Would the Health Card be beneficial to the patients?

Would the Health Card be beneficial to the patients?

We do not intend to respond to this question in this article, there is yet too little information to perform a pertinent forecast. Instead we will carry out a brief incursion during the past 25 years of health reforms in Romania to learn if the introduction of the health card starting May 1st, 2015 will have any chance to support the patient in getting better services.

The various reforms focused on healthcare system in the last 25 years are preparing for a significant leap towards digitization era by the compulsory use of health cards. At a first glance, based on medical authorities statements, this card will simplify patient access to health services and will help the overall system become more transparent and determine an increase of the efficiency of the allocated funds. Therefore, the first question that arises would be related to the real reform’s veracity for patients by introducing this card, in the way that it would prove useful to a greater extent for the deep disordered healthcare system characterized by inefficiency in spending money, or to the patients as final beneficiaries of these services? Thus, it is necessary to identify the real utility of those cards which, at a first glance, beyond what officials declare, appear to be more part of a controlling procedure for medical staff, related to their spending efficiency of social health insurance funds collected from taxpayers, who are thus entitled to actually receive high quality medical services, patient-oriented.

In a review of the past 25 years in terms of reforms implemented in the public healthcare system in Romania, an evolution in leaps that began quite lately can be noticed. Thus, during the first years that followed the fall of the communism, the healthcare system has been centrally coordinated by the Ministry of Health through the 41 County Health Departments and the Health Department of Bucharest. Consequently the first step of the reform was represented by the Social Health Insurance Law no. 145/1997 which restructured the financing of the system that included onwards compulsory health insurance based on the principle of solidarity and operating in a decentralized system consisting of county houses of insurance as autonomous public institutions, led by representatives of policyholders and employers boards, and by the National Health Insurance House.

Through the same Law 145/1997 was established the legal framework for foundation of family medicine institution as a medical specialty and academic discipline, by taking over the practice of general medicine. This phase preceded the hospitals reform, since at that time it was estimated that family medicine would cover 80-90% of medical needs of the population (usually those of a minimal gravity), resulting in a deagglomeration of hospitals, and consequently increasing performance.

After successive amendments over the coming years, Law no. 145/1997 was repealed by the Government Emergency Ordinance no. 150/2002 and replaced by an unitary legal act, Law 145/2002 – the organization and functioning of the social health insurance system, which maintained the status quo of the system.

In 2006, Law no. 95/2006 on healthcare reform was adopted, which provided the basic package of services covered by social health insurance which has remained to this day the legal basis of healthcare system in Romania.

After 2009, with the bursting of the economic crisis, a further reform of healthcare system became necessary in order to reduce arrears (debts older than one year accumulated by the healthcare system to drug suppliers) and curb expenditures. An important component of this process was the assesment process of hospitals in Romania and their classification into five categories based on which, starting with June 1st 2011, the financing methodology for medical facilities underwent significant changes, differences between hospitals from the same category being eliminated. Increase of budgets was considered especially for large hospitals, with best results, and expenses cut for hospitals with no adequate medical services. The assessment identified the need for closure of 67 hospitals on the grounds that staff and financial returns were too low to be further supported. Another component of the reform process was the transfer of hospitals under the local authorities management stipulated by new legislation introduced in 2010.

Public healthcare system in Romania benefits from a mixed funding facility: i) compulsory contribution; ii) allocations from central / local state budget. Therefore it is natural that public healthcare system be the main option of the Romanians even if the underfunding of the system and its defficiencies are well known and have been perpetuated over the past 25 years. The vulnerabilities caused by the low quality of health related services, especially within hospitals, additional costs for drugs encountered by patients during hospitalization and the high level of corruption are accompanied by the precarious state of infrastructure, the low level of salaries for medical staff, situation that encourages informal payments, leading to an inadequate quality of medical care and an unprofessional attitude from the system staff towards the patients.

According to Eurostat, in the year 2012, the medical system in Romania qualify for the lowest funding across the EU.

Expenditure on health as % of GDP within various European Member States

2006 2007 2008 2009 2010 2011 2012
Bulgaria 6,89 6,81 6,97 7,23 7,58 7,72
Czech Republic 6,69 6,52 6,82 7,85 7,43 7,50 7,55
Denmark 9,92 9,99 10,18 11,47 11,08 10,87 10,98
Germany 10,64 10,48 10,70 11,75 11,56 11,25 11,27
Estonia 5,02 5,16 6,06 6,93 6,32 5,83 5,89
Greece 10,19 9,48 9,79 9,27
Spain 8,39 8,49 8,93 9,60 9,65 9,44 9,30
France 10,85 10,78 10,91 11,60 11,55 11,52 11,61
Hungary 8,26 7,67 7,46 7,74 8,06 8,03 7,97
Austria 10,22 10,26 10,49 11,17 11,13 10,87 11,10
Poland 6,20 6,33 6,89 7,21 7,02 6,87 6,75
Portugal 10,03 9,99 10,22 10,81 10,80 10,23
Romania 5,09 5,24 5,44 5,66 5,95 5,60 5,56
Finland 8,34 8,04 8,31 9,17 8,99 8,95 9,09

In this context, the introduction of mandatory use of health card starting with May 2015 appears rather as a way to stop or reduce draining money from the system and  than as a benefit to the patient. Romanian authorities, namely the Ministry of Health, described the introduction of the health card as a reform designed to eliminate health system weaknesses and counter-performances by forecasting more stringent controls regarding in particular the effectiveness of money spending, but also by eliminating the bureaucratic process that citizens must undergo in order to access medical services for which they pay a compulsory contribution.

However, with only few weeks before seeing the card at work,  it appears to have more of a formal character, a minimal set of personal data being recorded on this magnetic media (e.g. holder’s insurance status, blood group etc.) with the aim to attach, exclusively with the consent of the patient, his/her medical file. The card cannot be used by third parties, requiring a validation code known only to the owner.

This card represents somehow the final stage of the reform started in 1997, but the results cannot yet be foreseen nor appear as potentially spectacular. Healthcare system, poisoned in the last 25 years with corruption and a chronic inefficiency of  public spending, seems quite difficult to be put on track by simply introducing a health card for the insured as an identity card to be shown to family doctor in order to be entitled to free of charge health related services. Healthcare professionals have expressed disagreement with the introduction of these cards, not really enthusiastic about the control exercised by use of such instrument. This opposition might translate into a new delay in the introduction of compulsory use of health card which yet not demonstrating their utility to patients by ceasing issuing prescriptions to false patients, rather than by an increase of the medical services quality.


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