KS Health Insurance Fund saves on citizens' health, patients uninformed about rights

SARAJEVO, (Patria) - The Audit Office of FBiH institutions conducted an audit report of the Sarajevo Canton Health Insurance Fund. Although they received a positive opinion, a number of objections were found. Some of them include insufficient transparency, failure to inform patients about their rights, which resulted in nearly three million KM remaining unspent.

The KS Assembly adopted the Restructuring Plan for Healthcare Activities and Reorganization of Healthcare Institutions, as well as an Action Plan defining the dynamics of reorganization, but no changes have occurred in the organization of healthcare, writes Akta.ba

The allocation of funds and contracting of healthcare services with healthcare institutions in the Canton Sarajevo for 2019, amounting to at least 291,265,877 KM, were carried out based on criteria that are not in accordance with the Law on Healthcare.

The Fund's expenditures and expenses for 2019 were realized less than planned by 50,591,008 KM.

This was partly a consequence of the Fund's acts not being available to all patients with medical indications, which prevented insured persons from exercising their rights to diagnostics and treatment for seriously ill children, refunds for medically assisted reproduction services, use of medical rehabilitation and financial aid for medical rehabilitation, treatment through special and additional healthcare programs, financial aid for purchasing medicines not on the Sarajevo Canton List of Medicines, and for treatment abroad, which is not in accordance with the Law on Health Insurance.

New contracts with suppliers for the realization of costs for insured persons for orthopedic aids based on a public call were not concluded, which resulted in insured persons using their rights less.

A supplier was not selected for the provision of family medicine services, for deficit healthcare services, and consultative-specialist healthcare services, thereby violating the Law on Public Procurement, and active competition was not ensured when selecting a supplier for the maintenance of existing integrated information systems.

An interesting observation by the auditors is that the President of the Management Board and the former Director of the Fund concluded an employment contract in 2017, which stipulated that the director would receive the same salary even in case of dismissal and would be assigned to another indefinite-term position upon the expiry of his appointment.

This is not in accordance with Article 11 of the Law on Salaries and Benefits of Members of Management Bodies and Other Institutions of KS, Cantonal Public Enterprises, and Public Institutions Founded by KS.

The auditors were not presented with proof that the Management Board had decided on such a contract, and thus the President of the Management Board did not comply with the Rules of Procedure of the Management Board and Article 17 of the Fund's Statute.

The Commission does not have Rules of Procedure and has not adopted a procedure based on which insured persons will be included in therapy.

Instead, the document "Procedure for the treatment of insured persons suffering from rheumatoid arthritis and similar diseases with biological therapy for 2018-2019" was applied, which was prepared by two doctors, who are also members of the Commission representing KCUS.

Here, new irregularities were found because the Commission, based on the proposals of these doctors from KCUS (who are also members of the Commission) and solely on the basis of medical documentation, approved the inclusion of patients in this program.

It should be noted that there is a waiting list for inclusion in this program, but there are no criteria for harmonizing the waiting list and the inclusion of patients from the list.

"The Fund did not publish the existence of the Agreement that establishes the right of insured persons to use biological therapy for rheumatoid arthritis, and the Commission, in accordance with the Agreement, did not adopt a written procedure based on which insured persons were included in therapy," the report states.

Insufficient efficiency in the implementation of the Program for Diagnostics and Treatment of Seriously Ill Children, and insufficient transparency, are the conclusions of the auditors, all of which resulted in unspent allocated funds for the mentioned purposes in the amount of 1,380,984 KM and unused rights.

The Fund also did not publish in the Official Gazette of KS, nor on the notice board or website, the regulations, agreements, and programs that define the conditions and criteria for exercising the right to reimbursement for individuals for medically assisted reproduction services, use of medical rehabilitation, and financial aid for medical rehabilitation, and treatment through special and additional healthcare programs.

As a result, due to insured persons not being informed about the conditions and application methods for awarding funds, unspent funds remained solely in these positions in the total amount of 2,712,158 KM, with the largest amounts in the positions for additional funds for treatment under special programs (1,213,249 KM), the program for treating children (980,984 KM), and the program for assisted reproduction (413,095 KM).

"Therefore, we conclude insufficient transparency and efficiency of the Fund, which is not in accordance with Article 4 of the Law on Budgets in FBiH. Also, all patients with medical indications, given that they were not informed of their rights, were not in an equal position, which is not in accordance with Articles 8 and 11 of the Law on Health Insurance," it was concluded in this report.