Are Bulgarian Hospitals Doctoring Patient Data?

Dimitar Iliev

Comparing the way expensive oncology medicines are dispensed at hospitals in Bulgaria and Portugal, something doesn’t add up

A pharmacist delivers vials of chemotherapy drugs at the Portuguese Institute of Oncology in Lisbon. Photo: Dimitar Iliev

If the devil is in the detail, the detail was measured in kilograms.

At the Portuguese Institute of Oncology, an imposing building near the Spanish Square in Lisbon, I noted that the average weight of cancer patients receiving chemotherapy was 70 kilograms – a far cry from the 108-110 kilograms that is typical of patients on similar treatments at several hospitals I’d been to in my home country of Bulgaria.

Something didn’t add up. Why would Bulgarian patients weigh so much more?

Body weight matters because potentially life-saving cancer medicines are administered according to a complex formula based on a person’s mass, height and skin surface area. So the bigger a patient, the more medicine is needed.

And if my statistics were to be believed, Bulgarian patients needed a whole lot more oncology medicine than their counterparts in Portugal.

Which means a whole lot more money. Cancer medications are among the most expensive drugs in Europe, so every milligram is precious. In Portugal, a vial of Avastin costs 964 euros while a vial of Herceptin is 1,252 euros. Prices in Bulgaria are comparable.

The value of such drugs was clear when I saw how carefully they were housed in a purpose-built store at the Portuguese Institute of Oncology. The chief of the pharmaceutical department, Antonio Paulo Nascimento Melo Gouveia, let me enter the two enormous refrigerators where drugs are kept under strict temperature control: 2-8 degrees Celsius.

In a special compartment, pharmacists were painstakingly measuring out chemotherapy drugs to fulfil prescriptions based on the weight of patients. Behind a window, two women were diluting doses, extracting powder from vials. The goal was to use every milligram without wasting a single grain.

Pharmacists in sterile clothing prepare medicines at a special facility at the Portuguese Institute of Oncology in Lisbon. Photo: Dimitar Iliev

“I’m proud of what we do here - the preparatory plant, the store,” Gouveia said. “Cameras surround the outer and the inner space of the pharmaceutical store.”

So why would Portuguese cancer patients weigh so much less than their counterparts in Bulgaria?

Both Portugal and Bulgaria have about the same average body mass index, a ratio of weight relative to height, according to a recent survey from Loughborough University in Britain and the University of Sydney in Australia. So it’s not that patients are likely to be starting from different baselines.

“Is it possible that Bulgarians and Portuguese patients are so different?” I asked.

“No, I don’t think,” Gouveia said. “Patients are similar.”

What then?

It’s important to know that oncology medicines are not like other drugs. The reason they are so expensive is that they are innovative, patented products without cheaper generic equivalents.

In Portugal, hospitals procure drugs through a transparent tender process. At the Portuguese Institute of Oncology, Gouveia said: “I buy and distribute to patients oncology medicines worth 36 million euro yearly. They are tendered and negotiated directly with the producers and paid by the hospital itself.”

In Bulgaria, the National Health Insurance Fund pays for drugs. There is no cap on how much money can be allocated – so the state essentially pays whatever hospitals deem necessary for treatments. And those calculations are made without much scrutiny.

Hospitals order as much as much as 300 million leva (153 million euros) of oncology medicines each year, according to Dimitar Petrov, vice chief of the Bulgarian National Insurance Fund.

“The money comes from the state,” Petrov said. “The tenders for the medicines are organised by the Insurance Fund. The spending is limitless.”  

In fact, Petrov said, much of the medicine ends up going to waste.

“I would admit that 25-30 percents of the medicines are thrown away – at least one out of four vials,” he said. “Due to a lack of special equipment to prepare the mixtures and inadequate planning of the patient's treatment, it is thought that the doctors are ’pouring down the sink’ kilograms of extremely expensive oncology medicines.”

But others suggest there is more going on than inefficiency and waste.

Some health experts I spoke to said Bulgarian doctors have been known to put aside excess amounts with a view to sending them to Germany, where prices are about double. Known as “parallel export”, the lucrative process relies on Bulgarian wholesale traders.

So Bulgarian cancer patients are certainly not more corpulent than their Portuguese counterparts. The discrepancy in average weights hints at a scam in which some doctors may be fabricating patient statistics so they can order more drugs than are strictly necessary and export the excess amounts for profit.

Dimitar Iliev is an award-winning investigative reporter specialising in organised crime, smuggling and financial affairs. For the Balkan Fellowship for Journalistic Excellence, he is delving into illicit practices in the pharmaceutical industry in Bulgaria.

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Dimitar Iliev

Dimitar Iliev is an award-winning Sofia-based reporter with 25 years of experience.