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18 July 2023 | Policy Analysis
Enhancing the role of the family doctor -
08 December 2022 | Country Update
Approval of the National Strategy for surveillance, control and prevention of HIV/AIDS cases in Romania for the period 2022–2030 -
30 September 2022 | Country Update
The National Strategy for Tuberculosis Control in Romania for 2022–2030 -
31 May 2021 | Policy Analysis
Extension of primary care services to reduce the pressure on hospitals -
15 April 2020 | Country Update
A new model of care for TB patients -
18 December 2016 | Policy Analysis
Regionalization of health care and hospital network rationalization in Romania
5.4. Specialized ambulatory care / inpatient care
Specialized ambulatory care
Specialized ambulatory care is provided through a network of hospital outpatient departments, polyclinics, specialized medical centres, centres for diagnosis and treatment, and specialist physician offices that sign contracts with the DHIHs. The majority of hospital outpatient departments are public (86%) (372 are public compared to 61 that have private majority ownership), while other types of specialist ambulatory care providers are mainly private (288; 97%) private polyclinics versus 10 public; 214 (86%) private specialized medical centres versus 35 public; 28 (80%) private centres for diagnosis and treatment versus 7 public; 9222 (91%) private specialist physician offices versus 938 public (2013 data; National Institute of Statistics, 2015a). Specialized physicians who work in ambulatory care generally divide their time between the public and private sectors, with many employed in hospitals and working after hours in private settings, with or without a contract with the DHIH. For doctors working in public hospitals, private sector work is only permitted for out-of-hours services.
Insured patients have access to specialized ambulatory health care services included in the basic benefits package. Patients usually require a referral from their family medicine physician in order to access specialized ambulatory medical care, but there are exceptions for 58 conditions and patient groups (see section 5.2).
Inpatient care
Inpatient care is provided by a large hospital network. Hospitals are categorized in accordance with the catchment area and the services provided (Ministry of Health, 2015a).[6]
- Regional hospitals (or district clinical hospitals) (13 in 2015) have the competences and resources to treat complex cases that cannot be treated at the local or district hospitals, including in neighbouring districts
- District hospitals (41 in 2015, one in each district’s capital) have a complex organizational structure, including an emergency unit; they provide services for the entire district and treat cases that cannot be treated at the local level.
- Local hospitals (59 municipal hospitals, 62 town hospitals and 1 rural hospital in 2015) are general hospitals that provide services of moderate complexity for their catchment population.
- Emergency hospitals (77 in 2015) are district, general local or specialty hospitals that have a complex organizational structure, are well equipped (they may have a mobile emergency unit) and are geographically accessible.
- Specialty hospitals (115 in 2015) provide services in a certain specialty, such as paediatrics, psychiatry, TB and other infectious disease.
- Long-term hospitals for chronic diseases (10 in 2015) provide long-term (several months) services for patients with chronic diseases.
- Clinical hospitals (76 in 2015) perform teaching activities under contracts with universities.
- Institutes and clinical medical centres provide teaching and technical coordination of activities in a specific domain, such as the Mental Health Institute, which coordinates the activity of mental health hospitals, or have a methodological role for the entire medical specialty.
- Health centres are health care institutions that provide inpatient and ambulatory specialty care in at least two specialties for a larger catchment area (including several villages).
Hospitals are also classified according to their competence. There are five competence levels, ranging from I to V, with category I hospitals providing health care services of the highest complexity. These hospitals have the highest level of capacity regarding medical equipment and specialized medical staff. Category I hospitals usually provide services in several medicosurgical specialties, although some (subcategory I M) have high competence in only one field of activity (such a subcategory also exists for category II hospitals). Category V hospitals are hospitals with the lowest level of competence. They provide health care services for chronic patients; health care services in one specialty, such as TB, infectious diseases, psychiatry, recovery and others; or palliative services.
As regards ownership, hospitals can be divided into public hospitals, private hospitals and mixed-ownership hospitals. Private hospitals can be run by NGOs or commercial societies. They can also operate private wards within public hospitals, although this is rare. There has been a substantial increase in the number of private hospitals since the late 2000s, from 30 in 2008 to 161 in 2014 (see section 4.1.1). The majority of public hospitals (80%) are under the administration of local councils (Ministry of Health, 2015a). Other hospitals are administered by the Ministry of Health (13%) or other ministries (Ministry of Transport, Ministry of National Defence, Ministry of Internal Affairs) or governmental institutions (Penitentiary Administration, Romanian Information Service, Ministry of Justice, Romanian Academy) (7%). Public hospitals are established or closed by governmental decision, initiated by the relevant administrative authority.
Public hospitals can be managed by a legal or a natural person on the basis of a management contract. The hospital manager is selected by contest or public bidding, and he or she should have a medical, economic or legal background and specific training in health care services management. The executive management is ensured by a managerial board that includes: the hospital manager, the medical director (i.e. a medical doctor), the financial director and, if the hospital has more than 400 beds, a care manager (i.e. a nurse). The medical director leads the medical council formed by the heads of hospital departments or wards, the head of the laboratory, the chief pharmacist and the chief nurse. The strategic management of public hospitals is ensured by an administration council, comprising five to eight members, including representatives of the Ministry of Health or DPHAs, representatives of the district or local council, a representative of the Mayor, representatives of the professional associations and a representative of the university for teaching hospitals.
Hospitals may also provide ambulatory specialty services (see above), day care and day surgery (see section 5.4.1), home care, laboratory and other diagnostic services.
Relationship between primary, secondary and other types of care
A major characteristic of the current health system is the lack of integration between the different sectors, namely public health, primary care, hospital care and other types of care, and the underdevelopment of care continuity.
After almost 25 years of health care reforms (see Vlădescu et al., 2008b), health care services provision in Romania remains characterized by overreliance on highly specialized inpatient care and underuse of primary and community care. Patients tend to bypass primary care services and directly consult specialists in hospital or call an ambulance, even for minor health problems (see sections 5.2 and 5.5). In 2014, over 43% of hospital admissions followed a visit to the emergency department, while only about 29% of the admitted patients were referred by the family medicine physician (NSPH-MPD, 2015). The model of care in place builds on separate specialized services and there is a shortage of interdisciplinary teams to ensure a more integrated approach to health care (Vlădescu et al., 2008b). There are currently no incentives to encourage a more integrated approach to service delivery. There are plans set out in the National Health Strategy 2014–2020 to change this by increasing the volume of services provided within primary and community care settings and to rationalize the use of hospital services (Fig5.2) (see also section 7.1). The Strategy explicitly refers to “the development of integrated district/regional health plans” but it does not provide further details on what these plans should consist of (Ministry of Health, 2014).
Fig5.2
- 6. According to Law 95/2006, the term ‘hospitals’ also includes medical units with beds, i.e. institutes and medical centres, sanatoria, preventoria, health centres and medicosocial care units. These medical units with beds do not appear as hospitals in the Ministry of Health’s statistics but they are paid in the same way as hospitals. ↰
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).
References
National Institute of Statistics (2022), Sistemul Conturilor de Sănătate în România 2020 [National Health Accounts 2020] https://insse.ro/cms/ro/content/sistemul-conturilor-de-s%C4%83n%C4%83tate-anul-2020
National Institute of Statistics (2020), Sistemul Conturilor de Sănătate în România 2018 [National Health Accounts 2018] https://insse.ro/cms/ro/content/sistemul-conturilor-de-s%C4%83n%C4%83tate-%C3%AEn-rom%C3%A2nia-0
Ministry of Health (2023) Strategia Națională de Sănătate 2023-2030 “Pentru Sănătate, Împreună“ [National Health Strategy 2023-2030. “Together for Health”] https://ms.ro/ro/transparenta-decizionala/acte-normative-in-transparenta/hot%C4%83r%C3%A2re-a-guvernului-privind-aprobarea-strategiei-na%C8%9Bionale-de-s%C4%83n%C4%83tate-2023-2030-%C8%99i-a-planului-de-ac%C8%9Biuni-pentru-perioada-2023-2030-%C3%AEn-vederea-implement%C4%83rii-strategiei-na%C8%9Bionale-de-s%C4%83n%C4%83tate
Eurostat (2023), Treatable and preventable mortality of residents by cause and sex, Population and social conditions>Health>Causes of death>Public health themes, https://ec.europa.eu/eurostat/databrowser/view/hlth_cd_apr/default/table?lang=en
Government of Romania (2023) Hotărâre nr. 521 din 26 mai 2023 pentru aprobarea pachetelor de servicii și a Contractului-cadru care reglementează condițiile acordării asistenței medicale, a medicamentelor și a dispozitivelor medicale, în cadrul sistemului de asigurări sociale de sănătate [Government Decision no. 521/2023 on the approval of benefit packages and the Framework Contract that regulates the provision of health care within the social health insurance system] https://legislatie.just.ro/Public/DetaliiDocumentAfis/270773
On 29 November 2022, the Government approved the National Strategy for surveillance, control and prevention of HIV/AIDS cases in Romania for the period 2022–2030. The document was a collaborative effort of the Ministry of Health, non-governmental organizations (NGOs), the National Committee of HIV/AIDS and TB coordination, and international experts.
The strategy was much welcomed given that reducing the rate of HIV infection is a public health priority. Over 1,000 new cases are diagnosed per year and there had been no new strategy after the previous one, in place between 2004 and 2007, ran to an end.
The main objectives of the strategy are to increase access the preventive services and diagnostic tests for the vulnerable groups, and to ensure universal, continuous, non-discriminatory and prompt access to treatment and a good quality of life for patients with HIV/AIDS, and to prevent secondary transmission of the disease.
The Strategy’s budget for the next three years is 1.2 billion RON (approx. 240 million euros).
More information (in Romanian):
https://gov.ro/ro/guvernul/sedinte-guvern/informatie-de-presa-privind-actele-normative-aprobate-in-cadrul-edintei-guvernului-romaniei-din-29-noiembrie-2022
On 7 September 2022, the Government approved the National Strategy for Tuberculosis Control for the period 2022–2030. The new Strategy follows the same main objectives of the previous strategy, in place during 2015–2020, namely, reducing tuberculosis (TB) prevalence and mortality and improving early detection and treatment of TB cases.
The new strategy envisages revisions and additions to the legislative framework, in order to implement a more patient-centred service delivery model, including adapting the financing model, increase the use of innovative diagnostic tests, vaccines and treatments, and introduce changes in the treatment protocols. All changes have been informed by the results of previous projects in the area of TB financed by the Global Fund, which also provided financial support for the new Strategy, and by continuous national research and innovation efforts. The Strategy development was further based on the WHO End TB Strategy and it benefited from the WHO technical expertise.
The long-term goal is to eradicate TB in Romania by 2035.
More information (in Romanian):
https://www.politicidesanatate.ro/strategia-nationala-tb-2022-2030-aprobata-schimbare-de-paradigma/Context
Despite the plans set out in the National Health Strategy 2014–2020 to reverse the balance of care by increasing the volume of services provided within primary and community care settings and to rationalize the use of hospital services (Vlădescu et al., 2016), the proportion of spending on hospital care has continued to increase. In 2019, this proportion reached 44%, which was the highest value among EU countries, for which the average was 29% (OECD/European Observatory on Health Systems and Policies, 2021).
The high use of hospital care is related to the narrow range of services provided by the family physicians. Family physicians act as gatekeepers to specialist care, but for less complex services they are often only able to issue a referral and are not permitted to provide the services themselves. Patients thus often bypass primary care and access hospital emergency departments, even for non-urgent medical problems. In contrast to hospital care, the share of health expenditure spent on primary and ambulatory care is the second lowest in the EU – 18.6% in 2019 (OECD/European Observatory on Health Systems and Policies, 2021).
Impetus for the reform
In line with the previous strategies, the new Programme for the Government for 2021–2024 includes a commitment to enhancing primary and ambulatory health care provision (Government of Romania, 2021). The implementing norms of the framework contract that defines the services to be provided by each level of care was thus modified in 2021, adding new services that family physicians are allowed to provide, and incentivising them to offer more preventive and home care services.
The implementing norms of the framework contract are approved by the President of the National Health Insurance House and the Ministry of Health, following a public consultation with all interested stakeholders.
Content of the reform
According to new regulations that will come into force on 1 July 2021, family physicians may provide and will be reimbursed for the following additional services for the patients on their lists, if they have the necessary training and devices: spirometry, electrocardiogram (ECG), 24-hour monitoring of heart activity, measurement of ankle-brachial pressure index (ABPI). Previously, these services could only be provided by specialists, even if they were necessary for the family physician to provide a diagnosis. By extending the list of services provided by the family physicians, their gatekeeping role will be strengthened.
The number of home visits for supervising chronic patients for which the family physicians will be reimbursed has been increased from one per quarter to one per month for each patient. Other incentives for increasing preventive services include a higher payment for follow-up of patients during the confinement period. These measures allow for a better supervision of the disease evolution and prevention of secondary complications that might force the patient to seek emergency health care and hospitalization.
References
Vlãdescu C, Scîntee SG, Olsavszky V, Hernández-Quevedo C, Sagan A. Romania: Health system review. Health Systems in Transition, 2016; 18(4):1–170 (accessed 31 May 2021).
OECD/European Observatory on Health Systems and Policies (2021), State of Health in the EU Romania Country Health Profile 2021 (accessed 31 May 2021).
Government of Romania (2021) Programme for Government 2021–2024 https://gov.ro/en/objectives/programme-for-government-2021-2024 (accessed 31 May 2021).
Official Gazette (2021) [Romanian Association of International Medicine Manufacturers]. Ordinul ministrului sănătății şi al preşedintelui CNAS nr. 1068/627/2021 privind aprobarea Normelor metodologice de aplicare în anul 2021 a Hotărârii Guvernului nr. 696/2021 pentru aprobarea pachetelor de servicii şi a Contractului-cadru care reglementează condiţiile acordării asistenţei medicale, a medicamentelor şi a dispozitivelor medicale, tehnologiilor şi dispozitivelor asistive în cadrul sistemului de asigurări sociale de sănătate pentru anii 2021–2022 [NHIH/Ministry of Health no. 1068/627/2021 Order on the approval of methodological norms for the implementation of the Government Decision no. 696/2021 on the approval of benefit packages and the Framework Contract that regulates the provision of health care within the social health insurance system for 2021–2022] https://arpim.ro/a-doua-editie-a-forumului-roman-de-diabet-unanimitate-in-decizia-de-implementare-imediata-a-legii-preventiei-diabetului-zaharat (accessed 31 May 2021).
In 2018, a project financed by the Global Fund was introduced to improve the efficiency of public health services provided for tuberculosis (TB) patients by shifting from predominantly inpatient provision to a model centred more on ambulatory and community care. Following up on this project, on 7 April 2020, the Ministry of Health approved the methodology for piloting this new model of ambulatory care for TB patients (Order no 590).
The methodology sets out the criteria for enrolling in the pilot for the patients; specifies which ambulatory facilities of the Institute of Pneumology Marius Nasta from Bucharest are included in the pilot and which services are to be provided to the patients.
The Ministry of Health has approved eight regional health services plans, aiming at: (a) reducing access inequalities yet streamlining inpatient care and shifting towards a more cost-effective outpatient care and (b) improving health infrastructure (Ministry of Health Ordinance 1376/2016). The establishment of regional health services plans is a conditionality imposed by the European Commission for the deployment of structural funds for the construction of three new regional hospitals, in the framework of the National Health Strategy 2014 – 2020, the main multiannual planning document for the health sector (Ministry of Health, 2014). Without the rationalization of the health service delivery, Romania is at risk of losing 150 million euros already approved by the European Commission through the Partnership Agreement signed with the Romanian Government (European Commission, 2014).
The development of health care infrastructure through EU structural funds, under the thematic objective “Promoting social inclusion, combatting poverty and any discrimination”, has two specific objectives: (1) improving quality and efficiency of the emergency hospital services, and (2) increasing access to health services, with a focus on community services and ambulatory specialty services, especially in poor and remote areas. Although the Romanian Government issued in 2014 the National Health Strategy 2014-2020 to facilitate the deployment of EU structural funds (Ministry of Health, 2014), the European Commission requested additional measures in order to approve and deploy the funds, in particular: (a) the definition of the regional plans for health services (b) the evaluation of the geographic accessibility of the health services and (c) a detailed monitoring and evaluation plan for the implementation of the 2014 -2020 National Health Strategy (AGERPRES, 2016). The turn-over of health ministers in 2015-2016 slowed down the process, but the short deadline for the fulfilment of the ex-ante conditionality (31 December 2016) obliged the Ministry of Health to take action and set up, through a ministerial ordinance, working groups from subordinated/coordinated technical institutes (i.e. the National School of Public Health and the National Institute for Public Health) to work on the previous the required measures.
Presently, the monitoring and evaluation detailed framework for the implementation of the 2014-2020 National Health Strategy has been elaborated; mechanisms for monitoring are in place and there is a wide mobilization of actions and institutions to monitor the implementation of the Strategy; the advantage of these is an increased commitment for the strategy implementation from all sides, policymakers and stakeholders.
The work on the regional health services plans was recently finalized; the structure of the health services plans was developed, based on an in-depth analysis of demographic and health status indicators, mapping present health care providers with a forecast of 2020 health care services. Eight regional healthcare plans (for the North-East Region, one of the poorest regions in Romania) were developed, approved through a Ministerial Ordinance and sent to the European Commission for feedback and approval.
It is expected for Romania to succeed in the coming years to rationalize inpatient care, through better planning and concentration of high-tech care, moving from inpatient care to more cost-effective outpatient care and ensuring equal access while using available EU funds for upgrading the health infrastructure.
Authors
References
AGERPRES (2016). European Commissioner Cretu urges completion of documents for three regional hospitals in Romania. Romanian National News Agency AGERPRES, 30 September 2016 (http://www.agerpres.ro/english/2016/09/30/european-commissioner-cretu-urges-completion-of-documents-for-three-regional-hospitals-in-romania-19-29-25, accessed 17 October 2016)
European Commission (2014). Summary of the Partnership Agreement for Romania, 2014-2020. Brussels, European Commission (http://ec.europa.eu/contracts_grants/pa/partnership-agreement-romania-summary_en.pdf; accessed 19 December 2016)
Ministry of Health (2014). Strategia Națională de Sănătate 2014–2020. Sănătate pentru prosperitate [National Health Strategy 2014–2020. Health for wealth]. Bucharest, Ministry of Health.
5.4.1. Day care
According to the Framework Contract, day care includes cases that require medical supervision for up to 12 hours, day surgery cases discharged on the same day and cases that need daily contact (for diagnosis, monitoring or treatment) of less than 12 hours per visit. According to the RO-DRG database, the most frequent health care services provided on a day care basis in Romania are: control of high blood pressure, radiotherapy for cancer, monitoring of HIV/AIDS patients, control of diabetes and endoscopy (NSPH-MPD, 2015).
Day care is provided in hospitals and health care centres under contract with the DHIHs, with approval from the Ministry of Health to provide such care within their structures. Day care services expanded considerably in 2014, following an amendment of legislation that allowed a wider range of services to be provided as day care (from 28 to 272 procedures) and a change in the payment for day surgery and day care (see section 3.7.1 on the change in payment mechanisms for day care). In 2014, day care cases accounted for 41.6% of all hospital cases compared to 36.5% in 2013 (NHIH, 2015c). Provision of day care remains underdeveloped compared to other countries and there remains scope for further increasing the provision of day care in Romania; for example, in 2014, only 13.8% cases of cataract were carried out as day surgery (NSPH-MPD, 2015), compared to 99.7% in Estonia, 41.2% in the Slovak Republic or 37.1% in Hungary (2012 data; OECD, 2014a).