PROIECT DE SPECIALITATE (Восстановлен)

8/7/2019 PROIECT DE SPECIALITATE (Восстановлен)

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Introduction

Actuality of the topic. Since 1991 the Republic of Moldova made the transition to

market in terms of socio-economic crisis. One of the conditions necessary for normal

functioning of all areas of life in society is to develop and implement practical

methods of regulation and control in health.

Reduction of budgetary resources, lack of material resources and high percentage

of loans made to the budgetary policy of Moldova to be much tougher.

One of the possible ways of restoring the health situation at the present stage is the

implementation of health insurance as a form of activity which requires the

implementation of the health care system of market relations with all laws

characteristic of these relationships.

Because health insurance is aimed at health, it acquire a very pronounced social

aspect.

The current situation in Moldova allows to highlight a number of problems related

to human health and functioning health care system:

Continuous deterioration of health status;

Decreased population accessibility to health services;

Decreased quality of care that patients that does not meet the standards of

modern medical care;

Ineffective use of resources allocated to the branch, etc.

The need to further improving the population's access to medical services, requires

a careful study of the evolution of social health insurance system as a whole, its a

permanent correction for the efficiency.

But both the effectiveness and efficiency of health insurance are inevitably

subordinated financial opportunit ies which provide financing system in return as

mentioned previously, the population's health needs.

Working from the insurance market lasting several forms of health insurance is

confirmed to be the most appropriate format for organizing the health system .

Competition occurred in these relationships requires medical institutions to provide



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quality services, determined by practice performance methods of investigation and

treatment, as well as improving the quality and conditions of service.

Health Care Reform is one of the major social changes in Moldova.

Health care insurance is the most progressive and effective current method and has

a wide application in many countries of the world market economy.

With health care reform, shifts to the insurance model of medicine is to achieve

goals including a special place it has higher quality medical services provided

curative and preventive institutions of the Republic of Moldova.

Thus, quality of service provided has become a theme frequently addressed in

socio-economic studies within the industry because it is one of the factors that

positively affects saving and material resources to raise effectiveness of medicalinstitutions.

The aim of the study: to study the health insurance market and developing

technologies to improve organizational quality and volume of health care by health

insurance.

Objectives of the study:

1. Analysis of the health insurance market in countries that practice mixed type of

health insurance and in Moldova;

2. Studying the possibility of joining the mandatory medical insurance scheme

with voluntary health insurance in the Republic of Moldova;

3. Developing technologies to increase the quality of organizational and volume

of medical services to insured persons;

The originality of this work consists in tackling health care reform by passing the

security model, this creates additional financial resources for health care for the high

quality health services to provide health professional s with a respectable income,

which would meet the quality and social value their work.



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Chapter I. Place and role of health insurance in the context of social security

1.1. Health insurance and its role on the insurance market.

During the existence and development of human society, man was preoccupied

with issues related to providing material and financial resources. Intensive

development of society has led to opportunities for human intervention for

preventing or reducing the negative consequences of d amage to generating

phenomena. Of all ways and methods used by humans for the prevention of loss

events, the most suitable was proved to be insurance. From this perspective,

insurance has taken a fairly large scale in countries of the world, becoming, in r ecent

years, a branch of the global and national economy.

Appearance of insurance was determined by need of protecting themselves

against natural disasters, accidents, through the accumulation of livelihood in terms

of loss or limitation of working ability after illness or old age. As the development of

society, have enlarged effective means to limit the loss events and the methods and

ways of ensuring the population. Factors that have led to insurance, are the economic

and social. Among economic factors, the principal may be nominated:

1. changing economic conditions with the transition from one type to another

type of economy and, correspondingly, the diversification of relations between

people;

2. development of international relations and as a result, the need to guarantee the

goods against risk.

At present, increase the importance of social factors, among which occupies a

special place:

intense development of the phenomena of urbanization and, correspondingly,

the population concentration in large cities; increased risk of illness and traumare;

increasing number of factors and events producing damage;

organization in groups and guild members shall assist each other.

Cultural aspect of social health insurance is deeply rooted in the countries where

they were generated and initially introduced. Germany is considered to be the source



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of this approach to health insurance because she was the first Western European

country which, in 1883, introduced in official state law structures social health

insurance voluntarily. Most researchers in the field agree that the birth of health

insurance in 1883 was signed by German Chancellor Otto von Bismarck, who

introduced the first compulsory social insurance program nationwide, yet its

precursors are more difficult to identify.

The merit of Chancellor Bismarck is one which has created a social insurance

system. In addition to insurance funds, made by contributing of employers and

employees and which were intended to provide financial support not only the cost of

medical care but subsistence workers during the disease a year later was introduced

compulsory insurance against accidents. Operating mechanisms were similar, beingbased on contributions, and funds management system employers and employees.

The German example was followed some years later by Austria and Italy, as early

twentieth century to be taken in Sweden and the Netherlands.

The economic crisis of the '30s determined even the U.S. government to take a

series of concrete measures in order to create a social se curity system, including

health care, despite constant opposition from business circles, traditionally reluctant

to any state intervention. After the Second World War and, especially, by the mid-

70s, the economic growth has also contributed to the development of adequate social

security systems, a process which - along with their diversification - has led to cover

a more significant segment of the population.

Today we can say that the health insurance system is a result of the level of

development and civilization of the nation. The manner in which this system is

implemented in each country depends on a combination of factors, which may be

mentioned: the level of economic development and socio -cultural, nature programs,

human resource requirements, characteristics and evolution of family social life,

traditions, retirement age, reporting to the disease, medical services and benefits.



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Health insurance appeared in order to protect people on their day by day life. Also

health insurance became an insurance product which provides profit for the

insurance companies on the insurance market.

The current system of social health insurance, almost universal in Western Europe,

is the culmination of a historical process of 700 years. During this period, the number

of people covered with health insurance grew from a small number of workers from

the trade to all citizens or at least all citizens whose income is below a relatively high

income. Equally important is that the main concept of this form of social insurance

has changed, moving from wage replacement and the death benefit to pay for

outpatient medical services, hospital care and pharmaceuticals. Administrative nature

of social health insurance has changed over time, starting with voluntarycooperatives and later, in 1883 in Germany, the Netherlands in 1941 and 1996 in

Switzerland has evolved into a state -legislative.

After making mode, there are two forms of insurance: compulsory and voluntary

(optional).

The mandatory health insurance, the relationship between the insured and the

insurer, the rights and obligations of each party, terms and conditions for their

implementation are established by law. Relations between the insured and the

insurer, the rights and obligations of each party, terms and conditions for their

implementation are established by law.

Mandatory health insurance is meant to ensure the unique standards (general)

population social protection in health insurance. In Moldova's conditions, this type of

insurance is designed to maintain financial areas t hat fall behind in their socio-

economic development and not have opportunities to independently form the

financial basis for payment of medical services required value. Insurance, as a type

of business, aims to match individual risks between group members and not allowed

to enter the insurance group objects, capable of refocusing the group risk category in

the direction exceeded the average. In social terms, this section is called



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"discrimination". The essence of insurance, in this case can be expressed by the

words "always a group - never social".

This limitation manifested commercial insurance, which may be a mechanism for

financing public goods. Therefore, commercial health insurance in Moldova, in our

opinion, may be performed exclusively as voluntary. Voluntary health insurance is

protection to ensure guaranteed supplies for all citizens who are insured by the

individual or collective voluntary insurance of citizens' own account, payments from

the revenues or profit enterprises. However, volume and cost of care and services

offered under such a contract depends on the size of contributions. Size of

contribution, in turn, is determined by the health insurer by each insured or group of

policyholders. In addition, the size depends on the insurance contribution rates for those medical services that are required for the quota given, according to specific

contracts. In this case, the universality of participation is missing, a feature of

compulsory health insurance. The need for compulsory medical insurance is in

Moldova, as the state confirms that the protection of people's health has a crucial

importance for the success of market reforms, stabilization and further development

of society and not having sufficient resources in its budget for this protection, us e for

this purpose compulsory insurance, based on mandatory contributions of employers

and the citizens themselves, funding guaranteed level of health insurance. If,

however, some members of society or some organizations are able to protect health

at a higher level than that guaranteed, then use the voluntary medical insurance.

Compulsory health insurance system is organized and functions having the

following principles:

a) the principle of uniqueness, organizes and ensures that the state compulsory

health insurance system based on the same rules of law;

b) the principle of equality, whereby all participants in the mandatory health

insurance (premium paying compulsory medical insurance, medical service and

medical assistance beneficiaries) are provided with a n on-discriminatory treatment in

respect of rights and obligations under the law;



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c) solidarity principle, under which payers of insurance premiums paid

mandatory healthcare contributions according to income and healthcare benefits

insured as required;

d) mandatory principle according to which natural and legal persons under the

law have the obligation to participate in compulsory health insurance system and

health insurance rights shall be exercised in correlation with the obligations;

e) contributiveness principle according to which the health insurance funds are

based on insurance premiums paid by the payers established by law;

f) distribution principle, which states that funds made mandatory health

insurance is redistributed to pay obligations of mandatory health insurance system,

according to law;g) principle of autonomy, under which compulsory healthcare system is

administered independently, under law, and health care providers providing care in

this system works on principles of self-financing and profit.

For the uninsured, pre-hospital emergency health care costs for primary care and

specialized medical care and hospital outpatient care for socially conditioned

diseases with major impact on public health, are covered from the compulsory health

insurance funds means care, according to the list established by the Ministry of

Health.

The quality of the insured person is confirmed through the issuance by the insurer,

in the established policy of mandatory health insurance, under which the full amount

insured person receiving medical assistance provided in the program and granted the

unique health care providers.

The insurance policy is a document of strict accounting and issued by the insurer

based on:

a) lists the nominal record of insured persons employed by employers listed and

updated;

b) lists the nominal record of insured persons at state expense, provided and

updated by authorized institutions;



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c) identity documents and other documents certifying the right to obtain policy by

persons obliged by law to provide individually.

The voluntary health insurance, the relationship between the insured and the

insurer, the rights and obligations of each party is determined by the insurance

contract. The conditions of voluntary insurance are set by the insurer, in accordance

with the laws and regulations of the Supervisory Authority.

Voluntary health insurance can be both collective and individual, but not mass,

unlike the universal compulsory. For individual insurance, the insurer concluded

insurance contract with each customer individually. In the case of collective

insurance (group), the insurer conclude the contract not with a particular person, but

with staff representatives of workers (government and trade union committee).Voluntary health insurance is complementary to the mandatory. Following insurance

protection under the voluntary medical insurance contracts is not basic social

protection, but add the element of social protection guaranteed by the mandatory

health insurance. This type of insurance plays an important role in the context of lack

of funding from the budget.

There are two approaches. Let us compare the insurance products that underlie

them.

First approach. Insurance is based solely on risk-related expenses for medical aid.

In this case the insurance products of voluntary health insurance has medico -

technological nature. In it is described that care received by the insured in case of

occurrence of insurance case. These actually are the same paid medical services

received by the contribution (payment) of the insurer. This approach is much more

expensive just as the insurer receives for managing this product. Unfortunately, we

can not omit this fact, because he gives the best idea (views) of the Law on

compulsory health insurance.

The second approach. Optional health insurance is based on the principles of

health insurance. The purpose is to ensure all interest related medical issues,

maintaining and protecting health, but not only that part which relates to the



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provision of healthcare. Insurers take a number of risks of expenses that arise from

the use of ineffective methods of treatment, loss of body parts or its function,

decreased work capacity. All have a f inancial expression and placed under the

grading of risks can be transferred to insurance. Liability insured under these risks

can suddenly increase the attractiveness of the insurance product to potential

customers. Of those exposed to conclude that compu lsory health insurance and

voluntary health insurance can not be merged into a single insurance company health

insurance practice by the principles and approach second accident insurance.

We choose the latter approach and all subsequent exposures will be d isplayed in

this key.

E stablishing principles and rules of insurance productsWith the advent of health insurance requirements for implementation of voluntary

health insurance appears the necessity of establishing insurance programs.

Basic principles:

1. Activity in base of laws in force.

2. Strict division of fields of activity for setting correct programs.

3. Findings of the necessary volume of medical services rendered on a program

in correlation with the cost of medical services.

4. Differentiation by the volume of maintenance programs.

5. Using statistical methods in the formation of insurance programs.

6. Forecasting.

7. Adaptation .

8. Implementation.

Problematic situation for voluntary health insurance can be determinate by the

following case: it is necessary for the insurer to form an attractive package of

services, but in such a way, given that the package will not stimulate the increase of

medical services.

Unlike the mandatory insurance, voluntary medical activity is an important form

of commercial finance and insurance is a part of persons insurance(Table 1 .1.1).



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Table 1.1.1

The main distinctions between mandatory health insurance and

voluntary health insurance

N

r. Mandatory health

insurance

Voluntary health insurance

1. A compartment in thesocial security system.

Form of insurance with financial-commercial activity, which refers topersonal insurance.

2. It covers only the law onmandatory health insurance.

It is regulated by the Law onInsurance and other governmentordinance refers to entrepreneurialactivity.

3. Terms of assurance shall bedetermined by the CNAM.

Terms of assurance shall bedetermined by insurance companies.

4. Is binding. It has a voluntary character.

5. Universal Is done individually, in groups or families.

6. Is performed, usually byinsurance companies withnon-profit.

Is carried out by insurance companieswith different forms of ownership.

7. Insurers are employers andemployees, state, localadministrative bodies.

Insurers are individuals andbusinesses.

8. Prices are set by law, incoordination with thecompulsory subjects.

Prices are set by contract, based onactuarial mathematics.

9. Revenues may only be usedfor developing the corebusiness - insurance required.

Revenues can be used in anycommercial activity commercial.

10.

The unique program isapproved by the state.

Assurance program is establishedunder the contract between the insurer and the insured.

11.

Prices for services providedby medical institutions areestablished by agreementbetween the subjects.

Prices for services provided bymedical institutions are established bybilateral agreement.

12.

The volume of medicalservices is limited byfinancial ability of medicalinstitutions.

The volume of medical services islimited by the amount of insurance.



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1.2. Social bases of health insurance

Health insurance is part of a broader context, known as social policy, having as

main object of study social services and which, together with human health, as well

as areas of reference include: social security, housing, education, unemployment and

imprisonment. They are not limited to a simple analysis of society and its problems

(poverty, inequality, discrimination, marginalization, unemployment), but have in

mind and mechanisms to address the problems in question, resulting in decisions and

actions welfare to be achieved. Everything is analyzed in the context of social

policies and the institutional architecture that implements programs and providing

welfare support. For this reason, in addition to actions directed towards achievingpublic welfare, are envisaged and arrangements based on specific actions that each

area can be achieved at as high a level of efficiency and effectiveness. Taking the

political science concept of cyclical political process, generate and review of social

policy can be described as an interactive model, as it is presented in Figure 1. 2.1.

F igure. 1.2.1. Policy cycle

All these features are associated with the concept of welfare, which is - in fact - the

main objective of social policy. The measures undertaken, both economically and

from a social perspective, aim to improve quality of life by providing community

members a decent living, a concept known as collective welfare. Individual and

Identify socialproblems

Evaluation of

policies and

effects

Political

proposals

Implementing



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collective welfare can be achieved both by direct mechanisms arising from the

functioning, in which case we are dealing with a primary distribution, related to

mechanisms of resource allocation and income and the redistributive nature of the

transfer mechanisms.

In the process of operationalization of social policies can make a record of their

focus to an object generically called social security, representing all actions taken by

the society for the prevention, reduction and elimination of consequences of events

considered "social risks" that have a bearing on the level living and the quality of life.

Disease, ignorance, poverty are considered to be fundamental risks human which

may generate each other or may become centers generating new ones.

Social protection system is a set of programs that are designed to protectindividuals from the situation interruption or loss of earning capacity.

Social security can be defined as a set of measures laid down by law, aiming to

maintain income individual or family concerned to provide an income if all sources

of income have disappeared or when, exceptionally, involved enough large spending

that may put population at risk.

Meanwhile, Social Security can provide financial resources people in need from

different cases (illness, disability, unemployment, loss of spouse, maternity and child

care increase, the withdrawal of active life).

One can see easily that social security programs are designed not only to protect

individuals, but also their families, in situations where loss of income or insufficient

income.

For this reason, the ultimate organization of the International Labor Organization

(ILO) uses three criteria for defining social security:

1. Linking financial support of medical treatment and / or medical care, income

maintenance measures in case of involuntary loss (in whole or in part) of ability to

work in a manner in which to include family financial problems;



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2. The existence of legal provisions concerning rights and obligations of

individuals in relation to each of the components of the system (public, private,

public-private partnership);

3. Appropriateness of mechanisms for security management system principles

specific to each component.

Another concept is the basic social security, representing a special form of

protection that society attaches to its members support one way to counteract the

effects of various economic risks (loss of income due to illness, due to reduced

working capacity in old age, because of unemployment).

Health insurance differs significantly from other forms of public aid or support.

The benefits depend, in general the contributions and rights of those who arereceiving them. Contributions come from individuals employed, from employers and

in some cases, from state budget. They are collected in special funds that provide

financial support to beneficiaries.

Health care services and health insurance benefits from an increased interest in

social insurance, not only because it covers a distinct category of risk, but also

because this sector consume appreciable amounts of resources. A marked

demographic reality of the aging population, due to technological development in the

field, makes the demand for health services to provide a strong dynamics.

It must be said, however, that health insurance is not just a way of managing these

risks, which may add other methods or techniques, among which we mention:

y Control, by practicing a proper diet, a program of exercise, avoiding s moking,

excess alcohol products;

y Avoiding risk (for example, proscribing certain dangerous sports);

y Voluntary private insurance system to cover medical expenses, the costs of

long-term treatment, or reduction in income during incapacity for work;

y Establishing personal reserve for medical expenses not covered by the public;

y Transfer risk (for example, by clause of the contract of employment that

employers provide accountability for certain medical costs of employees).



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1.3.Principles of classification of health insurance.

Medical insurance are classified by the same principles as other types of insurance.

As mentioned in previous chapters, it is necessary to classify the concepts of medical

insurance, health, medical expenses for illness. These concepts are not s ynonymous

and its information content is very different, also the principles of classification are

only principles and are not defining in classification. Each principle is part and other

principles of classification. It allows to easily understand the contents of each medical

insurance. So health insurance can be classified as follows:

According the law:

1. mandatory health insurance;

2. voluntary medical insurance.

According the territorial principle:

1. medical insurance for the entire population;

2. medical insurance for a certain area;

3. international medical insurance.

According to the number of insured persons:

1. individual health insurance;

2. family medical insurance;

3. collective medical insurance;

4. medical insurance for the entire population.

According to thevolume of coverage:

1. Complex:

advanced medical insurance;

complex health insurance;

complex medical expenses insurance;

complex insurances for diseases.

2. Insurance on certain groups or diseases:

medical insurance for certain groups of states or diseases;

health insurance for certain groups of conditions or diseases ;



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health insurance costs on certain groups of states or diseases.

According to the manner of payment by the insured person:

full payment ;

pay a share of the amount of insurance or expenses; payment by applying various reliefs;

with overlapping claims,

cash;

by transfer;

insured;

service provider.

According to the manner of payment of ser vice providers:

actual expenses payment;

paying the cost of day / bed;

according to the norms for treating a case of insurance;

by paying the annual budget, based on the number of insured persons attached

to the service.

According to the period of insurance:

insurance for short period - one year or less;

insurance average - 1-5 years;

insurance for long - 65;

health insurance for whole life.

Health insurance is a form of insurance designed to cover all or partial

hospitalization costs if hospitalized exceeds a certain number of consecutive days

(usually 3 or 5), the cost of medical treatment as a result of illness or injuries in

insured or compensation coverage for illness or income during illness.

The risk of death is not insured.

Insurance premiums are different for men and women. As in other types of health

insurance contracts, it establishes a waiting period, only after which the coverage

becomes effective, it can be 3-6 months.



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Costs covered include:

hospital;

of convalescence;

treatment at home after discharge; maternity allowances;

advice from a family doctor;

consultation, diagnosis and / or fees to specialists (radiology, ultrasound,

oncology);

surgery;

private ambulance services;

repatriation costs;

rental of a wheelchair, and others.

Level premium insurance is calculated according to the occupational categories,

due to various risks.

Insured amounts paid may take the following forms:

1. Lump, representing a daily allowance of a fixed amount for hospitalization or

surgery;

2. Reimbursement of expenses of hospitalization in the form of allowances for

private hospital services, medical / surgical.

In the papers devoted to insurance risk assessment is a new concept - the

cumulative risk.

The concept of cumulative risk is understood all the risks that accumulates the

likelihood of a case and the same insurance. This action occurs in case of the force

majeure (natural disasters). Methods of prevention, compared with other medicalservices related to treatment of diseases, are much cheaper and easily subject to

calculation. A major application of preventive methods have collective contracts,

especially in adverse conditions where persist the teams work.

It is possible to finance preventive services at the expense of the employer and

insurer (Figure. 1.3.2.).



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F i 3 The purpose and r i sks of ol unt ary healt h i nsurance

Insurance object

Material interest regarding

health maintenance and

recovery

Risks of the first

order

Risk of loss of

health from illness

Risk of loss of

health as a result of

trauma, poisoning

Deepening the risk

of chronic and

acute diseases

The risk of chronic

diseases

Risks of second order

Expenses for medical

services

Damage from medical

technology

The damage from the

ineffective treatment

Insurance Cases

Medical services

under contract

Loss of

employmentLoss of a body part Death



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Chapter II. Studying the health insurance market in the Republic of Moldova

and in countries with highly developed economy.

2.1. Existing medical insurance forms in countries with developed economy.

Every system of health insurance is different, so that basic health services package

definition is directly and indirectly influenced by the particular systems of each

country, even if they do not work in isolation. In the following we intend to

emphasize the structure and content of the basic package of several developed and

developing countries, selected from different geographical regions in order to

highlight the main factors of influence to be taken into account in this respect.

1. European Experience

In Ireland, the insurers were not impose restrictions regarding the c overage of

health care providers. There are, however, the requirement to establish a minimumlevel of benefits to cover all health services and offers insurance plans should cover

care in public hospitals. Virtually all health plans cover both services in public

hospitals and in private, which represents the largest part of private health insurance

market. Plans with the lowest coverage level support accommodation, meals and

semi-private care in public hospitals, or an equivalent level of coverage in private

hospitals, while more comprehensive plans bear the full cost of treatment in any

private hospital.

Although it represents only a fraction of the total cost, and all plans must provide

coverage complementary to the contributions paid by those who seek th e services of

public hospitals, the hospital costs for personal expenses is limited.

In contrast, coverage for primary care is less comprehensive, so that over two

thirds of the population supports the individual costs for this type of medical services.

Over time, private health insurance market has not proposed to cover these costs but

to provide protection for medical costs in case of disaster.

We are not dealing with a list of priorities in terms of medical services but with an

implicit approach to the basic package, used for both hospitalized patients and for

those who are not hospitalized.



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In the Netherlands, the basic package of health services is defined mainly by the

Central Government, by establishing broad categories of services. Basically, it

established a list of categories of service that every patient has the right (the nature of

the medical, pharmaceutical,) specifying the areas of care covered by the insurance

scheme, without specifying in detail what are the rights of the insured.

Nomination excluded from the basic package of services is a government decision

to regulate medical care. This excludes a number of transplants and plastic surgery

procedures, stipulating which of the categories of transplant are covered and that

access to a range of other medical services is allowed only under certain conditions.

Through such regulations of some services are excluded as well as reconstructing

eyelids, body sculpting, fertilization "in vitro", sterilization, and circumcision. Policyon fertilization "in vitro" has changed several times, insurers now cover only those

medical procedures after a first attempt at fertilization (paid directly by the insured)

has failed.

Pharmaceutical prescriptions during hospitalization is a part of the right to medica l

care, they are funded, in general, by the hospital budget. Insurers may cover, in

addition, a very expensive part of the cost of drugs prescribed during hospitalization.

An exception to the usual rules of health services is a specialized psychiatric care

in the area, whose coverage is provided by a special law. Outpatient psychotherapy is

covered financially within certain limits and only if there is a reference to the general

practitioner or psychiatrist. Rights of patients with such disorders include treatment,

supervision, accommodation and food, special regulations are applied for child care

and for treatment with substances that generate addiction. The introduction of mental

health care in the basic package is an objective of future legislation on the matter.

In the Netherlands, pharmaceutical costs are relatively low compared with other

European countries, medicines represent less than 9% of total health budget. In recent

years, however, the cost of spending on medicines significantly increased, whic h can

be explained partly by the increase of elderly population, the increasing incidence of



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chronic diseases and medical prescriptions, an additional factor in this regard is the

emergence of new drugs, more expensive than those used previously or replace them.

In an effort to preserve public access to pharmaceutical products, government took

a series of measures to control drug costs for patients not hospitalized, the Health

Ministry is responsible for deciding whether a new drug will enter or not in the

package and also it decides which to remove from the package of medicines made

from a therapeutic standpoint.

Government is the settlement system which adopts the basic package of drugs and

he also sets maximum prices, by a law dedicated to this purpose. In addition,

government actions aimed at boosting the role of the market on a competitive basis in

order to maintain prices at a level as low as possible.Approved drugs do not automatically qualify for settlement in the basic package,

some of which are only partially compensated, while others go through an evaluation

procedure and analysis before taking a decision in this regard. Determining factors in

the evaluation process are the therapeutic effect of the products concerned and that

they do not exceed the cost of similar drugs from the basic package.

The settlement system determines the compensation for medicines, based on the

average cost of drugs with similar effect that can be replaced and which are

considered as a group of substitute products. If the price of a particular drug is higher

than the group average, the additional cost will be borne by the consumer. Basically,

there are enough alternatives available to allow selection of a drug completely

compensated, so that patients can buy medicines wit hout having to pay extra.

Ministry of Health intends to lower the cost of medicines are not patented, as well as

compensation for drugs for which there is a proprietary alternative.

Programs to support pharmaceutical research is subsidized by the governmen t.

They were initiated by the pharmaceutical industry, in collaboration with the

Government of universities and research centers. The purpose of these programs is to

sustain and increase the number of interdisciplinary studies pharmaco -economic

field.





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structured in terms of practice development, which led to the appearance of 31

therapeutic guides, which refers to the 23 disorders in some groups of diseases. These

guides therapeutic, self-regulated, are used by doctors as a rule of practice in the

field, both within and outside their hospitals. They serve as a landmark in defining

the best standards of care, according to clinical diagnosis. Paramedical care such as

physiotherapy, speech therapy services, curative and ergo -therapy treatment are

covered partially.

Germany has the richest practice of health insurance and decentralized system of

compulsory health insurance. Germany currently consumes approximately 8.1% of

gross domestic product. Almost 90% of the population engages in mandatory health

insurance and 10% receiving medical ser vices through voluntary health insurancejudgments. 3% of the population full fill compulsory health insurance policies

through voluntary health policy to higher quality health services, in a more

comfortable and in full volum to the doctor or health care institution preferred.

The financing of medical institutions in Germany are divided as follows: 60% by

health insurance funds, 10% through voluntary health insurance, 15% through state

allocations and 15% of citizens through their own sources.

Health insurance funds are accumulated from three sources: state budget, the first

employer and employee premiums. Average premium is 13% paid equally by

employer and employee.

In Germany there is no law on compulsory health insurance. Health insurance is

divided into three main categories: social, by law and voluntary:

1) Social Insurance

It is a supplement to Social Security that allows to obtain health services in

ambulatory and stationary conditions and the dentist. On these policies most patients

receive also free medication. For this policy the insured person does not pay

anything. All costs are incurred by local government policy where the insured person

lives. Policies (one for GP and one for the dentist) are remitted to the insured person

in each quarter. Policy is withdrawn by the doctor when addressing, such the person



- 25 -

which have social policy of carrying health insurance can not appeal to another

doctor than the designated by policy, but if necessary, the GP sends a patient to any

specialist who patient needs. There in a free choice of doctor in Germany. So even

people who have no income and access to qualified medical assistance. Persons who

are under the protection of social assistance (homeless people - people without

residence visa and other categories) do not benefit from these policies.

2) Ensure by law

This type of insurance covers 80% of the population of Germany. It is mandatory

for all employees with lower income levels than established (currently this income is

about 6000 ¼ / month). Insurance is carried by hospital houses. These houses are

organized on the principle of ter ritorial or special guild houses seamen, miners,federal homes, homes of farmers. However, the person is free to choose their own

insurance fund. Insurance premiums are paid by the insured person a percentage of

her/his salary in half and is paid by the employee and the employer. Each house has

insurance that different percentage value, from 9 to 14% from salary. Evidence of

accumulated resources and other necessary information are entered on magnetic

cards. The insured person may receive medical services a t any medical facility in

Germany. If the insured person has a higher income than he established he covers a

part of the cost of medicines, and if revenues are lower than the level set the person is

exempt from payment of a part of premium. Students are required to ensure

admission to the institution. The monthly premium for a student is about 80 ¼.

Compensation paid by health insurance can be divided as follows:

1. compensation for maintaining health - health enlightenment and methods of

disease prevention;

2. compensation related to prevention of dental diseases (including schools and

kindergartens), specialists in preventive measures, including supply of medicines,

dressing materials, curative and auxiliary supplies as well as preventive measures for

women;



- 26 -

3. compensation for early diagnosis of diseases. Insurance policies provide that

policyholders aged over 35 years every two years have to pass a rigorous medical

examination, annual inspections of cancer prevention for women aged over 20 years

and men aged over 45 years;

4. compensation for treatments that are divided into:

dental care, including prosthetics;

free supply of the standard package of medicines and dressing materials

Note: additional costs related to procurement of drugs and dressing materials are

more expensive and higher quality are incurred by the insured;

auxiliary material supply, with payment of 10% for insured adults;

free supply of hearing, and hearing aids, orthopedic and if these devices have a

fixed price;

patient care by a qualified home if hospitalization is indicated, but it can not be

done. Also are given care and housekeeping help if the policyholder can not meet

household obligations and the in family are children up to 8 years old or disabled

persons dependent on help of the third person;

medical expenses and other additional expenses related to medical

rehabilitation.

5. compensation for incapacity. This compensation constitutes 80% of the total

amount of income after paying all taxes, starting in the seventh week of incapacity for

work because of illness.

3) Optional Insurance

Voluntary health insurance in Germany is a luxury service. Under existing

requirements can be insured people who have an income less than ¼ 6,000. Until the

contract the person is subject of a medical examination as t he insurance premium

depends on health status, age and other causes. Free Issue of medicines through

voluntary health insurance is not provided. In case of hospitalization of the insured,

provided a room for him individually and curing by the head of the c linic. Holder of

voluntary health insurance policy benefits from increased attention from health



- 27 -

workers. The only downside of voluntary health insurance is that (and this is

legislated), if the person was denied social security office or by law for ensuri ng the

voluntary return to traditional social insurance is not allowed.

In France, compulsory health insurance is carried out centrally by law, regardless

of ownership. Mandatory health insurance is made centrally, by law, regardless of

ownership. Large and small collectives and free professional people, conclude

mandatory health insurance contracts. Over 80% of the population engages in social

health insurance. One of the features of the French system is franchising of insurance

payments. Mandatory health insurance pays only 75% of the cost of medical

expenses, the remaining 25% pays the person independently or by contracting

voluntary health insurance. Compulsory health insurance in France covers themajority (70-90%) the cost of drugs purchased.

An important feature of state activity in the social insurance is the management of

prices for medical services and cost of drugs domestically. Prices are reviewed twice

a year periodicity, and, mainly, to raise them.

French insurance companies offer to the population a much wider spectrum of

medical services than those included in the package of medical services required and

mandatory health insurance system of France compensates in some cases and certain

expenses incurred by the insured.

As in other countries, health insurance funds in France consist of financial

accumulation of individuals, employers and transfers from state budget allocations.

In Great Britain the negotiations between state and society on the organization of

health care continues over 50 years. In 1948 in England was nationalized health care,

and this time, negotiations between state, society and the patient does not cease.

Collaboration continues to build a model tends to the optimal functioning of the

public health care system and a fruitful collaboration between the three participants in

this system.

Special interest in British health care system is the work of two organizations

defending the rights of the patient:



- 28 -

a) a state organization, through its legal representative as Parliament in health

problems (Health Service Ombudsman);

b) nongovernmental organization. Movement in defending victims of medical

mistakes - AVMA (Action for Victims of Medical Accidents).

Supplemental health problems delegate of Parliament was held in 1973. This

service is a service department of the delegate of the Parliamentary Human Rights

(Parliamentary Ombudsman). This service specializes in handling complaints about

the shortcomings in the work of national health care (and government departments

the medical staff and outpatient, dentists, ophthalmologists, family physicians).

Authorized person is not subject to parliamentary government and is independent of

the national health system. A staff from 80 people is filled with experts specificallytrained, with medical and legal studies.

This service is represented by expert groups in three regions of Great Britain:

England, Scotland and Wels. It should be noted that the legal settlement of the case

and medical expertise are free. Preliminary, is compulsory the defendant to file

complaint to the county health and wait for an answer, it is also necessary that the

moment of appearance of deficiency in treatment does not exceed one year. The

purpose of this service is independent assessment of the state health service and

helping patients. Conclusions of the parliamentary delegate are presented for

hearings and decision making, for the need to improve public health system.

Movement in defending victims of medical errors was born in 1982 as a charitable

movement in support of patients who suffered from various incorrect treatments. The

purpose of this movement is to protect, as far as possible, patients of medical errors,

or where it is impossible to minimize them. In case if could not avoid medical error,

patient or family should receive compensation concerned.

Movement in defending victims of medical errors on the position of the company

cautions health care system that believes that the adverse effects of treatment are an

inevitable result of insufficient funding and medical s taff overload. As a result - and

recognize the consequences of errors. The work of this movement in England has



- 29 -

imposed famous English legal system to recognize that medical errors are a particular

area of activity that requires some reforms in the judiciary of the country as well as

special training for judges to adopt the correct and timely decisions.

2. American Experience

The United States health care is one of the most complicated, costly (health

spending is about 14% of gross domestic product) and one of the most burdensome as

a system for management. The U.S. government covers more than 40% of all

spending for medical services rendered to insured persons.

The state covers two basic programs: "Medikeid" and "Medicare".

State insurance program "Medicare" is a program that ensures people over age 65

or who are approaching that age, but has serious health problems. Some of thenecessary financial resources for formation of fund of this program shall consist of a

special tax that pays the employees, another pa rt is paid by the employer, in sum, that

tax revenue is about 15% of employed Americans. The last necessary part of fund

that remains is covered by the state.

Program "Medikeid" provides insurance to the poor, mostly women and children

from socially vulnerable families. This program pays admission to nursing homes for

elderly people requiring constant care and can not do without the help of others; for

these services are spend more than half of the funds this program.

Funding for the program is twofold: the federal funds, about 50%, another part is

paid by other governments in each State.

In the United States is highly developed tradition of insurance of employee on

company account. In addition to health insurance employees can benefit for life

insurance from loss of working capacity and other types of insurance. Traditionally,

employers insure employees, but the costs for medical services provided are franchise

- the insured person pays 20% of these costs and 80% of the insurance company pays.

These types of insurance are a little like social health insurance practiced by other

countries and represents commercial insurance, but on the account of the owner. In



- 30 -

the U.S. they are called ³insurance compensations´ because the insurance company

compensates the 80% of expenses incurred for treatment.

Another commonly practiced form of insurance in the U.S. is so-called ³directed

expenditure´. The essence of these schemes is that health workers and most of them -

hospitals, nursing homes for the elderly, networks or associations of health workers

with free practice, enter into contracts to provide medical services to insured persons

in return for fixed premiums for each person. In this variant the risk that spending

will exceed revenue is removed on the shoulders of health care providers, evident and

their economies remain the same.

2.2. The place of health insurance and problems related to it in the national

sector of Republic of Moldova

The transition of the republic built on the company planned economy to a marke t

economy has had repercussions in all spheres of social life, conditioning the

substantial changes in socio-demographic situation of the country. Analysis of the

demographic processes across the country during the transition shows a pronounced

reduction in population. The process of decreasing the population of Moldova has

held in several cases, the main being the dramatic fall in birth rates in recent years,

increased mortality and migration tide.

Medical insurance occupies a special place in the public welfare system. On the

one hand, it is closely related to other types of social insurance: unemployment

insurance cases revenue, loss of working capacity, the injury, as from disease,

accident at work, unemployment and disability, there is a close mutual c onnection.

On the other hand, it differs from other types of social insurance by the degree of

population coverage. If the unemployment insurance need people who came from the

work activity, so medical insurance need employees and citizens alike are not

enrolled in labor.

Unlike other types of social insurance, social assistance is granted medical

insurance rather than cash, but natural, because the disease can be treated based on



- 31 -

the use of certain drugs and medical services. In health insurance (and the stage of

rehabilitation) should be paid and provided the interested medical goods and services.

In health insurance, medical assistance is determined by size of target -set of

patients need (medical care, treatment, etc.), which provides absolutely required, for

ethical reasons and, unlike other types of social security does not depend on the

previous wage.

In transition economies, given the sudden descent level of social protection should

focus on mandatory social health insurance on reasonable scale.

In the first half of the 90's, Moldova has worsened indices that reflect population

health: reduced life expectancy, increased mortality (including newborn), the

morbidity of infectious diseases (tuberculosis, diphtheria, dysentery bacterial,syphilis, etc.). In transition economies, health is one of the factors that influence the

degree of adaptation to the current economic situation. For many poor health prevents

them find their place in the market economy.

Birth indices both fell in Moldova due to shrinkage in the number of women of

appropriate age, both because women refuse to give birth. The primary reason is lack

of confidence in tomorrow, the second material problems arise, the third position -

living conditions.

The decrease of birth in Moldova occurs on the back ground of population increase

in mortality (Table 2.2.2).





- 33 -

Table 2.2.3

Changes in the age structure of the Moldovan population (%)

Age 1979 1998 2005 2005 weight in

% to 1979

0-910-19

20-29

25,916,1

17,3

18,318,3

18,0

16,918,0

13,9

65,3111,8

80,3

30-39

40-49

50-59

14,8

10,4

7,9

11,5

12,6

10,5

15,7

13,4

9,0

106,1

128,8

113,9

60-69

70 and over

4,9

2,9

6,4

4,4

7,8

5,3

166,0

182,8

As shown (Table 2.2.3), the age structure of population is a perceived reduction in

the rate of younger age groups as a result of reduced birth rate. At the same time

increase the rate of old age groups. So, for example, the share of population aged 0 -9

years in 2005 constituted only 65% of the corresponding rate in 1979. Also the share

of age groups over 60 increased by 166 and 182.8%, respectively.

The demographic factor in the next 10 years will have a destabilizing influence on

the economy (social and military spheres).

Income difference also plays an important role in stimulating people's initiative toconclude a contract of health insurance and oriented towards increasing the efficiency

of labor, which in turn is exacerbating inequality. Inequality, t herefore, is a close

connection with economic efficiency, and the company is putting the task: how

should redistribute income, to minimize loss of effectiveness.

Director E. and J. Stigler (USA) have concluded that compels state income

redistribution in favor of the interests of the wealthy and middle class but the poor

have almost nothing.

Redistribution to social protection is performed by several methods:

transfer payments, it means benefits paid to low-insured groups, pensioners,

unemployed etc.;

price regulation at important social production;



- 34 -

indexation of fixed income and transfer payments in relation to the inflation

rate;

statutory minimum wages in all spheres of the economy;

imposing progressive taxes for which tariff revenue increases as the nominalsize. This determines the actual size of the income tax roll and rate, influencing the

size of savings, determine the size of the real demand.

The system of social protection in transition economies must ensure the health and

lives of all population groups in case of the general risks of life (old age, sickness,

unemployment, accidents, etc.), to standardize the initial distribution income market

conditions (special allowances unemployed, housing subsidies, payment of

compensations to families with many children, pensions and student grants) and

prevent worsening working conditions in production (the injury prevention field

production, protection of youth work, etc.) and the general situation labor markets

(middle looking for work, professional counseling, paying benefits to persons who

work only a half day).

Insurance is an effective means of social protection of population in conditions of

market economy, it carried the principle of a single space (general) social issues

unique standards when the state (general) population social protection, minimum

guarantees in payroll administration, paying pensions and granting benefits,

scholarships, medical assistance in the areas of education, environmental protection

of the population - by creating the appropriate legal basis to national and local

territorial level, in line with economic conditions change: the standard of living, price

index and labor income growth.

Providing social assistance to ensure a record number of people with the poor

class, the principle of social self-protection system, where the administration of social

insurance bodies are freed from direct state administration system.

Health insurance market is largely affected by the causes of deaths occurring after

illness.



- 35 -

In CIS countries, first in cases of death are cardio-vascular diseases, the second -

oncological diseases, on the third - the reason is external (accidents, suicides,

murders, accidental poisoning, including alcohol). The last group of diseases is an

important factor in the loss of potential years of life, because they affect youth and

people of average age.

The same situation is in Moldova (Table 2.2.4).

Table 2.2.4

Mortality causes of Moldova's population (in%)

1995 2005

Total deaths 100 100

Reasons: Infectious Diseases 1,2 1,6

Cardio-vascular diseases 43,2 50,3Malignant Tumors 13,6 11,6

Respiratory Diseases 6,6 6,2

Digestive Diseases 9,5 9,1

Nervous System Diseases 0,7 1,0

Accidents and poisoning 10,6 9,5

Other diseases 14,6 10,7

As we draw conclusions, the place it occupies predominant causes of death

between cardio-vascular diseases for which the rate of growth is a visible trend.

Worsening socio-economic conditions of life of people, reckless attitude towards

healthy lifestyle (improper food, smoking, alcohol), lower health -epidemiological

control, ecological crisis because of factors which increa se social stress and the

morbidity and mortality.

The economic crisis has negatively influenced health care in Moldova, to maintain

previous volume level for the granting of basic health services.

The transition to market relations, the liberalization of prices and tariffs for goods

and services, the cause of the increased cost of treatment and preventive care, has

worsened the problem of funding. Regardless of the large number of doctors and

hospital beds per capita, medicine is no longer able to protect h uman health. It's not a



- 36 -

secret for anyone that is currently in Moldova patients are forced to come into

budgetary hospitals with medicines, linen, own food.

Medical insurance system in the transition economy is a system of reports on the

protection of material interests of the population, health related. This protection is

made contributions towards the expense of training to ensure health insurance funds,

to pay for healthcare insurance if needed.

Any type of insurance, primarily health insurance to be charged correctly, should

be well thought out on a technology plan.

The unique program of compulsory insurance provides that upon occurrence of

health problems, the insured person or emergency service is addressed to the family

doctor. In the case of voluntary health insurance, the person may apply to private or emergency medical service specialist medical institution, upon request, for

consultations, investigations and treatments. Placing scheduled (for chronic diseases)

in public medical institutions shall be made only upon:

ticket issued by the family residence under visa of the patient (principle of

territoriality);

regional advisory councils medical decision;

Regulation stating internment scheduled medical institutions (waiting lists).

The causes of bad health in Moldova are the prevalence of risk factors in lifestyle

and environment, and the absence of effective prophylaxis and the low level of

medical services. The situation is not corrected by the already developed programs

because of insufficient funding.

Health is not only one basic human rights, but also a state resource, a necessary

condition for progress of society, to be achieved through: improving people's living

standards; promoting a healthy lifestyle, environmental protection and enhancing

efficiency of healing and prevention of diseases, improving health services through

more sustained application of economic levers and diversification of financing of

medical institutions; strengthening the institutional capacity of public health sector by

issuing the legal and health management restructuring.



- 37 -

Conclusions

Making a full study on the insurance market problems and the mechanisms of legal

regulation of health insurance in Moldova have arrived at these conclusions, and also

formulating some proposals:

1. For a more extensive protection of population against unwanted consequences

of insurance events, the state creates conditions for ensuring the protection in

individual insurance - health insurance. The establishment and development of health

insurance is a necessary condition of national economy's recovery.

2. Research situation on the insurance market in Moldova currently generates

Track the conclusion that market is still in formation stage. Research on the market

situation this is due to: 1) low purchasing capacity of the main consumers of insurance, 2) inadequate capitalization of the insurance, 3) unfavorable taxation

system, 4) lack of economic incentives, 5) lack of knowledge and experience in

implementing on the market types of mass insurance.

3. A current issue of the domestic insurance market is the small number of

proposals from insurers. Moldovan insurers currently offering 30-40 budge types of

insurance services, while insurance market research in developed countries shows

that the services of over 300 insurance the most varied types.

4. Considering that in most European countries the insurance supervisory bodies

are separated by institutional and absolutely independent, we believe that for

effective supervision of insurance activities, Insurance Supervision Inspectorate and

non-state pension funds must be separate from the Ministry of Finance and

subordinate to Government directly. Control bodies must be independent, free from

departmental interests, have clear responsibilities, based on the law.

5. We believe that financing of the insurance supervisor should be done at the

expense deductions of insurance premiums collected by insurers on all types of

insurance or certain types, based on the estimate approved by the Government.



- 38 -

6. In order to guarantee the payment ability and financial stability of insurers, we

believe necessary to operate on the insurance law of RM a number of restrictions on

insurers by the end of legal documents.

References:

1. Law on mandatory health insurance Nr.1585-XIII from 27.02.98

2. Law on Insurance nr. 407-XVI from 21.12.2006.

3. Capsizu Valeriu,Lascu Dumitru, Covali Olga Finanarea ingrijirilor de

sntate in rile cu economia in tranziie // Studia Universitatis. Seria Ätiine

Exacte i Economice´. í Chiinu:CEP USM, 2008, Nr. 8 (18)- P. 142 - 147.

4. C. Eco, Iu. Malanciuc, V. Idricean. I mportana marketingului in perioada de

trecere asistemului ocrotirii sntii la economia de pia // Revista ÄSntatepublic, economie i management in medicin´. Chiinu, 2004, nr. 4, p. 21 -23.

5. C. Eco, Iu. Malanciuc, V. Idricean. P rincipiile conceptuale ale asigurrilor de

sntate// Analele tiinifice Volumul I, Problemele medico-biologice, farmaceutice,

de sntate public i management. Zilele Universitii 16-17 octombrie 2003, p. 398-

403.

6. V. Idricean. C alitatea serviciilor medicale i aprecierea ei in cadrul

asigurrilor de sntate // Analele tiinifice Volumul II, Problemele actuale de

sntate public i management.Zilele Universitii consacrate jubileului 60 de ani ai

invmintului medical superior din Republica Moldova. Ediia VI 3 -7 octombrie.

Chiinu, 2005, p. 260-263.

7. V. Idricean. C alitatea serviciilor medicale i aprecierea ei in cadrul

asigurrilor de sntate // Analele tiinifice Volumul II, Problemele actuale de

sntate public i management.Zilele Universitii consacrate jubileului 60 de ani ai

invmintului medical superior din Republica Moldova. Ediia VI 3 -7 octombrie.

Chiinu, 2005, p. 260-263.

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