Dimova Antoniya, Rohova Maria, Atanasova Elka, Kawalec Paweł, Czok Katarzyna
Department of Health Economics and Management, Varna University of Medicine, Varna, Bulgaria.
Faculty of Health Sciences, Institute of Public Health, Jagiellonian University Medical College, Krakow, Poland.
Value Health Reg Issues. 2017 Sep;13:50-54. doi: 10.1016/j.vhri.2017.08.001. Epub 2017 Sep 9.
Bulgaria has a mixed public-private health care financing system. Health care is financed mainly from compulsory health insurance contributions and out-of-pocket payments. Out-of-pocket payments constitute a large share of the total health care expenditure (44.14% in 2014). The share of drugs expenditure for outpatient treatment was 42.3% of the total health care expenditure in 2014, covered mainly by private payments (78.6% of the total pharmaceutical expenditure). The drug policy is run by the Ministry of Health (MoH), the National Council on Prices and Reimbursement of Medicinal Products, and the Health Technology Assessment Commission. The MoH defines diseases for which the National Health Insurance Fund (NHIF) pays for medicines. The National Council on Prices and Reimbursement of Medicinal Products maintains a positive drug list (PDL) and sets drug prices. Health technology assessment was introduced in 2015 for medicinal products belonging to a new international nonproprietary name group. The PDL defines prescription medicines that are paid for by the NHIF, the MoH, and the health care establishments; exact patient co-payments and reimbursement levels; as well as the ceiling prices for drugs not covered by the NHIF, including over-the-counter medicines. The reimbursement level can be 100%, 75%, or up to 50%. The PDL is revised monthly in all cases except for price increase. Physicians are not assigned with pharmaceutical budgets, there is a brand prescribing practice, and the substitution of prescribed medicines by pharmacists is prohibited. Policies toward cost containment and effectiveness increase include introduction of a reference pricing system, obligation to the NHIF to conduct mandatory centralized bargaining of discounts for medicinal products included in the PDL, public tendering for medicines for hospital treatment, reduction of markup margins of wholesalers and retailers, patient co-payment, and the introduction of health technology assessment. Although most of the policies have been introduced since 2011, there is still weak evidence for improvement regarding cost containment and effectiveness.
保加利亚拥有公私混合的医疗保健融资体系。医疗保健资金主要来自强制性医疗保险缴款和自付费用。自付费用在医疗保健总支出中占很大比例（2014年为44.14%）。2014年门诊治疗的药品支出占医疗保健总支出的42.3%，主要由私人支付（占药品总支出的78.6%）。药品政策由卫生部、国家药品价格和报销委员会以及卫生技术评估委员会负责实施。卫生部确定国家健康保险基金（NHIF）为哪些疾病支付药品费用。国家药品价格和报销委员会维护一份正面药品清单（PDL）并设定药品价格。2015年针对属于新国际非专利名称组的药品引入了卫生技术评估。PDL界定了由NHIF、卫生部和医疗机构支付费用的处方药；患者的确切自付费用和报销水平；以及NHIF未涵盖的药品（包括非处方药）的最高限价。报销水平可以是100%、75%或高达50%。除价格上涨情况外，PDL每月修订。医生没有分配药品预算，存在品牌处方做法，并且禁止药剂师替换处方药品。控制成本和提高效益的政策包括引入参考定价系统、要求NHIF对PDL中所列药品进行强制性集中议价折扣、医院治疗药品的公开招标、降低批发商和零售商的加价幅度、患者自付费用以及引入卫生技术评估。尽管大多数政策自2011年以来已实施，但在成本控制和效益改善方面仍缺乏有力证据。
