CERTAIN CLINICAL PATHS ENDANGER THE SYSTEM
Dr. Rainov, how has the fulfilment of the 2006 budget of the National Healthcare Insurance Fund been going on so far? According to the doctors' union, more than BGN100MN will appear insufficient for hospital aid. Is this the item on which money will be used up first?
- The law on the fund's 2006 budget is quite clear about the amount of expenses that can be made on healthcare insurance payments (BGN1.219BN). As of May 31, about 43% of the total annual plan has been spent. For stomatological aid 48% of the planned amount was used, for hospital assistance - 44.9%, for home treatment medicines - 41%, for medical and diagnostic activities - 39%, for primary assistance - 36 per cent. It can be noticed at first sight that some of these items - stomatological and hospital aid, for example, are close to the upper limit, yet they are within the budget forecast. I mean, figures show that no shortage of financial resources is expected to emerge. Especially as three summer months are to come and they usually see lower levels of medical service consumption.
According to the latest figures showing hospitals' revenues, some of the hospitals have received higher revenues from January to May compared to the first five months of 2005. However, larger hospitals reported smaller revenues and they probably find it difficult to maintain the quality of treatment and the level of salaries for the personnel?
- As a whole, 65% of the medical institutions reported bigger revenues from the healthcare fund in 2006 compared to the amounts they received from the fund and the Ministry of Healthcare in 2005. However, municipal hospitals usually operate lighter diagnoses, whereas big university hospitals take up operations that consume more resources. An absolute growth of the revenues was reported by Sveta Marina hospital in Varna, Sveti Georgi hospital in Plovdiv, Sveti Ivan Rilski in Sofia. Lower revenues were reported by big ungainly hospitals - Alexandrovska, Tsaritsa Yoana and Pirogov in Sofia, Dr. Georgi Stranski in Pleven, the multiprofile hospital in Bourgas. We make analyses of what happens in the hospitals every month. Still, figures must be analysed profoundly - we must seek the specific reasons for the change - in the management, the structure of the personnel, the drug policy, the investment strategy of the hospital. For example, the revenues of Alexandrovska hospital went down on the account of Sveti Ivan Rilski because of the transfer of the neurosurgery clinic where expensive clinical paths were carried out.
Are there hospitals that may go bankrupt in the near future?
- I wouldn't use the bankruptcy word. As you know, in the current year hospitals are mainly financed by the healthcare fund for activities they have done. Of course, those of them which are operating better generate more revenues. But in order for the hospitals to be sought, it is not just the quality of medical aid but the management, too, that is important. When it is really professional, internal assessments are made for improving the quality and optimizing the operations. The manager's role is to strive for more flexible management, to make the hospital more market-oriented. Despite some last year forecasts when we announced the healthcare financing from one source, at present most hospitals cope with the new economic conditions. Looking at the reports in comparison to 2005, I can say that the system is working. In financial aspect, it has never been more stable. However, more efforts are needed in order to make it economically efficient and, of course, providing higher quality of services to the patients.
Recently we heard about doctors who have six jobs. Are there other striking violations?
- This case is as impressive to us as it is to you. Besides, revisions made so far revealed that about 100 specialist doctors work at more than three medical institutions under the 2006 National Frame Agreement. That is why we started to inspect these doctors' agreements and schedules. Figures in the analyses show that the same patients are simultaneously in pre-hospital and hospital institutions receiving drugs from both of them. Within a month the same patients are reported on several clinical paths which is absurd, of course. Therefore, we are taking measures to put an end to this vicious practice.
Tell us concrete clinical paths on which the number of cases written is exaggerated!
- There are such paths indeed. But let's take the objective circumstances into account. You know that from the start of the current year the number of clinical paths increased from 120 to 299. However, some mistakes have been made in the haste. It turned out that the system is endangered by several clinical paths. We can see it from the figures. In the case of certain diagnoses, figures go to an extreme height which is many times above the one reported in 2005. These are diseases that are not contageous and not related to epidemic. Take path N106, for example: Decompensated diabetes of people over 18 years.
Can hospitalisation on this path be forged?
- Almost every person, after drinking a cup of coffee with three spoons of sugar, may be accepted in hospital and registered on this path. This is caused by the lowered hospitalisation criteria. They need to be made more precise. It is a similar case with the paths Intensive care in case of realized risk pregnancy, Decompensated diabetes, etc. There are opinions that some hospital activities are not financed sufficiently. However, the crowd registered on the paths I mentioned shows that there are also ones financed quite well...
Maybe such corrections will be made by the annex that is under preparation to the frame agreement?
- Of course, one and the same diagnosis cannot be present in several clinical paths. If that's the case, of course, patients are reported on the most expensive one. We must remove all defects shown by the system through the annex. Of course, it will happen after coordination among the managing boards of the healthcare fund, the doctors' union and the stomatological union. Their first meeting is scheduled for June 26.
It is almost certain now that for the patients stomatological services will grow expensive on the account of the healthcare fund. Give us examples for clinical paths whose prices will be changed by the annex.
- I think that if we use the analyses and specify the algorithms and rules of hospitalisation - criteria which a patient must meet in order to be accepted for hospital treatment, prices of paths may not need to be reduced. I personally think that this is a very extreme alternative which we probably will not come to.
The negotiation of a new accord on drugs is in course - drugs for which the fund pays either partially or thoroughly...
- Yes. Again, we expect that some of the prices go down. In order to make the agreement become valid quickly and achieve a better economic effect, we are going to use the annex to the frame agreement. If we fail, the prices and drugs contracted will remain for the next frame agreement.
When is the annex expected to become valid?
- Approximately in the end of July.
Let's go back to the violations that fund controllers find out during their inspections. Is there a doctor who have been given the gravest sanction - termination of his contract?
- No such case has been registered since the start of the current year. Still, we want to create working conditions that would not allow people to make violations. Prevention is more important. Otherwise, the result is rough administration which does not help anybody.
Still, you informed the economic police and the prosecutors' office about violations of doctors in the past months. How many cases are there and what can you say about them?
- Two months ago we collected the information about violations found in all regional funds. It turned out that some of our colleagues did their controlling work quite well. Things are getting serious in cases in which the police and the prosecutors are involved, because the violations relate to filling in documents with inaccurate data by people on duty.
Is the number of these cases about one hundred?
- Between 120 and 130 cases are sent to the prosecutors' office a year. It is not a great number for 30,000 doctors, but we would not like to hide them.
It is to be noted that this year inspections are made in contract partners as well as in regional healthcare funds. Three directors were dismissed a month ago - probably because they didn't do their job properly?
- Before we start inspecting our contract partners, we must be sure that everything is right with us. We have special methods to assess the work of the funds' directors. When one of them receives a low rating for the indicators of the methods, spot inspection is ordered to reveal the reasons. This should be considered normal practice.
In the end of 2005 you said that after June 2006 the first measure for bringing bigger revenues to the healthcare sector will be known - increase of the healthcare instalment or regulated additional payment.
- By making an analysis in the middle of the year we want to show what we propose with the fund's budget right now. That was the aim of the single financing. Now we know how much money has been spent on each activity. From now on, if we want more money, it is the respective institutions to decide. Bulgarian Parliament is the legislative body. We are here to prove for what and how we are going to use the money in order to achieve the best possible effect to patients and doctors. We are going to do it in the end of the first half of the year. Our obligation is to work within the limits of the budget.
But it would be hardly possible to guarantee the same budget without subsidizing from the State. What a solution would you propose?
- Anyway, we should take into consideration not only the political and economic situation in Bulgaria but the international financial institutions as well - the World Bank and the International Monetary Fund. My personal commitment is to maintain the system financially stable. Of course, we'll insist on more funds next year in order to be able to offer to people more and better quality medical services. We'll demand a higher percentage of Bulgaria's gross domestic product (GDP) for healthcare. But the financial framework and the healthcare fund's budget is finally approved by the National Assembly. The issue is a global one and the solution cannot be explicit as some people from the Ministry of Healthcare expect.