Are there still restrictions on issuing referrals for the individual patient when they need to consult a specialist? In which document are such limits regulated, if any?
Georgi Atanasov, Pazardzhik
In the countries where there is a solidarity model of he alth insurance, such as ours, there are objective criteria for the need to carry out certain examinations or consultations with a specialist doctor. They primarily provide prevention activities and dispensary monitoring of patients in need. The rest is designated for activities for acute cases, with the distribution among general practitioners according to the patient list, and among outpatient medical care specialists - according to the number of reported and paid primary visits and physiotherapy courses in the previous quarter.
There are separate possibilities for all general practitioners to refer unlimited children up to the age of 18 for consultation by a doctor with acquired speci alty in "Pediatrics", "Pediatric Gastroenterology"; "Pediatric endocrinology and metabolic diseases"; "Pediatric Cardiology"; "Clinical Allergology and Pediatrics"; "Pediatric Clinical Hematology and Oncology"; "Pediatric Neurology"; "Pediatric Nephrology and Hemodialysis"; "Pediatric Pneumology and Phthisiatry"; "Child Psychiatry"; "Children's rheumatology" - once for each acute condition and illness. The number of directions and amounts for research are determined according to the doctors' patient lists, taking into account various indicators: dispensary patients by diagnosis, age, chronic diseases, etc. features determining the consumption of he alth services. Based on these criteria, medical care providers have a precisely defined number of medical referrals for examinations and tests for each quarter, which should be spent in a timely manner and according to the needs of patients.This limitation is imposed by the fact that the Fund has a precisely defined financial resource, according to the Law on the budget of the NHIF, adopted by the National Assembly.
Medical care contractors can exceed their designated directions/regulatory standards (RS) by an additional 10% and 15% and with the balances from the previous months, and in case of need for additional RS, they submit an application to the РОЗОК for granting additional to those already determined for the quarter, according to the relevant procedure. In all cases, however, despite the fact that there is no precisely defined number of directions that the he alth insured can use within a calendar year (i.e. there is no precisely defined limit for each he alth insured), the doctor is the one who assesses the need for consultation with a specialist, according to the patient's condition - whether it is urgent or delayed.
We specify that the general practitioner cannot issue a new referral to a specialist for the same condition (diagnosis) in the same month, provided that the medical referral is valid for up to 30 days from the date of the primary examination with the specialist and he has the obligation within this period to carry out the necessary secondary examinations.The specialist determines within this period (of 30 days) the need for secondary examinations, as well as how many they should be, according to the patient's state of he alth. If the referrals are for doctors with a different speci alty, there is no obstacle for the personal physician to issue them - at his discretion and if necessary.
Regarding the determination of regulatory standards, the normative documents are the NHIF Budget Law and the so-called Rules for the terms and conditions for approval by the National He alth Insurance Fund for each National He alth Insurance Fund and for each quarter to the contracts with the contractors of outpatient primary and outpatient specialized medical care of the number of assigned specialized medical activities and the value of assigned medical-diagnostic activities. Pursuant to Art. 3 of the Law on the budget of the NHIF for 2017 and Art. 2, para. 1 of the "Rules for the terms and conditions for approval by the NHIF for each NHIF and for each quarter to the contracts with the providers of outpatient primary and outpatient specialized medical care of the number of appointed specialized medical activities and the value of the appointed medical-diagnostic activities" (Rules), the Supervisory Board of the NHIF approves quarterly the number of assigned specialized medical activities (SMD) and the value of medical diagnostic activities (MDD).