CC BY
13THE VOLUNTARY HEALTH INSURANCE IN BULGARIA DURING THE PERIOD 2017 - 2021
Mihaylov N.,
Doctoral candidate in the Department of Health Economics, Faculty of Public Health „Prof. Tzekomir
Vodenicharov, MD, DSc", Medical University - Sofia Nikolov N.,
Doctoral candidate in the Department of Health Economics, Faculty of Public Health „Prof. Tzekomir
Vodenicharov, MD, DSc", Medical University - Sofia Zlatanova T.,
Professor in the Department of Health Economics, Faculty of Public Health „Prof. Tzekomir Vodenicharov,
MD, DSc", Medical University - Sofia
Popov N.
Professor in the Department of Health Economics, Faculty of Public Health „Prof. Tzekomir Vodenicharov,
MD, DSc", Medical University - Sofia DOI: 10.5281/zenodo.6616408
ABSTRACT
This article pertains to the development of the Voluntary Health Insurance (VHI) market in Bulgaria last five years. In 2012, there were proposals for changes to the Health Insurance Act. These proposals were adopted by the National Assembly and pledged health insurance companies within August 2013 to bring their activities in accordance with the Insurance Code to carry on insurance business in general insurance. Subject of this analysis is the voluntary health insurance market in last five years period (2017-2021). The research includes the insurance product "Sickness". Objects of analysis are the following financial indexes of the market - premium income, payments and market share. During the period discussed a clear tendency for growth of the gross premium income and the payments can be observed in all insurance funds realizing voluntary health insurance activity through "Sickness" insurance. It doesn't forget that the COVID-19 was a challenge which tested the entirety of our country's healthcare system through 2020-2021. The pandemic was an emergency, quite dynamic, and necessitated quick and thoughtful actions which also affected Voluntary Health Insurance.
Keywords: Health care financing, health economics, health Insurance.
Introduction:
In Bulgaria there are two kinds of health insurance: compulsory health insurance and voluntary health insurance (VHI). With the Health Insurance Act of 1998 a single mandatory health insurance (MHI) scheme was created (National Health Insurance Fund -NHIF). The changes of the same law from 2002 created the possibility for the creation of many Voluntary health insurance companies [1]. The main social role of the VHI fund is to meet the health insurance needs of the portion of the population that are not happy with the mandatory health insurance scheme. VHI companies are created on the principle of self-financing. The contingent of heath insured people (organizations) become clients by choosing a fund by their own free will (voluntarily) between the existing VHI companies in Bulgaria [2]. Thanks to free market principles, the best fulfilment of the health needs of the population is possible only if the VHI companies provide the best quality of health services at an acceptable to the insured price with the least hassle.
The mission of VHI fund has many important medico-social, humanitarian, ethical interactions and also has important economic implications for the client, his family and their work collective [3].
In the last twenty years the VHI funds were unsuccessful in the creation of a contemporary market of health services, despite the fact that in 2012 there are 21 licensed VHI funds in Bulgaria [4]. The reasons for this are: the lack of tradition in the field of heath care, low income of the population, the redundancies of the
health services provided by MHI and VHI for which the person has to pay two health insurance fees, the informal payments for health care in the hospitals, and etc [5].
Regulatory Changes in Health Insurance
In 2012, there were proposals for changes to the Health Insurance Act. These proposals were adopted by the National Assembly and pledged health insurance companies within August 2013 to bring their activities in accordance with the Insurance Code and apply to the regulator for a license to carry on insurance business in general insurance. To facilitate the procedure for re-licensing business was exempt from tax [6].
The procedure for re-licensing of health insurance companies was needed because Bulgaria had to apply in respect of the VHI those insurance directives and the provisions on the free movement of capital enshrined in the Treaty on the Functioning of the European Union. The change was required because, according to the European institutions voluntary health insurance is no different than insurance to cover health risks. In case of default of European legislation, Bulgaria was threatened with a fine - a risk that the country has managed to avoid.
All changes connected to the relicensing of health insurance companies lead to stress in the VHI market. A part of health insurance funds increased their capital in accordance with the new requirements and kept their positions and contracts. Other funds underwent mergers to meet the new requirements. And other funds
were acquired by insurance companies licensed in general insurance who took interest in the health insurance market.
ANALYSIS
The current analysis encompasses the activity of health insurance funds, who have a license in general insurance and who have been working in the area of Voluntary Health Insurance during the 2017-2021 period. The data this research is based on are officially published by the Financial Supervision Commission (FSC).
In the Health Insurance Act (HIA) in Art. 82 it is written that "Voluntary Health Insurance shall be performed on the grounds of a medical insurance contract in the meaning of Chapter Forty, Section IV of the Insurance Code". Article 222a of the Insurance Code states that "A medical insurance contract obliges the insurer to cover risks related to the occurrence of disease or accident and connected with the financial provision for certain health services and goods, in return for an insurance premium" [7]. In the reports published by the FSC there aren't independent data for the medical insurance contracts. FSC publishes data on insurances according to their respective risk, which is why in those there are data on "Sickness" and "Accident" insurances. The object of the current analysis is the insurance funds that have realized voluntary health insurance activity regarding the insurance product "Sickness", as, according to research (N. Popov, 2015), the
voluntary health insurance realised through the product "Accident" is only 4% and "Sickness" has established itself as the principal insurance product at 96%.
Voluntary health insurance is carried out by licensed insurer in general insurance and insurers from an EU member state, who carry out general insurance activity in the Republic of Bulgaria in the conditions of the right of establishment.
In Bulgaria, since 1997, the Law on the Bulgarian National Bank the currency board, which operates to this day, is implemented. This law fixes the exchange rate of the Bulgarian lev at 1.95583 BGN to 1 Euro.
The most important indicator of the activity of an insurance fund is its premium income. This shows the fund's actual activity - the value of all their existing contracts. The premium income of the insurance companies who provide the product "Sickness" accounts to 51751005 BGN in 2017, 53036642 BGN in 2018, 65731968 BGN in 2019, 70160779 BGN in 2020, and 78905815 BGN in 2021. During the period researched we can observe a clear tendency for growth of the gross premium income of all insurance funds carrying out activity in voluntary health insurance through "Sickness" insurance (Figure 1). The big growth of the premium income in the last year - 2021 - is noticeable compared to the previous 2020 - 12.46%. This is partially caused by the development of the COVID-19 pandemic.
78 905 815
70 160 779
65 731 968
51 751 005
53 036 642
2017 r. 2018 r. 2019 r. 2020 r. 2021 r.
Figure 1. Premium income for "Sickness " insurance for the period 2017-2021 in Bulgarian lev.
The payments of insurance companies, who provide the insurance product "Sickness" accounts to 30223068 BGN in 2017, 35509659 BGN in 2018, 424557788 BGN in 2019, 40616279 BGN in 2020, and 45727768 BGN in 2021. It is noticeable how acceptable the direct costs - the payments - are relatively acceptable and don't exceed the premiums for the product and follow the tendency for growth of the premium income for "Sickness" insurance. The slight lowering of
the payments inn 2020 is caused by the COVID-19 pandemic. On one hand, it is due to the measures and strict restrictions implemented at the time (transforming clinics into ones specialized for COVID patients, stop of planned operations, etc), and on the other hand it is due to the period in which patient limited their medical visits because of their fear of the sickness.
45 727 768
2017 r. 2018 r. 2019 r. 2020 r. 2021 r.
Figure 2: Payments for "Sickness" insurance for the 2017-2021 period.
The market share of "Sickness" insurance from the entirety of the insurance activity in general insurance during the 2017-2021 period is as follows: 2.96% in
2017, 2.54% in 2018., 2.72% in 2019 r., 2.88% in 2020, and 2.99% in 2021.
2021 r.; 2,99%
2020 r.; 2,88%
2017 r.; 2,96%
2018 r.; 2,54%
2019 r.; 2,72%
Figure 3: The market share of "Sickness" insurance for the 2017-2021 period.
In short, we need more public private engagement - which is why we call these shared resilience solutions. Because these sudden, far-reaching and indiscriminate shocks are increasing. And as a society we need solutions. And voluntary health insurance while not being a silver bullet, can and should be part of the solution - not part of the problem [8].
CONCLUSION
As a whole, the market for voluntary health insurance fulfilled by the "Sickness" insurance is shaping up to be a dynamic one. It grows with an envious rate, which is visible in the yearly increase of premium income. This is clear evidence that there exist a niche in the health services market, which is utilized more and more successfully by the voluntary health insurance funds. The payments of the insurance companies, who provide the "Sickness" insurance product clearly demonstrate that they are carrying out a considerable volume of actual activity.
Compared to the entirety of the healthcare expenses in the Republic of Bulgaria it is relatively small. In terms of general insurance activity, this activity takes up between 2.5 and 3%. The reasons for this are the low income of Bulgarian households and the fact that most people who have health insurance aren't aware of what benefits they get from mandatory health insurance and what benefits they can get from the "Sickness" medical insurance, as well as the overlap with the National Health Insurance Fund in covering of multiple activities and health services.
Insurance funds providing voluntary health insurance through the medical insurance "Sickness" are invariably faced with the issue of achieving a positive influence and health education of the people they insure. Their activity also significantly incorporates healthcare for the healthy individual. Promoting health as an all-encompassing prophylactic strategy is not concerned solely with the health lost but also with the positive
health and the opportunities for maintaining it. This is the path towards raising the health indicators in insured people, which would result in achieving better economic results for the insurance funds.
References
1. Health Insurance Act.
2. Nikolov N., N. Mikhailov, N. Popov, T. Zlatanova. Voluntary Health Insurance in Bulgaria, Proceedings from the fourth scientific conference with international participation "Multidisciplinary approach in health care", November 19, 2020. Medical University of Sofia, Central Medical Library, 2021, ISBN 978-619-7491-32-6, pp. 20-22.
3. Zlatanova, T., Tsv. Petrova-Gotova, N. Popov, D. Shtereva-Tzunni, R. Yaneva, Economics of Healthcare, GorexPress, Sofia, 2017.
КЛ1Н1ЧНИЙ ВИПАДОК ТРОМБОТИЧНО1 ТРОМБОЦИТОПЕН1ЧНО1 ПУРПУРИ, ЯКА ПРИХОВУВАЛАСЯ ЩД МАСКОЮ ВАЖКОЮ ПРЕЕКЛАМПСП
Дука Ю.М.
Днтровський державний медичний yuieepcumem, доктор медичних наук, доцент кафедри акушерства, гтекологи та перинатологи факультету пклядипломно'1 освiти Ющенко М.1.
Днтровський державний медичний yнiвeрситeт, очний аспiрант кафедри акушерства, гтекологи та перинатологи факультету пклядипломно'1 освiти
CLINICAL CASE OF THROMBOTIC THROMBOCYTOPENIC PURPOSE HIDDEN UNDER THE
MASK OF SEVERE PREECLAMPSIA
Duka Y,
Dnipro State Medical University, doctor of medical sciences, associate professor of obstetrics,
gynecology and perinatology Faculty of Postgraduate Education Yushchenko M.
Dnipro State Medical University, full-time graduate student of the Department of Obstetrics,
gynecology and perinatology Faculty of Postgraduate Education DOI: 10.5281/zenodo.6616410
АНОТАЦ1Я
Наводиться опис дiагностики та ефективного лшування тромботично! тромбоцитопешчно!' пурпури (ТТЛ), що розвинулася в останньому тримес^ ваптносп. У хворо! 26 рошв на 32 тижш ваптносп з'яви-лися змши з боку лабораторних маркерiв на rai вiдсутностi скарг. В аналiзах кровi було виявлено анемiю, ретикулоцитоз, тромбоцитопенiю, пiдвищення АлСТ, АлАТ, у сечi - пiдвищення рiвня бiлка (протеiнурiя). Пацieнтцi проведено визначення полiморфiзмiв у генах тромбофiлii та ангюгенезу на початку вагiтностi. Термiнове розродження на п'ятий день хвороби iз попереднiм введениям преднiзолону забезпечили наро-дження здорово! дитини масою 1460 г, довжиною 39 см, з оцшкою за шкалою Апгар 4/6 балiв. Пiсля по-логiв, на тл терапii преднiзолоном, зберiгалися тромбоцитопешя на рiвнi 52х109/л, кумбс-негативна гемо-лiтична анемiя, протеiнурiя, мiкрогематурiя. На mдставi мшроангюпатично!' гемолггично!' анемii та тром-боцитопенii, появи генералiзованого петехiального висипу та екхiмозiв, встановлено дiагноз тромботично! тромбоцитопенiчно!' пурпури. Згодом дiагноз був остаточно пiдтверджений виявленням низько! активно-стi ADAMTS-13.
4. Financial Supervision Commission (FSC). www.fsc.bg.
5. Yaneva R. Social Priorities and Market in Healthcare, Medical Meridians Magazine, ed. of the Center for Sustainable Development, 2020, no. 2, ISSN 1314-1090, pp. 16-20
6. Andreeva-Raynova T., Ts. Vodenicharov, N. Popov. Challenges for health insurance in Bulgaria. Health and Science, December 2016, Year VI, Issue 4 (024), pp. 16-19.
7. Insurance Code.
8. https://www.eiopa.europa.eu/media/speeches-presentations/speech/crisis-and-recovery-challenges-and-opportunities-insurance_en.
