News and Media

There are no problems with the regulatory standards provided for the last quarter of the year. This was announced by the press center of the NHIF in connection with the emerging information that the refferals for specialists have been cut by 20% and those for testing – by 40%. According to the Fund, the difference between the estimated refferals for the last quarter of 2014 and for the fourth quarter of 2013 was 2%, as shown in the table:

Forth quarter of 2013 Forth quarter of 2014

Refferals for consultations with specialist (total) 1 616 359 1 583 098

In connection with acute cases 1 197 621 1 106 306

Dispensary monitoring 418 738 476 792

In 2014, in the National Framework Contract for Medical Activities (NFC for MA 2014) the Bulgarian Medical Association and the NHIF agreed upon a price increase of the examinations, which the institution pays to the specialists for the health insured patients. To comply with the parameters of the National Health Insurance Budget Act, the increase of the funds for examinations is at the expense of the volume of the regulatory standards. The decrease of the refferals for consultations with specialists compared to last year is due to the increased in the number of dispensarised persons with mandatory consultations assigned.

The NHIF informs that the general practitioners and specialists can use an additional 10% above the set quarterly regulatory standards. There is also the possibility of exceeding the regulatory standards by an additional 15% to be compensated in the next quarter, and the unused refferals of the preceding quarter can be absorbed in the current.

There is an option the unused refferals for dispensary monitoring to be transferred for acute cases. Also defined are the reserves in the NHIF and the RHIF, out of which additional resources for general practitioners and specialists should be allocated, if they have expressed such a need.

Assoc. Prof. Dr. Sotir Marchev, MD, was born in 1961 in Blagoevgrad. He graduated with a gold medal from English High School, and then, also with honors, the Medical University in Sofia. He has two specialities – internal medicine and cardiology. Specialized echocardiography and invasive cardiology and electrophysiology in Vienna, Osaka, Belgrade. He has Accreditation of Echocardiography of the European Society of Cardiology and is an honorary member. Associate Professor of Cardiology at the Medical University in Pleven.

– Assoc. Prog Marchev heart diseases are crucial for the individual, but sometimes also influence history. What is the Bulgarian example?
– Exactly 1000 years ago, on October 6, 1014 Tsar Samuil, seeing his blinded army, died suddenly. After his death, the First Bulgarian Kingdom fell quickly under Byzantine rule. And you can say that this changed the course of history.

– What are people dying from under sudden stress?
– This is a very exploited topic in television series and is a frequent source of fear in everyday life. Recently I saw my patient nervously treading outside his home. I asked him what he was doing. “My favorite football team is playing and now are the penalties. I came out, I do not want to watch and get another heart attack,” he explained. And indeed, during football games it has happened, someone from the spectators to be carried out on a stretcher. Recently a letter from a Mexican writer was broadcasted, whose grandfather died in 1994, after seeing Stoichkov score a goal against Mexico.

– Would he be alive today if he was not watching?
– From 1994 the contemporary cardiology knows the answer. On the 17th of January Los Angeles was shaken by a major earthquake – the richest city in the richest state (California) of the richest country (USA). Earthquakes are an example of the impact of sudden stress on health. During the earthquake, some patients carried Holters for blood pressure monitoring and ECG. The data from the devices shows how patients’ pulse from 85 per minute reaches 160 when the earthquake strikes. There are also records of blood pressure rising from 130/80 before the earthquake to 160/120 during the quake. Then the damages were large; buildings, bridges and trestles collapsed. Insurers and reinsurers went bankrupt. On the day of the earthquake the number of patients with infarction was significantly higher than that on the same day of previous years, when there was no earthquake. But in the weeks after the earthquake, the number of heart attacks appeared to be smaller than on those days in past years. The conclusion is that the heavy sudden stress from the earthquake has caused heart attacks of people who anyway would have had a heart attack in the coming weeks. The stress during the earthquake provoked these attacks.

– Are there other indisputable examples?
– The great earthquake (9th degree on the Richter scale) in Japan on March 11, 2012. The cases of acute coronary syndrome sharply increased after the earthquake at the expense of a decrease below the usual level in their number three months later. To put it bluntly, the answer to the above question is: angry or not – the difference is 3 months of life. The patients who died due to the stress of the football game would probably have had a heart attack in the coming weeks. Tsar Samuil was about 70, and even if the Battle of Klyuch had developed differently, most probably he would have had a heart attack shortly afterwards.

– In your practice have you personally observed the effects of stress?
– The most recent example is from May 24 this year when we had an earthquake in our country. We gathered the Holters of the patients from the hospitals of the Bulgarian Cardiac Institute during the quake. Each person reacts individually, according to his fear of earthquakes. In all the pulse rose, but the usual changes were for example: from pulse 65 per minute before the earthquake to 90 per minute during the quake.
Everything said so far applies, of course, only to the sudden stress and ischemic heart disease. The statistics of the earthquake in Japan in March 2012 showed that in contrast to the acute coronary syndrome, in which the initial increase in cases was offset by further reduction, the incidence of cardiac insufficiency observed only increased without compensatory decrease later.

– How the sudden stress causes cardiac insufficiency?
– We have more data on the effects of sudden stress on women. Usually elderly women on bad news get transient cardiac insufficiency and very few of them die. Most often, after 3-4 weeks almost all recover. This condition is called stress cardiomyopathy. It was first discovered in Japan in 1990. During the illness the left ventricle resembles an amphora.
But in the Japanese history there are no amphorae, nor pots, so they called the disease Taco-tsubo – a Japanese vessel, which most closely resembles the amphora. It is used to catch octopuses. “Taco” means octopus, “tsubo” – cup. We described this disease in Bulgaria for the first time in 2006 and since then it is diagnosed more widely. Most often the patients are elderly women, usually after negative news. For example, one of the patients received ultimative term to repay the loan, but no money. Another who had lost her daughter and herself took care of her granddaughter, was surprised by the 16-year-old girl with the message that she is pregnant. Third patient had suddenly lost her husband. Another patient’s husband was cheating and the whole village knew…

– Diagnosis in women?
– It occurs rarer in men and in young people. For example, a young tinsmith had received taco-tsubo cardiomyopathy, when his employer, rushing to complete the facility, sent him to work on a wet and slippery roof.
The ECG and the laboratory tests of the patient with stress cardiomyopathy are like with acute infarction, but the invasive examination shows that his/her blood vessels are passable. If the invasive tests are not carried, everyone will think it was an infraction. It is caused by stress hormones – adrenaline and noradrenaline, which directly affect the heart muscle. This stress in men, as in Tsar Samuil, can lead to sudden death. In women without coronary artery disease and clean coronary vessels a protective mechanism is triggered and muscle cells cease to respond to the stress hormones. Thus the taco-tsubo cardiomyopathy occurs.
The bad news is that stress can really break your heart, and good – that usually condition resolves in few weeks.

– The advice not to worry is easy to give but difficult to abide by. What else can the medicine offer?
– In 1988, the Nobel Committee awarded the Nobel Prize in Medicine to Sir James Black for the discovery of the first H2-blocker (cimetidine) and the first beta-blocker (propranolol). For these discoveries the Queen declared him a knight, and hence – the title sir. Beta-blockers are medicines that block the path of the nerves from the brain to the body.
The person is worrying, but this stress does not reach the organs. In all Olympic events associated with shooting (biathlon, shooting, etc.), the beta-blockers are considered doping and banned. The stress of the competition does not reach the shooter’s hand and he shoots more accurately (speaking in medical language beta-blockers reduce peripheral tremor). In young men, beta-blockers have a significant side effect. If they see a beautiful naked woman, the excitement in their brain does not reach their penis, i.e. beta-blockers can cause erectile dysfunction. Of course, women do not develop this side effect.
The beta-blockers reduce sudden death after myocardial infarction. But not all. The beta-blockers, which reduce sudden death, are fat-soluble and enter the central nervous system. Those, which have no preventive effect are water soluble and do not enter the central nervous system. In sudden deaths the modern cardiology considers the brain as the trigger and heart as the target. Or, as the saying goes, “all woes come from the head.”

Interview with Assoc. Prof. Dr. Sotir Marchev, MD (04/10/2014; Liubomira Nikolaeva, 24 hours)

People want control over the health care system, but do not bother to carry it out in person, even if such an opportunity is provided to them. This becomes evident from the report of the NHIF of the issued codes for access to the personal health records.

From the introduction of the service in April last year until now only 16 309 people have applied for the issuance of a unique access code (UAC). Moreover – the data of the requested UAC for this year only shows that the interest in the service decreases: in the period January – 6th of October 5352 UAC were issued.

The Health Insurance Fund provided this information in connection with the submitted in recent days signals by citizens that in their electronic health records incorrect data is entered.

The Fund reminds also that even people with terminated health insurance rights have the possibility to request and obtain UAC and through it gain access to the information about the medical and dental care provided in the last six years.

In the electronic health dossier is stored the information of the choice made by every citizen of General practitioner (from 2000 to present), and the performed and recorded activities of the General practitioner, specialists, hospitals, laboratories and pharmacies – from 2009 until now.

In the electronic health dossier, the information on activities conducted and reported by the providers of dental care, as well as information regarding the European Health Insurance Cards issued is stored.

From NHIF note that for any discrepancy between the medical care received and activities reflected in the electronic health dossier, the insured may lodge a complaint with the NHIF.

“So every health insured has the possibility in person to control whether his money for health were used as intended, which he remitted in the form of health insurance installments, and thus to assist the practice of civil society control in the public interest,” note also from the Health Insurance Fund.

The Health Ministry will purchase almost 40 000 vaccines for a total amount of BGN 4.27 million without a tender, through direct negotiation procedure. The aim is to control the crisis with the 6-valent immunizations.
The crisis started as the only company that participated in the summer tender and won it failed to deliver the vaccine. This is about one of the two included in the Positive list 6-valent vaccines, which is in the form of injection. The company, however, offered to provide quantities in vials. But this form does not appear in the Paid list.

The Minister suspended the execution of the contract, because otherwise he would have committed legal offence. But on the last day for appeal – 8th of October this year, the supplier filed a complaint with the Commission for Protection of Competition against the decision of Dr. Nenkov. While the case is considered, the Ministry of Health can not buy the vaccines and thousands of newborns can not be vaccinated.

“I decided to refer to art. 90 of the Public Procurement Act, which allows in extreme situation to proceed to direct negotiations, despite the appeal of the producer,” explained Dr. Nenkov.

Thus on the website of the Ministry of Health (again on the 8th of October) appeared the direct negotiation procedure, where, however, only one invitation is given – to the second producer. “Only he qualifies as the first producer is appealing and said that before the summer he can not deliver the 6-valent vaccine, so there is no one else to invite” (in the Paid list there are only two vaccines from two producers), explained from the Ministry of Health..

If again there is an appeal and if Nenkov is convicted, the sanction will be a personal fine of BGN 15 000. “I figured that I can take a consumer loan and pay it, but I can not let anyone put me and the Ministry of Health on our knees,” the Minister said. His deputies and a patient organization promised to give money if it comes to conviction. “To solve the casus, we will address the World Health Organization and UNESCO,” said Nenkov.

His team predicts a new crisis with vaccines and in the beginning of 2015, as the vaccination calendar for next year is not ready yet. “Against the vaccination calendar there is resistance in the Ministry of Health on the grounds that the changes we offer do not exist anywhere else in the world no. And it is not so.” snapped Nenkov. He wants the immunization calendar to describe diseases against which immunization of children in Bulgaria will be compulsory, not to indicate the type of vaccines protecting against these diseases. In this way, even if a vaccine is missing, there will be a way for public procurement and the Bulgarian children will not remain unprotected.

Currently in the Regional Health Inspections there are enough 4-valent vaccines to immunize the newborn. And the vaccination against hepatitis B can be made additionally, until a new delivery for the 6-valent vaccine is secured. “Revaccination of 6-year-olds will be delayed, but this will in no way affect the health of the children,” assured Dr. Nenkov.

Among them are some of the best-selling medications for pain, flu and allergies.

The result of the imposed antimarket one year moratorium on the increase of prices of the over-the-counter medicines is that at the end of the moratorium some of them logically have increased. A total of 112 medicines had price increases in the short window between April and early August this year, when the moratorium was not in effect, became evident from the statement of the National Council on prices and reimbursement of medicines.

The previous caretaker government froze the prices of the over-the-counter medicines as a social measure – till April 2014. At the end of her mandate Tanya Andreeva, however, decided to prolongate the moratorium – from 8th of August till the end of the year.

Anticipated

As the experts in the sector warned a year ago, immediately after the suspension of the moratorium in April the prices of some of the medicines increased because during this period their production costs increased or because the manufacturers begun to equalize the prices of the medicines with those in other European countries. Until last year, the government had not intervened on the market of over-the-counter medicines – medications for headache, pain, flu, cold, cough or rash, vitamins, because it is not covering with funds from health insurance fund any part of them. This market is worth BGN 356 million at BGN 2.3 billion total market of medicines and their sales do not affect public spending on prescription medicines of chronically ill of BGN 1.5 million. And there are the high costs of medicines that can not be rolled over, as prices here are the lowest in the EU and the public funds for the sick poor are insufficient. Thus the moratorium was perceived as a populist measure which will not be felt particularly by the users. The reason is that the market of over-the-counter drugs is extremely competitive and the producers usually sell them well below the maximum registered price, as in group compete at least 10-15 medicines of the same group. As anticipated after the suspension followed rise in prices.

It feels like much more

According to the Council on prices the average increase in the prices of these medicines was 26%, but in most cases we are talking about pennies. Moreover, because of the huge competition these products are not sold at the maximum possible price. The Council on prices comments that the medicines with increased prices are only 7.4% of all over-the-counter medicines – a total of 1544 total products. Thus the price increase for the noted period relative to all over-the-counter medicines is only 2%. For example, the Chairman of the Bulgarian Pharmaceutical Union prof. Ilko Getov estimated some days ago that it comes to an average increase of 3-4%. The 112 medicines with new prices are among the best-selling and obviously the feeling is for a more wide scale rise. Among the medicines with increased prices are some popular preparations against influenza.

Why are they with new prices?

A year ago, the manufacturers were allowed to register a new price twice a year. Now this opportunity is once a year and with the rate of inflation. Since this is a free market, the companies can take into account the increase in production and marketing costs, electricity prices and other. In this way the companies explain the increase, adding that in addition to the increased production costs, the marketing costs for the country have also increased.