The NHIF has offered the BMA to begin negotiations to reduce clinical pathway prices. The BMA immediately replied that they disagreed, and instead wanted an update of the NHIF budget by BGN 150 million.

Obviously, the NHIF is facing increasing pressure to pay more than they have. The problem has become more severe over time and a budget revision will be inevitable. The proposed mechanical reduction of pathway prices by a certain percentage is not a good solution.

Instead of figuring out on the calculators how many BGN they can save from each pathway, the NHIF and the BMA can achieve much more in their negotiations. Here are some ideas:

It has long been time for a significant part of the clinical pathways to be transferred to outpatient care. For example, all pathways providing same day surgery, diagnostic and therapeutic pathways that do not necessarily require hospitalization, skin disease pathways ENT, eye care, etc. The National Framework Agreement has now provided 5 pathways for outpatient care, and the analysis shows that their number could increase to 100. If they are implemented in outpatient care, their prices can be reduced and this would not be unfair as the costs would be less.

Another thing the BMA and the NHIF could agree upon is the introduction of price indices in pathways. It makes a difference whether a 25-year-old in his/her prime is treated or an 80 years old patient. It is logical that the costs of treating an elderly person would be higher; therefore, introducing an age factor patient index would be fair. The same applies to the presence or absence of chronic concomitant diseases. Obviously, for the sick person who has received abdominal surgery and has concomitant diabetes there would be more expenses than if there were no diabetes. Therefore, it is only fair to introduce indices in terms of the presence or absence of serious chronic diseases.

The third thing the NHIF and the BMA could negotiate is to allow outsourcing for the clinical pathway activities – their execution by external contractors. These may include laboratory and imaging tests, pathology, etc. This would allow hospitals to avoid unnecessary costs for personnel and equipment, and hence would reduce the pressure for hospital admissions at any cost.

The next thing the NHIF could accomplish even on its own is to review its reimbursement list. Minimum reimbursement for home treatment medicines is proportional to maximum hospitalization. The NHIF should increase the reimbursement of these medicines, particularly antibiotics, and this way it would reduce the “interest” of patients in being hospitalized. The same applies to some difficult tests as CAT, EMG, MRI, EEG, etc. Facilitating the access to them would be cheaper than paying for the same via clinical pathways.

Finally, clinical pathway prices are certainly not inviolable. We do not need a very thorough analysis to see that there are both under evaluated (in most cases) and overpriced pathways. Therefore, individual pathway price negotiations should not be excluded a priori.

Reaching an agreement on these issues is fully achievable trough negotiations, and there is hardly a better time than the present.
This means that the NHIF and the BMA should start negotiations for a National Framework Agreement Annex, as opposed to negotiations under Article 12 of the contract. Such negotiations did not have to not be postponed till the 1^st of June. They could have begun immediately.