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June 1, 2015
The NHIF has offered the BMA to begin negotiations to reduce clinical pathway prices. The BMA immediately replied that they disagreed, and instead wanted an update of the NHIF budget by BGN 150 million.
Obviously, the NHIF is facing increasing pressure to pay more than they have. The problem has become more severe over time and a budget revision will be inevitable. The proposed mechanical reduction of pathway prices by a certain percentage is not a good solution.
Instead of figuring out on the calculators how many BGN they can save from each pathway, the NHIF and the BMA can achieve much more in their negotiations. Here are some ideas:
It has long been time for a significant part of the clinical pathways to be transferred to outpatient care. For example, all pathways providing same day surgery, diagnostic and therapeutic pathways that do not necessarily require hospitalization, skin disease pathways ENT, eye care, etc. The National Framework Agreement has now provided 5 pathways for outpatient care, and the analysis shows that their number could increase to 100. If they are implemented in outpatient care, their prices can be reduced and this would not be unfair as the costs would be less.
Another thing the BMA and the NHIF could agree upon is the introduction of price indices in pathways. It makes a difference whether a 25-year-old in his/her prime is treated or an 80 years old patient. It is logical that the costs of treating an elderly person would be higher; therefore, introducing an age factor patient index would be fair. The same applies to the presence or absence of chronic concomitant diseases. Obviously, for the sick person who has received abdominal surgery and has concomitant diabetes there would be more expenses than if there were no diabetes. Therefore, it is only fair to introduce indices in terms of the presence or absence of serious chronic diseases.
The third thing the NHIF and the BMA could negotiate is to allow outsourcing for the clinical pathway activities – their execution by external contractors. These may include laboratory and imaging tests, pathology, etc. This would allow hospitals to avoid unnecessary costs for personnel and equipment, and hence would reduce the pressure for hospital admissions at any cost.
The next thing the NHIF could accomplish even on its own is to review its reimbursement list. Minimum reimbursement for home treatment medicines is proportional to maximum hospitalization. The NHIF should increase the reimbursement of these medicines, particularly antibiotics, and this way it would reduce the “interest” of patients in being hospitalized. The same applies to some difficult tests as CAT, EMG, MRI, EEG, etc. Facilitating the access to them would be cheaper than paying for the same via clinical pathways.
Finally, clinical pathway prices are certainly not inviolable. We do not need a very thorough analysis to see that there are both under evaluated (in most cases) and overpriced pathways. Therefore, individual pathway price negotiations should not be excluded a priori.
Reaching an agreement on these issues is fully achievable trough negotiations, and there is hardly a better time than the present.
This means that the NHIF and the BMA should start negotiations for a National Framework Agreement Annex, as opposed to negotiations under Article 12 of the contract. Such negotiations did not have to not be postponed till the 1st of June. They could have begun immediately. -
The manager of the Health Fund Dr. Glinka Komitov had predicted that “based on the current performance towards the end of April, we could expect a deficit in the Health Insurance Fund budget at the end of 2015.” According to the NHIF representative, the deficit is formed by medicines and hospital care, so therefore the efforts should be directed primarily at reducing precisely these cost elements. The Fund expects the shortages of medicines for home treatment in the country, of medical devices and dietary foods for special medical purposes to be BGN 108-109 million. The shortage for cancer medicines as of the 30th of April was BGN 59 million, and for hospital care – about BGN 125 million or in total sum – BGN 292 million. Since there is a reserve of BGN 93 million, however, the shortage would be about BGN 200 million. Dr. Komitov explained that this year the base has been lower for the three items and hence the implementation of the budget has been higher than last year.
In connection with these forecasts, Minister Moskov announced that there will not be a deficit of BGN 200 million in the NHIF budget at the end of the year. He added, however, that if there were no changes made to the healthcare system and it continued to function like before, the deficit may be even larger than BGN 200 million. The Minister noted that at present the public spending on healthcare was BGN 4 billion, but BGN 1 billion were not spent as intended. From his words it became clear that there was resistance from the sphere in question where that one billion was spent. “This is a noisy billion. You know, it can produce a media wave, it can make noise, it can create stress in humans,” he said.
Dr. Moskov also announced that the good intentions for changes were being used before the elections to arouse fears and concerns among people and for political purposes. When asked whether there were contradictions within the coalition regarding his actions he replied that there was a majority behind the management program of the government. According to him, for there to be a change to the situation in the country, the parliament majority has to support the changes. “The conversation takes place inside the coalition, topics are being discussed, better solutions are being considered, and behaviors towards the parliamentary forces that oppose the government are deliberated upon. In other words, this is a conversation within the coalition, within the partnership, which forms the government support. There is no big drama,” he added.
Among the reforms lying ahead, Dr. Moskov indicated the breaking up of the health insurance package into primary and secondary. He noted that one of the main directions of the change was the emergency assistance reform, where there was a 4-year plan for its restructuring. After that he pointed out the structural reform and change in the method of funding where the idea was not to pay for structures, but for treatment: “Because the way of payment will propel hospitals to merge. Because the way of payment will fund the treatment, the outcome, and the complexity, but not who, where and why created the hospital or something else,” said the Minister. He announced that part of this restructuring was the national health card, which would make apparent that one cannot open a new hospital where there were already enough of them. “If you want to invest in hospital infrastructure, then go where there are no hospitals, because there are whole areas in the country where the access to people like you and me in Sofia, is impossible for these people – whether in Deliorman, whether in the Rhodopes, whether somewhere else. And this is state policy – where to direct investment, where to promote investments,” the minister added. He also noted that part of the reform was to improve the control and cost effectiveness. In his words, this was related to e-health.
Dr. Moskov said that the planned hospital and dispensary mergers were part of the transition from structure financing to paying for the treatment. He once again explained that at that time many hospitals did not offer comprehensive treatment and the patient was forced to go back and forth from one place to another.
The Health Minister pointed out that in order for such circling around not to happen, patients should be offered complex treatment. He added that the NHIF would conclude a contract only with those hospitals which offer such comprehensive services. “Starting next year the NHIF will enter into contracts with hospital or hospital groups which can provide one’s full treatment for the major diseases in the basic package. Whether their choice will be to merge, – and this will become clear through the mechanisms of the compulsory health card – to join together in a functional union or to make a consortium, this will be recorded for each city and for each individual case,” said Moskov. He emphasized that this is done both – in the interest of patients and in the interest of doctors.
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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.
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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 31st 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.