THE PRESENT EXPERIENCE AND CHALLENGES BEFORE THE BULGARIAN HEALTH INSURANCE SYSTEM IN THE FIELD OF HOSPITAL CARE Jeni Nacheva Director of Department for Budget and Financial Parameters in the National Health Insurance Fund of Bulgaria

PRESENT SITUATION IN THE BULGARIAN HEALTH CARE SYSTEM Aging population and growing morbidity rate of chronic diseases, which cause increasing demand on health care and especially inpatient care Unbalanced financial flows to the different health care levels; Lack of monitoring and control on the expansion of health facilities; Ambiguity in definition and functional organization of emergency care; Lack of coordination among public institutions in the health care activities; Lack of specialized personnel and incentive resources for keeping them; Quality issues;

FINANCIAL FRAME Health care costs per person for the period 1999 – 2007: from BGN 114 in 1999; to BGN 288 in 2007 г.; expected BGN 396 in 2008.

NHIF’S AVERAGE MONTHLY HEALTH INSURANCE PAYMENTS Year Average Monthly Health Insurance Payments (in BGN) Number of Health Insured Persons Average per Insured Person (in BGN)

HEALTH INSURANCE PAYMENTS FOR HOSPITAL CARE 2001 – 2008 TRENDS NHIF starts to finance the hospital care from the second semester of In 2006 NHIF covers the whole hospital care. The share of health insurance payments for hospital care in NHIF’s budget increased to 55 per cent in 2006.

THE TRENDS IN THE HOSPITAL SECTOR “ Open” payment and reporting system for hospital activity without cost-control mechanisms; Lack of coordination between inpatient care demand and hospital capacity and inpatient resource allocation; Increasing supply of hospital care – no administrative planning of hospital care capacity; Building up the Emergency Portals results in open access to hospital care; Lack of cost control mechanism; Lack of coordination in responsibilities and activities between outpatient and hospital care; Lack of quality incentives in payment mechanisms; High level of informal payments from the patients.

HOSPITAL CARE PAYED BY NHIF SECOND SEMESTER OF 2001 – 2008 Year Number of Clinical Pathways (CPs) Number of Diagnoses, Covered by the CPs Number of Treated Patients NHIF’s Payments for Hospital Care (in BGN) Average Payment per Patient (in BGN)

MAIN FACTORS FOR BUDGET DEFICIT Absence of control in hospital care sector; No limitation in hospital supply capacity financed by NHIF  In 2007 hospitals have opened 74 new structures (clinics), for contracting additional CPs with NHIF.  In 2007 there are opened 20 new health facilities (incl. 14 private, 4 public и 2 municipal), who have contracted provision of 174 CPs.

MAIN FACTORS FOR BUDGET DEFICIT(2) The opened Emergency Portals in hospitals : The share of the emergency hospitalization equals to 33 percent of all hospitalization. Increased number of outpatient facilities who contracted inpatient care – precondition for induced demand; Increased number of rehospitalizations - 20 percent of hospitalizations.

STRATEGIC CHANGES ON THE INITIATIVE OF THE NHIF Changes into the Health Insurance Act:  Introducing of budget payment as new payment mechanism for hospitals based on hospital specialization, bed capacity, personnel characteristics. Expected advantages:  Increasing the resource responsibility of the hospitals;  Incentives for effective and efficient hospital care;  Resource allocation influenced by bettered hospital management;  Introduction of business planning in hospitals;  Money follows the patient – effect.

STRATEGIC CHANGES ON THE INITIATIVE OF THE NHIF (2) Development on the national level of the management and control of the allocation of health facilities and medial specialists; Restriction on contracting with new facilities during the financial year; Introducing the accreditation as an obligatory criteria for contracting with NHIF; Intensified medical and financial control on hospital activity; Introduction of new obligatory reporting document - Declaration by patients about conducted payments.

OPERATIONAL MEASURES FOR 2007 AGAINST FIXED ISSUES Bettering the payment mechanisms for hospital activity – introduction of budgets; Development of integrated national health strategy in the control of health facilities’ activity. Development of integrated national health strategy for reduction of informal payments in health care sector. Continuous monitoring and analyses of the quality of hospital care; Decentralization of financial responsibilities – involving the regional HIF in the process.

CHALLENGES FOR NHIF To eliminate all duplicated and non-effective activities with the means of: Increased audits in monitoring the way of the patient in the health system; Audits of medical practices which account activities against all standards and requirements; Enforcing control at point of place – interim control; Exploring patients opinion

CHALLENGES FOR NHIF (2) To eliminate all duplicated and non-effective activities with the means of: Development and support of the integrated network system in NHIF; Improvement of the efficiency and results in operative control related to the kind, capacity and quality of the provided health services and the parameters defined in the contract; Development of the models for electronic accountancy aiming to monitor all activities provided to the patients and wholesome medical care.

NEEDS OF FUTURE LEGISLATIONS CHANGES Determine tendency towards to pay in cash for the activities include in the main package guaranty of NHIF; Developing financial plans for hospitals work in accordance with the owner and financial institution; Introduction measures contracting of NHIF with hospitals through: National health insurance card,  Determine criteria for contracting,  Introduction criteria and requirements for quality with negotiate and contract fulfillment. Exactness criteria to register new structures in the hospitals for health care and new hospitals; Exactness criteria for hospitalization laying patients to the hospitals. Clean range definition for emergency help.

LAW AMENDMENTS AND LEGISLATIVE DECISIONS Normative based rules, scope & prices of health activities within the specified annual budget parameters; Coordination of activities of all interest parties related to preparation and specifying of national health policies for the forthcoming year; Finalizing of national health card project, including analysis and re- structuring of the bedding capacity. Creation of strict criteria for getting license and registration of new health point, as well as planning of bedding capacity; Participation in negotiations for health services providers.

STRATEGIC AIMS, TOWARD TO FINANCIAL EFFECTIVENESS Preventive system, promotion and early detected of the cases – MH, MLSP, and NHIF; Methods to stimulate health mode of living and healthiness choice; Methods to stimulate personal liability for medical treatment; Methods, in all political sphere influence on the public health and ensure equality in the health insurance.

READINESS FOR IMPLEMENTATION OF THE MAIN GOALS OF THE EUROPEAN HEALTH CARE STRATEGY AND POLICY Informative of engagements in health sector according development of the European health strategy and politics; Acquisition capacity for effective participate in the European Community programs; Equalization of the nationality health strategy to the European; Introduction of electronic European health insurance card, personal health file and electronic health portal for the purpose of the doctors and patients.

THANKS FOR YOUR ATTENTION