As Patients We Trust You,
As Clients We Would Like To Know

Medicine is a mysterious realm. No patient can adequately judge upon a better treatment, although many try. Rumors circulate in the public, of course, adding credits to this or that doctor or professor, and with the same ease the same persons lose their credits in the eyes of concrete patients remaining uncured (at best) owing to concrete, objective or subjective, reasons.

What is underway now is no less mysterious, as we are on the threshold of joining medicine with economy. The system of paid medical services functioning already for a number of years may be characterized as chaotic: bearable (or unbearable) tariffs frighten the nervous, the poorest or the most naive, while those better adapted still know how much and whom to pay. Experienced patients are well acquainted with cheaper modifications and synonyms in the sea of drug denominations. The same refers to a healthier category, whereas the richest are not to be encountered in ordinary policlinics and hospitals: they go abroad for treatment despite prices. Why, it is a matter of prestige for the "new"! The fate of gravely ill or injured people is, of course, awful both morally and financially as they are fully dependent on the personnel and their sufferings give them no choice ...

Well, enough black paint! Let's view the problem from another angle adding a golden financial hue to the grayish healthcare palette.

The Law On Compulsory Medical Insurance adopted in 1998 defined only general principles and notions of transition to insurance medicine. Since 1998, the problem has been sporadically touched upon in the mass media, but in somewhat vague and contradictory terms. Soothing generalities produced by medical officials in charge of the reform lacked concrete market-related information: who pays whom, how much and for what?

As a result, the public at large, struggling for immediate survival, failed to keep the vital economic problem in the focus of attention. Meanwhile, the 1998 law serving as a starting point, a package of normative acts has been developed in the almost 4 years preceding its implementation fixed for January 1, 2003. The work has not been too much publicized, and the most exhaustive (and unpleasant) information started leaking to papers and TV in late-2002, that is on the very eve of supposed transition. Indeed, the problem of reducing the number of official and professional holidays is
publicized much wider.

Should we generalize the economic anamnesis of the case, being all potential patients and payers, the four elementary questions asked above is quite enough: who pays whom, how much and for what?

Thus, who pays: the list of payers is defined to perfection. It takes into account all the subtleties of potential evasion techniques and may be regarded as the best worked out element of the legislation submitted for adoption. The payers are: all those employed, elected, working under contracts, free entrepreneurs, etc., that is everyone liable for taxation; employers jointly with their employees; central budget covering the premiums of invalids, students and employees of budgetary institutions; local public budgets responsible for insuring pensioners, children and the unemployed officially registered. In the latter cases it becomes evident that all taxpayers are going to pay twice for the same package of medical services as the central budget and the local budgets are relying not in the least degree on the income tax deduction.

Next, whom are we going to pay? The institution founded with a view of managing the process is named the National Agency for Compulsory Medical Insurance and defined as an administrative non-profit structure with a net of territorial branches. The question immediately arises as to the body that is going to be financially responsible for accumulating and managing the flow of funds from the state, donors if any, and the insured individuals, for the funds distribution and investment, choice of banks involved, etc.

It is unclear whether the National Agency will be fully in charge of this economic activity (it can't be so as it is a non-profit organization) or whether it is going to manage its finances in some other way, although it's high time for the notion to be precised. In any case, compulsory independent audit should be needed from the very start (an expensive service, by the way), with annual reports widely publicized.

Another problem: the majority of our employed public are used to two kinds of long-standing deductions, that is the income tax plus the social/pension fund contribution. Now a new aspect arises: we are demanded to pay for something that should have been strictly defined beforehand (by January 1, 2003, suspended until July 1, 2003) and made known to everybody as soon as possible, as anyone could become a patient the next day - God save! - due to an accident, for example - just look at our slippery streets.

Those paying straight to the Agency (free entrepreneurs are envisaged to do so) will undoubtedly demand the policies issued to them on the spot plus detailed information regarding their rights. Those paying indirectly through monthly deductions - what documents are they going to obtain in order to be guaranteed the very package of medical services defined (has it been defined yet?) within the limits of insurance medicine and not the state-provided minimum? What is the procedure of obtaining such documents and explanations for those employed and too happy to have a job to run around medical authorities missing working hours.

One more payment-related problem: our premiums designed to improve the state of the healthcare system are not likely to influence the financial situation of the medical personnel who are budget supported. Hence, the four-digit sums in lei as "gratitude" fees are due to change hands as before.

So how many times are we supposed to pay? As taxpayers, as the insured, as the "grateful", and .. oh, yes, what about the medicines? Doctors' prescriptions, as anything else, are subject to fashion, influenced by advertising. The way of forming drug supplies for hospitals, the means of curbing the tendency towards prescribing more expensive varieties that has manifested itself with some family doctors, the mode of choosing drug suppliers for insured medicine - all of these and a host of other problems should have already been solved.

The third question already answered for us is "How much?" Concrete figures became public only by the end of 2002, that is on the very eve of supposed reform implementation. 339 lei 36 bani as a fixed premium payment defined for free entrepreneurs, artists, housewives, etc., and 2% of the salary for those employed. The latter case is more complex, as the 2% is only the tip of the iceberg. Social insurance contributions are made by employers at a rate of 29% of the pay-roll fund. Add 2% more for the joint coverage of the 4% premium payment per employee and try to understand the reason your employer is not overjoyed.

There are rumors of supposed initiative by the Ministry of Labor to start reducing the rate of employers' social insurance contribution by 1% annually. Thus the burden lifted off employers' shoulders will gradually be relocated onto ours. If the project is realized then in 2004 the majority of the population will perhaps have 4% of their
salaries deducted to the social and medical insurance funds, plus the income tax.

What are the other miracles in store? There surely are some as, according to the Law On the Amount, Order and Time of Payment of Compulsory Medical Insurance Premiums approved by Parliament in the first reading in late-2002, concrete sums of deductions are to be yearly revised and recalculated by the National Agency, that is by the interested party. Inflation rate taken into account, an increase in the costs of treatment is inevitable in the years to follow, as well as in our premium rate. Add extra services not covered by insurance, plus medicines, plus "gratitude" fees, and ...
oh, be healthy!

The fourth question on "What are we going to pay for?" remains still practically unanswered by now.

It is no secret: healthcare system in Moldova is in a state of decay. Hospitals and policlinics receive scanty financial support, with their staff doing their utmost to "resuscitate" the buildings, equipment, and so on. It is sad to hear and read optimistic reports in the mass media narrating about country hospitals whose staff are making repairs of the wards and corridors in their free time or "with their own means." Just imagine a surgeon engaged in hard manual work "in his free time" and performing operations with his poor injured and tired hands! As to the "means" - these are beyond
definition.

The reverse side of this enthusiasm is fear of losing jobs in case a hospital is considered no more serviceable because of poor sanitary conditions. Besides, the process of accreditation (licensing) of medical institutions, started on the eve of the reform and designed for five years has led to the necessity of new demands made to
medical institutions as regards sanitary state, personnel qualification, provision with equipment, level of services rendered, and many other parameters. By the way, the process of accreditation must have been completed by the time of launching insurance medicine, which once more attests to insufficient preparatory work for the reform.

On the whole, accredited or not, our doctors are no worse trained that their Western colleagues, and they still manage to work miracles in spite of all the difficulties and obstacles. It is not their fault that the money allocated from the budget for the state-guaranteed free medical aid minimum plus revenues from paid medical services is used by the branch ministry for covering debts. However, the huge indebtedness remains in spite of a considerable decrease in the number of patients. Will the National Agency conclude contracts with medical institutions having troubles in the financial sphere such as those located in Chisinau alone? If not, who will cure us? And where?

Under the reform, we are going to have two medical aid minimums paid for by ourselves as taxpayers and insurance system clients: these are the state-guaranteed and insurance-guaranteed ones. Will the two be simply added together, thus making us pay twice for the same service? Indeed, does the 2003 State Budget envisage special allocations to insurance medicine? No, and medical officials are trying to treat us to a mixture of two different notions speaking about budgetary allocations to the Medical Insurance Fund. It seems that the state-provided minimum of medical services is being presented as the state allocations to insurance medicine, that is as the state subsidies that are in fact lacking.

Another problem: the two minimums might generate 3 categories of patients: budgetary; percentage and fixed premium insured, and self-supported, the latter becoming a gold mine in the rare occasions of their stay at any state-run hospital. Let us think about the former two categories as more typical ones: who will judge upon the cost of their free packages and extra payments? Who is going to do the calculations in the absence of specially trained staff which are a luxury to employ? Are there any techniques developed yet?

What else are we going to pay for? In the words of Mr. Gheorghe Rusu, director of the National Agency for Compulsory Medical Insurance, 94% of the Insurance Medicine Fund will be spent for covering medical services, 2% will form a reserve fund, 2% - a preventive fund (is it prophylactic?), and 2% will cover administrative expenses. Well, two percent of about a milliard lei (970 mln lei according to pre-2003 publications, and over a milliard lei according to the most recent ones) is twenty million lei. It would be interesting to know more about the structure of the Agency, its staff and their salaries, premises, equipment, supposed activity and numerical strength, and functions of territorial branches, etc.

Acting under the aegis of the Ministry of Health, the Agency seems to lack independence from the very start. What it has already failed to do is advertising. Yes, the economic campaign had to be advertised, the pros and cons of the project were to be demonstrated to the prospective clients through booklets, leaflets, posters, etc., aimed at convincing the public of the benefits of being insured in general and by the National Agency in particular. Why, it's much easier to impose obligatory deductions as premium payments and make fiscal bodies responsible for their collection and charging fines. By the way, who is going to pay the fiscal bodies for extra work?

What are the mechanisms of lodging complaints connected with inadequate treatment? The patient himself, if still alive of course, will never be able to prove the doctor's fault, and no clinic director will admit any fault or error committed by his accredited staff members. Imagine moral satisfaction of an insistent and perhaps qualified winner who appeared healthy enough to become the victorious party. The Agency is compelled to form a respective commission of experts, pay them (from which of the funds?), investigate the case, and - what next? Punish the doctor? Underpay the hospital? And what about the happy winner: is he likely to be paid for damage inflicted as the insurance business presupposes all over the world?

One more problem: quick recovery is to a great extent dependent on the conditions the patient is in. Gone are the times of overcrowded hospitals, but processions of patients' relatives with pillows, and bed linen, and food, and what not are still there. The norm of 25 patients per nurse persists. Certain sanitary-hygienic procedures are still conducted (or bought) by relatives, and so on. That is why private clinics emerge, and
are successful, and attract the best of specialists who are decently paid there. That is why there are rumors of the Ministry's decision to drive private clinics out of their premises rented from state-run hospitals. Struggling for patients' money, it's easier to get rid of the competitor who had raised the initial capital in order to first rent the shabby hospital premises, repair and equip them, to start working with people only after that. It would be more wise on the part of medical authorities to encourage reasonable contract-based cooperation between the two, the more so as they render services to different population strata: despite relative reasonability of private clinics' tariffs, these are still not accessible to everyone.

Thus, it is the conditions in hospitals that would also interest potential patients - no, not patients but rather clients now. As patients we should obey, as clients we are entitled to ask questions and receive definitive answers.

The transition to insurance medicine is premature in the absence of strictly defined state subsidies, initial capital and special reserve fund. It seems that the reform whose implementation has been suspended by the decision of the President was conceived as
a means of universal absolution of all the "sins" and faults of the existing medical system. What next? Myriads of problems wisely predicted by officials, with solutions to be found on the spot. No doctor starts treatment without the knowledge of anatomy. What is the anatomy of the insurance medicine so actively lobbied by our medical authorities? Will the autopsy show?

Olga Dimo, Silvia Sofronie, ULIM