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The situation with the private Cardiology Hospital in Vidin should be recorded in textbooks as an example of how power is misused without punishment

– Dr. Katzarov how is power (mis)used without punishment in the structure of healthcare? You specify the situation with the private Cardiology Hospital in Vidin as an example in this respect. Why?
– The situation with the private Cardiology Hospital in Vidin should be recorded in textbooks as an example of how power can be abused without punishment. In early 2013, a private company entered into a lease of several abandoned premises.

The investment in repairs and equipment exceeds 3 million BGN. By the end of 2013, the hospital was fully equipped and over 30 employees were employed on permanent contracts. In January 2014 the Regional Health Inspection issued a statement that the new hospital fully met the requirements for receiving an authorization to operate. All documents were filed with the Ministry of Health. The Minister of Health, according to the Law on Healthcare Institutions, was required within 30 days to issue an authorization to operate or give a reasoned refusal. Dr. Tanya Andreeva, the Health Minister at that time, in violation of the law did neither one of these things, nor the other. For ten months the MH was silent. For ten months over 30 people – doctors, nurses and other staff – received salaries, but did not work. The new hospital appealed to the Supreme Administrative Court the silent refusal of the Minister of Health. The Supreme Administrative Court repealed the silent refusal as unlawful and issued directions to the Ministry to make a decision to issue an authorization to operate. Then followed another absurdity – the Ministry of Health appealed the decision of the Supreme Administrative Court before five judges.

– Why are you defining this appeal as a new absurd?
– It is absurd because the silent refusal – there is no ruling and this fact cannot be changed, even if fifty-member panel were to examine it. Obviously, it is a case of delay. A delay that will cost a lot to the state budget.

– How much will this delay cost to each one of us as taxpayers?
– When the five-member panel of the Supreme Administrative Court eventually confirms the decision to supersede, the state will not only pay for the unnecessary legal costs. There is every reason for the state to pay the existing but defunct hospital a compensation for any loss of profits – incurred investment costs, staff salaries and loss of potential revenue. The waste of money does not stop there. The state, in the face of its Health Minister, decided to “invest” 1.8 million BGN to purchase an angiograph for the State Hospital, although the adjacent private hospital had already purchased and installed one. Moreover, the State Hospital does not even have a Cardiology Department. Activities in the field of Cardiology at State of Hospital “St. Petka” are carried out in the Department of Internal Medicine. In this department works a cardiologist and “three more cardiologists, who have a diploma, but no more than that” who are appointed part-time, but they are not really working. In order to perform activities in Invasive Cardiology it is necessary to have a structure with III level of competence in Cardiology, and that means six cardiologists on a basic labor contract, of which two with a Certificate in Invasive Cardiology and the related equipment. Minister Andreeva transferred 600,000 BGN in advance; Minister Nenkov also joined the game, making the next transfer of 600,000 BGN. Thus by the end of the year Vidin will have two angiographs, but none of them will be working – one because it was not issued a permit, and the other – because there is no one to work with it. The state will bear the losses of several million BGN, while the sick, as it has happened so far, have no access to modern diagnosis and treatment.

– Are not these ministers responsible for the incurred financial losses to the state budget?
– One thing is certain, the ones who are guilty for this situation, Minister Andreeva and Minister Nenkov, will not suffer losses, as everything will be left for the taxpayers to pay. When they take the oath, Ministers promise to respect the Constitution and the laws of the country and, as good governors, to take care of public interest. Public interest has not been protected. Whose interest defended the Ministers – we do not know, because they have not given any explanation so far. This fact increases the suspicion of power abuse, and perhaps something else.

– Now the new ministers are to swear such an Oath. Is it possible for the parties to reach a consensus on healthcare when forming a new government?
– Each one of the elected in the Parliament parties has set among its priorities
to reform the healthcare system. This is one of the topics regarding which an agreement will be sought when forming the new government. Reaching an agreement on a plan to reform the health system is not only important, but much more complicated then reaching an agreement for example, for the construction of the “South Stream” or the exit from the crisis with the Corporate Commercial Bank – two other topics of talks for the new government.

– Why do you think that it is much more difficult to reach such an agreement?
– Healthcare concerns every person – we start our life in hospital, and many finish it there. Almost 10% of the gross domestic product passes under one form or another through the healthcare system, making it one of the most important ones for the economy and the country’s finances. The fact that healthcare is placed as a priority, however, does not imply that the reform will take place, much less that a successful health reform will take place.

– What is the basis, upon which such a successful healthcare reform can be built?
– In the pre-election party programs one can read many proposals – some good, others – not so good, third – frankly populist, and mutually exclusive. In the recent years, the debate on healthcare has focused on a few issues – the deficit in NHIF, the emergency aid, the debts of Public Hospitals, the quality of and the access to medical services, including the additional payment for them, the amount of the health insurance coverage, and the prices on medicines. Probably this is the reason that most people think of hospitals and ambulances when talking about healthcare. Healthcare is much more. Besides hospitals and ambulances, healthcare systems include the clean air, water, food, work conditions, health education, prevention, and other factors, which have a direct impact on public health. These areas also need serious changes, even though it seems easier to reach an agreement about them.

– Which is the difficult topic, according to you?
– The difficult topic is medical healthcare – seeking and receiving medical care. Before writing their healthcare reform plan, the ruling coalition has to answer one basic question: what is medical healthcare – a market for medical services or social work?

– Why do you identify this question as most important?
– The question is fundamental to the direction of the future health care reform because the measures to be taken by the government in one case and the other are opposed. If the ultimate goal is to make the patient the center of the healthcare system, the decision has to be to stimulate the market, because the user benefits most from the free market and the fair competition. The reform should be aimed at the deregulation, privatization, competition, freedom of choice, etc. If one wants administration to be at the center of healthcare, one has to treat it as social work. In this case, the reform should be aimed at strengthening the regulation, zoning, budgeting, subsidies, etc. There is a middle road, but it does not lead anywhere or it just leads to the spot we are at now. For information – have a look at the last several governments.

Three hospitals refused to admit for treatment a 47 year-old woman from Kazanlak with acute myocardial infarction. After a whole day of wandering between health facilities Dafinka Boneva was hospitalized at the University Hospital “St. George” in Plovdiv, where doctors saved her life. The treatment, however, will be paid by the Plovdiv health facility that accumulates debts because of the large number of patients admitted without health insurance. The doctors in Plovdiv warn that there is an agreement between small hospitals and emergency care such patients to be diverted only to large clinics.

The case of the 47 year-old Dafinka had to wander between different hospitals in serious condition, which is not a precedent – the doctors of the University Clinic in Plovdiv explain. The woman was referred by the Emergency Centre in Kazanlak to the hospital in Stara Zagora, from there to Haskovo, because she had no health insurance. Because everywhere refused to examine her, the patient with heart attack had to be transported all the way to University Hospital in Plovdiv.

Dr. Gincho Tonev – Head of Department of Invasive Cardiology – University Hospital “St. George”: “The order of the current Minister is patients in such conditions, with acute myocardial infarction to be hospitalized in the nearest hospital having the adequate structure, namely Invasive cardiology. This thing has not happened.”

In Plovdiv the patient received medical care and has already been discharged in good health. However, her treatment costs the hospital BGN 7 000 – amount that the woman can not pay. Cases like this are almost daily in the health facility.

Physicians claim that there is a tacit agreement between small hospitals and emergency care not to admit uninsured patients. Dr. Gincho Tonev – Head of Department of Invasive Cardiology – University Hospital “St. George”: “We all suspect such thing and we are almost certain.”

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In connection with the case the hospitals of the Bulgarian Cardiac Institute in Yambol, Veliko Tarnovo, Pleven, Shoumen and Varna declared their willingness to accept for treatment all patients in need of emergency cardiac care, regardless of their insurance status – 24 hours a day, 7 days a week. In emergency cases, for patients with acute condition, the specialized hospitals are ready to send modern ambulances with medical teams to any part of the country. “The vocation to save life stands far above any economic or bureaucratic obstacles” the BCI declared.

After a 10-month delay the state prosecution paid BGN 100 000 compensation to the three doctors charged in the death of 5-month-old Maria in Pazardzhik hospital seven years ago. Then the child died of sepsis after a 5-day stay, and the doctors, who at different times were on duty at the clinic, were accused for her, the newspaper reminds.

During the proceedings the forensic examination of national consultants proved that doctors were innocent. After a lengthy trial, the doctors were acquited by all instances. All three in turn brought action under the Responsibility of the State and Municipalities Act against the prosecution for unjust accusations, stress and humiliation caused which they won.

Several days ago the doctors Georgi Pavlov and Tanya Daneva received BGN 40 000 each and their colleague Petjo Hadjiiski – BGN 20 000. The final decision of the Supreme Court of Cassation was delivered in January, but the payment of the compensation was delayed because the prosecution did not have sufficient funds. The compensation determined by the magistrates is among the significant amounts in this kind of cases in our country.

“I feel satisfied because it was proven that we have done all that is needed to help the child,” said Dr. Paul George. But he painfully recalls the stress he was under after the indictment. “I was wondering whether it can continue with medicine. I stopped taking specialization examinations and graduated only when we were acquited. I started smoking heavily and brought myself heart problems,” the pediatrician said.

Whether money can compensate for the suffering is difficult to assess. He still can not erase the memory of the accusatory stares and the suspicion of his colleagues and people.

The other two doctors – Dr. Daneva and Dr. Hadjiiski, stay away from any publicity. They have long since left the Pazardzhik and work in Plovdiv in an attempt to settle their lifes anew.

In Bulgaria there is no legal definition of the term “medical” error and the lack of specific legislation categorically requires a broad and thorough public debate involving all stakeholders before adopting such. The increasing number of court cases related to the professional responsibility of physicians in outpatient care is an occasion to present an extract of the proposal of Health Insurance Company “DALLBOGG – Life and Health”: PROFESSIONAL RESPONSIBILITY OF MEDICAL STAFF – suitable for general practitioners and specialists in outpatient care.

More information can be obtained at dallbogg.com and on tel. 0700 16 406

Comments by Dr. Stojcho Katzarov, Chairman of the Board of Directors of the Center for Protection of Healthcare Rights.
People say: Hospitals are commercial entities and this interferes with medical care. Why and what hinders? No explanation given. It is not necessary. It become like spell, refrain that one hears before and after elections, between election and during the elections.

When something is repeated by ten people ten times and is written about in ten media, it no longer needs proof. It can comfortably fit in election programs. Even in management programs.

However, nobody yet has thought about what the hospitals should be if there are not commercial entities. Nobody mentions this. Or they rely on surprise? However, no one asks, as if everyone is aware. But they are not.

Well, what are the hospitals? Can they be cooperatives? Can they be civil partnerships? A legal non-profit entity?

In fact, the law now allows the hospitals to be register as cooperatives. Nothing prevents the Minister of health to re-register for example Hospital Alexandrovska, Pirogov, ISUL and all district hospitals as cooperatives. The law allows it. It allows the owners of any private hospital to become cooperatives. But they are not. And nobody does it.

The Commerce Act allegedly interferes because “it drives hospitals to be profitable”. Is this it? Then write a law that will lead them to be at a loss. But you do not want them to be at a loss.

The Commerce Act allegedly led the hospitals to accumulate debt. The hospital with the highest debt – BGN 120 million is MMA and it is not a commercial entity. Who is making it accumulate debts?

The hospitals could not register for VAT, so piled obligations. But please, please, hospitals are not registered for VAT, not because of, but in spite of the Commerce Act – due to restriction in the VAT Act. This saves 20% in costs to the NHIF.

The health is not a commodity. Of course it is not. No hospital sells health. They sell medical services. Unlike health, these services are goods. They cost money – for salaries, insurances, medicines, X-ray and ultrasound machines, surgical instruments, gloves, aprons, food for the sick, heating, fuel, electricity etc. And this has absolutely nothing to do with the Commerce Act. However the hospitals are registered the costs are costs and someone either the MH, the NHIF or patients themselves will have to pay, otherwise … Otherwise there will be no medical care.

“Drive the money changers from the temple.” No problem. Only that the temple does not switch on systems does not provide anesthesia, lithotripsy or extracorporeal circulation. In the temple people light candles, and lately they not even from wax.

The commercial companies may fail. So it is thankfully. Not only that, there is nothing wrong, but even it is very useful mismanaged companies to go bankrupt. However, one of the reasons there are so many hospitals in Bulgaria is that the state does not allow the bankruptcy of its own ones. Whether protecting them from creditors or subsidizing them, whichever. On the other hand, if the state was allowed it would bankrupt all private and most municipal hospitals. So far it has not succeeded, but attempts continue.

The real reason for the problems is not the commercial registration of the hospitals, but the state itself, through its organs the state hinders free competition and tolerates some over others.

The truth is that the commercial registration gives freedom to the doctors, no matter how restricted by a number of other provisions. Those who seek the annulment of the commercial registration really want – though not dare to say so – the Minister of Health again to become the employer of all doctors. They want a strict hierarchy, subjection, submission and obedience.

Logically, the power is bad only for those … who do not possess it.

The removal of the commercial registration of the hospitals will benefit only those in power. All others will lose. Most to lose – the patients.

At a meeting held last week the government approved amendments to the Regulation on calculation and payment of cash compensation and benefits from public social security related to the introduction from the 1st of January 2015 of an electronic medical certificate. This was announced by the press office of the Council of Ministers. According to the changes the data entered in the electronic register of medical certificates and decisions on appeal, should be taken into account in assessing the right and determining the amount of the cash compensations and benefits.

Regulated are the entities that present the data contained in the issued medical certificates to the NSSI – attending doctors and medical advisory committees through the medical institutions they are subordinated to.

The insurers and self-insured will no longer be obliged to check whether their medical certificates are issued in accordance with the legislation regulations. The requirement to attach the report of the Medical advisory committee or a transcript of the death certificate to the medical certificates of persons on leave due to death or serious illness of a mother of a child up to 2 years old will be dropped. In both cases, the documents will be collected automatically.

Specified are the beneficiaries and the documents for submission, and the starting point from which the period for payment of compensation is calculated, depending on whether the payment is made on the basis of the data in the issued medical certificates and the documents submitted in the relevant territorial unit NSSI, or on the basis of documents only.