Context
Spending on hospital care has been traditionally the largest part of health expenditure in Romania. While shifting the focus of care from the hospital to the ambulatory sector has been on the policy agenda for more than ten years, hospital spending as a share of current health expenditure increased by ten percentage points over the past nine years, from 35.6% in 2011 to 45.6% in 2020 while expenditure levels for ambulatory care (including primary health care) increased from 11.4% in 2011 to 13% in 2019, but decreased to 11.2% in 2020 (National Institute of Statistics, 2020, 2022). The poor spending on primary health care is also reflected in low activity levels: family physicians are providing care mainly for acute cases as well as for fragmented monitoring of chronic patients (Ministry of Health, 2023). The specific need for more disease prevention and health promotion services is reflected in the high level of preventable mortality rate in the country (358 deaths per 100 000 population in 2020), which is almost double the EU average rate of 180 (Eurostat, 2023).
Impetus for the reform
The National Health Strategy 2023–2030, which is still in the approval process, has as one key objective to redefine the role of primary health care and to improve its performance. According to the Strategy Action Plan, this will be attained by increasing the number of preventive services in primary health care, and the participation of family physicians in integrated networks to enhance the active monitoring of chronic patients. Until now, patients with chronic conditions were consulting family physicians mostly for requesting new prescriptions, but active monitoring of these patients was only marginally part of these interactions.
As a new Framework Contract (a Government Decision that regulates the conditions for the provision of healthcare) has been issued in July 2023, the Ministry of Health and the National Health Insurance House have proposed changes to the payment methods of family physicians as an incentive to increase the provision of preventive services and hence the number of beneficiaries of these services.
Content of the reform
Family physicians were previously paid through a mix of 50% capitation and 50% fee-for-service. Starting in July 2023, the capitation to fee-for-service split has been replaced by 35% to 65%. Also, a new payment method – payment for performance – has been added. This is paid yearly, as a lump sum, based on the achievement of specific indicators in the previous year (for example, number of people over 40 years of age being assessed for health risks). The evaluated risks for people between 40 and 60 years of age are related to cardiovascular diseases, circulatory diseases, cancer, diabetes, and renal diseases.
Further, the risk factors for mental health and reproductive health are also included. The evaluated risks for people over 60 years of age are also related to osteoporosis, dementia, and depression. The reform includes that patients found at risk following the relevant assessment will be closely monitored and will receive disease prevention counselling.
As the new legislation applies from July 2023 onwards, the first payments for performance will be issued in 2025, based on the activity of the year 2024.
Besides the change in payment for family physicians, the new Framework Contract has other provisions to support better provision of services, such as: establishing annual preventive check-ups for people between 18 and 39 years of age, allowing family doctors to refer patients to additional lab test which might increase the diagnostic accuracy, decreasing the required minimum number of persons family physician has to enroll on their list (from 1000 to 800), as well as increasing financial bonuses for new family physicians that decide to practice in rural areas (50% income increase, except for those areas with no other family physician where a 100% income increase is planned) (Government of Romania, 2023).