WITH DEFICIENCES OF VIEW
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The Court of Accounts of the Republic of Moldova, on May 26, examined the Financial Audit Report of the Government Report on the Execution of Compulsory Health Insurance Funds (CHIF) in 2021.
The system of Medical Insurance Funds is managed by the National Medical Insurance Company (NMIC), which is the sole administrator of this significant value budget. Income and expenditure indicators in 2021 amounted to about 11 billion 500 million lei.
One aspect found refers to the process of contracting and reporting primary and specialized outpatient medical services, amounting to 2 billion 600 million lei, for which the medical institutions report the visits made. The reporting method is not correlated with the only persons served, although these types of services are contracted for the number of persons who are registered in the territory served. Thus, the contracting and the specificity of the reporting of primary and outpatient medical services do not ensure the evaluation of the volume of medical services provided for the contracted population. These circumstances indicate the need to take the necessary measures to ensure the functionality of the system, which would facilitate access to information on medical services provided to the only patients served.
Another aspect, mentioned by the auditors, refers to the investigations necessary to establish the diagnosis that were provided by the bilateral contracting for the provision of services. During this process, there are deficiencies at the stage of contracting and prescribing them, in the amount of about 200 thousand lei, being found the following situations:
- Some medical institutions contracted and paid for investigations in the amount of 120 thousand lei, which could be provided within the medical institution, because they had the appropriate medical equipment.
- Another situation concerns the prescribing for 77 people of high performance investigations based on the bilateral service contract. It was stated that these investigations prescribed by specialists, in the amount of 65 thousand lei, necessary to establish the diagnosis, are provided in Annex no. 5 of the Single Program. Thus, these medical services were to be provided by other institutions contracted and financed from the CHIF account, but were performed within the bilateral service contracts.
- With reference to the process of performing the diagnostic services, the audit team requested the NMIC, the evaluation of the medical records of the patient in the hospital, in view of the medical aspect and the need to prescribe high-performance investigations. It was established that 248 investigations were prescribed with arguments, and for another 53 investigations in the amount of 15 thousand lei, paid from CHIF, they were prescribed without arguments.
The analysis of how to contract and pay for 40 Community Mental Health Centers, as well as 41 Youth Friendly Health Centers, amounting to 73 million lei, established that they were financed differently from one Center to another, although some Centers have the same number of staff, they serve the same population and make the same number of visits. Under these conditions, the real cost of a visit was differentiated and varied significantly from 160 lei per visit, up to 1400 lei.
Another aspect addressed by the audit relates to the information reflected in the automated information system "Reimbursed Medicines", data that serve the NMIC as a basis for making payments. Thus, was analyzed the regularity of the prescription of the compensated medicines by the family doctors or the specialists, who in 2021 prescribed over 5 million prescriptions, in the amount of 640 million lei. The audit found data from the automated information system "Reimbursed Medicines" with erroneous records in 115 thousand prescriptions worth 15 million lei.
With reference to the expenditures from the Funds for pre-hospital emergency medical assistance, in the amount of 1 billion lei, it is indicated that during 2020 and 2021 these services were contracted and paid according to the “global budget” method. This principle is not based on exact funding criteria and result indicators. Thus, although the number of requests made and the number of people receiving emergency medical care evolve from one quarter to another, the funding was made regardless of the volume of services actually provided. The volume of financial means contracted and paid according to the “global budget” method in 2021, increased by 220 million lei, while the only provider of pre-hospital emergency services serves the same number of population.
The evaluation of the process of contracting and performing emergency hospital services, established that the National Center for Emergency Hospital Care contracted emergency hospital services (open tender), in the amount of 23 million lei, from two medical institutions. Thus, although the medical institution was contracted by the NMIC as the only provider of pre-hospital emergency medical care, the former purchased emergency pre-hospital medical services from two other private medical institutions. This situation was motivated by the insufficient capacity to provide services for the entire population of the Republic of Moldova.
Starting with 2022, pre-hospital emergency medical care has gone from the principle of financing “global budget” to contracting on the principle of “per capita” based on the number of population and the related tariff.
With reference to the realization of the medical services of 2 special programs: operating treatment for cataracts and prosthesis of large joints worth 218 million lei, it is noted that the process is performed by including patients in waiting lists, managed by the NMIC. Audit assessments on patient transparency and access to surgery have determined that insufficient action has been taken to update waiting lists, which undermines the assessment and reporting of data. Thus, the following were found:
- although, 10,000 surgeries were performed, the audit established that only 2,900 people (29%) of the total benefited from interventions according to the waiting list;
- for 22,000 patients who are on waiting lists, their 'active' or 'suspended' status was not indicated;
- the reason for the exclusion of 10100 patients was not indicated, including whether the patient had surgery or was excluded from the waiting list for various reasons.
So far, no urgent list of patients requiring surgery has been developed. Thus, the request to transfer 546 people from the general list to "urgent" does not provide ample information regarding the assessment of all people on the general waiting list, which require emergency medical interventions.
The audit noted that the number of people requiring costly interventions increased by 20,000 people, and at the end of the year there were 19095 people waiting in line.
Based on the above findings, the Court of Accounts notes that the Government’s Report on the Execution of Compulsory Health Insurance Funds provides, from all significant points of view, a real and accurate picture of their execution in 2021, being prepared according to the applicable reporting framework.
