The first health reforms initiated by the government are already happening. With the support of the deputies from the parties Patriotic Front and Alternative for Bulgarian Revival last week were adopted conclusive amendments to the Health Insurance Act, which significantly modify the current system of healthcare. Some of them were met with extreme distrust by the opposition politicians who bombarded with criticism the Minister of Health Dr. Petar Moskov, drawing quite apocalyptic results of the innovation. On his part, the Minister explained that the structuring of healthcare, which was at the basis of that law, had existed in many other countries that perform better than Bulgaria, but there had been no apocalypse happening there.
The most serious debate logically flared around the most significant change in the system – the division of the health insurance package into primary and additional. According to the idea of the government, the most socially significant illnesses that cause about 90% of deaths and disability among people are separated in so-called “basic package”. Maternal and child healthcare diseases and conditions also fall into this group. Minister Moscow explained repeatedly to lawmakers and the media that the health indicators of the Bulgarians at that moment had worsened extremely and that we had been at one of the first places in mortality and morbidity negative ratings. He indicated that in order to reverse that trend, it was necessary that health resources were pointed in that direction – both financial and human. From his words it became clear that that was the recommendation of the experts from the World Bank. The Minister ensured that all diseases that fell into that package would be treated quickly and without having the patient pay extra for them. He noted that people had to pay additional sums for the treatment of almost any disease at that moment, regardless whether it was a serious socially significant disease, or could be postponed. Dr. Moscow promised that that would change and that the basic package would include everything concerning socially significant diseases – from the prevention to the treatment of the most severe conditions, where therapy would be performed quickly.
“No person will be sent back in an emergency, and no person with a socially significant disease will be sent back. This is an important thing. For example, cardiovascular diseases will be included the basic package. The way so far: a person goes somewhere, enters am hospital and begins wandering around, paying for all kinds of consumables, paying the doctor and you name whom… The idea is that now we will not be paying,” explained the MP from the party Reformist Bloc, Assoc. Prof. Dimitar Shishkov.
The so called “additional package” is the brainchild of the limited funding of our system. The government holds that with the limited resources available to the Health Fund, the most logical is to look seriously at funding only for the diseases placed in the basic package. In the additional package, for which there is not enough money in the NHIF, fall conditions that can be postponed without jeopardizing patients’ lives or lead to the deterioration of their health. The idea of the ministry here is that for these diseases the Fund will provide money while it has, after which patients will be included in waiting lists or if one does not want to wait, then they should provide for themselves via additional insurance funds.
The packages’ division brought about a number of issues raised mostly by the opposition politicians. One of the most important ones is whether there is patient discrimination because of their right to timely treatment. According to the opposition, there is discrimination, because people are divided into those who can be treated immediately, and those that have to wait. From there, a division between rich and poor was also noticed – the rich will obtain extra coverage, while the poor will have to wait and, as some MPs said some days ago, “to die.”
However, from the various statements made by Dr. Moscow and the MPs from the ruling coalition it became clear that the additional package has two main functions. One is to eliminate cash payments under the table, legalize the already existing at the moment surcharge by the inclusion of insurance funds. The second is linked precisely with the participation of the funds – the creation of the second pillar of health insurance and a gradual shift towards the de-monopolization of the NHIF. According to the ruling coalition, the inclusion of insuring persons is getting prepared for a model change. When this would take place, though, remains unknown.
There have been attacks in the direction that there is still no public information about which diseases would be included in which package and what would the financial impact on the system be. Here, the Minister explained, what was sought was not financial impact – what was sought was a change the health indicators of the Bulgarians in a positive direction. A few days ago he said that the lists of diseases would be ready by October, after which they would be discussed.
Another important aspect of the Health Insurance Act (HIA) changes is connected with the health system financing. There are several texts that modify the current situation. One of them is an attempt to answer the problem of the huge number of uninsured Bulgarians. There is currently no clarity how many they are, although in the public domain there were some numbers, such as 250 000 people, who are able to pay their contributions, but do not wish to do so. Several hundred thousands of poor have been spoken about, who cannot afford to pay, because they have no income. All are theoretically affected by the adopted text, according to which the restoration of health rights will be subject to the payment of contributions for a period covering five years back in time. For those who want to pay their debt to the National Health Insurance Fund by the end of 2015 there was a grace period of 3 years.
According to the government, this measure will greatly enhance the collection of contributions and the Fund will collect additional millions. The reason is that from now on those who are bad payers will be able to use only the emergency package. It is expected that a third package will be created to significantly reduce the number of people who use the emergency services for conditions that are not urgent, as emergency conditions will be determined by clear criteria.
Here the main concerns of the opposition are related to the number of poor, which is too big, and they cannot afford to pay sums exceeding BGN 1,000 that are the due amount for five years back without interest. The problem is compounded by the fact that the number of those whom the state provides for as poor, is not great, and many people remain outside this category.
It is precisely with those whom the state provides for that the next issue, relating to the financing of the system, is connected. The state has managed to escape from its obligation to pay the full fee for the groups of citizens whom it provides for over the next ten years. It currently provides only half of the amount due. It was recorded in the text of the HIA that next year the state will pay 55% of the outstanding 8-percent contribution, and this amount will be increasing by 5% per year until it reaches 100% in 2026
Here is the place to recap that because of the small amounts of money coming into the Fund, the management of the Bulgarian Medical Association, as well as the trade unions, wanted the state to start paying the full coverage as early as next year, or at least only for children. According to their calculations, had the state agreed to pay only for children, it would have provided BGN 300 million extra budget or thereabout for the Fund, as much as the planned deficit for 2015 is.
One of the most important texts proved to be a paragraph where a decision was taken for the NHIF to pay for activities according to the volumes agreed upon in the National Framework Agreement. Here it should be noted that the changes in the HIA returned the practice of negotiating prices and volumes to take place between the Fund on one hand, and the doctors and dentists – on the other. So it becomes absolutely important for the state of the system what prices and volumes will the NHIF and the professional organizations negotiate. Previous years’ experience shows that there are always significant differences between the proposals of the Fund and the doctors, which often leads to the failure to sign an agreement and the adoption of unilateral decisions by the NHIF.
In this sense, it can be assumed that the paragraph in question imposes limits on medical activities through legislation, since the text indicates that the NHIF will only pay the volumes agreed upon. Currently, these limits are imposed by a decree of the Council of Ministers.
There is, of course, the deal between the BMA and the NHIF, that there will be no limitation of the volumes, but prices could be reduced. What happens when this option occurs became apparent a month ago when the NHIF announced it had exceeded volumes and suggested reducing the prices of clinical pathways. After the Doctors’ Union did not agree to that, what is now considered is the transfer of activities and procedures from hospitals to primary care.
The key moment in the future of the healthcare system is linked to another change in the HIA – the NHIF shall be entitled to examine patients’ dissatisfaction and if it proves to be justified – to impose sanctions on medical institutions and even to terminate contracts. The government says the measure would increase the control and quality of the offered services. The reason is that the Fund will have about 2.2 million “controllers” per year – as is the number of hospitalizations. Almost none of the politicians said it was a bad idea, but the remarks of the opposition came from fears it could be used as vigilant justice on some hospitals. According to them, certain patients may get paid to file unfounded complaints. They hold that this could lead to deliberate vigilant justice exercised by the Fund or government hospitals in dealing with disobedient hospitals or those designated to be privatized. It was noted that there was a lack of clarity regarding the criteria for dissatisfaction because the Ministry of Health had yet to determine them.
The ruling coalition responded by pointing out that the termination of contracts would be a punitive measure for serious violations and would be made after a certain number of complaints came in. At the same time the MPs agreed that before reaching the final sanction there would be financial penalties, depending on the seriousness of the offense.
The changes in the HIA are essential for the healthcare future in our country. The government argued that they were dictated by the World Bank and imposing a new model that already exists in the European countries with the best healthcare. Concerns about how some of the changes will fit into our current reality and whether they can change certain negative practices still remain. Especially in the conditions of a political war between the government and the opposition, the war field unfortunately being the healthcare in the years to come.