WITH DEFICIENCES OF VIEW
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The Court of Accounts of the Republic of Moldova, on the current date of May 29, examined the Financial Audit Report of the Government’s Report on the execution of the mandatory medical assistance insurance funds (MMAIF) in 2022.
Mandatory healthcare insurance funds are systemic, involve multiple institutions at different levels, and are managed by the National Medical Insurance Company (NMIC), which is the sole administrator of this significant budget on the expenditure side, and the State Fiscal Service (SFS) on the revenue side. At the same time, to achieve the audit objectives, samples were also collected from entities such as: the Ministry of Health, the Ministry of Finance, the State Fiscal Service, the National Bureau of Statistics, the Public Services Agency, the National Social Insurance House (NSIH), the Transplant Agency, public medical and sanitary institutions and other entities involved.
The quantitative significance of this budget indicates that the share of MMAIF expenses in the national public budget in 2022 was 12%, being executed on the revenue side in the amount of 12 billion 639 million lei and on expenses 11 billion 963 million lei.
MMAIF expenses, in 2022, did not reach the specified level, a situation determined by the decrease in the volume of medical services provided to the population by 819 million lei, at all levels of medical assistance. The lack of fulfillment of all medical insurance funds at the specified level determined the accumulation of financial means in the account, in the amount of 1 billion 351 million lei, which is 676 million lei more than on January 1, 2022 (01.01.2022).
In the opinion of the Court of Accounts, the Government’s Report on the execution of the MMAIF in 2022 provides, under all significant aspects, a correct and faithful picture, with the exception of the possible effects of some aspects exposed on the basis of the audit opinion, being issued a qualified opinion.
Concerning the expenses reported in the subprogram "Hospital medical care" in the amount of 3 billion 254 million lei, the audit was unable to evaluate them. This situation was caused by the fact that the hospital medical services reported by the medical institutions cannot be delimited in those paid by NMIC versus those performed by the medical institutions, but not paid by the Company. It was found that 52 medical institutions over-contracted in 16,364 treated cases, amounting to 152 million lei that were not paid. NMIC as well as the medical institutions do not have monitoring measures and exact delimitation of the amount of hospital services reported and paid.
Regarding the hospital medical services provided under the special program "Operative treatment for cataracts" it was found that they were contracted and paid with the application of lower rates than those approved by the Ministry of Health for the year 2022.
The application of their own tariffs for cataract medical services provided to citizens was carried out by 9 hospital medical institutions, which led to a decrease of 22 million lei in the volume of financial means for 6400 cataract medical services. The application of their own tariffs for cataract medical services provided to citizens was carried out by 9 hospital medical institutions, which led to a decrease of 22 million lei in the volume of financial means for 6400 cataract medical services.
With reference to the waiting lists for cataract surgery and prosthetics of the locomotor system, the number of people waiting for the intervention within these special programs is constantly increasing. In context, it was stated that in 2022, NMIC sent to medical institutions the list of 2776 people for locomotor prosthetics. However, only 1158 or 42% of the remitted persons benefited from medical services.
For cataract surgery, it is revealed that 2100 people or 46% of those included in the lists benefited from these medical services. The situation was motivated by the patients' refusal, going abroad, etc., but it was also determined by the reduced capacities of medical institutions in increasing access to treatment, as well as by the difficulties encountered by NMIC when updating the lists.
The processes for the provision of medical services in 2022 continued to attest to deficiencies, which are expressed through:
- non-regular preparation of the List of urgent patients requiring surgical interventions. Thus, 1515 people were urgently referred for surgical interventions, which does not provide ample information with reference to the evaluation of all people on the general waiting list, who require emergency medical interventions;
- in the case of 171 people from the waiting lists, it was indicated that they performed the intervention for money. The exposed situation reveals that the waiting time to benefit from surgical interventions is long, which led people to go to the medical institutions on their own and pay the cost of the services, which amounted to about 1 million lei;
- 730 people had surgery before being placed on the waiting list;
- 1269 people benefited from the intervention, although the audit did not have information regarding the fact that NMIC sent the list of these people to medical institutions for the intervention.
Regarding the medical prophylaxis services required to be provided within the dental medical assistance, it was found that the medical institutions in the audit area, which were contracted by NMIC they did not ensure the mandatory annual dental medical examinations of all children in kindergartens, general and professional secondary education institutions. The district and municipal dental centers were contracted in the amount of 28 million lei for the provision of dental medical assistance, which also covers the annual prophylactic examinations.
Primary and urgent pre-hospital medical services are contracted according to the "per capita" principle for the entire population of the Republic of Moldova. Thus, the financing of medical institutions that provided primary medical services in the amount of 2 billion 388 million lei and pre-hospital emergencies in the amount of 1 billion 045 million lei was carried out according to the "per capita" principle for the entire population of the country.
The allocation of financial means was made for about 3.4 million people based on the data from the Information System "Register of persons registered with the family doctor within the medical and sanitary institution that provides primary medical assistance".
According to the data presented by the National Bureau of Statistics on 01.01.2022, the number of the population with habitual residence in the Republic of Moldova was 2.6 million people, with 815 thousand people less compared to the number of people registered in the NMIC’s information system. Thus, the possible impact of financial means on contracting "per capita" of primary and urgent pre-hospital medical assistance in the amount of 797 million lei is denoted.
In 2022, public medical and sanitary institutions provided free medical services for refugees from Ukraine, a process provided by the Decisions of the Commission for Exceptional Situations of the Republic of Moldova. Thus, the health system provided medical services for foreign citizens refugees from Ukraine, in the amount of 55.5 million lei, at all levels of medical assistance. The expenses for the medical services were covered by four international organizations, through transfers with a special purpose in the medical insurance funds, which were performed throughout the conclusion of partnership agreements with NMIC.
Concerning the reimbursed medicines, the audit found deficiencies such as:
- Pharmaceutical service providers issued 361 prescriptions, drugs and medical devices in the amount of 94 thousand lei, applying fixed compensated amounts higher than those approved. Therefore, NMIC compensated and paid the providers of pharmaceutical institutions with 8 thousand lei more.
- Concerning the breast exoprostheses, it is noted that they were not included in the list of compensated medical devices needed for 850 people, although financial means in the amount of about 400 thousand lei were planned.
The Court of Accounts stated that NMIC is to strengthen internal controls, as well as undertake the necessary measures to ensure the use of MMAIF’s funds according to the needs of the insured persons.
