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In healthcare money is never enough anywhere, even in the richest countries, stated the manager of the NHIF Dr. Rumyana Todorova in response to the question whether she was pleased with the NHIF budget for 2015. “But if we concentrate, we should say ‘yes’”, – she indicated and pointed out once again that the sum is by BGN 252 million more than the originally adopted by the Parliament budget for 2014

„In my view, the money would not be enough“,- she said just the same and explained: „Relative tranquility will be brought into the system, but there are certain objective laws in healthcare, which, no matter what the budget is, no matter how well calculated it is, cannot be covered 100%.” Dr. Todorova noted that there is a continuous increase in the number of patients and once again noted that the annual average number of cancer patients increases by about 9000, which means nearly BGN 70 million to the NHIF. “Of course, this is related to the constantly improving diagnosis and new technologies. On the other hand, the access to better medicines prolongs life and enhances the credibility of the institution and the resorting of patients to the mandatory health insurance increases, “- she said.

According to the manager of the NHIF there will be a change, but it can not happen all of a sudden. “For me 2015 will be a buffer year, during which we will work on legislative changes and at the same time we will use all the opportunities for the control and correct targeting of cash flows, while these reforms are taking place,” she said, adding that according to her a year is absolutely sufficient to lay the foundation for the changes.

Dr. Todorova said that the medical referrals will not become inapplicable in 2015 and that they are a form of control in outpatient care. “On the other hand there is a proposal by the BMA for them to participate in the methodology for the allocation of funds to hospitals and to participate actively in the control. There is even a proposal by them for 90% of the resources which were actually paid the Health Fund in 2014 to be distributed for 2015,” – she informed.

Regarding the problem with the drug costs the NHIF manager commented: “Drugs are in the hands of the physician and logically it has to be so. The doctor is the one who will choose which medication to use, what is the most suitable thing for the patient. No financial institution can say that. Perhaps this is the place where the insurance institutions should become operative. I.e. there should be an additional resource, because with this resource the Fund cannot cover everything.” She brought up the medicines for rare diseases as well, which were transferred to the NHIF in 2011. At that time the Fund paid for them BGN 24 million, while now the amount is BGN 69 million, reported Dr. Todorova.

And, once again the manager of the NHIF brought up the slashed control capacity of the Fund regarding the money that has been spent by it. She indicated that the financial penalties, which the institution can impose if irregularities are detected, range between BGN 200 and 500, and asked: “Should not the sanctions in the “Control” department be more serious? Should they only be in cash? Should we focus on terminating the contract with the establishment, if it has not performed the action? ”

The state has to warm to its role, summed up Dr. Rumyana Todorova and clarified: “As well as to pay its health insurance contributions as much as we pay and to warm to its role of a regulator and guardian of this system.”

A package of legislative measures, which based on their administrative deadlines could come into force in February, was published for public comment last week on the website of the Ministry of Health. The next year measures include a transfer of activities from inpatient to outpatient care, clearer rules for long-term negotiating the prices and volumes of medicines and more stringent conditions for opening new pharmacies and hospitals. This was announced by the Minister of Health Dr. Peter Moscov from the rostrum of the National Assembly during the presentation of the draft budget of the National Health Insurance Fund for 2015. According to him, the proposed budget provides system security.

The focus of the institution for next year is to improve the quality in the healthcare establishments with which the Health Fund is already working, and the possibility of new hospitals to conclude a contract with the Fund will be limited to a maximum. The restriction is recorded in the transitional and final provisions of the NHIF budget, where it is stated that medical institutions which after December the 31^st, 2014 received their first permit for medical activities, as well as medical establishments with new activities, cannot conclude contracts and additional agreements with the National Health Insurance Fund till the end of 2015.

Additionally, in the middle of the next year a working group with representatives of the state, the Health Insurance Fund and the Medical Association will prepare an annex to the National Framework Agreement for 2015, which will indicate the diseases which could be transferred from inpatient care to outpatient care and thus expenses can be reallocated, pointed out Moskov.

Another idea is the proposal to the Pharmaceutical Union that is being prepared, according to which new pharmacies may be opened only in places where there are none according to the state standards. Furthermore, according to the Minister, the Health Ministry is in an advanced process of signing a Framework Agreement with pharmacists in which are determined the funding and volumes of drugs for years to come.

The parameters of the new drugs that will be entered into the positive list necessarily have to be negotiated in advance, is convinced Moskov. At a later stage the introduction of an electronic drug market is being considered. This exists in many countries and has been proven to reduce the cost of the procedures. Such a market would allow hospitals to conduct tenders electronically and would ease the requirements for bidders, which would put at an equal basis the small and the large companies.

There are beta-blockers (BB), which do not affect the glycemic metabolism in patients with type 2 diabetes (DT2) complicated with heart failure (HF) and carvedilol even improves the regulation of glucose – showed the results of an observational study published in the journal Cardiovascular Diabetology.

The prognostic significance of BB in patients with systolic heart failure has long been known, but in diabetics the treatment with BB is suboptimal (drugs are not included or the dose is not optimal).

This fact may have important clinical implications for patients, since in some 12% of the patients with DT2 is observed systolic heart failure, and in the group with HF – 6 to 25% are diabetics. Therefore, for the proper treatment of this population it is particularly important to use BB which allow to maintain good glycemic control.

Earlier, in the study GEMINI (GEMINI – The Glycemic Effects in Diabetes Mellitus: Carvedilol-Metoprolol Comparison in Hypertensives), in hypertensive patients with DT2 who did not have systolic heart failure, the administration of carvedilol was associated with beneficial effects on the metabolism of glucose (most probably, due to the increased uptake of glucose) compared to metoprolol tartrate.

The treatment with carvedilol did not affect the glycemic control (did not lead to a change in the baseline of glycosylated hemoglobin A1c) while achieving an improvement in insulin sensitivity and a decrease the progression of microalbuminuria compared with metoprolol tartrate, concluded the authors of GEMINI.

The aim of this study was to evaluate the effect of two different BB: the non-selective BB carvedilol and the beta 1 selective BB bisoprolol on glycemic control, the lipid profile, the renal function and microalbuminuria in patients with HF and DT2.

125 people took part in it, without BB therapy before enrollment. 80 of them started treatment with carvedilol, and the remaining 45 – with bisoprolol, with gradual titration to the maximum tolerated dose, which was 26.5 ± 21.1 mg daily for carvedilol and 5.8 ± 3.0 mg daily for bisoprolol.

The rest of the therapy was carried out according to the recommendations for the treatment of HF. The average follow-up period in the carvedilol group was 1.9 years, and in the bisoprolol group – 1.4 years. The two treatment groups did not differ considerably in terms of demographic characteristics, ejection fraction of the left ventricle, functional class of heart failure and concomitant therapy.

Patients treated with carvedilol had significant reductions in glycosylated hemoglobin levels (HbA1c) – from 7.8 to 7.3, compared to the ones on therapy with bisoprolol where the values of HbA1c were not significantly lower – from 7.0 to 6.9.

The glomerular filtration rate (GFR) showed a decrease in the course of study, without significantly differing depending on the applied BB. The percentage of patients with microalbuminuria remained stable during follow-up. No significant changes in lipid profile were observed.

This study, with a sufficiently long follow-up period, was able to prove that carvedilol did not worsen glycemic control and the lipid profile – its administration even lead to significant reduction in the baseline HbA1c

Tchaikapharma – High Quality Medicines Inc. produces licensed Dilatrend (carvedilol) and is a Marketing Authorization Holder of the product.

Dilatrend has been in the list of NHIF since the 16^th of November 2014, with the following codes:
Dilatrend 6.25 mg x 28 tabl. – CG 221
Dilatrend 12.5 mg x 28 tabl. – CG 220
Dilatrend 25 mg x 28 tabl. – CG 219

Starting today till the end of December the medically insured citizens can change their GP, if they wish to.

It is not necessary for the people who have chosen a new family doctor to notify the former one, this happens through official channels. For the change a patient has to have a registration form for the permanent choice of a GP, which can be printed from the website of the National Health Insurance Fund (NHIF). Only the fields with the patient’s data are to be filled out, while the other information is filled out by the newly selected doctor, who has to have a contract with the Fund. There is information that also has to be filled out in the health insurance booklet, which remains with the patient and its number is entered in the form of a permanent choice.

The new GP has to undertake his/her responsibilities from the date he/she was selected.

Patients with health insurance have the possibility to change their GP two times a year – in December and in June. At any time of the year it is possible to make a temporary choice of a doctor when it is necessary – as in the case of residing for over a month (but not more than five months) in another city. The form for a temporary choice of a doctor is also available on the website of the NHIF.

User fees for pensioners should not be increased, but a way should be found that they are compensated. To increase the tax for the rest of the people is also not a solution. He indicated that in most European states there is alleviation for seniors.

To say nothing that there are states where they have been covered by the state or the health funds. It is not clear whether a populist decision is not at the expense of the health units, he added.

Before the beginning of the conference “The patient at the center of the system,” dedicated to the priorities in healthcare, the former Director of the Military Medical Academy, now an MP from GERB and chairman of the health committee in the parliament, commented the schedule  set by the Health Minister Petar Moskov and included an electronic health card, the basic package of activities to be undertaken by the Health Fund, and those who would be taking up the health funds, the contracts with hospitals, etc.

This type of schedule should be accepted before the budget. It should be corrected according to the budget possibilities. According to such a schedule timeframes should be set which would be the basis for the conversations with other subjects – the BMA, patients’ organizations. The problem is at the expense of what and whom should the reform take place. The patient is most important, his/her requirements and to what degree the financial resources, which the state could provide, are important to the patient. The patient has to control the funds which come with him/her. There is the question about the effective use of the funds for healthcare and the controlling organ should be the Health Fund. Part of the control functions of the audit and the ministry should be transferred to the NHIF. But this is among the priorities of the health minister.

With regard to the idea of merging hospitals on a regional basis General Tonev said that the problem in this merging is it should not lead to even greater costs for the system.

The electronic health card would allow the Ministry, the Health Fund, and the hospitals themselves to receive direct information flow, which at any time would be able to indicate where the patient is, what has been done and how much it costs. Of course, there is duplication of activities, and they lead to the payment of the same meaningless service. The main problem is the lack of coordination, the question is more organizational, he said.