POSSIBLE APPROACHES TO BENCHMARKING VOLUNTARY HEALTH INSURANCE FUNDS IN BULGARIA

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1 Possible approaches to benchmarking voluntary health insurance funds in Bulgaria POSSIBLE APPROACHES TO BENCHMARKING VOLUNTARY HEALTH INSURANCE FUNDS IN BULGARIA Petko Salchev, Nikolai Hristov, Lidia Georgieva, Medical University of Sofia (Bulgaria) ABSTRACT Following the adoption of the Health Insurance Law in Bulgaria (1999), which provided the legal framework for the development of voluntary health insurance, several health insurance funds were established. While Bulgaria had two licensed voluntary health insurance funds in 2001, in 2003 their number grew to six, and in 2009 this number stood at over twenty. Despite the increasing number of funds in recent years, their share in health care spending remained at 1-1.5%, which is below the European average. To this date, the scientific community in Bulgaria has not produced any serious, in-depth studies in this field. The economic data published by the Commission of Financial Supervision (CFS) conform to EC regulations, but do not allow non-specialists to get a realistic assessment of voluntary health insurance funds (VHIF). This article introduces a methodology for comparing VHIFs and establishing a complex index (Benchmark Index BI) based on 5 groups of indicators related to several available variables. This index is intended as a tool for analyzing the voluntary health insurance sector and managing resources through a set of analytical indicators and variables. It can be used to create a certain type of ranking of VHIFs. Keywords: voluntary health insurance, market, comparing methods, benchmark index INTRODUCTION The development of the insurance market has greatly influenced the roles of businesses dealing with the organization and provision of insurance services. Some of the major challenges to all the market players concerned include the constant demand for new forms of insurance, the development of competition and a free market for the services offered, the growing motivation of companies and individuals to buy new types of coverage, and the higher insurance culture of businesses and individuals. The main challenges facing voluntary health insurance are related to: Honesty, loyalty, transparency and heightened social sensitivity to clients needs; In-depth knowledge of legislation, regulatory mechanisms and requirements concerning different forms of insurance; Individualized marketing and client servicing; Development of insurance forms and models to increase the motivation for enrollment in insurance plans; Provision of measures for safeguarding clients interests ensuring security of the invested money, collected information, etc.; Perfect knowledge of the theory and practice of insurance relations, forms of insurance, and different methods and models; Provision of clear, accessible and understandable information regarding insurance relations; Knowledge of the various options for meeting the different individual or company insurance problems and needs; Transformation of the service seller role into the personal consultant and counselor role for all involved in this business; Introduction of organizational, informational and other innovations focused on the client. Following the adoption of the Health Insurance Law in Bulgaria (1999), which provided the legal framework for the development of voluntary health insurance, several health insurance funds were established. While Bulgaria had only two licensed voluntary health insurance funds in 2001, in 2003 their number grew to six, and in 2009 this number stood at over twenty. Despite the increasing number of funds in recent years, their share in health care spending remained at 1-1.5%, which is below the European average. Journal of Health Policy, Insurance and Menagement 101

2 Petko Salchev, Nikolai Hristov, Lidia Georgieva Table 1. Comparison of public and private funds General government (Percentage of GDP) Private insurance enterprises (other than social insurance) (Percentage of GDP) Austria Belgium Bulgaria Switzerland Cyprus Czech Republic Germany Denmark Estonia Spain Finland France Hungary Iceland Japan Lithuania Luxembourg Latvia Netherlands Norway Poland Portugal Romania Sweden Slovenia Slovakia United States Source: Data from Eurostat, The market for voluntary (private) health insurance funds in Bulgaria has been growing in recent years, but with some unfavorable features: Unclear packages of services offered; Supply of services identical to those offered by mandatory public insurance; Low share in total health care spending; Ambiguity concerning the type of insurance offered additional, replacement or supplementary; Lack of motivation for getting coverage among the general population (for fear of Ponzi schemes); Predominantly corporate-based insurance insurance packages for whole companies due to tax concessions. Table 2. Public health care spending by year Public spending/years Total health care spending Including: Ministry of Health ,80 National Health Insurance Fund ,00 Municipalities ,10 Others , May 2011 N o 1

3 Possible approaches to benchmarking voluntary health insurance funds in Bulgaria Table 3. Health insurance funds (number, premium income and claims paid) Voluntary (private) health insurance Number of funds Premium income 3,315 6,405 11,628 17,788 22,297 25,353 30,307 Claims paid 0,427 2,571 5,625 9,466 12,598 15,319 21,108 Premium income as a percentage from total public spending Claims paid as a percentage from total public spending When analyzing the services and packages offered (Table 4), it becomes clear that premium income comes mainly from other packages, followed by those for outpatient medical treatment and reimbursement; claims paid demonstrate a similar structure. The data demonstrate ambiguity in the offered services; no fund is able to specify what it means by other packages and reimbursement of expenses. In spite of the upward trend in this type of insurance in Bulgaria, the scientific community has not been engaged in serious, in-depth studies in this field. In the course of the last 9 years, there have been 36 publications related to voluntary health insurance: a third of them are literature reviews, two are monographs on the underlying principles of different insurance models, five investigate the activities of certain insurance funds, and several present discussions on future developments of the health insurance system. Accurate and accessible information regarding health insurance activities can be found exclusively in the data published by the Commission of Financial Supervision (CFS). In principle, managerial and customer decisions can only be based on reliable data concerning insurance companies. In view of this Table 4. Distribution of premiums and claims paid according to type of package during the studied period PACKAGE TYPE Premiums (trimesters) Claims paid I II III IV I II III IV 1. Health promotion and disease prevention 12.40% 12.55% 11.07% 10.75% 10.83% 12.51% 10.31% 10.28% 2. Outpatient medical services 18.47% 18.54% 26.51% 25.98% 23.81% 23.18% 26.13% 27.22% 3. Inpatient medical services 11.63% 12.10% 16.20% 16.10% 6.25% 6.55% 5.40% 4.97% 4. Dental services 3.30% 3.02% 0.94% 1.15% 8.69% 8.24% 5.45% 4.78% 5. Services related to daily wants, transportation, etc., during medical treatment 1.32% 1.49% 0.74% 0.73% 0.26% 0.27% 0.19% 0.19% 6. Reimbursement of expenses 9.98% 9.48% 15.07% 14.36% 18.36% 17.96% 17.18% 16.46% 7. Other packages 42.91% 42.82% 29.48% 30.92% 31.81% 31.29% 35.35% 36.09% TOTAL: 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% Journal of Health Policy, Insurance and Menagement 103

4 Petko Salchev, Nikolai Hristov, Lidia Georgieva fact, economists, statisticians, and managers around the world have come up with increasingly complex methods of comparison and assessment of organizational structures in health care. Comparing voluntary health insurance funds in Bulgaria is a daunting task due to the lack of readily available data and the vagueness surrounding assessment practices. Decisions seem to be based on general considerations and expert statements, and do little to reflect objective realities. To this day, the only comparisons have been based on the market shares of different insurance funds. The economic data published by the CFS conform to EC regulations, but do not allow non-specialists to get a realistic assessment of voluntary health insurance funds (VHIFs). This article introduces a methodology for comparing VHIFs by establishing a complex index (Benchmark Index - BI) based on 5 groups of indicators related to several available variables. This index is intended as a tool for analyzing the voluntary health insurance sector and managing resources through a set of analytical indicators and variables. It can be used to create a certain type of ranking of VHIFs. By facilitating comparative analysis, these indicators can be used for evidencebased management. The creation of complex mathematical methods introducing abundant data is one of the challenges for decision-makers and managers, who prefer to use clear and concise data in their practice. The establishment of a simplified and easy-to-use integrated BI is a compelling task for the scientific community. Such an index could help the various stakeholders in the health care system in several ways: Patients in choosing a VHIF (social efficiency); Politicians in deciding on resource management and allocation (economic efficiency); Managers in assessing operative management (operative efficiency); Medical professionals in assessing medical activities (medical efficiency). METHODOLOGY FOR THE CREATION OF A BENCHMARK INDEX AND THE COMPARISON OF VOLUNTARY HEALTH INSURANCE FUNDS The main challenges and limitations to creating a BI can be summarized as follows: Diversity of the size, type, and activities of different VHIFs; Difficulty in finding reliable and accessible data on VHIF activities; Choice of easy-to-use mathematical and statistical models for data processing and summarization; Slow adoption of new IT technologies; The desire of politicians to support, and of managers to participate in, the process of evaluating VHIF. The BI was constructed according to the following algorithm: The grouping of indicators in separate groups (pillars) and the calculation of an index for each pillar; The calculation of an integrated BI as a derivative of pillar BIs; Comparison of VHIF on the basis of integrated BI. This approach enables swift analysis and assessment by both non-professionals with no formal evaluation skills, and professionals who want to base their managerial decisions on such estimates. The approach affords some fairly straightforward comparisons among VHIFs, which nevertheless can be used to illustrate complex aspects of organizational stability, economic stability and efficiency, public importance, and technological development. It also seems easier to understand for the general public if component indicators rather than general tendencies are analyzed (Saltelli, 2007). The main considerations for and against the use of component indicators in an integrated BI, are given in Table May 2011 N o 1

5 Possible approaches to benchmarking voluntary health insurance funds in Bulgaria Table 5. Use of BI component indicators For Summarizes a complex of multi-mathematical realities to support decision-making. Easier to interpret. Enables evaluation of progress over time. Diminishes the discernible size of the set of indicators, without losing information. Allows the inclusion of more information within the framework of existing limits. Facilitates communication with the public (i.e. general public, media, etc.) and promotes accountability. Allows customers to compare options effectively. Source: adapted from Saisana & Tarantola, 2002 Use of BI component indicators Against May send misleading signals. May simplify political decisions without in-depth analysis. May create the basis for misuse, e.g. raise support for a certain policy or organization, especially if the adoption of such indicators is not a transparent process with sound statistical or conceptual foundations. The choice of certain indicators is subject to political and scientific arguments. May be interpreted incorrectly and lead to serious decisions being discordant with the objective situation. The strengths and weaknesses of any BI largely ensue from the quality of the main variables included in its calculation. Ideally, all variables should be selected on the basis of their significance, analytical stability, timeliness, availability, and other solid considerations. For the purposes of comparison and for the creation of a BI, we have selected the following pillars (groups) of indicators: 1 st pillar activities, organization and efficiency 1) number of individual insurance policies sold; 2) number of family policies sold; 3) number of group policies sold; 4) number of corporate policies sold; 5) total number of insured persons; 6) number of regional representatives (offices); 7) number of contracts with medical and dental facilities and pharmacies; 8) number of refused claims; 9) number of complaints 10) number of accepted complaints. 2 nd pillar premium income according to package type 1) health promotion and disease prevention; 2) outpatient medical services; 3) inpatient medical services; 4) dental services; 5) services related to daily wants, transportation, etc., during medical treatment; 6) reimbursement of expenses; 7) other packages; 8) total. 3 rd pillar market share 4 th pillar claims paid according to package type 1) health promotion and disease prevention; 2) outpatient medical services; 3) inpatient medical services; 4) dental services; 5) services related to daily wants, transportation, etc., during medical treatment; 6) reimbursement of expenses; 7) other packages; 8) total. 5 th pillar financial parameters 1) intangible assets; 2) investments; 3) claims; 4) other assets; 5) expenses for future periods and accumulated capital; 6) liabilities. The selection of these indicators is based on the following criteria availability, transparency, potential for collection and analysis, respect for trade secrets. Other indicators can be selected for a BI as well. Mathematical model used in calculations The min-max normalization model was chosen for calculating particular indicators. In this method, the minimum value is subtracted from the value in question and then divided by the range of data of the indicator. However, there is a danger that so-called extreme values could obstruct the transformation of data into an indicator. On the other hand, min-max normalization could enhance the scope of indicators situated in a small interval, which improves the effect of the complex index. The formula used for min-max calculation is as follows: l = x min(n) max(n) min(n) Where: x value of the indicator for the fund in question; min (n) minimum value of the group of indicators; max (n) maximum value of the group of indicators; Journal of Health Policy, Insurance and Menagement 105

6 Petko Salchev, Nikolai Hristov, Lidia Georgieva Table 5. Integrated Benchmark Index (IBI) of VHIFs Insurance fund IBI IBI IBI IBI (October 2008) (End of 2008) (March 2009) (April 2009) Period 1 Period 2 Period 3 Period 4 GENERALI ZAKRILA DOM-ZDRAVE MEDICO DZI-HEALTH INSURANCE DOVERIE NADEZDA UNITED HEALTH INSURANCE BULSTRAD ZDRAVE EVROINS-HEALTH INSURANCE BULGARIA ZDRAVE MUNICIPAL HEALTH INSURANCE FUND VSEOTDAINOST TOKUDA HEALTH INSURANCE FUND HEALTH INSURANCE INSTITUTE PLANETA DALBOG: ZIVOT I ZDRAVE PRIME HEALTH CKB WEISS MEDIKA EVROPA Table 6. VHIF ranking Insurance fund RANK RANK RANK RANK (October 2008) (End of 2008) (March 2009) (April 2009) Period 1 Period 2 Period 3 Period 4 GENERALI ZAKRILA DOM-ZDRAVE MEDICO DZI-HEALTH INSURANCE DOVERIE NADEZDA UNITED HEALTH INSURANCE BULSTRAD ZDRAVE EVROINS-HEALTH INSURANCE BULGARIA ZDRAVE MUNICIPAL HEALTH INSURANCE FUND VSEOTDAINOST TOKUDA HEALTH INSURANCE FUND HEALTH INSURANCE INSTITUTE PLANETA DALBOG: ZIVOT I ZDRAVE PRIME HEALTH CKB WEISS MEDIKA EVROPA May 2011 N o 1

7 Possible approaches to benchmarking voluntary health insurance funds in Bulgaria Table 7. Market share of VHIFs in the 3 rd and 4 th period studied Insurance fund Market share Market share Period 3 Period 4 GENERALI ZAKRILA 19.46% 19.25% DOM-ZDRAVE 8.50% 8.43% MEDICO % 13.36% DZI-HEALTH INSURANCE 2.51% 2.35% DOVERIE 16.07% 13.83% NADEZDA 2.86% 3.13% UNITED HEALTH INSURANCE 2.50% 3.15% BULSTRAD ZDRAVE 1.26% 1.89% EVROINS-HEALTH INSURANCE 1.28% 2.34% BULGARIA ZDRAVE 21.43% 18.51% MUNICIPAL HEALTH INSURANCE FUND 4.52% 5.08% VSEOTDAINOST 0.22% 1.25% TOKUDA HEALTH INSURANCE FUND 0.66% 0.70% HEALTH INSURANCE INSTITUTE 0.51% 0.44% PLANETA 0.36% 0.41% DALBOG: ZIVOT I ZDRAVE 4.26% 4.92% PRIME HEALTH 0.22% 0.27% CKB 0.05% 0.09% WEISS MEDIKA 0.74% 0.61% EVROPA 0.00% 0.00% When calculating and comparing VHIFs, we used data published by the CFS prior to October When calculating and comparing, we did not utilize the 1 st pillar, due to lack of actual data. The results obtained after calculating separate indicators in the pillars are presented in Table 5. It is evident from the data that the values of the indicators for the leading insurance funds tend to increase. The opposite is true for some funds, which suggests that their activities have deteriorated (the last two funds in the table). When comparing IBI data, rank analysis and market shares, it becomes evident that although the VHIF Bulgaria Zdrave occupies first place according to market share in the 3 rd period, it does not come first in terms of the IBI ranking. The IBI presented in this paper makes it possible to assess and compare the position of every VHIF, additionally allowing interested professionals to base their managerial decisions on supplementary analysis of each indicator and pillar. Comparison by each indicator separately demonstrates that real analysis and ranking is impossible without the application of an integrated index. A ranking of VHIFs according to their market share is different from a ranking by the IBI, because of the inherent higher informational value of the latter. CONCLUSIONS AND RECOMMENDATIONS On the basis of the presented analysis and proposed methodology, we have formulated the following conclusions and recommendations: 1. It is necessary to develop models and methods for analysis, assessment and ranking of VHIFs to disseminate transparent and adequate information among the general public and the professionals concerned. 2. The data published by the CFS, which is mainly a regulatory and supervisory body, are not sufficient for the analysis and comparison of VHIF activities. Journal of Health Policy, Insurance and Menagement 107

8 Petko Salchev, Nikolai Hristov, Lidia Georgieva 3. It is necessary for the Association of VHIFs to assist in the introduction of independent assessment and ranking of VHIFs, which will make their activities transparent to society. 4. The proposed methodology enhances the opportunities for patients and company managers to make informed choices when choosing health insurance policies. 5. More studies and analyses in the field are necessary to accelerate the adoption of evidencebased policies in voluntary health insurance. REFERENCES 1. Advisory Group on the Risk Equalisation Scheme. Report of the Advisory Group on the Risk Equalisation Scheme: the Minister for Health and Children s Independent Review of the Risk Equalisation Scheme. Dublin, Advisory Group on the Risk Equalisation Scheme, Anell A, Svarvar P. Health care reforms and cost containment in Sweden. In: Mossialos E, Le Grand J, eds. Health care and cost containment in the European Union. Aldershot, Ashgate, Beck K, Zweifel P. Cream-skimming in deregulated social health insurance: evidence from Switzerland. Developments in Health Economics and Public Policy 6, 1998: Datamonitor. European health insurance 2000: what s the prognosis, doctor? London, Datamonitor, European Commission. Liberalisation of insurance in the single market an update. Dated 15 October Brussels, European Commission, (1997). (http: //europa.eu.int/comm/internal_market/ en/finances/insur/87.htm, accessed 5 January 2002). 6. Gauthier A, Lamphere J, Barrand N. Risk selection in the health care market: a workshop overview. Inquiry, 32, 1995: Gulliford MC et al. Access to health care: a scoping exercise. London, National Health Service (NHS) Service Delivery and Organisation Research and Development Programme, Knight J. Private medical insurance: how to get the best care and treatment for you and your family at the lowest price. Moneywise, July, Kulu-Glasgow I, Delnoij D, de Bakker D. Self-referral in a gatekeeping system: patients reasons for skipping the general practitioner. Health Policy 45, 1998: Manning WG, Marquis MS. Health insurance: the trade-off between risk pooling and moral hazard. Santa Monica, RAND Corporation (Pub. No. R NCHSR), Mossialos Elias, S. Thomson. Voluntary health insurance in the European Union. European Observatory on Health Systems and Policies ISBN Natarajan K. European health insurance markets: opportunity or false dawn? London, FT Financial Publishing/Pearson Professional, Office of Fair Trading (OFT). Health insurers improve consumer information [press release]. Dated 3 July London, OFT. 14. Van de Ven WPMM, van Vliet R. How can we prevent cream skimming in a competitive health insurance market? The great challenge for the 90s. In: Zweifel P, Frech III H, eds. Health economics worldwide. Amsterdam, Kluwer, Youngman I. The health insurance opportunity: a worldwide study of private medical insurance markets. Dublin, Lafferty, Å. Ñ Ë Ó ëapple ÌËÚÂÎÂÌ Ì ÎËÁ Ì ÏÓ ÂÎË Á ÙËÌ ÌÒËapple ÌÂ Ì Ï ˈËÌÒÍË ÛÒÎÛ Ë: ÙËÎÓÒÓÙËfl Ë ÚÂıÌÓÎÓ Ëfl (èappleó ÎÊÂÌË III ) - 4, 2004, N o 2, ISSN ÅÓapple ÊÛÍÓ, ë ÂÚÓÒÎ. ÑÓÔ ÎÌËÚÂÎÌÓÚÓ Á apple ÌÓ ÓÒË Ûapplefl Ì Úapplefl  ÓÔ ÎÌËÚÂÎÌÓ Ë Á ÙËÌ ÌÒËapple ÌÂÚÓ: ë Ò ë ÂÚÓÒÎ ÅÓapple ÊÛÍÓ, Á Ï.-Ôapple Ò. Ì ìë Ì ÄÒÓˆ. Ì ÎˈÂÌÁËapple ÌËÚ appleûêâòú Á Ó appleó ÓÎÌÓ Á apple ÌÓ ÓÒË Ûapplefl ÌÂ Ë ÔappleÓÍÛappleËÒÚ ÅÛÎÒÚapple - á apple ÌÓ ÓÒË Ûapplefl ÌÂ, apple Á Ó applefl ÉÂapple Ì à ÌÓ. // è appleë, ïii, N o 139, 23 ÎË 2003, Ò. 18. ISSN: Ç. èâúíó - çó ËÌË Ó Î ÒÚÚ Ì Á apple ÌÓÚÓ ÓÒË Ûapplefl ÌÂ. 2, 2002, N o 2, 50. ISSN Ç. èâúíó - èóîëúëí Ì Ó appleó ÓÎÌÓÚÓ Á apple ÌÓ ÓÒË Ûapplefl ÌÂ Ö appleóôâèòíëfl Ò Á. 1, 2001, N o 1, ISSN Ç. èâúíó - éúìó ÂÌËÂ Ì Ô ˆËÂÌÚËÚÂ Í Ï Á apple ÌÓÚÓ ÓÒË Ûapplefl Ì - 5, 2005, N o 1, ISSN May 2011 N o 1

9 Possible approaches to benchmarking voluntary health insurance funds in Bulgaria 21. Ç. èâúíó, ç. èóôó, å. ÑflÍÓ ÄÌ ÎËÁ Ë ÓˆÂÌÍ Ì ÒÚÂÌ Á apple ÌÓÓÒË ÛappleËÚÂÎÂÌ ÙÓÌ. (è apple ÒÚ - Í ÂÒÚ ÂÌË appleâáûîú ÚË) - 6, 2006, N o 4, ISSN Ç. èâúíó, ç. èóôó, å. ÑflÍÓ ÄÌ ÎËÁ Ë ÓˆÂÌÍ Ì ÒÚÂÌ Á apple ÌÓÓÒË ÛappleËÚÂÎÂÌ ÙÓÌ (ÇÚÓapple ÒÚ - ÍÓÎË ÂÒÚ ÂÌË appleâáûîú ÚË) - 6, 2006,N o 5, ISSN ÇÂÎÂ, É appleëâî. ÑÓ appleó ÓÎÌÓ Á apple ÌÓ ÓÒË Ûapplefl ÌÂ Ö appleóôâèòíëfl Ò Á/ É. ÇÂÎÂ.//á apple ÂÌ ÏÂÌË ÊÏ ÌÚ, IV, 2004, N o 4, Ò ISSN: ÇËÚÍÓ, åëïë. Ç Ö appleóô Ó ÂÒÚ ÂÌÓÚÓ Ë ÒÚÌÓÚÓ Á apple ÌÓ ÓÒË Ûapplefl Ì Ò apple Á Ë Ú Â ÌÓ appleâïâììó : [àìúâapple Ò] Ôapple Ò. Ì ÄÒÓˆ. Ì ÎˈÂÌÁËapple ÌËÚ - Á Ó appleó ÓÎÌÓ Á apple ÌÓ ÓÒË Ûapplefl Ì / åëïë ÇËÚÍÓ. // á ÒÚapple ıó ÚÂÎ, XIII, N 7, Ôapple. 2006, Ò. 13. ISSN: É. ÇÂΠÑÓ appleó ÓÎÌÓ Á apple ÌÓ ÓÒË Ûapplefl ÌÂ Ö appleóôâèòíëfl Ò Á - 4, 2004, N o 4, ISSN É Î ËÌÓ, êûïâì. ç ÁÓapple Ì ÂÈÌÓÒÚÚ ÔÓ Ó appleó ÓÎÌÓ Á apple ÌÓ ÓÒË Ûapplefl Ì êâôû ÎËÍ Å Î appleëfl / êûïâì É Î ËÌÓ. // Å ÌÍË. àì ÂÒÚˈËË. è appleë, 2003, N o 3, Ò ISSN: É Î ËÌÓ, êûïâì. ç ÁÓapple Ì ÂÈÌÓÒÚÚ ÔÓ Ó appleó ÓÎÌÓ Á apple ÌÓ ÓÒË Ûapplefl Ì êâôû ÎËÍ Å Î appleëfl / êûïâì É Î ËÌÓ. // á ÒÚapple ıó ÚÂÎ, Iï, N 9, Ï È 2003, Ò ISSN: Ö. òëôíó ÂÌÒÍ, å. ÑflÍÓ, Ñ. äapple ÍÓ åó ÂÎË Ì Á apple ÌÓ ÓÒË Ûapplefl ÌÂ Ö appleóô Ë appleâ ÛÎËapple Ì Ôapple ÔappleËÂÏ ÂÒÍ ÂÈÌÓÒÚ ÒËÒÚÂÏ Ú Ì Á apple ÂÓÔ Á Ì - 8, 2008, N o 3, ISSN à. åë  åóúë ˆËfl Ì ÔÓÚapple ËÚÂÎËÚÂ Ì Á apple ÌË Á ÒÚapple ıó ÍË ÛÒÎÓ ËflÚ Ì Á apple ÌÓÓÒË ÛappleËÚÂÎÌ ÒËÒÚÂÏ. - 5, 2005, N o 5, ISSN à. åë  á apple ÌÓ Á ÒÚapple ıó Ì àá. ëä Ñ. ñâìó, ë Ë Ó , 2005, 6, 58. ISSN à ÌÓ, ÇÂÎË Í. á apple ÌÓÚÓ ÓÒË Ûapplefl Ì - Á ÎÊËÚÂÎÌÓ Ë Ó appleó ÓÎÌÓ / ÇÂÎË Í à ÌÓ. àíóìóïë ÂÒÍË ÊË ÓÚ, XXVIII, N 31, , Ò. 6. ISSN: à Ì Â, çëíóî. Ñ Ì ÌÓ ÚappleÂÚËapple ÌÂ Ì ÌÓÒÍËÚÂ Ì ÙËÁË ÂÒÍË Îˈ Á Ó appleó ÓÎÌÓ ÓÒË Ûapplefl ÌÂ Ë Á ÒÚapple ıó Ì / çëíóî à Ì Â. ÄÍÚË, 2003, N 3, Ò ISSN: ä. ÄÎÂÍÒË èapple ÌÓ appleâ ÛÎËapple ÌÂ Ì Ô Á apple Ì Ó appleó ÓÎÌËÚ Á apple ÌÓÓÒË ÛappleËÚÂÎÌË ÛÒÎÛ Ë Å Î appleëfl - 6, 2006, N o 5, ISSN ä. ó ÏÓ ÅÂÌ Ï appleíëì Ú Í ÚÓ Á apple ÌÓ- ÔÓÎËÚË ÂÒÍ ÚÂıÌÓÎÓ Ëfl - 7, 2007, N o 2, ISSN å. ÇÎ ËÏËappleÓ èappleë ÚËÁ ˆËfl, appleâ ÛÎËapple ÌÂ Ë Ô Á apple Á apple ÂÓÔ Á ÌÂÚÓ - 4, 2004, N o 2, ISSN å. ÑflÍÓ, ç. èóôó, Ç. èâúíó Infosure - ÌÓ ËÌÒÚappleÛÏÂÌÚ Á Ì ÎËÁ Ë ÓˆÂÌÍ Ì Á apple ÌÓ-ÓÒË ÛappleËÚÂÎÌË ÒıÂÏË - 6, 2006, N o 1, ISSN å. íapple flìóòíë Ë Ç. ã Á appleâ ËÍ è Á apple Ú Á apple ÂÓÔ Á ÌÂÚÓ - ˆÂÌË Ë ˆÂÌÓÓ apple ÁÛ Ì Á apple ÂÓÔ Á ÌÂÚÓ - 7, 2007, N o 4, ISSN å. íapple flìóòíë, Ç. ã Á appleâ ËÍ ÑÓ appleó ÓÎÌÓÚÓ Á apple ÌÓ ÓÒË Ûapplefl Ì ÁÏÓÊÌÓÒÚ Á ÔÓÎÁ ÌÂ Ì ÓÔ ÎÌËÚÂÎÌË Á apple ÌË ÛÒÎÛ Ë ËÁ Ì Ó ı Ú Ì Á ÎÊËÚÂÎÌÓÚÓ ÓÒË Ûapplefl ÌÂ. ëô. á apple ÂÌ ÏÂÌË ÊÏ ÌÚ - 8, 2008, N o 6, ISSN å. íapple flìóòíë,ç. ã Á appleâ ËÍ, Ç. ëôëappleíóòíë éòìó ÂÌ Ô ÍÂÚ ÓÚ Á apple ÌË ÛÒÎÛ Ë Ë ÓÔ ÎÌËÚÂÎÌË ÁÏÓÊÌÓÒÚË Á apple Á ËÚËÂ Ì Á apple ÌÓÚÓ ÓÒË Ûapplefl Ì å Í ÓÌËfl. - 8, 2008, N o 5, ISSN ç. èóôó á apple ÌÓÓÒË ÛappleËÚÂÎÌËÚ appleâáâapple Ë Ì appleûêâòú Ú Á Ó appleó ÓÎÌÓ Á apple ÌÓ ÓÒË Ûapplefl Ì ÎÓ ËÍ, ÌÓappleÏ ÚË Ì ÛappleÂ Ë Ôapple ÍÚËÍ. - 8, 2008, N o 5, ISSN ç. èóôó, Ç. èâúíó ÑappleÛÊÂÒÚ Ú Á Ó appleó ÓÎÌÓ Á apple ÌÓ ÓÒË Ûapplefl Ì - ÒÚappleÛÍÚÛappleË Ò apple ÌÚËapple Ì ÒÚ ËÎÌÓÒÚ Ë ÒË ÛappleÌÓÒÚ - 5, 2005, N o 4, ISSN ç. èóôó, Ç. èâúíó, ã. ëô ÒÓ äóîíó ËıÚ ËÌ ÂÒÚËapple ÎË Á apple ÂÚÓ ÒË? - 5, 2005, N o 3, ISSN ç.èóôó, Ç. èâúíó ê Á ËÚËÂ Ì Ô Á apple Ì Ó appleó ÓÎÌÓÚÓ Á apple ÌÓ ÓÒË Ûapplefl Ì ÍÓÌÚÂÍÒÚ Ì Î appleòí Ú ËÍÓÌÓÏËÍ - 6, 2006, N o 6, ISSN èâúíó, ç. ÑÓ appleó ÓÎÌÓ Á apple ÌÓ ÓÒË Ûapplefl Ì ŠΠappleëfl / ç. èâúíó. ëóˆë ÎÌ Ï ˈËÌ, I, 1994, N 3-4, Ò ISSN: èóôó, ç. ÑappleÛÊÂÒÚ Ú Á Ó appleó ÓÎÌÓ Á apple ÌÓ ÓÒË Ûapplefl Ì - ÒÚappleÛÍÚÛappleË Ò apple ÌÚËapple Ì ÒÚ ËÎÌÓÒÚ Ë ÒË ÛappleÌÓÒÚ, ç. èóôó, Ç. èâúíó. á apple ÂÌ ÏÂÌË ÊÏ ÌÚ V, 2005, N 4, Ò ISSN: Journal of Health Policy, Insurance and Menagement 109

10 Petko Salchev, Nikolai Hristov, Lidia Georgieva 45. ê ÍÓ ÒÍ, ÉÂapple Ì. èappleëìˆëôë Ë Ôapple ÍÚËÍË ÒËÒÚÂÏËÚ Á Á ÎÊËÚÂÎÌÓ Ë Ó appleó ÓÎÌÓ Á apple ÌÓ ÓÒË Ûapplefl ÌÂ/É. ê ÍÓ ÒÍ. // ëóˆë ÎÌ Ï ˈËÌ, XI, 2003, N 1, Ò ISSN: ë. å ÍÒËÏÓ Ñ Î ÓÒappleÓ Ì Ú ÓˆÂÌÍ - ÍappleËÚÂappleËÈ Á Í ÂÒÚ ÓÚÓ Ì Á apple ÂÓÔ ÁÌ Ú ÂÈÌÓÒÚ - 4, 2004, N o 4, ISSN ë. çëíóîó - î ÍÚÓappleË, ÎËflÂ Ë appleıû ÔÓÚapple ÎÂÌËÂÚÓ Ì Ï ˈËÌÒÍ ÔÓÏÓ. 1, 2001, N o 1, ISSN è.ë Î Â, ã. ÉÂÓapple ËÂ, èappleëìˆëôë Ë Ôapple ÍÚËÍË Á apple ÌÓÚÓ Ë ÔÂÌÒËÓÌÌÓ ÓÒË Ûapplefl ÌÂ, ëóùëfl, 2008, ISBN ëì. äóì  á ÍÓ Ó Â (ÌÂ)ÒÔapple  ÎË Á apple ÌÓÓÒË ÛappleËÚÂÎÌ Ú ÒËÒÚÂÏ - 6, 2006, N o 6, 7-9. ISSN ëú. ÉÎ ËÎÓ Ë ç. ÇÂΠí appleòâìâ Ë Ôapple ΠÌ Á apple ÂÓÔ Á ÌÂÚÓ: ÓÒÌÓ ÌË ÔÓÌflÚËfl Ë ÔappleËÎÓÊÂÌËÂÚÓ ËÏ ÛÒÎÓ ËflÚ Ì appleâùóappleï Ì Î appleòíóúó Á apple ÂÓÔ Á Ì - 5, 2005, N o 1, ISSN ëú. ÉÎ ËÎÓ îëì ÌÒËapple ÌÂ Ì Á apple Â- ÓÔ Á ÌÂÚÓ ÛÒÎÓ ËflÚ Ì ÔappleËÒ Â ËÌfl ÌÂ Ì Å Î appleëfl Í Ï é  ËÌÂÌ Ö appleóô - 6, 2006, N o 6, ISSN í. ÇÂÍÓ, ë. ÑÊ Ï ÁÓ çó ÔÓ ıó Á apple ÌÓÚÓ ÓÒË Ûapplefl Ì Á ÔÓ Ó applefl ÌÂ Ì Í ÂÒÚ ÓÚÓ. - 8, 2008, N o 6, ISSN May 2011 N o 1