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Primary Health Care in Romania
Authors: Zs. Farkas-Pall1 MD, V. Pop1 MD
(1) University of Oradea, Faculty of Medicine and Pharmacy
Primary health care in Romania is based on the network of GP practices, working closely with local departments of the Ministry of Health and Health Insurance House.
The primary care team is commonly formed by the family physician and practice nurse. The number of nurses employed by the practice depends from the list size, if the practice list is around 1800 or more a second nurse can be employed full time or part time. Primary care practices do not usually employ social workers or other health care professionals, however they can collaborate with social workers employed by the local authorities
Health care in Romania is dominated by a public system which is financed mainly through mandatory social health insurance contributions. Employees contribute 5.5% of their monthly wage and employers add an extra 5.2% for each employee. Children- under age 18, students, the unemployed and low income persons are exempted from health insurance contribution .Adults are considered uninsured if they do not contribute to the health care fund, meaning they can only benefit free of charge from a basic health package which covers emergency care, pregnancy care, communicable disease diagnosis, prevention and treatment. The National Health Insurance House administers health care funds.
A private health care system where patients pay for health services, based on their own requests and preferred choices also exists
Public health services are free of charge for those insured, but limited funding will result in a paradox situation where people often have to pay for the theoretically free service, like lab tests, X-rays or scans.
General practice in Romania was recognized as a clinical specialty in 1991, with a 3 year vocational training postgraduate program. In 1999, general practice was transformed in family medicine, family doctors became independent professionals, self-employed and were no longer Government employees. Since 1999, GPs work under contract with the National Health Insurance House, owning their practice.
Romanian GPs have a gatekeeper role for the public system but not for the private system. This means that those benefiting from free services can't access any other service unless they are seen first by their GP. Patients who choose the private system can access any service through direct payment. Subsidized prescriptions are available only in the public system and there is a co-payment of 10-50%.
Most patients in Romania are registered with a GP of their choice, without limitations regarding the area in which they live. Patients can change the GP after a 6 month minimum period.
There are approximately 11400 GPs in Romania, of which less than 10% did not follow a specialist training in family medicine. The average patient list size is 1600, with some GPs caring for just 1000 patients (minimum accepted limit for a contract with the health insurance house being 800 in urban areas with no limit for rural practices) Most GPs work in single-handed practices.
The number of GP consultations per year is approx. 50 million and an added 2.5 million home visits. Same day appointments are usually available. In the last two years regulations have become more strict and patients are required to make appointments,. The referral rate to secondary and tertiary care is approximately 15%. GPs use computers in their daily activities for record keeping , prescribing and reporting to the health insurance house and public health authority. Since January 2013 a national e-prescription system is compulsory for all health care providers in contract with the state health insurance, after GP practices already running a pilot from August 2012.
Regarding payment, since 2010 a change in the per capita / pay-for-service system was made, and GPs now receive 50% of the income from pay-for-service and 50% from capitation fee. Pay-for-service is limited by the government imposing a 15' consultation time, meaning a GP working for 5 hours doing office consultations and 2 hours doing home visits will only be paid for a maximum of 20 consultations/day and 2 home visits/day. GP practices are closed during weekends or after normal working hours. Out-of-hours care can be organized in GP-lead centers, more of them being established in rural areas. This is depending for a large part on the initiatives of local authorities and their attitudes towards opening such a centre as they will have to cover the maintenance costs.
GPs have a series of restrictions in their capacity of prescribing, indicating further test and referring patients. These limitations make the work of GP’s difficult and they are a burden for the health expenditures.
Some examples: GPs need a recommendation letter from the specialist for prescribing certain medication in the state health insurance system for conditions like diabetes, COPD, asthma, mental health problems, pain management, and osteoporosis.
There is a minimal package of tests free of charge GPs can request for their patients but often laboratories or radiology clinics do not have funding for the tests requested in the ambulatory care, resulting in patients admitted as day patient or longer to hospitals in order to have their tests done, multiplying the costs of their care provision in an already insufficient budget.
After implementing the e-prescription project, two other projects are in the pipeline targeting primary health care in Romania: the patient’s electronic health record, to improve interdisciplinary management and electronic health insurance card, to be launched in 2014.