Romania’s public healthcare system is funded mainly by the state and the National Health Insurance House (CNAS). In theory, if you are insured, most hospital services should be free or heavily subsidized. In practice, however, many patients in Bucharest (and across the country) face unexpected additional expenses — medications, materials, certain procedures, “hotel” fees, and more.

Here’s how these costs arise, who pays them, and what solutions could help reduce the financial burden on patients.

Why out-of-pocket costs appear even in public hospitals

• Medical supplies, implants, prosthetics, non-reimbursed consumables
  Often, the materials needed for surgeries — prosthetics, implants, special sutures — are not stocked by hospitals or are not fully covered by CNAS contracts. Patients must buy them themselves or cover the price difference.
• Non-included or non-covered medications
  If post-operative treatment or prescribed drugs are not on the official list of reimbursed medicines or are considered optional, patients pay fully out of pocket. Even in public hospitals, auxiliary or supplementary medications may not be provided for free.
• Hotel fees and “premium” accommodation services
  Public hospitals often charge a hotel fee for better accommodation conditions. Sometimes this is not a matter of choice — the standard of equipment or available space may push patients into paying extra. Recent regulations set certain caps, but disparities remain.
• Imaging and laboratory tests with long waiting times → private option
  Because many public system investigations involve long waiting lists, patients often turn to private clinics and pay significant sums. Even when tests are carried out in state hospitals, if a special component or external interpretation is needed, extra costs may occur.
• Additional workforce – external doctors or collaborators
  In complex surgeries or procedures, hospitals may involve doctors or anesthesiologists who are not full-time employees but external collaborators. Their fees are not always fully covered by CNAS, leading to additional bills for patients.
• Uninsured or partially insured patients
  If you do not pay health contributions or your insured status is incomplete, hospitalization can become costly. For example, under fiscal amendments (Law 112/2016), an uninsured person who requires hospitalization may have to pay contributions for the services provided, calculated based on a minimum pension threshold.

Impact on patients in Bucharest

• For families with average or below-average income, a major surgical intervention can mean unforeseen expenses of hundreds or even thousands of lei, if implants or materials are not covered, or if hospitalization includes hotel fees paid by the patient.
• People who are behind on their health contributions or who assume they are insured but face coverage gaps (excluded services, external collaborators, lack of hospital resources) are the most vulnerable.
• Choosing between public and private care often becomes a cost–benefit decision: if waiting times are too long or a service is unavailable in the public system, patients may opt for private clinics and pay much more out of pocket.

What can be done to reduce these costs

• Greater transparency in public hospitals
  Clear information before surgeries on what materials/implants are required and which costs are not covered. Estimated price lists and financial counseling should be standard.
• Expansion of the basic package and reimbursed materials list
  Including more types of implants, specialized medical supplies, and post-operative treatments, so that patients are not forced to purchase them separately.
• Regulation of hotel fees and accommodation conditions
  Establishing a legal maximum and a minimum standard of conditions, so that differences are justified and not an implicit obligation.
• Monitoring external collaborators and ensuring full coverage through insurance/state funding
  Guaranteeing that external doctors, anesthesiologists, or specialists are either included in CNAS contracts or have transparent, regulated fees.
• Patient information and pre-/post-hospitalization counseling
  Upon admission, hospitals should provide patients with a written estimate of potential costs, including those not covered.
• Public policy & legislative control
  Laws should clearly regulate what is covered by the public system, what counts as “extra service,” what fees can be charged to patients, and penalties for unjustified charges.

Public hospitals in Bucharest essentially provide vital services covered by state insurance, but many categories of costs slip through the system and end up being borne by patients — from materials, implants, and auxiliary medications to accommodation fees and external collaborators.

For patients and their families, these “hidden costs” can mean significant financial strain and added stress during already difficult times.

Potential improvements involve greater transparency, expanded service coverage, clearer regulation, and proper patient information. Only in this way can the public health system become more equitable, predictable, and less burdensome for those who need it most.

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