A new law on healthcare reform has recently been promulgated and reconsiders the issue of voluntary health insurance. Its main objective is to provide access to quality healthcare for all citizens, while giving a better use to the public health funds. This law will attract more money in the system and allow for competition among healthcare providers. It emphasizes the quality of health insurance, with the aim of promoting efficiency through enhanced competition.
The provisions on voluntary health insurance are intended to improve the general statute of activities in this field by promoting preventive health insurance, but they will also trigger an increase in the income of personnel working in the system, which can help reduce the level of informal payments.
Private insurance companies play an important role in funding the access to high quality healthcare services, as they can cover benefits that are complementary or supplementary to public insurance and conclude contracts both with public and private providers.
We must underline that applying provisions on voluntary health insurance implies the drafting of methodological norms where the most significant ones concern a more explicit description of the basic benefits package covered through the public system. Basically, the very terms of complementary and supplementary used in voluntary insurance are only relevant if connected to a reference element which - in this case - is the basic benefits package itself.
If what they say it’s true and healthcare models cannot be imported, the same goes for the international experience in the field and the existing trends which represent, however, the basis for a theoretical approach of the issue we are dealing with.
Thus, we can identify a trend towards a clearer definition of the basic benefits package. If countries that have recently introduced a new legislation on health defined their basic benefits package more clearly, other countries with an older legislation on health defined this benefits package rather implicitly, but continue to work more and more with negative lists. In addition to negative lists with excluded services, the DRG system and the grouper for medical procedures are often used in defining the basic services. This reality can also be explained by the fact that an explicit definition requires a transparent and clear decision criterion for service inclusion or exclusion.
The process of defining the basic benefits package takes into consideration the fact that a successful reform conducted on a large scale usually lasts for several decades. A dedicated team, with the necessary skills and experience, must be created in order to draft and coordinate a detailed implementation strategy. Strengths of the already existing system can also be used in this process. The assessment rules must be established first and then, to ensure continuity in shaping the package, the changes must be gradually introduced in the healthcare system.
An extensive agreement of the stakeholders is needed from the very moment of setting the content of the basic benefits package, even though the social responsibility for its definition and drafting belongs to the government. Both technical and political issues must be considered when drafting this package. There are three technical problems that need to be addressed simultaneously. Firstly, the package’s content and purpose must be established, secondly, the package must be assessed and last but not least, how it is going to be funded.
The criteria used for setting the priorities for the basic benefits package are as follows:
• need for services, from the medical point of view;
• efficiency of procedures;
• economic efficiency;
• stimulating own responsibility towards healthcare.
In a common language they can be associated with the cost, the quality and the ethical criterion for the assessment of services.
Technical criteria must remain a priority, both in the phase of initial definition of the basic benefits package and in its subsequent developments. We must first consider the drafting of explicit lists for included and excluded medical services, but also other objective coordinates, as follows:
a) The explicit negative list of healthcare services that are not covered by the public system must be clearly defined. The existing exclusion list from Romania is a good starting point, but must be extended in line with the current and future budget limitations.
b) An explicit positive list of services covered by the public system must also be defined by improving and itemizing the existing one. We think that the DRN system might be used to group services provided to inpatients, and the medical coding system, linked to the one for diagnosis related treatment codes should be used to define the services in the basic benefits package for outpatients. A rapid integration of the DRG coding system implemented, for instance, in Australia, is recommended so as to ensure a harmonization with the ICD 10 AM diagnosis coding, already used in the international practice.
c) When assessing services, the cost, the quality and the ethical criterion are benchmarks to be considered in prioritizing their inclusion in the basic benefits package content. The list of priorities, starting from the above-mentioned criteria should then be itemized per category of services - high, medium or low priority - maybe accompanied by a graphic representation that associates green, orange and red colors.
d) A commission for the assessment of technology used in healthcare should be set up in order to define systematically (depending on the cost-efficiency criterion) the opportunity and need to introduce new technologies and drug treatments on the positive, priority list for the basic benefits package.
e) A multi-layered co-payment system for services provided to inpatients and outpatients, including pharmaceutical services, must also be introduced, depending on the above-mentioned priority lists. High priority cases will not have to take on these co-payments, while low priority cases will have to take on some co-payments, based on an adjustable scale. Such a context will set the basis for public-private collaboration in health funding activities.
f) Studies on the impact of defining the basic benefits package as noticed on expenses must be tested in various areas of applicability to allow for a correct assessment of the real financial costs needed to cover the included medical services. Depending on the impact studies’ results, the content of the basic benefits package might undergo some adjustments.
Stimulating the growth of the private health insurance sector must consider that a voluntary health insurance framework has already been created. Given this context, the basic benefits package can be reasonably limited according to its funding possibilities, which will reduce considerably the difficulties of the public system and cover the Romanians’ needs closer to an optimum level.
Thus, the public-private partnership will be able to make additional resources available to those who cannot afford voluntary health insurance. The initiatives aimed at promoting, directly or indirectly, the growth of the voluntary health insurance market, imply the introduction of fiscal incentives, including the deductibility of insurance premiums for this type of products. Also, the possibility of reducing the employees’ and the employers’ contributions to social health insurance is another possibility to be considered. | 
