Horațiu Moldovan, president of the National Health Insurance Company (CNAS), announces that in the coming days a platform will be launched through which health units “They will be able to view their own activity indicators compared to the average activity indicators at the national level in the category of the hospitals they belong to”. Recently, discussions have appeared in the public space about the way to finance medical units, after the situation at Floreasca Hospital, which was one step away from limiting admissions and rescheduling chronic patients. In the meantime, the situation has been resolved punctually, but the underlying problem remains. The cause is in the legislation, says the CNAS president.
What does the situation in Floreasca show about the financing system
At the end of last week, the manager of the Floreasca Hospital in Bucharest sent a note to the heads of departments requesting the limitation of admissions and the rescheduling of chronic patients who are not emergencies for the following month. The reason? The CNAS budget was exceeded by 10 million lei in the first three months of the year.
“The administrative issue related to the budgeting of this hospital has been resolved. There is no such reason for there to be any barriers to patient access other than the administrative capacity, the physical capacity of the hospital to treat patients. (…) The discussions in the public space appeared on Friday, on Monday the problem was solved. It was actually being resolved in the meantime, but someone probably didn’t have the patience to understand the administrative mechanisms that are currently in place.”said the president of CNAS, Horațiu Moldovan, for Adevărul.
He says that the “administrative situation” was determined by the legislation on hospital financing, which he wants changed.
“Current legislation does not encourage hospitals that perform, but encourages the passivity of smaller hospitals that do not provide sufficient services and adapted to the real health needs of the population in the area where they operate. In concrete terms, the hospital budget is represented by only half of the total amount of 34 billion of actual medical services, and the other half of salary supplements, the so-called salary influences, which hospitals receive regardless of whether they have activity or not. This thing has been in the legislation since 2015 and needs to be changed urgently.” shows the official.
Otherwise, says the CNAS president, “large hospitals will go from crisis to crisis, and small hospitals will struggle to attract non-existent patients and will be encouraged to make various artifices in order to benefit from the funds of the health centers. In no case does this system encourage small hospitals to resize their structure to the real health service needs of the population”.
Public platform on hospital performance
According to him, CNAS is also preparing the launch of an online platform that will allow comparing the performance of hospitals:
In the coming days, we will launch an online platform in the public space, through which hospital managers will be able to view their own activity indicators compared to the average activity indicators at the national level in the category of hospitals they belong to. This data will speak for itself, and the decisions that each hospital will have to make will be self-evident.
The platform will be public and even patients will be able to access it, announces Horațiu Moldovan.
“The role of CNAS is not to pay salaries, but services”
The CNAS president says that the reform of the financing method has already been discussed at a high level and agreed together with the Minister of Health and the Prime Minister.
From the very beginning, I agreed to this, and I presented it together with the prime minister, to the Government, last year. And we have committed together to do so.
However, the Minister of Health, Alexandru Rogobete, is going to resign, in the context of PSD leaving the Government. I asked Horațiu Moldovan what will happen in this case. ,“There are two left who can do this further,” was the answer.
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“Beyond personal decisions or opinions, there are some structurally functional issues, which are obvious to everyone. And there is no other solution than the logical one of including salary influences in the weighted case rate. I am sure that anyone will do this. Because there is no logical alternative. The same thing is mentioned and emphasized every year and in the discussions that CNAS has with the Court of Accounts, because the role and purpose of the National Health Insurance House is not to pay wages, it is to pay services”.
Patient representative: “The situation in Floreasca is not unique”
Radu Gănescu, the president of COPAC (Coalition of Patient Organizations with Public Affections) says that the situation in Floreasca, where expenses have exceeded the budget allocated by CNAS, is far from unique.
“These things happen frequently, because we have an unpredictable system. That is, hospitals do not know what number of services they will do in the next month, they only estimate statistically. And then including the funding is based on statistical data. Such things lead to a complicated situation. Because you, as a medical unit, cannot “close shop” on the 25th because you have spent the budget. You will have to continue your medical activity, to provide services for patients. Our hope is that such situations, like the one in Floreasca, will be avoided in the future. And somehow this way of financing will be an easier sustainable and more predictable one”, says Gănescu.
“The budget plan is not correlated with the real capacities of hospitals to care for patients”
Public health policy consultant Radu Comșa also speaks about the same problems identified by the CNAS president and the patient representative.
“I don’t have data related to Floreasca, in particular, but from the experience of working with other public hospitals, I can say that often the budget plan is not correlated with the hospitals’ real capacities to care for patients and with the demand for services in their geographical area, so that many of them end up providing less than they planned (and contracted), and others, such as the benchmark hospitals in university centers, are overburdened (the case of Floreasca). It’s a reality of the hospital system in our country, maintained by the way we organize and finance hospitals”he says.
In addition, Comșa adds:
We are still largely budgeting historically, which keeps the system in a state of maladjustment to epidemiological and demographic realities. In order to correct this situation, the critical role is that of the Ministry of Health, together with CNAS.
“More transparency from CNAS would be useful”
Regarding data transparency, the health policy consultant reminds that the allocation of funds by the CNAS can only be verified by consulting the budget executions. A cumbersome and incomplete process.
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Contract values between CAS and suppliers are not published and you can only find out information ex-post, from budget executions, but also those at a high level of aggregation. So, more transparency from the CNAS would be useful from this point of view, and it would help with time series and comparative analyses, for the institution to use in new allocation decisions.
Why do waiting lists appear?
Although the Floreasca crisis was finally averted, a problem affecting patients persists: waiting lists. In the case of interventional cardiology or radiology, for example, patients can wait months for necessary interventions because there is insufficient funding. Horațiu Moldovan, president of CNAS says:
Each hospital proposes to the Health Insurance Companies a number of patients that they can manage for each type of pathology. And, of course, the financial resources of the health insurance system are not unlimited. Because the only source of funding for the health system – or the main source of funding – is the UNFPA. and the FNUASS is based on the individual contributions of employees, those 10% that add up this year to an amount that was distributed based on the considerations on which the budget of each health insurance company was built. And these days the health insurance companies distribute this budget to all health facilities.
The budget has increased from year to year, adds the head of the National Health Insurance House. However, it remains insufficient.
“If we are ever in the situation of Germany, where this contribution – the equivalent of our CASS – is not 10% but 15%, compared not to Romanian salaries, but to German salaries, we will certainly be in a different logic from the perspective of health financing“, says Horațiu Moldovan.
