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The Council of Ministers has lodged an appeal against the ruling of the Supreme Administrative Court for the suspension of the validity of Articles from Decree № 57 of the Council of Ministers, reported the Center for the Protection of Health Rights. On the 13th of May, the SAC ruled that it is suspending several texts from the Decree relating to the limits imposed on hospital budgets, until a conclusion of the proceedings with regard to the case of an effective judicial act is reached.

The court motives are as follows:

“In this case, the contested in the appeal provisions of Annex № 2B from Decree № 57 / 03.16.2015 of the Council of Ministers, limit the possibility to receive payment in full for the work done when providing hospital care.

Due to the obligation of contractors under Article 59 of the Health Insurance Act to provide medical assistance to insured persons, as guaranteed by the provisions of Articles 81 and 85 of the Health Act, and the setting of limits to the preliminary business expenses of hospitals, could lead to a restriction of their activities. Determining the sums for hospital care within the NHIF budget would lead to the non-payment of certain activities carried out by medical institutions, and to property damages for them.

Since the contested provisions would hinder or delay the delivery of medical care, it is likely that this would inflict substantial and irreparable harm to patients. Applicants rightly cited as reasons that the limiting of healthcare activities would limit patients’ rights to benefit from their preferred medical institution inpatient care.

In the light of the facts outlined above, the request for the suspension of the contested secondary legislative normative act provisions is legitimate until a final resolution of the legality of this issue through a court order becomes effective.”

The reasons for which the Council of Ministers  has appealed the decision of the SAC have not yet been announced, so at the moment it is not clear with which of the arguments of the Court the government did not agree, commented from the Center for the Protection of Health Rights.

Dr. Moscov announced that the number of doctors who wished to work abroad had decreased.

The Bulgarian Ministry of Health is trying to stop the brain-drain of our doctors abroad. The state will pay the fees of the “most sought-after” specializing doctors.

Earlier this year, the Ministry removed paid specialization. The new rules did not apply to physicians who had already begun their specialization.
The government would pay for the doctors who are acquiring a shrinking specialty – such as infectionists, anesthesiologists, and pathologists.

„The thing I am talking about is within one million,. To pay the rest, the sum would have to be much larger, but we will make an effort and talk to the Finance Minister, estimates are being made at the moment. Our definite commitment is to the people who specialize in the most sought-after discilpines,” indicated Minister Moskov.

„The number of applications submitted by Bulgarian doctors wishing to work abroad has significantly decreased. Whether this is a lasting trend will become clear later, but it sounds encouraging so far. This year more than 130 hospitals have announced 729 position openings for young specialized doctors, and 297 of them have already been taken,” announced Minister Moskov.
He explained that the government program task the young doctors to become part of the system had been successfully accomplished.
Dr. Petar Moskov noted that the program had further stages that his team would be working on.

In order to restore their health insurance, citizens would have to pay the required past due contributions to the NHIF for the past five years, decided the members of the Parliamentary Health Committee during the second reading of the amendments to the Health Insurance Act.

The text proposed by the Government which provided that period to be 15 years back did not receive a single vote “pro”. The motive of the MPs was that the tax limitation could go back only five years.

The Committee also approved the proposal of the MP Dimitar Bayraktarov from the party Patriotic Front that there should be a grace period until the 31^st of December 2015, when citizens could pay the required past due contributions for the past three years. According to Bayraktarov, that type of preference would encourage citizens to pay their past due contributions by the end of the year. According to him, an information campaign on that issue would lead to increased collection.

The MPs from the opposition were against the idea insurance rights to be restored by making past due contributions for the last three or five years.  Dr. Emil Raynov said that the government was trying to transfer the health insurance burden onto the ordinary citizens. At the same time, the state remained an incorrect payer, paying only half of the contribution of the citizens it provided for. “You want to draw blood from a stone,” he said.

Dr. Ademov from the party Movement for Rights and Freedoms said that if the five-year proposal was accepted, it meant that some citizens would have to pay BGN 1,080 without interest. He noted that there were over one million Bulgarians who lived below BGN 340 per month and that they could not afford such a sum. According to him, these citizens would remain outside the health insurance system. Dr. Ademov also predicted that there would be an increase of the number of uninsured people and they would become more than the insured.

Bayraktarov replied to the opposition lawmakers that our health insurance system was solidarity and everyone had to pay. According to him, the change in the HIA allowed people to participate in the system. He said that in return for BGN 680 for three years, citizens would be able to use resources for over BGN 3 billion.

Dr. Krassimir Petrov from party GERB reminded that a huge percent of the uninsured citizens blocked hospital emergency rooms at that time. According to him, if lawmakers did not accept the proposal, it would discourage the accurate payers and many of them would stop paying insurance.

Assoc. Prof. Dimitar Shishkov of the party Reformist Bloc noted that a similar way to collect insurance taxes was applied in all Europe. According to him, there was no other way to make people obtain coverage.

Individual electronic health cards and electronic prescriptions would be a fact at the beginning of 2016 – assured the Minister of Health Dr. Peter Moskov. “Every insured Bulgarian citizen will have his or her individual package for outpatient care, matched to their age and condition,” he explained. Moscov emphasized that the country woul seek to ensure that “when a person goes to the hospital, a whole complex treatment routine will be created.” “Currently the Russe Hospital has a contract with two psychiatrists, whose consultations are paid. On the other hand, the mentally ill when they need other treatments are brought from the Psychiatry Dispensary to the General Hospital,” gave an example the Minister of Health.

“I want a patient to receive full treatment within a hospital,” he said. Regarding the dissatisfaction with the health system reform, he said that he understood that the reform had upset the comfort of certain communities. “The problem is that the healthcare system and the whole country as well are broken into small community comfort zones fragments. What happens to the patient should not occupy these comfort zones,” commented Moskov.

The current healthcare system financing methods in Bulgaria have put more people at risk of poverty, was noted in the World Bank report of May 12, 2015, which performed a systematic analysis of our country. It discussed the major problems of our healthcare and made a few recommendations.

According to the report, about 8% of GDP in 2012 in Bulgaria was spent on healthcare. In comparison with the countries of the region, the total healthcare cost in Bulgaria was above the average, and the public expenditure was around the average for the region. The problem was that the direct personal payments (DPP) represented 47% of the total costs. Statistics showed that in 2000 they were 20%. In regard to this indicator Bulgaria is currently far from meeting the criterion of the WHO for adequate financial protection, which sets a ceiling of 15-20% for DPP as total health expenditure share. Moreover, over 4% of the population in Bulgaria is impoverished every year because of the DPP. In 2013, 3/4 of the DPP was spent on medicines that are not well covered by the state health insurance system.

The World Bank experts also identified as a serious problem that the financial protection provided by the healthcare system was undermined because about 7-12% of the Bulgarians who did not live permanently abroad, were uninsured. The vast majority of them were inoperative vulnerable people with a low socio-economic status.

The healthcare system in Bulgaria was not effective because it was too oriented to expensive residential care, with non-optimal use of more economical preventive and primary care services, believed the experts. According to the report, the coverage of most preventive services in Bulgaria was much less than in other EU countries, except Romania. Bulgarians also had fewer contacts with doctors providing primary care services and specialist physicians, compared to citizens in the other EU countries. Meanwhile, the number of hospitalizations per capita had jumped by 65% ​​for the period 2000-2010, while hospitalizations in other countries had either remained at the same level or had decreased. In 2011 the level was so high that practically one in four Bulgarians had been hospitalized.

The report also mentioned that our hospital system was very fragmented. The hospital density was 4.6 hospitals per 100 000 people compared with an average of 2.7 for the EU. Many hospitals had very few patients, which was highly inefficient. The three busiest hospitals discharged more than 95 patients a day, but 103 establishments in the lower section of the list together accounted for only 5% of hospital stays. That meant that approximately one in three hospitals in Bulgaria discharged not more than five patients a day. That fragmentation lead to resource duplication among institutions and prevented the application of economies of the scale that were required in modern healthcare, indicated the document. According to the World Bank experts, that interfered with the proper orientation of the necessary investments.

One of the main recommendations of the World Bank was for Bulgaria to reorganize its hospital system. They advised the NHIF to purchase services selectively, i.e. it should be able to decide with which hospitals to enter into contracts. In order to support that process, information on the care services quality had to be generated, collected and published, and the hospital payment systems had to be reformed. There might be a need of reforming emergency care, in order to improve the consistent provision of care and the access to it, emphasized the report.

The report also recommended improving the efficiency of medicine purchases. The World Bank noted that the current medicines pricing methods and the selection of those to be reimbursed provided almost no guarantee for the balance “price-quality”. The policies at that time did not encourage generic medicines market competition, but a lot of the prices on both – patent and of non-proprietary medicines – were unfavorable in comparison with the countries with much higher paying capacity. “Some expensive medicines that contribute to the rapid growth of costs are not likely to be cost effective in Bulgaria and should be subject to price (re)negotiation, severe use restrictions, and in some cases – removal from the list. If Bulgaria is able to promote greater competition in the non-proprietary medicines market, together with measures to meet demands and reasonable prescription, this could improve medicine costs effectiveness significantly,” said the report.

The experts also recommended strengthening the stationary care alternatives. According to them, the specialists in primary care needed greater capacity to manage the prevailing set of diseases and to coordinate the care for their patients. “In particular, permanent medical education should be implemented effectively and attractively. Regulations and incentives should be adjusted so that the chronic disease management would be extended through primary care. Payment systems and accountability mechanisms would also need to be adapted for all provider types (primary, outpatient, emergency and residential care) to ensure the treatment of more patients on the proper level of care,” was also written in the report.