the
reimbursement of the order, or its parts, primarily from
the perspective of the rights of the providers of health services to conduct business according to the article. 26
paragraph. 1 of the Charter. The Constitutional Court therefore addressed the question in the first place,
whether this Decree does not cause unacceptable restrictions.
VIII./a
The starting points of the review
47. The essence and purpose of the right to choice of occupation and preparation for it,
as well as the right to do business and engage in other economic activities referred to in article.
26 paragraph 2. 1 of the Charter is the freedom of individuals to choose and implement
the way you will provide the resources for their needs. It is not
while essential, whether the action, which should lead to the achievement of this
objectives, carry out an employment relationship or as an entrepreneur on your own
liability.
48. Those rights may be an individual within the meaning of article 3(1). paragraph 41. 1 of the Charter
Sue only within the limits of the law, which is to be carried out. According to the article. 26 paragraph 2. 2
Of the Charter, the law may lay down the conditions and limitations for the exercise of certain
occupations or activities, and for any purpose which is not constitutionally
inadmissible [cf. findings from 20 June 2006, SP. zn. PL. ÚS 38/04 (N
125/41 SbNU 551; 409/2006 Coll.), section 29]. The legislature thus has a relatively
a wide, if not absolute, available for a specific definition of the content
and the way of realization of this right [cf. find out on May 23, 2000
SP. zn. PL. ÚS 24/99 (N 73/18 SbNU 135) or the discovery of 12 October. July
2001, SP. zn. PL. ÚS 11/2000 (N 113/23 SbNU 105; 322/2001 Coll.), part of the
(VIII) (a). H]. Even in the case of fundamental rights according to art. 26 paragraph 2. 1 of the Charter
However, apply the requirement arising from its article. 4 (4). 4, when
determination of the limits of these rights, it was investigated the nature and meaning of them. It
means that if certain restrictions affect the very essence and sense
the basic law, then such restriction does not constitute a breach of the
just assuming that it will be necessary to achieve their legitimate
(or constitutionally senior) objectives. In the case of the right to choose a profession and
the preparation for it, as well as the right to do business and engage in other economic
activity would be a limitation with regard to their nature and the meaning of it was
where would the result has been a certain group of individuals
significantly impeded or obstructed access to certain occupations or
the ability to perform a specific activity or if the
specific job or activity has ceased to be eligible to ensure
resources for their needs to those who are concerned. Any
the restriction must, of course, respect the principle of equality in the rights within the meaning of
article. 1 first sentence of the Charter, and its article. 3 (2). 1 [find SP. zn. PL.
TC 1/12, paragraph 278].
49. the Constitutional Court, in assessing the compliance of the law or other legal
Regulation with the law business, which has the nature of economic rights,
proceed as in the case of social rights, to review in
the existing case law, and developed the so-called. the test of reasonableness [cf.
find of the day 5. October 2006, SP. zn. PL. ÚS 61/04 (N 181/43 SbNU 57;
16/2007 Coll.), the discovery of 12 October. in March 2008, SP. zn. PL. ÚS 83/06 (N
55/48 SbNU 62; 116/2008 Coll.), the finding of 24 September. April 2012 SP. zn. PL.
TC 54/10 (N 84/65 SbNU 121; 182/2012), section 48, or find SP. zn.
PL. ÚS 15/13, paragraphs 50 and 51], consisting of the following four steps:
and the meaning of and the essence of) the definition of economic or social rights, that is,
its essential content,
(b) whether) an assessment of the Act or other legislation without prejudice to the
the existence of economic or social rights or the actual implementation
its essential content,
(c)) to assess whether the legislation contained in the Act or other legal
the regulation pursues a legitimate aim, i.e. whether it is not arbitrary, the primary
by reducing the overall standard of fundamental rights, and
(d) the question of whether) consideration of means used to achieve it is reasonable,
Although not necessarily the best, the best, the most effective or the wisest.
50. If the Constitutional Court in the second step of the test of reasonableness to the conclusion
that the challenged legislation is affecting the very existence of any of the
These rights or the actual realization of its essential content, then
does not continue in its implementation and, instead, shall consider the admissibility of intervention to
This right within the (more stringent) test of proportionality. This means,
Whereas, Furthermore, will be evaluated in the following order,
and whether the intervention) pursues a legitimate (or constitutionally qualified)
the objective of the restriction of a fundamental right,
(b)) that this intervention to achieve this appropriate (requirement
Fitness)
(c)) that this goal cannot be achieved by other means, which would be this
the law more friendly (requirement need), and
(d)) that the interest in achieving this goal in the context of a particular legal relationship
outweigh the fundamental rights concerned (requirement of proportionality in
a narrower sense).
51. The legislation that touches the constitutionally guaranteed the social,
economic or cultural rights, does not constitute an unacceptable
restrictions only in the case that as a whole will stand in terms of all such
defined requirements. If this were not so, the Constitutional Court would have to
conclude about its conflict with the constitutional order.
VIII./b
Definition of the namítaného intervention
52. The test of reasonableness in the first instance the definition assumes that the and
How is hitting contested legislation into law to do business in accordance with
article. 26 paragraph 2. 1 of the Charter. The Constitutional Court notes that criticised the intervention
in the matter of the border should be understood as a claim to reimbursement of providers
for the paid services provided in the year 2015, which occurs by setting
the total lump-sum payment to providers of inpatient care in section 3.5 and section
Annex No 1 and the maximum total reimbursement to providers of ambulatory care
in section 5.10 of part A of annex 1. Just pointing to these provisions
the petitioner's objections and put forward the intervener to calculate the amount
remuneration, consisting in the taking into account of the shortfall in the stage
financial requirements for providers of health care services in geographically and
demographically disadvantaged areas (see paragraphs 4 to 6), and in
negative impact of the use of stage transition coefficients of insured persons (see
paragraphs 8 to 10). The essence of both of them is the claim that the contested
the Decree provided for the amount of the reimbursement is in relation to some of the providers
so low that they justify this conclusion about the violation of their right to do business.
53. To illustrate how the border touches the
that fundamental right, it is desirable to point out some of the specifics of the
business in the field of the provision of health services. First of all it is
is characterized by an extensive public service regulation, which
told to ensure that all persons in accordance with article 6(1). 31 of the Charter
access to health care a certain quality. To achieve this, stores
the law the providers of health services to a number of obligations, including the
that in some cases (e.g., in the case of an urgent care) must not be
patients on their part denied necessary health care. The real
the fulfillment of these obligations should, however, avoid, if they
related costs borne solely by the providers of health services,
or individual patients as their beneficiaries. In relation to these
operators would not have been possible to consider these costs reasonable.
Precisely for this reason there is a public system in the Czech Republic
health insurance, whose participants are compulsory for the person as defined in §
2 (2). 1 of the law on public health insurance, which on its
the basis can be provided from the paid service. This system has
with regard to the total number of insured persons and the amount of collected
resources completely dominant share of expenditure for health services. It is not
therefore surprising that a substantial part of business providers
health services is crucially dependent on whether and to what
of them are entitled to a reimbursement of this system (cf.
find SP. zn. PL. ÚS 19/13, paragraph 35). Rules for the determination of its amount, as
are laid down in the Decree, reimbursement significantly influence the overall
the income of the individual providers and thus their
business activity, which must adapt to it arising
options. In its broadest sense, interfere with their rights
do business.
VIII./c
Assessment of the intervention in terms of the nature and meaning of rights business
54. The essence and sense of fundamental rights guaranteed by article. 26 paragraph 2. 1 of the Charter,
that were defined above (see paragraphs 47 and 48), in relation to the law of the sea
to do business and engage in other economic activities specified by
in a way, that it's about the freedom to exercise a gainful activity
separately on their own account and responsibility for profit. This
the law guarantees the very possibility of performance of such activities, as well as
the obligations and restrictions which apply to it, will not prevent its
the main purpose (cf. find SP. zn. PL. ÚS 19/13, paragraph 66, or the award of
on 15 December. September 2015, SP. zn. PL. ÚS 13/14, paragraph 14). This is not to say that the
any entrepreneur should be guaranteed the right to profit, but that the range of
the obligations laid down by law governing the individual entrepreneurs in
the context of its activities, it may not be their business
meaningless in terms of its ability to achieve.
55. The remuneration calculated on the basis of reimbursement of the decree are for
a substantial part of the providers of health services completely the prevailing
source of income. At the same time, that the obligations connected with the exercise of this
activities in order to ensure the availability of health care significantly
confined space to ensure that these providers in response to possible
the low level of payments could reduce their spending. Primarily so they cannot make
at the expense of legally required scope and quality of the
health services. Úhradová Decree should touch the nature and
the meaning of the right business, if, on the basis set out above
reimbursement was provided with regard to the scope of covered services so
low, that would effectively-without any other compensation-transfer
the costs of health care provided free of charge, which should be covered by
public health insurance, the individual provider, and from
for this reason, they made it impossible to achieve at least a reasonable profit.
Such a consequence would be, of course, possible to State in relation to the
a particular segment of health care services as a whole, defined as forms
or the scope provided by the health care, though not necessarily throughout
the territory of the Czech Republic. It would indeed be a State where it would
providers with regard to the amount of the reimbursement rule settings in this
segment in its essence could not make independent decisions that would
in the case of them continuing their activities at least potentially
Open the path to possible profit. On a par with the following defined intervention,
that is touching the essence and meaning of rights, can be built and
setting up the rules of calculation of these payments, which renders their
the final amount of the individual provider for an unpredictable, for example. in
as a result of permission of health insurance companies that amount without any
justification (arbitrarily) begun (cf. find SP. zn. PL. ÚS 15/13, paragraphs 60
up to 62). It remains to add that the prejudice to the nature and purpose of the basic law
does not mean his violation, and even if, in certain
the area was the possibility of doing business significantly limited or even
excluded. Such an intervention would be necessary, as mentioned above,
judged much more strictly in terms of both its desirability and
intensity of interest in the achievement of its objectives (see test
proportionality, in point 50).
56. The contested Decree provides for the total lump-sum payment providers
inpatient care and the maximum total reimbursement to providers of ambulatory care
for the paid services provided in the year 2015, according to the amount of the reimbursement to which they
qualify for the paid for services provided in the previous year. When their
the calculation so as reimbursement for past years, decrees issued by,
based on the premise that individual providers will have in this
in a comparable performance. Referred to, however, does not mean that the
provided for remuneration remains constant. To editing occurs
through a variety of variables and coefficients including coefficients
transition policy holders whose purpose is to strike a balance between
financial requirements providers on the one hand, and the possibilities of the system
public health insurance on the other. It is clear that
the solution maintains the continuity of the legislation as regards the
setting the amount of the payments. This also enables their predictability, and
even though the resulting amount can be compared with the previous year with the
regard to the next occurs in fact higher or lower. With a specific
Indeed, providers must change when the issue of the reimbursement of the Decree every year
calculate and adapt to it.
57. The Constitutional Court notes that the very principle of the calculation based on
the above principles are clearly the nature and meaning of the law shall not affect
do business. This conclusion also applies to its specific implementation
in the contested Decree, in which the coefficients of the transition
insured persons (in this respect, however, the Constitutional Court set aside
the question whether in the case of the limitations of the above payments to providers of outpatient
care contains the úhradová Decree effective way of compensation for the costs
urgent care provided in excess of those limits, because this was not
the subject of this procedure). The applicant nor the intervener does not claim that
thus established would calculate the amount of payments in a particular segment of health
services in General, and precluding the meaning of business activities in terms of
achieve its purpose. The appellant argues that this effect only in respect of
to providers in a geographically and demographically disadvantaged areas.
The intervener again expressly acknowledges that thereto does not occur
does not exclude, however, that the use of the coefficients of the transition policy holders in other
years of such a status would cause. His objections in relation to these
the coefficients are directed mainly to the fact that as a result of their use
occurs when the vast majority of providers to reduce the amount of the reimbursement on the
that should otherwise be entitled, without this reduction in match (often
unchanged) the scope of their production. In a situation where neither the petitioner
nor the intervener claimed that the existence of the intervention, which would touch
the essence and the meaning of the law, business, and even did not declare any considerations of
which would be the consequence of such a de facto judge, Constitutional Court
responsible area to beyond the pending proposals from
own initiative was further findings or make their conclusion on
such intervention justifying. The existence of such facts cannot be
at this point, be considered even for the generally known.
58. The method of calculating the amount of payments does not rule out that some
providers of health care services will be (possibly even for multiple years)
run at a loss, even this fact is in itself, however, not affect
the essence and meaning of rights business. Each provider must above all by myself
strive to ensure that its activities as effective as possible, and when it
to avoid unnecessary costs. In so doing, even if it turned out that some
providers due to the specific conditions in the place of your business
While setting the amount of payments actually cannot achieve profit, in
the plane of that right if it were a consequence of their own
the decision regarding the method and place of business and its associated
business risk.
59. Nevertheless, it must be recognised that, to ensure the activity of certain
providers may be given to the public interest, resulting, in particular, from the constitutional
the requirement to provide access to locally and temporally available health care
provided free of charge on the basis of public insurance. The identification of the
This interest in a specific case and taking into account in the calculation of the amount of the
of payments so that the operation of such devices economically paid off, already
However, going beyond the subject of the reimbursement of the order, which is the only area
laying down rules for the calculation of these payments. To assess and ensure the
This public interest are other tools which can be used to sort
the possibility to conclude with the competent health insurance provider based on
§ 17 para. 1 and 5 in fine of the Act on public health insurance agreement
the subject will be different (in terms of favorable provider)
determine the amount of reimbursement, or. regulatory restrictions. The Constitutional Court stresses
the exercise of this permission cannot be understood merely as an expression of autonomy
will health insurance companies. First and foremost, it is a means
use of the health insurance company must proceed, if it is necessary to
the fulfillment of its obligations pursuant to § 46 para. 1 of the same Act to ensure
the provision of paid services to its affiliated persons, including their local and
time availability. Its purpose is not the provision of a short
the benefice to one of the providers on the basis of free health considerations
the insurance company, but rather the ability to make adjustments to the remuneration referred to in
reimbursement of the order, if its application in particular cases
threatened the availability of health care. In the case of providers of inpatient
care would be modified as follows the starting point for the total remuneration
fixed remuneration to which they are entitled according to the payment notices
in the coming years, if in this respect, maintain their existing
concept.
60. that the individual agreement does not mean a departure
from the legal opinion in finding SP. zn. PL. ÚS 19/13, according to the
which cannot be found in the mere possibility that the health insurance company
from its resources on a voluntary basis (i.e. on the basis of the individual
the arrangement between her and the provider) to pay the necessary costs
urgent care, which was provided beyond the úhradovou Decree
set the limitations, the relevant guarantee or system solutions to the problem
setting the amount of the payments as a result of these costs would be borne by itself
provider (point 73 cit. Award). This permission, and the other purpose monitors
It's the ability to take into account in determining the amount of remittance to the specificities of the
individual providers, which are important in terms of the request
the availability of health care and cannot be meaningfully taken into account already in the
the calculation of the amount of the payments under the settlement Decree.
VIII./d
The legitimacy of the objectives of the intervention
61. Due to the fact that the contested Decree is under consideration
action, without prejudice to the substance and meaning of rights, Constitutional Court
not perform its review in the context of the proportionality test. Instead,
He went on to the next step of the test of reasonableness, in which it assessed whether
pursues a legitimate aim, i.e. whether there is a substantial reduction of an arbitrary
the overall standard of fundamental rights.
62. In general, it can be concluded that the limitations of the above payments-to which
There was determination of the total remuneration to providers of inpatient care
the maximum total reimbursement to providers of out-patient care-it contributes to
finding a balance between the financial requirements for health providers
the services and capabilities of the public health insurance system, and thus to
equitable redistribution of its funds. It is one of the means
acting on the providers of health services to its business
carried out efficiently (see find SP. zn. PL. ÚS 19/13, paragraph 74). The constitutional
the Court does not find it any reason for that would be as follows, expressed as the purpose, not of the
constitutional terms. To achieve it in the broader context of the
application of the coefficients of the gradient can also be used, although their primary insurance clients
the aim is only to edit or settlement of expenditure of individual health
insurance companies with respect to changes in the number of insured persons (see section 44 and
45.) this partial purpose, however, is constitutionally illegal.
63. the need for a settlement of the expenditure is due to the existence of multiple medical
insurance companies. The Constitutional Court stresses that guaranteeing the right to free
health care must be provided regardless of in which medical
the insurance company, which is part of the public health insurance system in the
The Czech Republic, the patient is insured. You cannot, therefore, accept to
lack of resources of some of the health insurance companies, which
He was basically accidental consequence of the structure of its policyholders,
inability to services covered by public insurance. Essential
must be only whether there is enough money in the system
public health insurance as a whole. However, therefore, can be certainly
regarding the effectiveness of the reallocation of those queried funds between
several health insurance companies, which perform the same function, and separately in the
Basically, cannot affect the scope of its expenditure on the reimbursement provided by the
health care services, the Constitutional Court does not find it above the primary goal
the coefficients of the transition policy holders for arbitrary or illegitimate. Nothing to it
do not change or its partial projection to calculate the total lump-sum payment
providers of inpatient care, and the maximum total reimbursement to providers
out-patient care.
VIII./e
The reasonableness of the intervention in terms of achieving its objectives
64. In conclusion, the test of reasonableness is the Constitutional Court dealt with the question of whether it is
intervention under consideration also reasonable in terms of the achievement by the reference
goal. Populate this condition can be stated in relation to the already mentioned
stopover, which is the settlement of expenditure of individual health
insurance companies with respect to changes in the number of their policyholders. The use of the
the coefficients of the transition policy holders in the calculation of remuneration clearly is
to be eligible to contribute to its achievement. However, as regards the objective of the
finding a balance between the financial requirements for health providers
the services and capabilities of the public health insurance system, in relation to the
It is already the method of calculating raises some doubts. Cannot be
Indeed, overlooked that as a result of the use of the listed factors is not
in the event of a significant part of the providers to the anticipated 3% increase in the
the amount of the payments. Instead, this increase will be lower depending on changes
the number of insured persons of the individual insurance companies in the individual regions, which
but in and of themselves may not have cost-and thus the financial
-providers of health services requirements of no importance. The use of the
these coefficients may not be doing and generally will not be neutral from
point of view a summary of all payments, on which arises a providers
paid for services provided in the year 2015 are entitled to individual health
insurance companies (see paragraph 44). Principle of the calculation will be so in the case of series
providers, especially doing business outside of the city of Prague, have
their use results in a reduction of the total amount of payments in comparison with
by how much would get when a different method of calculation.
65. that impact can be summarized by using the coefficients of the transition
insured persons for the purpose of settlement of expenditure between the different health
insurance companies as a result of the reduction in your means of payment of certain
providers. This is despite the fact that the link between this
the purpose and the amount of payments for each provider is not obvious,
or is very loose. The Constitutional Court in this regard does not exclude that
of the settlement could be achieved by other means, which would
was more in relation to the amount of the payments to individual providers, even
outside the úhradovou Decree. At the same time, however, does not consider the chosen solution
unreasonable in terms of the main objectives of the intervention under consideration. Settlement
individual health insurance expenditure is needed to ensure that
the public health insurance system is unable to fulfil its function, i.e.
that it could be covered by health care, which his insurance policy holders
are written by providers of health care services.
66. Denying the existence of the contested Decree is clearly not given nor in terms of
other elements of the calculation of the total lump-sum payment or the maximum total
the remuneration. Interference with the right to take under consideration, therefore, passing all the
steps of the test of reasonableness.
67. The conclusions, of course, cannot be interpreted in the sense that they
in the future, calls into question the effectiveness of any increase in payments
health care providers. In a situation where their current
the setting does not deviate from the constitutional order of a defined framework for determining the
conditions and restrictions on the right to do business, however, answer the question as to whether to
such a step should happen, do not belong to the Constitutional Court. Her assessment
has the nature of political decision-making, which is called (and also
much better equipped with the democratic legislature) and responsible to the Government.
VIII./f
To the alleged inequality as a result of the use of the coefficients of the transition policy holders
68. the applicant and the intervener to justify non-compliance of the contested
the decree with the right to do business under art. 26 paragraph 2. 1 of the Charter also
arguing that it provided for the method of calculating the total lump-sum payment or
the maximum total reimbursement does not hold water in terms of the principle of equality,
expressed in the article. 1 first sentence of the Charter. This Decree in their opinion
does not reflect the different conditions of the individual providers and their
financial requirements arising out of the range of provided health care.
Neither of these objections, however, the Constitutional Court cannot regard.
69. Úhradová Decree lays down the methods of calculating the amount of the payments, which are
apply to all providers, depending on the type of the provided
health services. If they are in the case of bed care given the differences of
the perspective of the comparison of the resulting value of these payments for the individual
providers, this is due to the fact that this value depends on the
the amount of the payments in previous years, which was gradually taking into account
the range of provided health services and their related
the financial requirements. These differences reveal that the settings
the optimal amount of the payments to individual providers, taking into account all
relevant (or even very specific) the circumstances and find
the balance between expenditure from public health insurance and financial
requirements for providers of health care services, is very complex. The chosen
the solution, when the úhradová Decree, albeit with certain modifications, preserves
continuity and thus the predictability of the total amount of payments, therefore, cannot be
be considered as necessarily leading to unjustified inequalities. General
representation of all the relevant circumstances at the level of the period
podzákonného law, in the opinion of the Constitutional Court
probably cannot be meaningfully performed because it would be in the final
as a result of just not without a certain degree of discretion when their
an individual assessment.
70. the Unfounded claim of inequality is inherent in the fact that
the transition coefficients policyholders as opposed to hospitals not apply even in
the calculation of the amount of the payments of external providers of outpatient services.
Such a comparison is too simplistic, according to the Constitutional Court, as
in the case of both types of providers will apply a different method of
the calculation, which reflects the specifics of their activities (see the arguments
Ministry in point 21). Comparison of the amount of the remittance between different types of
providers, in order to have a meaningful value, in short, cannot be
reduce only on isolated comparison of how to
the total amount of payments reflected a partial payment for a particular kind of
health services. No further claims in more detail
specify the relevant differences, if any, the intervener
not apply.
71. It can therefore be concluded that the objection by the applicant and the secondary
a participant in the warrant the conclusion on non-compliance of the contested order, respectively.
some of its provisions, with the right to do business under art. 26 paragraph 2. 1
Of the Charter. This conclusion is also applied in relation to the namítanému
breach of the principle of equality under article. 1 first sentence of the Charter.
IX.
The assessment of the contested Decree from the perspective of the right to free health
care according to art. 31 of the Charter
72. with regard to the other claims, the applicant and the intervener argues
that the contested decree could lead to a violation of the right to free health
care on the basis of public insurance under art. 31 of the Charter. In the opinion of
The Constitutional Court may, however, such a consequence of the Act only indirectly.
Úhradová indeed, the Decree does not affect the rights of patients to provide
health services of specified quality. In no way does not regulate their relations with
providers, or health insurance companies. The possibility that at the
the basis of limiting that right, it can therefore be accepted only in
the plane of the factual, if úhradová the Decree so limited
individual providers the right to do business, that these were not able to meet
its obligations for the provision of health services, which would be as a result of
This fact may become unavailable for patients (this effect
the Constitutional Court has already admitted in finding SP. zn. PL. ÚS 19/13, see his point
77). Even in this case, but it was not possible to look at the cause of this
the State of isolation. Ensure the right of access to free health care
is the subject of extensive legal provisions contained in a number of laws, of which
In addition to the law on public health insurance to mention in particular the law
No 372/2007 Coll., on health services and conditions of their provision
(Health Services Act), as amended, and not
only reimbursement of the order, which, in this respect, the law rather
complementary. In any case, it's not just a question of a specific settings
the amount of the payments.
73. For these reasons, the Constitutional Court does not consider the argument of the applicant, and
the intervener, which sees a mismatch with the law, the contested Decree
the free health care under art. 31 of the Charter in its possible
a future de facto effect, as substantiated. The test of reasonableness in the
This place does not come into account already in the absence of direct intervention in the
of this right.
X.
The assessment of the contested Decree in terms of employees ' rights in the
fair compensation for the work referred to in article. 28 of the Charter
74. For similar reasons in the end fails to pass or claim of secondary
the participant, according to which the contested Decree endangers the ability of the
providers of health services financially kidnap higher salaries in
health care and hence the implementation of the rights of the employees concerned in the
fair compensation for the work referred to in article. 28 of the Charter. Úhradová Decree is
does not affect the content of the employment relationships between providers and
their employees. The finding of a violation of this right at the same time, you cannot
start by simply referring to a hypothetical possibility that these employees
will not be paid a salary because of lack of funds.
XI.
The conclusion of the
75. For all these reasons, the Constitutional Court came to the conclusion that the contested
the decree is in the range, which lays down the method for calculating the total lump-sum
reimbursement to providers of inpatient care and maximum total remuneration
providers of out-patient care, as well as the related factors
the transition of the insured, i.e., in the range defined by its particular § 4 paragraph 2.
1 and points 3.5 and 5.10 part and its annexes 1 and annexes 12 and
13, in accordance with article 6(1). 1, art. 26 paragraph 2. 1, art. 28 and article. 31 of the Charter. A proposal from the
at its abolition, based on the above objections, the complainant and
the intervener, therefore it is not justified, therefore, the Constitutional Court pursuant to §
70 paragraph 1. 2 of the Act on the Constitutional Court ruled on his refusal.
76. Just for completeness, the Constitutional Court notes that this finding is not
aprobována the constitutionality of the reimbursement of the decree in its entirety, even in
those sections in respect of which the claimant's argument, or nesměřovala
in intervention, which were not the subject of the Constitution, or
assessment.
The President of the Constitutional Court:
JUDr. Rychetský v.r.
