BUCHAREST, ROMANIA – Amalia Solescu, 67, a retired economist, says she visited her family physician last month to ask for the discounted medicine guaranteed to her by her medical insurance. But she says her doctor said no.
Surprised, she asked why. She says her doctor told her she had to buy it herself, despite the money she has contributed to the National Health Insurance Fund. But Solescu says she can’t afford the medicine that costs 30 euros, $45 USD, with her pension of 250 euros, $360 USD.
Worried, she says she then asked for an appointment with a specialist for her annual hypertension and osteoporosis treatments. But again, her family doctor denied coverage of her treatment. Increasingly alarmed, Solescu wondered, if the need arose, could she check into a hospital this year? Yes, her doctor said – but she’d have to pay for all the costs herself.
“‘It’s like you’re no longer insured,’” she says the doctor told her.
Solescu says she wished that the family doctors would hurry up and abandon their protests against the National Health Insurance House, the autonomous public institution that administrates and manages the national health insurance system. Because the parties hadn’t signed a new contract, she and her fellow Romanian citizens couldn’t access their health insurance.
But she says she empathized with the doctors’ plight as she remembered how she felt when the Romanian government threatened to cut all pensions a few months ago. So she went home without arguing.
Millions of Romanians were without health insurance last month until family doctors and the National Health Insurance House negotiated a new contract. Doctors say their protests led to some successes, such as the elimination of limits on discounted medicine and the number of times chronically ill patients can visit the doctor. But they say the contract deal was mostly negative, limiting the number of patients that doctors can see a day, excluding some groups from all health care services and eliminating pay increases based on professional experience. Doctors say these changes exacerbate other issues, such as technical problems that prevent people who have insurance from receiving care, extreme budget cuts and rising rent. Insurance officials say the new provisions aim to improve quality and that they are operating within the available funds.
Romania’s health care budget increased from 3.4 percent in 1995 to 5.4 percent in 2009, according to the World Health Organization. But it shrank back down to 3.6 percent in 2010, ranking the nation last in the European Union, according to the Romanian College of Physicians, a national and professional organization of physicians.
Contract Dispute Limits Care
Like Solescu, thousands of Romanians had similarly worrisome doctor visits last month as doctors and the National Health Insurance House were locked in a dispute over a new contract. For weeks doctors refused to sign the agreement, citing an inability to provide quality care under the proposed contract.
“The old contract with the National Health Insurance House expired, and we [didn’t] agree to sign the new one,” says Dr. L.M., a Bucharest-based primary care physician and family doctor who declined to give her full name to protect her job.
She says the dispute left millions of Romanians without their medical insurance benefits.
“I couldn’t provide discounted medicine, specialist appointments, nor medical vacation certificates,” she says.
L.M. says the doctors refused to sign the initial contract, hoping to force further negotiations.
“The new contract’s provisions are unacceptable,” she said at the time of negotiations.
Romanian family physicians function on a contract-based model, according to the National Center for Studies in Family Medicine. Though private entities, they are contracted by the National Health Insurance House through its different district departments. Contracts are negotiated each year at a national level.
“People get scared easily,” L.M. said during the contract dispute. “If other doctors accept to sign the contract and I don’t, I’ll be the one left out and I’ll lose my job.”
But doctors eventually suspended their protests and signed the new contract. Relieved patients like Solescu were able to get their discounted medicine again.
Still, doctors say the full dispute has not been resolved.
On the same day family doctors publicly announced they’d give up the protests, the group’s two leaders, Dr. Doina Mihaila, president of the National Federation of Family Doctors Employers, and Dr. Rodica Tanasescu, president of the National Association of Family Medicine, resigned from their leadership posts.
“I resigned because I failed in bringing supplementary funds for family medicine,” Mihaila says. “I thought I missed my mission, though my colleagues told me, ‘You did your best!’ and asked me not to quit my position.”
Yet Mihaila says she doesn’t regret giving up the protests. She says family doctors signed the new contract for the sake of their patients, who aren’t guilty for authorities’ “inefficiency.”
“People expressed solidarity and offered us their support,” she says. “People pay their insurances, and they should benefit from them. We couldn’t have prolonged this situation forever.”
Mihaila says doctors were also under pressure from authorities to sign the contract.
“Family doctors from all over [the] country were manipulated and threaten[ed] by the county Insurance House’s representatives,” Mihaila says.
L.M. says this happened to her.
“I was told I have to sign an additional act,” L.M. says. “I thought the additional act belonged to the old contract, so I signed. Then, I found out it was actually about the new contract.”
Mihaila says the process left her no choice but to resign.
“I’ve been in this fight for 11 years now,” she says. “But this year I experienced such a deep feeling of usefulness and such a bitter taste as never before.”
Some Negotiation Successes
Despite the leaders’ resignations, they say their negotiations yielded some successes that will benefit patients and doctors.
One example is the elimination of the budget limit sum for discounted medicine that the new contract law wanted to introduce.
“Basically, that provision meant a patient who paid his insurance but visits the family doctor towards the end of the month gets no discounted medicine because there are no more funds left,” Mihaila says.
Mahaila says the doctors successfully negotiated against this.
“We managed to regain patients’ rights to discounted medicine,” she says.
L.M. says she is grateful for this negotiation.
“They have tried this upper-limit trick before,” L.M. says. “A few years ago, I had a limit sum for children. I can tell you, after only one week, there [was] no money left at all!”
Chronically ill patients are also now allowed to see their doctor every month. The new contract law tried to limit their visits to once every three months.
“One doesn’t have to be a doctor to understand chronically ill patients need regular checks,” says Mihaila, still resentful.
Pediatric doctors are also once again paid per service for vaccines, regular checkups and periodic health examinations.
New Contract Excludes Some From Care
But family doctors say they failed to negotiate on other provisions of the contracts that will hurt both doctors and their patients.
According to the new contract, only medically insured patients are able to benefit from primary care. Before, patients who didn’t pay into the National Health Insurance Fund – like babies and the unemployed – could still receive primary health care.
“Many people will be left out now, for example, youth aged 18 who are still in school, or people who never worked or 0- to 2-months-old babies who are never recognized by the electronic system,” L.M. says.
Monica, 30, who declined to give her last name to protect her privacy, says that she was entitled to basic health care without having insurance during her pregnancy before the new contract came into effect, but that this will no longer be the case under the new contract. She says she already has had a taste of what this will be like.
“During my pregnancy, I was automatically granted access to primary care,” she says. “Yet, I still appeared as ‘uninsured’ in the national electronic database. My family doctor couldn’t even recommend me for some simple medical tests.”
Family doctors say they aren’t happy about another new provision that imposes a maximum limit of consultations per day: 20. Insurance officials say the limit aims to improve quality of care.
“We are supposed to spend at least a quarter of hour with every patient,” L.M. says. “Yes, I understand this, but when it comes to patients with chronic diseases, whom we, as family doctors, we are not supposed to treat but recommend them to medical specialists, we don’t need 15 minutes to write that reference note.”
Ana Mircescu, a nurse, agrees.
“I am no family doctor, [but] I can tell you this whole new contract thing is a real imbecility,” she says. “The doctors could have consulted up to 50 patients a day. Now it’s maximum 20.”
Mihaila says this is a drastic reduction from the past.
“A few years ago, we were free to see as many as 70 patients a day,” she says. “This was maybe a better way to do things.”
She says the new measure will also squeeze already overcrowded hospitals, which will have to pick up the slack left by the limit.
“Indeed there will be an increased pressure on hospitals, which are already in a terrible situation,” she says.
But she also acknowledges that limiting the number of consultations a day is necessary for logistical reasons.
“You know, there’s no bottomless sac,” she says. “The National Insurance House needs to be able to calculate the minimum amount of funds to be discounted.”
Family doctors will also now be paid according to the number of insured patients – patients who pay into the national fund – they see, not by the number of subscribed patients – patients on their consultation lists – as the old contract allowed.
“We negotiated this, but didn’t get it after all,” Mihaila says. “Being paid accordingly to the number of subscribed patients would have meant supplementing the funds for family medicine, and that was impossible.”
The new contract also imposes sanctions on doctors who have more than 2,200 patients subscribed on their lists at any given time.
“Yes, these doctors’ incomes will be reduced between 2 to 13 percent,” Mihaila says. “But I agree with this. You see, this is about the quality of the medical service. A doctor who works five hours a day doesn’t have time to consult that many patients.”
But many doctors voice displeasure about the new measure, saying the penalty will cut down on their earnings.
“I am going to lose funds anyway,” L.M. says, discouraged. “I have already over 2,200 patients.”
The family doctors’ leaders had hoped to obtain milder penalties for “crowded doctors,” but Mihaila says the authorities disagreed for economic reasons.
“A milder penalization would have meant authorities granting supplementary funds for family medicine,” Mihaila says. “Once again, this was not possible.”
Another provision under the new contract removes pay raises for doctors based on their professional experience. L.M. says she feels her professional experience is no longer valued here.
“We are no longer paid per service in concordance with our professional titles,” L.M. says. “I am a primary care physician, but my professional title no longer enables me to a funding growth.”
But Mihaila says that this new measure saved the family medicine system because it ensured equal pay for all family doctors.
“We went to negotiations with the authorities, and we found out that if the professional title rule was respected as it should have been, then authorities will cut funds from the other doctors in order to be able to ensure this growth for more experienced doctors. So we said, ‘OK, let’s give up professional titles so that all family doctors receive the same amount of funds.’”
Doctors say these contract provisions add to existing woes in the health care system.
Doctors say that technical problems in the health care electronic system – despite costing more than 100 million euros, $145 million USD – frequently leave qualified patients without care. They say the software of the national integrated electronic system, which keeps a personal medical record of every Romanian citizen, fails to update and doesn’t recognize many categories, such as babies under 3 months old, future mothers who have the right to medical care during their pregnancy and even insured people.
“Unfortunately, the National Insurance House database is full of errors,” Mihaila says.
As a result, many people who pay to be insured are denied access to discounted medicine.
“That’s a [real] problem,” Mihaila says. “It’s like the electronic system was a thief. Many times, I went to the National Insurance House myself and filed the necessary documents for my patients to be recognized as insure[d]. Well, after months, they still appear as uninsured in the database.”
L.M. agrees.
“This software is really not working properly,” L.M. says. “Sometimes it takes four hours for the website to load! Imagine, what if I have a medical emergency? Do I leave the patient unattended for hours, waiting for the website to unblock?”
Dorin Ionescu, director of the National Health Insurance House, admits the system isn’t perfect but says it’s not the software’s fault.
“There are indeed errors in the database,” Ionescu says. “But the software is working properly. Our partner institutions who forward us demographic data have errors in their databases, and when we update our own database, we get the same wrong data.”
Although the database’s technical difficulties aren’t novel, the change in the way doctors are paid under the new contract – by insured instead of subscribed patients – will exacerbate its effects.
Doctors say family medicine funds are also being cut every year.
“2008 was the last year when we had decent funding,” L.M. says. “Ever since then, the funds for family medicine were fewer and fewer.”
Mihaila agrees.
“The first important reduction was in 2009, when we got 30 percent less money,” Mihaila says. “Then, we got less and less.”
But Ionescu denies this.
“I can affirm with much certitude that, during the last three years, family medicine’s budget did not diminish,” he says.
Regardless, doctors say the funds aren’t enough.
“The funds we get from the National Insurance House are not enough to pay salaries and keep our health units functioning properly,” says Razvan Ceres, 40, a family doctor.
“The National Insurance House pays 2.36 euros [$3.42 USD] for one consultation,” Mihaila says. “Please tell me, what can one do with 2 euros [$2.90 USD] today? If you go to a private clinic, the most humble doctor will charge you between 19 euros [$27.50 USD] and 23 euros [$33 USD].”
The National Health Insurance House maintains that Romanian physicians earn up to 9,000 euros, $13,000 USD, a month, according to an article last month in the Libertatea Daily, a Romanian newspaper.
“Well, that’s certainly not true for me!” says L.M., irritated. “Last month, after I paid everything – the two nurses, maintenance, electricity, medical certificate costs – I was left only 118 euros [$170 USD].”
According to the Mures Family Doctors Association, a regional branch of the National Association of Family Medicine, a Romanian family doctor earns around 200 euros, $290 USD, a month.
“This is why many dispensaries will not [stay afloat], and their owners will have to close,” Mihaila says.
L.M. says the problem lies in the flow of the funds paid by citizens.
“You see, the problem is health insurance funds go first to [the] government, and government decides how much money is given to family medicine,” L.M. says.
She says this leads to insufficient funding for family medicine.
“At the moment, we don’t even get 9 percent of the National Health Insurance Fund,” she says. “We are a lot below Western standards.”
Ionescu says the matter is not black and white.
“It’s hard to tell whether there is enough money for Romanian family medicine,” he says. “It depends on how one defines family medicine, what does family medicine do and how much does Romania afford to pay compared to other countries.”
Family doctors leaders say they went into negotiations asking for 25,000 euros, $36,270 USD, in supplementary funds for family medicine. But authorities said there was no more money left.
“The worst thing is that they asked me, ‘Which other health sector you would like us to cut funds from in order to give more to family medicine?’” Mihaila says, still in shock. “Well, that was really rude. How could I have said, ‘OK, cut from hospitals,’ when I am aware of the terrible situation of Romanian hospitals?”
Doctors say that on top of shrinking funds and salaries, they have to deal with rising annual rent. Although Romanian primary care physicians are independent, private health care providers who have the right to hire qualified medical staff and even maintenance staff, they must work in state-owned buildings and pay annual rent.
“During the last five years, we paid 1 euro [$1.45 USD per] month,” Mihaila says. “However, starting this year, the rent grew to 50 to 60 euros [$73 USD to $87 USD per] month.”
On top of rent, family doctors must pay for all medical equipment and maintenance materials for their dispensaries.
“Once in three to four months, I have to pay it from my own pocket,” L.M. says with resign. “Actually, most physicians were forced to renovate from scratch the buildings they are now working in.”
Family doctors say that, according to the renting contract, they were entitled to eventually buy the dispensaries, but the authorities never agreed to sell.
“We invested a lot, and we invested in a space that is actually not ours,” Mihaila says.
She says some dispensaries will be forced to close, reducing the care available for patients.
“Now the rent’s growth means many health units will be closed because their owners will no longer afford to pay,” she says.
Moving Forward, Seeking Solutions
Romanian Health Minister Cseke Attila told the press earlier this year that there were too many family doctors in Romania, according to the Evenimentul Zilei, a daily Romanian newspaper.
At the moment, there are about 11,000 family doctors in Romania and 4,800 family medicine residents who practice under them, according to a Romanian community medical portal.
More than 1,000 doctors – 30 percent of them family doctors – left Romania during the first four months of 2011, according to the Romanian Doctors’ College. The organization estimates that more than 3,000 doctors will have left Romania by the end of the year.
“Of course, I consider the option of going to work in another country,” says Nadia Rachita, 35, a mother of two, who says she earns just 175 euros, $255 USD, a month as a family medicine resident here. “If I can’t find a job here, I might leave next year.”
Mihaila says the system is strangling doctors here.
“Now we have the noose around our neck,” she says. “If they tighten it a bit more, they will kill us!”
