State medicine: the condition is serious, the prognosis is unfavorable

the medicine: LAZY MONOPOLY
Irina Eliseeva, Boris Grozovsky, OPEC.RuState medicine is turning into a "lazy monopoly" – a system that even the withdrawal of some consumers does not force to change.

The more doctors and places in hospitals there are in the region, the worse the health of the population. These are the conclusions of the section and the round table on healthcare development within the framework of the big April HSE conference.

Lazy MonopolyThe state is going to switch to single–channel financing of medicine - to pay not for the maintenance of beds, but for services performed within the framework of the compulsory medical insurance system (CHI).

But even within the framework of compulsory medical insurance, polyclinics do not yet have incentives to improve the quality of patient care, Tatiana Sklyar from the Graduate School of Management of St. Petersburg State University told the medical section of the HSE conference.

Tatiana Sklyar and Igor Baranov analyzed the problems of the CHI system in two Russian capitals (see the presentation to the report). Neither the dissatisfaction of consumers with the quality of state medicine, nor their transition to a private healthcare system does not force the institutions of the CHI system to improve their work, Sklyar notes.

In general, those who are at least partially satisfied with the work of CHI clinics in Moscow and St. Petersburg are slightly more than those who are not satisfied (slide 4). 6-7% are completely satisfied. The respondents say that their assessment of the work of polyclinics has deteriorated over the past two years.

Traditionally attributed to polyclinics problems – low qualifications of doctors and paid services – irritate only 14% and 11% (respectively) of the surveyed Petersburgers, 17% and 2.5% of Muscovites. Perhaps patients simply do not expect highly qualified doctors and full free services from polyclinics, Sklyar noted. The main problems of polyclinics:

1. low level of service (55-63% of respondents think so): queues, impoliteness of staff, inattention of doctors;
2. lack of resources to provide assistance (55-56% of respondents): there are no doctors, diagnostic equipment, low qualification of doctors, it is difficult to get to a specialist (slide 6).

The fee for medical services is already very high. 64% of respondents in St. Petersburg and 52% in Moscow had to pay for medical services in polyclinics. At the same time, shadow payments are more common in Moscow, and official payments are more common in St. Petersburg (slide 7). There are much fewer shadow payments in paid medical institutions than in the state system, but they are there too.

There is no competition within the system of "free" medical care, Sklyar notes. As a result, medical institutions in the CHI turn into a "lazy monopoly", which is satisfied with the care of some consumers. Employees of such an organization are not interested in improving the quality of products, improving its work, researchers from the Graduate School of Management of St. Petersburg State University say.

Access to a private system does not become an incentive for change. The lazy monopoly does not have any financial damage from "voting with its feet", it does not receive feedback. A negative selection is gradually being carried out among the patients of the polyclinics of the CHI system: only those who cannot leave remain. The departure of the dissatisfied from the CHI system allows it not to change, the report says.

A completely different life in private clinics. They introduce their own standards of service, improve the system of staff incentives, budgeting, they have development plans, the researchers note according to the results of a survey of physicians. At the same time, the lack of reform in the public sector hinders the development of private medicine: now, according to doctors interviewed by Sklyar and Baranov, private clinics compete mainly not with each other, but with the shadow market of medical services in institutions of the CHI system. This is an unequal competition: taxes are not paid from the shadow service provided by the medical institution of the CHI system, and this service itself is actually paid for repeatedly: before it was financed by the state budget.

Resources are not usefulThe provision of hospitals, doctors and medical staff in the regions does not lead to an improvement in the results of health care in the regions, showed HSE Professor Sergey Shishkin, who led the work of the health development section.

These results are the level of morbidity and mortality, life expectancy at birth. Morbidity (the number of diseases per capita) is higher in those regions where the gross regional product per capita is higher, the population is older and where the provision of medical personnel is greater (see the presentation to the report).

But with the growth of per capita state financing of medicine, the pain decreases (slide 10).

There was also a high correlation between the morbidity of the population and the age of doctors: doctors of the Soviet generation treat better, Shishkin noted.

The mortality rate of men of working age is noticeably falling with an increase in well-being in the region and is growing along with per capita retail sales of alcohol. The availability of doctors and medical staff in the region also correlates positively with the mortality of men (but less than with the morbidity of the entire population – slide 12).

Life expectancy increases the most from north to south – along with the average temperature in January. Well-being in the region has a positive effect on life expectancy, as well as an increase in the share of CHI funds in the financing of regional medical state programs (slide 14).

Interestingly, such regions get better results with less resource provision (number of beds and medical staff per capita, slide 15). But the higher the provision of inpatient hospitals in the regions, the more often they resort to hospitalization of patients, Shishkin showed (slides 16-17). The healthcare system is focused on inpatient treatment – in regions where the bed stock is higher, hospitalization occurs much more often, says Shishkin. It turns out that resource availability does not improve health outcomes, but only increases the system load.

Advanced training of doctors is also a "waste of money," Shishkin notes: in regions where doctors are more in need of such courses, morbidity and mortality are already lower, and life expectancy is higher (slide 20-21).

What to guarantee to the populationAlexey Kalinin and Igor Sheiman (HSE) worked on the topic of state guarantees of medical care that should be provided by the CHI system (see the presentation to the report).

In Western countries, medical state guarantees call into question the principle of clinical autonomy of the doctor. Medical care is clearly rationed (it is known which service costs how much), and the state guarantees themselves show what the state provides, and for which medical services it is necessary to pay. Explicit definition of state guarantees and priorities of medical care in Russia will counteract the increase in fees in healthcare, will reduce the differences in the availability of medicine in the regions, said Sheiman.

State guarantees should be specified at two levels: at the macro level, it is necessary to rank diseases that are primarily included in state guarantees, and at the micro level – standardization of priority medical technologies for the treatment of these diseases. The range of diseases whose treatment is a priority for the state includes those that lead to the greatest damage (mortality and morbidity); the standard also prescribes which medical technologies are priority in the treatment of selected diseases. In practice, state guarantees are established for a limited range of diseases, while priority medical technologies are highlighted (slide 8).

There is no complete specification of state guarantees in any of the 9 countries (including the USA, Chile, Sweden, Denmark), whose experience was reviewed by Sheiman. The system is most effective in those countries where "the population was not promised much" (USA, Chile), and where people are used to paying for medical services, Sheiman noted. At the same time, in some countries, only new technologies are prescribed in state guarantees (Israel, Great Britain), in others, on the contrary, it is prescribed which technologies are ineffective to use, and which technologies are preferable in the treatment of certain diseases (New Zealand).

The implementation of the Oregon Medicaid Guarantee Plan in the USA (1989-1997) was unsuccessful. 693 most important pairs of "disease – treatment method" were prescribed there, an analysis of the costs of treating individual diseases was carried out. But because of the fixed medical budget, doctors had to cut off diseases with the highest unit costs for treatment. Patients were outraged: it is impossible to limit the analysis of cost effectiveness, said Sheiman.

In 1993-97, the system was adjusted – the list of diseases increased to 743, state guarantees were changed taking into account patient surveys. The system is still in effect. Each disease is assigned a rank in it (slide 16). At the same time, the state does not promise the patient specific services or standards of care. State guarantees only show which diseases can be treated under state guarantees, and with the help of which technologies this will be done.

In Chile, 56 priority diseases for state medicine were selected. At the same time, it was taken into account how severe these diseases are, which diseases the poor are most susceptible to, etc. (slides 18-20). Clinical efficacy (probability of cure) was taken into account. The lowest "weight" of the six criteria for selecting diseases in the system of state guarantees was economic efficiency.

It is quite realistic to rank diseases for inclusion in state guarantees, but it is much more difficult to do this with medical technologies, Sheiman believes. In order to set priorities and specify state guarantees, we need a system of criteria, interdisciplinary research and a system of regular public discussions of this work, Sheiman concluded. The program of state guarantees should clearly define which types of assistance are paid, which are free, adds Sergey Shishkin.

What will change?The concept of healthcare development until 2020

  it does not answer many important questions, Sergey Shishkin said at the round table:

1. what should be the ratio of the responsibility of the state and the employee for the payment of medical services,
2. what should be the ratio of private and public medicine,
3. the role of organizations providing primary, outpatient and inpatient care.

The complex chain of multi-channel financing of medical services leads to inequality in the cost and quality of their provision in the regions of Russia, the participants of the discussion are sure. The concept plans to switch to single-channel financing at the expense of the MHI. At the same time, it is necessary to clearly state who should pay and for what, and who is responsible, said Larisa Popovich, Executive Director of ROSNO-MS.

The main challenges to Russian healthcare in the conditions of the crisis are the reduction of state funding and the decrease in the availability of medical care, believes Sergey Shishkin. In this regard, the tasks of state policy in relation to Russian medicine should be reduced to smoothing inequality between regions, reducing inefficient use of funds, improving drug provision for target groups of citizens. "We are supporters of standards. This is a way that can ease these problems," Shishkin said.

He outlined three possible models for the development of Russian healthcare. The first option is a fragmented model in which there is no interaction between public and private medicine, and organizations providing primary and inpatient care are completely autonomous.

The second possible scenario is social differentiated. In this case, there will be clear social vectors for the development of the public and private health sector. State medical institutions will be designed more for the poor, and private medicine – for the well-to-do.

Finally, the third, most favorable model for Russia, is integrated, Shishkin believes. The state system then provides assistance to everyone within the framework of state guarantees, and private clinics can also do this, but mostly provide services that are not included in the list of guaranteed ones. To do this, it is necessary to specify state guarantees by changing the approach to the development of medical standards. It is also necessary to stop the growth in the payment of medical services, replacing paid services with free ones again, and introduce economic motivation into the behavior of doctors and medical institutions.

Portal "Eternal youth" www.vechnayamolodost.ru09.04.2009