Unit 11 - Contemporary Medicine: The Healthcare System through Socio-Political Lenses
UNIVERSITY GRIGORI T. POPA OF MEDICINE AND PHARMACY (RO)
Case Scenario 1: Increasing the efficiency of National Health Insurance House
(Adapted from an interview with dr. Vasile Ciurchea, President of the National Health Insurance House)
How do you manage internal slippages to prevent fraud and corruption?
When we detect an irregularity, we investigate it at the National Health Insurance House (NHIH) within the limits of the legislation. We offer our support of the investigative bodies whenever requested and we provide the necessary information and documents to them. Following the control actions carried out in May 2008 in 77 hospitals, sanctions amounting to approximately 7 million lei were imposed for the irregularities found. I welcome the Minister of Health's initiative to redirect sanctions from next year to the management team. We intend to increase the role of the hospital managers in order to make them accountable for both good and bad things.
2009 and 2014: two years in which NHIH management changed. What will you take along from what the previous president of the House started?
We cannot progress if we break away from the previous changes and we keep doing things anew all over again at each change of the decision makers. Upon taking office, we found in the institution the same team with which we worked in the previous term. The younger ones did understand that they had to become responsible for their actions in the system and coordinate with other offices for the achievement of bigger plans. As a director I think it is very important to be responsible for every man in the structure I coordinate. The healthcare system must work in its wholeness and not fragmented.
Often a leeway is invoked in the functioning of the system operated by NHIH. There are inherent dysfunctions. Do you think that the way your organisation communicates with the press or third parties needs to be reviewed?
We are trying to simplify and make the existing bureaucracy less aggressive. NHIH is a quite technical institution, which is why policy makers and healthcare providers have various dissatisfactions about how we communicate. There are also few civil servants in the NHIH to answer all requests. We analyse all the complaints and suggestions expressed by those involved in the system, listen to the opinion of patients, doctors, hospital managers and healthcare providers, and correct what is necessary within the Framework Contracts to ensure a legal ground enabling the system to function as efficiently as possible.
What can NHIH do for chronic patients?
This is about the chances that the Romanian medical system offers to patients to receive medication and treatment comparable to those in the advanced European countries. I think they are not only about financing, but also about the doctor-patient relationship and the confidence in the prescribed treatment; even if the latter does not pertain to the latest generation, it may have similar positive effects. Population awareness and technology development led to the early diagnosis of many cancers. Faster diagnoses are not always in line with NHIH's financial resources, thus leading to longer waiting lists. The only good part of these lists is that they identify funding needs. For some oncological diseases, new sub-programs have been created, for which specific funds have been allocated, so that the services provided can be monitored more clearly. We did not approve the treatment for all the patients who filed the necessary documents with the insurance houses. For an approved dossier, funding must be provided until the end of the treatment. Monthly, the NHIH approves about 500 new cases of patients with oncological conditions requiring expensive molecules. These new dossiers are added to the follow-up treatment. Over the past 6 years, the total number of patients with oncological disease who have had access to treatment, standard therapy or expensive molecules has increased on average by 3000 patients per year, from 90 474 patients in 2008 to 108,000 patients in 2014. Hepatitis is another problem that concerns us. In 2014, the estimated value of treatments for hepatitis was 470 000 RON for approximately 40 000 patients as compared to the previous year, when about 32 000 patients were treated and 387 million RON were allocated.
The priority objectives that I have proposed are to increase efficiency in managing public health insurance funds, to reduce waste and misuse of public money in the healthcare system. NHIH needs to be very vigilant in pursuing the way public and private healthcare providers meet their obligations towards policyholders that should mainly observe their contractual obligations towards NHIC. Improving the health system in Romania must be an objective in which all actors in the system participate.
Case Scenario 2: Romanian Residency Programs: Challenges and Solutions
(Adapted from an interview with Prof. Dr. Corin Badiu, Chair of Endocrinology at the Carol Davila University of Medicine and Pharmacy, Bucharest)
What is the current status of training graduates of the medical schools in Romania?
It is a problem in almost all the entire post-graduate education system. In 2006, an assimilation order was issued, which recommended the disappearance of many specialties and the inclusion of some in larger specialties. Highly traditional specialties, such as oncology or paediatric neurology, were included in internal medicine and adult neurology, respectively. These distortions affected everybody and led to concordant rules, which didn't last long, from 2007 to 2009. Afterwards, another Minister of Health reduced the training time by one or two years, considering that resident doctors spent too much time in school and needed to become independent faster.
What was the impact of these measures on the quality of medical education?
Romania needs a strategy to establish the number of doctors needed for a certain specialty per number of country inhabitants and to manage the quality of these doctors. Lately post-graduate training has deteriorated significantly. Complementary internships and basic training were reduced and only specialized training was maintained. Maybe this decision was made knowing that the residents did not consider the complementary modules important. Training must be uniform. For example, in Germany, there are activities that the specialist doctor has to master. After choosing his/her specialty, it is not possible to start learning or doing experiments which might threaten the health of real patients. This is learned during residency! If they had not been involved in, say, operations during their training, they are not allowed to perform major surgeries in their hospitals later on. If a general surgeon has to perform, say, a Hartmann surgery for sigmoid cancer, after the time he has obtained his certificate, it is implied that the surgeon knows how to apply the procedure correctly. If a resident has never been the main surgeon in such an intervention, he cannot perform it properly.
Do you have a concrete example?
When I was at CNPDS, one day I was in the commission that grants the titles of specialist doctor in one of the surgery commissions. One candidate received a case of breast cancer. He presented the case and insisted on the psychological impact of the disease on the patient. The chairman of the examination committee asked: "How is it done? Being asked elementary things, the candidate gave an answer that shocked everyone: "I am sorry to admit but during 6 years of college and 6 years of residency in the specialty of general surgery, I have not seen any type of breast cancer!” The committee chose to grant him the title of specialist.
"In general surgery, most residents do not see many cases. They are not allowed to perform many clinical tasks. It doesn't necessarily mean that they do not work, but it is mostly paperwork, not clinical work that they carry out.”
What solutions do you have for serious training of residents?
Education with responsibility. It is wrong to consider that the resident has no responsibility. His responsibility is progressive, but also according to the cases he has seen and to which he participated in the therapeutic process. I proposed, not long ago, a form by which residents are asked to make their own list of cases they had seen. Unfortunately, this remained in theory because it was too complicated to be put in practice. In fact, it was a list, reflecting the level of involvement of the resident: from level 0 (he was an observer of a case), to level 5 (in which he had the ability to coordinate a beginner resident). Considering all the protocols, we observe the progression, from 0 to 5. If we look at the list and find that the resident, at the end of the training, did not see any breast cancer, it means that it was the fault of our system. It is not a rare disease; it is a common neoplastic disease. The coordinator must make sure that the resident, at the end of the training, has accumulated all that has been recommended. That is the final quality control. In the last exam sessions, we systematically refused to grant the title of specialist doctor in cases as the one presented above because there has to be a minimum standard that we must observe.