2.9. Patient empowerment

2.9.1. Patient information

Patients’ rights to information are governed in several pieces of legislation, including Law 46/2003 on Patients’ Rights, Law 95/2006, the Medical Profession Deontology Code issued by the National College of Physicians, and the legislation on hospital accreditation. These mainly give patients the right to information about their health and available treatments, as well as to informed consent (see also information on patients’ rights in section 2.9.3), but also to information about the range of available services and certain information about the providers (see Table2.2). There is no formal evidence on how well informed patients are about their rights and if the available information is seen to be useful. In general, patients with access to the Internet can obtain a wide range of information (e.g. through forums and chat rooms) but the reliability of such information is questionable.

Table2.2

2.9.2. Patient choice

Statutory coverage of the health insurance system is obligatory and opting out is not permitted. Patients can choose their provider (family physician, specialist and hospital for elective care) and participate in treatment decisions.

Choice of provider

Patients have free choice of health care provider among all providers that have concluded contracts with the DHIHs and there is no geographical restriction. Registration with a family medicine physician is mandatory and they act as gatekeepers to secondary care since accessing specialist care requires a referral from the family medicine physician; however, there are important exceptions, with no referrals needed for certain conditions and patient groups (see section 5.2). Many patients choose university hospitals even if their family medicine physician recommends their district hospital. In such cases, the primary care doctor would usually issue a referral to the chosen hospital. No measures have been taken to change this practice. If a person chooses a provider located outside their district of residence, they must cover their travel costs out of pocket. As a result, patients do not usually choose a provider located far outside their place of residence. Patients can change provider at any time, except for their family medicine physician – they can switch to another family medicine physician no sooner than six months after registering. Switching is more common in cities, where there is more choice of provider. In the countryside and small cities, the choice is limited as there is usually only one provider and patients would incur travel costs if they wanted to use a provider from another locality. Choice of provider was extended as part of the application of the cross-border care directive (see section 2.9.6).

User involvement in treatment decisions

Patients have the right to be informed about alternative treatments and on their respective risks and the consequences of the lack of treatment. They also have the right to a second opinion (see section 2.9.3). However, there is no evidence on whether these rights are used in practice. Drugs are prescribed by their generic name (INN) (see section 2.8.4) and patients can choose any drug prescribed in primary and ambulatory care that contains the prescribed active substance. Patients also have a choice of medical devices. The only limiting factor is the price; the NHIH usually only covers the cheapest products and patients have to pay the full price if they prefer a drug or device that is different from the prescribed one.

2.9.3. Patient rights

The key legal act in the area of patient rights in Romania is the Law 46/2003 on Patients’ Rights. This Law includes some of the rights laid out in the Declaration of Patients’ Rights in Europe launched by WHO: the right to health care, health information, consent, protection of confidentiality and privacy (see Vlădescu et al., 2008b). The Law also has provisions regarding the obligation of providers to display patients’ rights in medical units and states the obligation of health authorities to issue annual reports on their compliance with Law 46/2003 on Patients’ Rights. The rights (and obligations) of the insured as parties in the contractual relationship with the NHIH are outlined in Law 95/2006, which also includes the right to a free choice of treatment, provider and the DHIH. The rights of patients with mental health problems are stated by the Law on Mental Health Promotion and Protection of Persons with Psychiatric Disorders adopted in 2002 (see Vlădescu et al., 2008b).

The main development in the area of patient rights in recent years has been the transposition of EU legislation, including Directive 2011/24/EU of the European Parliament and of the Council on the application of patients’ rights in cross-border health care, to the national law (see section 2.9.6). The following rights stated in the European Charter of Patients’ Rights present in the Romanian legislation are included in the national legislation: the right to preventive measures, free choice, respect for patients’ time, observance of quality standards, safety, innovation, avoidance of unnecessary suffering and pain, personalized treatment, complaints and compensation. A practitioner guide on patient rights was published in December 2015 (see Ududec, Scîntee & Overall, 2015).

2.9.4. Complaints procedures (mediation, claims)

The key channels through which patients can assert their rights are the departments of public relations of the DHIHs and the Professional Jurisdiction Departments of the District Colleges of Physicians. The public relations departments of the DHIHs follow up on patient complaints and communicate the outcomes to the patient. They issue monthly reports on both the information requests and the complaints. The Professional Jurisdiction Department of the District College of Physicians analyses complaints in accordance with the Deontology Code. The Professional Discipline Commission decides on the sanctions.

Patients can also complain directly to the Ministry of Health or to their local DPHA, where special departments process the complaints. The focus is usually on whether administrative rules and procedures were adhered to.

Finally, patients may also seek legal redress through civil courts (see Table2.3). There is no evidence on the utilization or effectiveness of the available complaints procedures.

Table2.3

2.9.5. Public participation

Participation of the Romanian public in health policy decision-making has increased in recent years. The number of patients’ organizations has risen and they have become more effective in making their voices heard. According to the Coalition of Organizations of Patients with Chronic Diseases in Romania (http://www.copac.ro/asociatii), one of the most active umbrella patients’ organizations, there are over 40 patient organizations in the country. Patients’ associations increasingly take part in various initiatives, such as the EU-financed project (implemented in 2013) titled “Mechanisms of consultation among authorities and patients’ associations”, and they support patients in legal suits, including against the government (for examples of such actions, see APCR, 2014). They are also consulted during the development of the Framework Contract (see section 2.8.1) and may be consulted on an ad hoc basis on other topics.

There are no countrywide surveys of patient satisfaction with the health system (see section 7.3.1). Occasional surveys have been conducted in the area of corruption (Asociatia Sf. Damian, 2010; MS&AID Romania, 2014) (see section 7.6) and interest in private providers (i.e. studies ordered by MedLife; IMAS, 2010, 2011, 2012).

2.9.6. Patients and cross-border health care

Romania transposed the Directive 2011/24/EU on the application of patients’ rights in cross-border health care into national legislation mainly through Title XVIII Cross-border health care of Law 95/2006, modified by the Emergency Ordinance 2/2014 and its subsequent regulations. Romanian citizens can access health care services in any EU Member State either by using the European Health Insurance Card (EHIC) for unplanned care (introduced in 2007) or, for planned care, with previous authorization from the NHIH or the Ministry of Health. The costs can be reimbursed up to the cost of the equivalent services in Romania. Necessary health care services and treatments that are not included in the benefit package covered by the NHIH can also be covered (including travel expenses) if a prior authorization has been obtained. Information on how to obtain cross-border health care is available through the National Contact Point within the NHIH (http://www.cnas-pnc.ro/?l=en).

In 2014, the number of reimbursement request forms for health care services provided abroad to Romanian insured patients in EU/EEA Member States or Switzerland was 47 774 and amounted to a total of €68.2 million. Out of these, 24 664 requests were for services provided on the basis of the EHIC, 1885 were for planned treatment and 21 225 for services provided on pre-authorization for residency change, i.e. for Romanian patients residing abroad who receive services outside Romania (NHIH, 2015a; NHIH, 2015b). In 2014, the NHIH submitted 1611 reimbursement request forms, amounting to around €733 260, to EU/EEA Member States or Switzerland (NHIH, 2015a).

In non-EU countries, Romanian patients can access health care services if they have a private health insurance covering them during travels abroad or if Romania has concluded a bilateral agreement with the visited country. There are currently 28 bilateral agreements in place covering health and/or social protection and 14 bilateral agreements covering other sectors (such as education, sport, etc.) that include health care services (for a list of bilateral agreements, see http://www.cnas.ro/page/alte-state.html).