Health care in motion

Analysis and steps to a solution.

Good health is the most important thing that we have. If we want to sustain it, however, we need to have a good health care system in place. Currently, all health care systems within the modern world are under pressure from the rising costs of technology, medicines and services.

While the scale of the problem differs from one country to the next, a common variable exists in each situation: the success of any health care system is not just dependent on the amount of money put into it, but also on the way in which citizens and governments conceptually approach it. The latter is the most important—of all the relevant factors within more advanced countries, cultural attitudes have molded the form of health care more than any other factor.

For example, the cultural emphasis on individual independence and importance in the United States means that Americans currently tolerate the fact that 45 million Americans have no health insurance to this day. Even though the health care cost per individual in the US is much higher than the European average, the standards are, at times, worse. The reason for this, simply put, is that in America, no one is allowed to die. Each high-risk birth must take place, and every patient with a chronic disease must be kept alive, no matter the cost.

In Europe we believe in a compromise based on social norms, with a dominant role for the state. In post-communist countries, the notion that the government is there to “take care of me,” is now in conflict with the fact that nothing is for free.

Three criteria

A working health care system must address and realize three criteria. First, everyone needs to know their position and options within the sector as well as their rights and their responsibilities. Next, financing must be effectively controlled and focused on quality. Lastly, all changes and plans must follow a single strategic plan.

In the Czech Republic there have been eleven ministers of health in the last eighteen years, and none of the aforementioned criteria have been fulfilled. It is hard for a successful family to emerge if one changes one’s partner every year and a half. The first minister of health, who has finally addressed true reform (or better put, who was allowed to do so in the face of conflicting political agendas and an objectionable financial situation) is the current minister, Tomáš Julinek. The huge health care tanker has finally left the socialist dock in the direction of modern European waters, but the ship remains burdened by remnants of the past, both societal as well as simply arising out of inexperience: among the latter is the inability of politicians to analyze, formulate, and effectively communicate solutions to the complex problems that healthcare reform presents.

Four problems and four solutions

Many problems exist, but there are four main ones. The first and foremost is Minister Julinek’s approach in attempting to privatize the entire system, from hospitals, clinics and even medical schools (the latter met with too much political resistance to pass). While privatization is not necessarily a bad thing, the minister should have first defined what services the state would ultimately offer and then specify where they would be placed within the grid of the system. Entire segments were left out, such as nursing home and hospice care for the elderly, which remains woefully undersized. For privatization to proceed, one therefore first needs to know what the state will offer, and where it will offer it. Once this is specified on a map, privatization can become more receptive to rational reflection. For example, if a certain service is only available within a state-run hospital in a given region or area, then that service should remain state-owned. But since the minister never defined which entities are to remain state-owned, the uncertainty which exists among healthcare professionals has now spread to the patients.

The second problem lies in the dominant role of the health insurance companies, their point system and their emphasis on quantity and not quality care. In the 1990s, the government allowed Czech insurance companies (these handle the claims of all Czech patients – there are no Czech insurance companies for private patients) to grow like wild-fire, and without adequate state control. Consequently, nine different insurance companies now offer “state health insurance.” The only difference between them is their customer approach; the services that they offer are the same. The presence of nine state-wide insurance companies is also unnecessary, since we are not paying for efficiency, but for nine different directors and their offices. The solution here is to have only one insurance company to take care of state customers, with the other eight being “freed” to offer other insurance services for above-standard (not covered by the state) care in an environment of healthy competition.

Also in need of addressing is the insurance companies’ system of remuneration. The financing system has been flipped on its head. While the number of procedures and the number of patients is remunerated, the actual results are not! The entire system is moving in reverse, rewarding health care providers for long lengths of stay and high numbers of patients treated, instead of rewards being based on how much the providers actually save. From a governmental point of view, these costs must be regulated at the top level down, instead of letting individual “segments” of health care fend for themselves.

The third problem is the points-based reimbursement system on which healthcare payments are made. This is bureaucratic nonsense, since the system unnecessarily converts the crown into a point and then back to a crown again. Services between provider and insurance company are negotiated via the point scale, and reimbursement to the provider is based on the amount of crowns per point that each provider negotiates separately with each insurer. All services should be negotiated and paid for in crowns, since healthcare costs crowns, not points.

The final problem is corruption. Corruption consumes twenty percent of the yearly health care budget. It works primarily at the level of “drug politics.” Instead of buying drugs for all of the entities at once (and getting a bargain price at the same time), the government gives the directors of hospitals and chief physicians the opportunity to choose which drugs they want to buy and prescribe. One only needs to look at just where the directors of oncological (and other departments that buy a lot of drugs) spent their vacations and compare it to their salaries to see just how deep the corruption is.

In the end, both physicians and patients abuse the health care system with corruptive practices. We have the highest average for patients visiting their doctor in the world—an incredible seventeen times per year. This means, that if one individual visited the doctor two to three times in a year, someone else must have gone thirty times. From my own personal experience as a doctor, I can not think of a single illness that needs a health check every two weeks over an entire year. In an attempt to curtail this trend, Minister Julinek implemented a payment system for patients in regards to check-ups and hospitalization, instituting a 30 crown fee for each visit to the doctor and a 60 crown fee for each day spent in the hospital. After the first six months, patients handed over a handsome sum of approximately 600 million crowns. The money was injected back into the system, resulting in better purchases of equipment and medicines, and the fewer visits meant shorter waiting times.

The problem with such an across-the-board payment system is illustrated by a situation in which many senior citizens found themselves. Those living off limited pensions felt that these health care charges were too great. The fact that it is impossible to get three warm meals per day on 60 Kč (the daily hospital fee) was lost on them. The Ministry should have focused on the people who actually do abuse the system by racking up thirty visits, thus sparing those who do not abuse the system.

Instead, in the recent October elections, the voters focused on this one point and overwhelmingly voted the Civic democrats (the party of Minister Julínek) out of office) and voted in the opposition (Social democrat) candidates in all thirteen districts. The voters succumbed to populists promises that their 30 crown payments would be paid for them by the district, thus proving that the communist-socialist mind-set is very much alive and well in the Czech Republic: Czechs still prefer not to have to pay anything at all out of their own pocket and, instead, have the state pay it for them from state funds, even if it means taking funds away from other needed areas such as teacher’s salaries, infrastructure repair etc. In the Czech Republic, we still have a long, long way to go.

Martin Jan Stránský
Physician, political commentator, publisher of the New Presence



The New Presenceautumn 2008

My priority is that patients recieve
and have access to the best care possible.