European Observatory on Health Systems and Policies


Health Systems in Transition (HiT) profile of Bulgaria

3.4 Out of pocket payments

OOP payments amounted to €1770.82 million in 2015, accounting for 47.7% of total health expenditure, 3.9% of GDP and €583.50 purchasing power standard per capita (Eurostat, 2018). In 2015, only five EU Member States had higher OOP payments per capita (Cyprus ranks first with 698 purchasing power standard, followed by Austria, Norway, Belgium and Finland). What is more, OOP expenditure per capita in purchasing power standards increased 1.6 times in comparison with 2010 and more than three times compared with 2003 (Eurostat, 2018). Out of total OOP expenditure, pharmaceuticals account for approximately two thirds, followed by outpatient (curative and rehabilitative) care accounting for 15%, and inpatient care accounting for an additional 9% (Fig3.10).

3.4.1 Cost-sharing (user charges)

Cost-sharing was established by the 1998 Health Insurance Act in the form of co-payments (referred to as user fees) for visits to physicians, dentists, laboratories and hospitals for the use of services covered by the NHIF (see Table3.5). User fees apply to all patients with some exceptions: children, pregnant women and women up to 45 days after delivery, patients suffering from chronic diseases listed in the NFC, patients with malignant neoplasms, medical professionals, those with income below a certain threshold and some other groups. The reduced user fees for retired individuals of BGN 1 (€0.51) per outpatient visit, introduced in mid-2008 and abolished in 2011, were restored in 2013. The NHIF pays the difference between the reduced and full user fees for pensioners to the outpatient care providers. Funds for this payment come from the state budget and are transferred to the NHIF by the MoH.

User fees are paid by the patients directly to the provider at the point of delivery.

Until 2012, user fees were defined as a fixed percentage of the minimum monthly salary (MMS) depending on the type of health care service used (for example, 1% of MMS per outpatient visit and 2% of the MMS per day of hospitalization up to 10 bed-days per year). Hence, user fees have been rising with increases of the MMS. The MMS is the lowest salary that employers can pay by law. It rose from BGN 79 (€40.4) in 2000 to BGN 290 (€148.3) in 2012 and to BGN 510 (€260.7) in 2018. Since 2012, user fees were fixed through a Decree of the CoM at BGN 2.90 (€1.50) per outpatient visit and BGN 5.80 (€2.96) for each day of hospitalization for up to 10 days per year.

Patients have to make a co-payment for dental services included in the basic benefit package. The same applies to cost-sharing in pharmaceutical care. Some pharmaceuticals included in the positive list are fully paid by the NHIF but patients have to make a co-payment for others. Co-payments are specified in the NFC (see subsection 3.7.1 Paying for health services).

Despite concerns over their regressive nature, co-payments are seen as a means of restricting avoidable demand for health care and are an additional source of revenue for the providers, which can be used to maintain practices and procure medical equipment and consumables.

Another form of cost-sharing may exist in hospitals when patients pay for luxury hotel services such as a single room, television or choice of a physician/team. The extra billing is based on the hospital’s price list and can differ from one hospital to another. In 2010, it became evident that there are big variations in prices for choosing a physician in the hospital sector (according to some media between €25 and €5000). To remedy this situation, maximum billing levels for choosing a physician and/or team were introduced. As of 2011, hospitals can charge a patient who wishes to choose his/her physician up to BGN 700 (€357) and a patient who wishes to choose a team up to BGN 950 (€485).

In public hospitals patients can choose from the so-called “VIP” services (for example, a “VIP” room). In most private hospitals all patients pay additional fees for luxury conditions because the hospitals do not have “regular” rooms. Extra billing for luxury conditions and choice of physician are included in the total reimbursement level. These extra services are an integral part of the overall hospital stay of the patient and cannot be used separately and independently from the medical services.

VHI may cover statutory user charges, especially for hospital services, dental services, medical devices and drugs (see section 3.5 Voluntary health insurance). When a patient receives medical or dental care paid by an insurance company, the statutory user charges listed above are not applicable.

3.4.2 Direct payments

Direct payments occur in three cases. First, patients pay for services or goods that are not included in the NHIF basic package at prices set by the provider. This includes, for example, many of the dental services, long-term rehabilitation and nursing care as well as elective plastic surgery services, some laboratory tests, implants and other medical devices, glasses and various pharmaceuticals.

Second, there are direct payments for services or goods that are included in the NHIF basic package but patients prefer (or are forced) to receive them outside the standard patient pathway in the SHI system. For example, if patients go to a specialist for a regular check-up (a service that is included in the basic benefit package) without a GP’s referral, they are expected to pay for the service. The same is also true if they go directly to a laboratory, hospital or another GP who is not their regular GP. Patients have different motivations for such behaviour. They may want to access the services they need more rapidly or demand services on their own decision. But the most important reason is that people often face administrative and other obstacles to services they need while following the standard patient pathway (for example, the GP refuses or delays a referral to a specialist, laboratory or hospital because of exhaustion of the monthly limits set by the NHIF). A direct payment also occurs when a physician refers a patient for consultation or tests to a non-contracted health provider. Unless the patient has VHI that covers the service, the patient must pay for the treatment out of pocket.

Regional inequalities to access, which exist in Bulgaria (Rohova, 2015b), may also contribute to direct payments for services and goods included in the NHIF benefit package.

For some medicines, which are partially covered by the NHIF, reimbursement is lower than the user fee for a visit to a physician. In such cases, the user fee will be higher or equal to the part of the medicine covered by the NHIF. Thus, patients may prefer to buy the medicine directly at full price instead of visiting a physician for prescription.

Third, uninsured individuals also have to pay directly for medical services or goods, unless they call an ambulance or visit an emergency centre.

Health care providers, regardless of their ownership (public or private), have their own fee-for-service price lists and determine how patients are charged in the examples above.

3.4.3 Informal payments

Informal payments include all unofficial payments for goods and services that are supposed to be free and funded from pooled revenue as well as all official payments for which providers do not give a receipt.

According to the latest Eurobarometer on corruption published in October 2017, 8% of Bulgarian respondents who had contact with the public health care sector in the last 12 months reported informal payments (European Commission, 2017a). This is the sixth highest number (shared with Latvia) after Romania (19%), Hungary (17%), Greece (13%), Lithuania (12%) and Austria (9%).

Tracing results from national representative surveys on informal payments and corruption practices in health care over the years it seems that informal payments have decreased in general, despite the fact that different research tools have been used (Table3.6).

Patients usually pay informally to secure better conditions of treatment and service quality in hospitals. Another form of informal payment is when relatives of patients in need of blood transfusion pay individuals to donate blood.

From the beginning of 2018, the NHIF will pay the portion of the user fee that is due for pensioners to outpatient care physicians if a receipt is issued to the patient in addition to the other reporting documentation. This measure is expected to have an impact on reducing user fees for which providers do not give a receipt (considered also as informal payments) but limited to only some patients.