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In order to restore their health insurance, citizens would have to pay the required past due contributions to the NHIF for the past five years, decided the members of the Parliamentary Health Committee during the second reading of the amendments to the Health Insurance Act.

The text proposed by the Government which provided that period to be 15 years back did not receive a single vote “pro”. The motive of the MPs was that the tax limitation could go back only five years.

The Committee also approved the proposal of the MP Dimitar Bayraktarov from the party Patriotic Front that there should be a grace period until the 31^st of December 2015, when citizens could pay the required past due contributions for the past three years. According to Bayraktarov, that type of preference would encourage citizens to pay their past due contributions by the end of the year. According to him, an information campaign on that issue would lead to increased collection.

The MPs from the opposition were against the idea insurance rights to be restored by making past due contributions for the last three or five years.  Dr. Emil Raynov said that the government was trying to transfer the health insurance burden onto the ordinary citizens. At the same time, the state remained an incorrect payer, paying only half of the contribution of the citizens it provided for. “You want to draw blood from a stone,” he said.

Dr. Ademov from the party Movement for Rights and Freedoms said that if the five-year proposal was accepted, it meant that some citizens would have to pay BGN 1,080 without interest. He noted that there were over one million Bulgarians who lived below BGN 340 per month and that they could not afford such a sum. According to him, these citizens would remain outside the health insurance system. Dr. Ademov also predicted that there would be an increase of the number of uninsured people and they would become more than the insured.

Bayraktarov replied to the opposition lawmakers that our health insurance system was solidarity and everyone had to pay. According to him, the change in the HIA allowed people to participate in the system. He said that in return for BGN 680 for three years, citizens would be able to use resources for over BGN 3 billion.

Dr. Krassimir Petrov from party GERB reminded that a huge percent of the uninsured citizens blocked hospital emergency rooms at that time. According to him, if lawmakers did not accept the proposal, it would discourage the accurate payers and many of them would stop paying insurance.

Assoc. Prof. Dimitar Shishkov of the party Reformist Bloc noted that a similar way to collect insurance taxes was applied in all Europe. According to him, there was no other way to make people obtain coverage.

Individual electronic health cards and electronic prescriptions would be a fact at the beginning of 2016 – assured the Minister of Health Dr. Peter Moskov. “Every insured Bulgarian citizen will have his or her individual package for outpatient care, matched to their age and condition,” he explained. Moscov emphasized that the country woul seek to ensure that “when a person goes to the hospital, a whole complex treatment routine will be created.” “Currently the Russe Hospital has a contract with two psychiatrists, whose consultations are paid. On the other hand, the mentally ill when they need other treatments are brought from the Psychiatry Dispensary to the General Hospital,” gave an example the Minister of Health.

“I want a patient to receive full treatment within a hospital,” he said. Regarding the dissatisfaction with the health system reform, he said that he understood that the reform had upset the comfort of certain communities. “The problem is that the healthcare system and the whole country as well are broken into small community comfort zones fragments. What happens to the patient should not occupy these comfort zones,” commented Moskov.

The current healthcare system financing methods in Bulgaria have put more people at risk of poverty, was noted in the World Bank report of May 12, 2015, which performed a systematic analysis of our country. It discussed the major problems of our healthcare and made a few recommendations.

According to the report, about 8% of GDP in 2012 in Bulgaria was spent on healthcare. In comparison with the countries of the region, the total healthcare cost in Bulgaria was above the average, and the public expenditure was around the average for the region. The problem was that the direct personal payments (DPP) represented 47% of the total costs. Statistics showed that in 2000 they were 20%. In regard to this indicator Bulgaria is currently far from meeting the criterion of the WHO for adequate financial protection, which sets a ceiling of 15-20% for DPP as total health expenditure share. Moreover, over 4% of the population in Bulgaria is impoverished every year because of the DPP. In 2013, 3/4 of the DPP was spent on medicines that are not well covered by the state health insurance system.

The World Bank experts also identified as a serious problem that the financial protection provided by the healthcare system was undermined because about 7-12% of the Bulgarians who did not live permanently abroad, were uninsured. The vast majority of them were inoperative vulnerable people with a low socio-economic status.

The healthcare system in Bulgaria was not effective because it was too oriented to expensive residential care, with non-optimal use of more economical preventive and primary care services, believed the experts. According to the report, the coverage of most preventive services in Bulgaria was much less than in other EU countries, except Romania. Bulgarians also had fewer contacts with doctors providing primary care services and specialist physicians, compared to citizens in the other EU countries. Meanwhile, the number of hospitalizations per capita had jumped by 65% ​​for the period 2000-2010, while hospitalizations in other countries had either remained at the same level or had decreased. In 2011 the level was so high that practically one in four Bulgarians had been hospitalized.

The report also mentioned that our hospital system was very fragmented. The hospital density was 4.6 hospitals per 100 000 people compared with an average of 2.7 for the EU. Many hospitals had very few patients, which was highly inefficient. The three busiest hospitals discharged more than 95 patients a day, but 103 establishments in the lower section of the list together accounted for only 5% of hospital stays. That meant that approximately one in three hospitals in Bulgaria discharged not more than five patients a day. That fragmentation lead to resource duplication among institutions and prevented the application of economies of the scale that were required in modern healthcare, indicated the document. According to the World Bank experts, that interfered with the proper orientation of the necessary investments.

One of the main recommendations of the World Bank was for Bulgaria to reorganize its hospital system. They advised the NHIF to purchase services selectively, i.e. it should be able to decide with which hospitals to enter into contracts. In order to support that process, information on the care services quality had to be generated, collected and published, and the hospital payment systems had to be reformed. There might be a need of reforming emergency care, in order to improve the consistent provision of care and the access to it, emphasized the report.

The report also recommended improving the efficiency of medicine purchases. The World Bank noted that the current medicines pricing methods and the selection of those to be reimbursed provided almost no guarantee for the balance “price-quality”. The policies at that time did not encourage generic medicines market competition, but a lot of the prices on both – patent and of non-proprietary medicines – were unfavorable in comparison with the countries with much higher paying capacity. “Some expensive medicines that contribute to the rapid growth of costs are not likely to be cost effective in Bulgaria and should be subject to price (re)negotiation, severe use restrictions, and in some cases – removal from the list. If Bulgaria is able to promote greater competition in the non-proprietary medicines market, together with measures to meet demands and reasonable prescription, this could improve medicine costs effectiveness significantly,” said the report.

The experts also recommended strengthening the stationary care alternatives. According to them, the specialists in primary care needed greater capacity to manage the prevailing set of diseases and to coordinate the care for their patients. “In particular, permanent medical education should be implemented effectively and attractively. Regulations and incentives should be adjusted so that the chronic disease management would be extended through primary care. Payment systems and accountability mechanisms would also need to be adapted for all provider types (primary, outpatient, emergency and residential care) to ensure the treatment of more patients on the proper level of care,” was also written in the report.

The members of the Parliamentary Health Committee approved the restoration of the arbitration committees. This happened during a meeting last Thursday, when the amendments to the Health Insurance Act were adopted at second reading. The final vote on the Act in the plenary chamber lies ahead.

The MPs debated whether Regional Health Inspection representatives should be included in arbitration committees. Most of them advocated the idea that this would affect the balance in decision making. According to them, the number of the Regional Health Insurance Fund representatives has to be equal to that of the professional organizations representatives. The heads of the Bulgarian Medical Association, the Bulgarian Dental Association, the Bulgarian Organization of Healthcare Professionals, and the Bulgarian Pharmaceutical Union, who had attended the meeting, supported the view that there should be parity. In the end, the lawmakers decided to eliminate that part of the bill which guaranteed committees to include Regional Health Inspection representatives.

The Ministry of Health even suggested the number of Regional Health Inspections position openings to be reduced from 2877 to 2502 position openings. The draft amendments to the Rules of the Regional Health Inspections Department have been published on the website of the Ministry of Health for public comment.

After motivated proposals made by the Directors of the Regional Health Inspections, it was determined that state inspections should reduce the total amount of position openings by 375 position openings, and the rest are to be distributed between the inspections.

The MPs rejected a proposal to amend the Health Insurance Act, which regulated the amount of fines imposed by the NHIF for various violations. They accepted the viewpoint of the Ministry of Health and the professional organizations that the Health Insurance Act did not need such a text. The President of the Dental Association Dr. Borislav Milanov noted that since the National Framework Contract negotiated prices and volumes, it was appropriate it would also determine the fines. Deputy Minister of Health Dr. Boyko Penkov had similar views that sanctions should be regulated in the National Framework Contract. In the long run, the MPs voted that the fines are to be negotiated among the NHIF, the Bulgarian Medical Association and the Bulgarian Dental Association in the Framework Contract.

Meanwhile, the MPs did not accept the proposal of Dr. Emil Raynov from the Bulgarian Socialist Party to transfer to the NHIF budget a sum of BGN 1.4 billion. He motivated his idea by reminding that the amount taken from the reserve of the NHIV by the preceding government of the party GERB had to be recovered. The proposal was supported only by the opposition lawmakers.

Nebivolol is a third generation beta-adrenergic receptor blocker with vasodilating properties. It has the highest affinity for beta-1 receptors when compared to other beta-blockers (BB). Due to the leverage effect on endothelial nitric oxide synthase (eNOS) and its antioxidant activity, nebivolol significantly improves the endothelial function.

Endothelial function and dysfunction

Endothelium modulates the function of blood vessels and provides structural integrity. Endothelial cells synthesize nitric oxide (NO), which has powerful anti sclerosis activity and, along with prostacyclin, inhibits platelet aggregation, the neutrophil adhesion to endothelial cells, and the expression of inflammatory molecules. At a higher concentration NO inhibits smooth muscle cell proliferation.

The endothelial dysfunction treatment should aim not only to increase the NO level, but also to reduce the free radicals which neutralize it – superoxide and peroxynitrite.
It has been established that medicaments which are limited to the delivery of NO – like organic nitrates – due to the stimulation of the production of peroxynitrite worsen rather than improve the endothelial function.

The ideal drug for endothelial dysfunction treatment should stimulate the NO synthesis and simultaneously reduce the oxidative stress in the vessel wall.

Nebivolol is a third generation BB with vasodilating properties, thanks to its direct stimulating effect on eNOS. The mechanisms of action include a negative chronotropic effect, the inhibition of sympathetic stimuli from the brain vasomotor centers, the inhibition of peripheral alpha-1 adrenoceptors, the inhibition of renin activity and a decrease in peripheral vascular resistance.

The  high selectivity for β1- versus β2-adrenergic receptors explains the limited effects of nebivolol on airway reactivity and insulin sensitivity, as well as the lesser negative inotropic action of the drug in patients with heart failure (HF).

As in other BB, nebivolol has important electrophysiological properties, such as increasing the threshold of ventricular fibrillation, and reducing the dispersion of the QT interval and P wave, which is associated with risk reduction for ventricular arrhythmia and atrial fibrillation.

The indications for the application of nebivolol include arterial hypertension (AH), chronic heart failure (HF) and ischemic heart disease (IHD).

Arterial Hypertension
The efficacy and safety of nebivolol in doses of 5 and 10 mg in patients with hypertension grades I and ΙΙ have been demonstrated in numerous clinical studies. The response of systolic blood pressure (BP) to nebivolol is similar to the use of other BB and calcium channel blockers (CCBs), and is more pronounced than that of angiotensin-converting enzyme inhibitors.
The effect of the drug on diastolic blood pressure is not so pronounced, contributing to the safety of nebivolol.

Heart Failure

Large randomized trials and meta-analyzes have demonstrated that BB reduce morbidity and mortality in patients with chronic heart failure by about 30%. This effect is due to the decrease of adrenergic stimulation, modulating the balance between sympathetic and parasympathetic activity, influencing the heart rate and variability, and improving the myocardial function.

It is important to note that while other BB act mainly by decreasing the stroke volume, nebivolol and carvedilol cause peripheral vasodilatation, maintain the stroke volume, the cardiac output, and the chronotropic response during exercise.

Moreover, compared with bisoprolol, nebivolol and carvedilol do not lead to an increase of the pulmonary capillary wedge pressure (but rather improve it).
The average age of the patients included in trials with the use of BB in heart failure was 60 years. In this respect, SENIORS was an exception, as it included patients over the age of 70. It established a 14% reduction in all-cause mortality and improvement of the cardiac dimensions and function when nebivolol was used, as compared to placebo.

Ischemic heart disease

There is evidence that in comparison with atenolol, nebivolol more effectively improves exercise tolerance and time to onset of chest pain during ECG stress tests.
Moreover, nebivolol and carvedilol increase the coronary flow reserve in patients with Ischemic heart disease and non-ischemic cardiomyopathy more effectively compared to other BB, which is probably associated with an increased ischemic threshold.
Nebivolol is contraindicated in patients with severe bradycardia, atrioventricular block above the second degree, cardiogenic shock, decompensated heart failure and severe liver diseases failure.

Tolerability and safety profile

In patients with bronchial asthma and chronic obstructive pulmonary disease, the higher selectivity of nebivolol to beta-1 receptors compared to other BB results in better tolerance.
For the same reason nebivolol has no adverse effects on the libido and the sexual function. On the contrary, there is evidence that the drug improved erectile dysfunction, which could significantly increase the compliance of patients. Due to its vasodilatory effect (and unlike older beta-1 selective BB), nebivolol does not lead to the deterioration of insulin sensitivity and an increased risk of type 2 diabetes (neutral metabolic profile). It has no adverse effects on lipid parameters.