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30 September 2022 | Country Update
Implementation of telemedicine in Romania -
30 April 2021 | Country Update
Improving access to prescription medicines and medical products -
07 August 2018 | Country Update
Increased financing for continuity care centres -
14 June 2017 | Policy Analysis
Ensuring better access to medicines
5.2. Patient pathways
The patient’s first contact with the health system is usually through the family medicine physician with whom he or she is registered. The consultation is free of charge if the patient is insured (see section 3.3.1). Uninsured patients can only visit the family medicine physician for free in a medical emergency, if they are suspected of having an infectious disease, if they are pregnant or in labour, or for family planning and other preventive services. Family medicine physicians are not required to assure provision of primary care out of hours, at weekends or during public holidays, but they perform on-duty calls in turn in continuity care centres. Patients usually rely on ambulance services and/or hospital emergency departments if they need medical assistance, including non-urgent care, during those times (see section 5.5).
The family medicine physician may refer the patient for laboratory or other tests. If the medical condition is beyond the competence of the family medicine physician, the patient is referred to a specialist in an ambulatory care setting or hospital. A referral from a family medicine physician is not needed for regular specialist check-ups for 58 specified conditions and patient groups, including: cardiac failure of class III–IV on the NYHA scale, TB, some mental health problems, high-risk pregnancies, hepatitis, patients after transplant, patients with rare diseases, and so on. Patients diagnosed with these conditions or belonging to these patient groups can see a specialist directly.
After being seen by a specialist in the ambulatory care setting or hospital outpatient department, the patient is given a prescription, if needed, and the family medicine physician receives a letter (directly or through the patient) informing him/her about the patient’s health status and of any completed or prescribed treatments. The extent of patient cost-sharing for drugs varies from 0% to 80% (see section 3.3.1). Some drugs covered by the statutory health insurance can only be disbursed after an authorization process: the patient must prepare an application containing a medical report from the medical specialist, a proof of identity and documents evidencing his/her insurance status and submit all of this to the relevant commission (responsible for the particular disease) at the NHIH or DHIH level. The commission then reviews the application and, if the decision is positive, issues an authorization, which the patient then submits to the pharmacy together with the prescription in order to receive the drugs.
Chronic patients are followed up either by a specialist in the ambulatory care setting or by the family medicine physician; this includes patients with hyper blood pressure, dyslipidaemia, diabetes type 2, asthma and other obstructive respiratory diseases, and renal chronic diseases. The family medicine physician carries out home visits to patients with restricted mobility.
Family medicine physicians or specialists in both hospital and ambulatory care settings may refer the patient to physiotherapy and rehabilitation services, or prescribe home care services, or health aids and therapeutic appliances, as necessary. Such care is free of charge if it is provided by a health care provider who is under contract with a DHIH. If the patient prefers to use a non-contracted provider, they will have to bear the cost of the visit or hospitalization. At each point of the care pathway, except for medical emergencies, the patient must present his/her National Health Insurance Card in order to receive care free of charge.
Implementation of telemedicine was not a policy priority in Romania, although there were numerous small projects in place before the outbreak of the COVID-19 pandemic in early 2020. In the context of rising infection rates, specific legislation issued during the state of emergency allowed family physicians and specialists to offer remote telephone or online consultations and this possibility remained in place for chronic patients even after the state of emergency was ended. In 2020 the main health care law (Law no. 95/2006 on Health Care Reform) was modified to provide the legislative framework for further development and use of telemedicine.
In September 2022, the implementation methodology for telemedicine was approved by Government Decision. It includes the list of eligible specialties and services that can be provided by the means of telemedicine, as well as the required conditions (that is, technology, skills, data transmission, information safety, documentation archiving, etc.). Further development of telemedicine and e-Health will be supported by the EU, within Romania’s Recovery and Resilience Plan.
More information (in Romanian):
https://legislatie.just.ro/Public/DetaliiDocument/259367
https://gov.ro/ro/stiri/unda-verde-de-la-comisia-europeana-pentru-pnrr&page=1
A measure to facilitate patients’ access to medicines and medical products prescribed under the national curative health programmes was implemented by the National Health Insurance House (NHIH) through the Order no. 429 from 29 March 2021. The Order allows community pharmacies to disburse medicines and medical products to any patient enrolled in these programmes after presenting a prescription. Previously, pharmacies would not get reimbursed if the prescribing physician was not in a contractual relationship with the same District Health Insurance House (DHIH) as the pharmacy, which obstructed access to treatment. For example, a patient who chose to see a physician outside of his or her hometown, would then also need to also visit a pharmacy in the same location.
More information (in Romanian): https://legislatie.just.ro/Public/DetaliiDocumentAfis/240204
Emergency Ordinance 57/2018 has been issued in June, to ensure continuity care centres remain open, as 97% of the 2018 approved funds for this purpose have been already spent.
Continuity care centres ensure permanent (24 hours) provision of care. They result from the agreement among a group of family physicians to perform on-duty calls for their patients. At these centres, family doctors perform emergency tasks (e.g. first aid, referrals to laboratory or to secondary care level) and patients attend them when their family physician is off service and they are unable to wait another day.
By this legislation, the government supplemented the Ministry of Health budget with 25.1 million lei (about 5.4 million euros), which will be transferred to the National Health Insurance Fund. Family physicians will be paid additionally according to on-duty call hours (on top of the services offered in their own primary health care premises) by separate contracts with District Health Insurance Houses (DHIHs).
Currently, there are 352 continuity care centres in contract with DHIHs, and other 27 have expressed their interest.
Context
Until recently, very expensive drugs covered by statutory health insurance (SHI) were disbursed only based on an authorization issued by disease-specific commissions at the level of the National (NHIH) or District Health Insurance House (DHIH). The authorization process was very complex and patients claimed reduced access to medicines mainly due to: the many trips required to obtain all the requested documents by the patient (i.e. once to the specialist, twice to the NHIH/DHIH, then to the pharmacy); and long waiting times for obtaining the authorization, especially if the paperwork was complex (many files involved) and if the specific commission could not gather more than once per month, delaying the process.
Over the years, there has been constant public pressure on the central authorities to modify the procedure of disbursing these drugs, culminating with an NGO (Give the Gift of Life Association) suing the National Health Insurance House (NHIH) in September 2016 for putting in danger the life of cancer patients (Medica, 2016).
Impetus for the reform
The new government in power in Romania since December 2016 has included better access to expensive medicines among the main objectives of its Government Programme (Government of Romania, 2017a). Immediate action has been taken by passing the Government Decision 18/2017 that changes the process of disbursing expensive drugs, starting in March 2017 (Government of Romania, 2017b).
Content of the reform
According to the Government Decision 18/2017, the new process eliminates the stage of seeking authorization from the disease-specific commissions, and hence, drugs are released by pharmacies to the patient only based on the prescription from the specialist physician. When prescribing drugs, the specialists are expected to follow the clinical protocols and to fill an electronic file in the health insurance electronic system.
This simplification of the process will improve the access to pharmaceuticals corresponding to 106 INN (International Nonproprietary Names). Previously, disease-specific commissions at NHIH authorized the release of pharmaceuticals for 70 INNs used for the treatment of cancers, rare diseases (such as hemophilia, multiple sclerosis, tuberous sclerosis, etc), rheumatic diseases, hepatitis B and C, infertility and obesity. Disease-specific commissions at DHIHs authorized the release of pharmaceuticals for 36 INNs used for the treatment of cardiovascular diseases, substitutive treatment of cancers, treatment of Parkinson, ADHD, diabetes, growth disorder in children, epilepsy (Ministry of Health, 2017).
It is not clear how the implementation of this policy will be evaluated, but the expected outcomes are an increase both in patients’ satisfaction and access to medicines. However, patients’ representatives are closely monitoring the implementation of this policy.
The Alliance of Chronic Patients in Romania organized a public debate in June 2017 on the early effects of the prescription process of new medicines. It was concluded from the debate that specialists are hesitating in freely prescribing the expensive medicines, being afraid of resulting accused of mistakes following the protocols. Further, the public debate organized by the Alliance identified that access to medicines is still impeded by the discontinuities in medicines procurement. The Alliance has proposed training for physicians on how to apply the protocols and local/hospital commissions that might guide the physicians and better regulation of medicines procurement (APCR, 2017).
References
APCR (2017). Implicații legale ale prescrierii de medicamente în România: de la răspunderea personală la impactul asupra pacienților! [Legal implications of medicine prescription in Romania: from personal accountability to the impact on patients!]. Bucharest, Alliance of Chronic Patients in Romania
Government of Romania [Guvernul României] (2017a). Program de guvernare 2017-2020. Politici în domeniul sănătatății [Programme for Government 2017-2020. Health policies]. Bucharest, Government of Romania
Government of Romania [Guvernul României] (2017b). Hotărârea nr. 18/2017 pentru modificarea și completarea Hotărârii Guvernului nr. 720/2008 pentru aprobarea Listei cuprinzând denumirile comune internaționale corespunzătoare medicamentelor de care beneficiază asigurații, cu sau fără contribuție personală, pe bază de prescripție medicală, în sistemul de asigurări sociale de sănătate, precum și denumirile comune internaționale corespunzătoare medicamentelor care se acordă în cadrul programelor naționale de sănătate, precum și pentru modificarea și completarea unor alte acte normative în domeniul sănătății. [Decision no. 18/2017 for amending and completing the Government Decision no. 720/2008 for the approval of the List of International Non-proprietary Denominations of Medicines to which insured persons benefit, with or without a personal contribution, on medical prescription, in the health insurance system, as well as the international Non-proprietary Denominations corresponding to the drugs granted under the national health programs as well as for the modification and completion of other normative acts in the field of health] (https://lege5.ro/Gratuit/ge2dgojvheya/hotararea-nr-18-2017-pentru-modificarea-si-completarea-hotararii-guvernului-nr-720-2008-pentru-aprobarea-listei-cuprinzand-denumirile-comune-internationale-corespunzatoare-medicamentelor-de-care-benef, accessed 15 June 2017)
Medica (2016). Vrem eliminarea aprobării dosarelor în comisii [We want to remove the approval of files by the commissions]. Medica, The journal of physicians from România. News 07.09.2016 (http://medicalnet.ro/vrem-eliminarea-aprobarii-dosarelor-in-comisii/9836/, accessed 26 May 2017)
Ministry of Health (2017) Nota de fundamentare a Hotărârii de Guvern pentru modificarea și completarea HG nr. 720/2008 pentru aprobarea Listei cuprinzând DCI corespunzătoare medicamentelor de care beneficiază asiguraţii, cu sau fără contribuţie personală, pe bază de prescripţie medicală, în sistemul de asigurări sociale de sănătate, precum şi DCI corespunzătoare medicamentelor care se acordă în cadrul programelor naţionale de sănătate, precum și pentru modificarea și completarea unor alte acte normative în domeniul sănătății [Substatiation of the Government Decision for the modification and addition of the GD no 720/2008 for the approval of the List of INN corresponding to the pharmaceuticals included on the positive lists fully or partially covered by health insurance]