Health care in Hungary (cont.)

Health care reform in Hungary is a work in progress. So, reader beware, this post will often conflate the past and the present, the present and the future. But the past is a very recent past (and sometimes the present), and with any luck the future will not be a distant future (indeed some of it is the present). So with this time warp caveat, let’s proceed!

The health care system which nowadays looks so rosy in the eyes of doctors and patients alike was actually pretty dismal. There were (and still are) too many hospitals, some of which are not up to snuff: 160 functioning hospitals in a country of ten million. The buildings of most of them are in terrible shape. The larger hospitals have several buildings quite far from each other which complicates communication among departments. Most of the buildings are old and cannot serve the needs of a modern hospital. Some of the smaller hospitals, especially outside of Budapest, don’t have enough experienced personnel. The old saying "practice makes perfect" is doubly true in the medical profession. It does make a difference whether a doctor performs four heart operations a year or four hundred. Statistics amply prove that point: there are very good and very bad results, let’s say, in comparing the survival rates of heart attack patients. According to one expert, half of the 160 hospitals should have been closed. It is better to travel a few more kilometers to a well equipped hospital with experienced personnel than to go to a small hospital ten minutes away where the rate of survival is much lower.

The government didn’t dare to close eighty hospitals. They are closing merely four or five. Nonetheless, the country is is teeming with dissatisfaction: protest follows protest. The opposition thinks that although only four or five hospitals are being closed forcibly, the smaller, not quite vital hospitals eventually will have to close on their own. They simply will not have enough business and will go bankrupt; the EP (the Health Care Fund) will no longer save them. Perhaps the opponents of the reform are right and a more rational hospital structure will replace the present one in an organic transformation.

The current (pre-reform) system is too hospital centric. There are still too many hospital beds (in 2005 79,847 as opposed to 1994 when their number was even higher at 98,453), and these beds must be filled because the hospitals’ income depends on occupancy rates. So, the doctors keep patients in the hospital whether they need it or not. Or at least they claim to keep the patients. A standard ruse: the hospital says that the patient was discharged on Monday, but in fact the doctor sent the patient home on Friday. Let me mention right here that this kind of cheating will be increasingly unlikely in the future because the patients will have to pay a small amount of money for every day of hospital stay and they will certainly complain if they find that the hospital tried to falsify the records. Moreover, from here on the patients will get a detailed description of the procedures performed and how much each cost (similar to Medicare statements in the United States). This also serves to drive home the fact that health care is not free, as too many people believe.

Hospitals abound while outpatient specialty practices are far too few. The plan is to build up such practices in order to shift the emphasis from hospitals to specialists’ offices.

The current system of payments to primary care physicians is also going to change. Today everybody has to pick a "family doctor" who now gets paid based on the number of patients under his care (more for older patients, less for younger ones, but still essentially a per capita system). So it is not in the interest of the family doctor to treat one of his patients even if he could easily handle the case. Here is one example. The family doctor could clear earwax from the patient’s ear but he doesn’t because he will not get a cent more from the EP for this service. So he sends the patient to a specialist at the local hospital. As one can imagine, this procedure costs a great deal more in the hospital than it would have in the office of the primary care physician. Or the primary care physician can skip routine preventive procedures. Is it really necessary to check a patient’s blood pressure if you’re not getting paid for it? The health care reforms are trying to address some of these problems. In the future, the doctors will get paid for services rendered. (I hope they’re setting up a fraud unit if Medicare abuses are any indication of the potential problems ahead.)

One of the reforms already introduced is co-payment, and it has led to a predictable upheaval. The sum is ridiculously low–300 ft. ($1.50), and there are innumerable exceptions. Children under 18 are exempt, people who have given blood a certain number of times are exempt, the very poor are exempt. By the time one adds all these up, one has the distinct feeling that the majority of the people don’t pay a penny. The co-payments remain with the doctors and the hospitals. Again, the idea is to drive home the reality that nothing is free. Also, the government doesn’t make it a secret that the hope is that the "gratuity" might be eliminated with the introduction of the co-payment, although the amount is too low for that, in my opinion. Another hope is that with the co-payment the number of visits can be somewhat reduced. At the drop of a hat everybody was running to the doctor whether it was really necessary or not. The initial results show that in that respect the government reforms are succeeding.

The government reforms will change the current system to a real "insurance based" one. That is, if someone doesn’t pay insurance he will not get "free" treatment. He will have to pay the entire cost of the procedure. There is a grace period until January 2008. As far as I remember, close to 800,000 people were freeloaders. Daily more and more people are paying up. As a result, after years of deficit, there is a surplus at the EP. And soon enough the EP will not be the only provider of health care insurance. There will be several other insurers (perhaps five or six) representing a partnership between the private and public sectors. The current plan calls for the state to have a majority stake in each enterprise. This is a compromise solution. The liberals (SZDSZ) wanted to have entirely private insurers in addition to EP; this seemed too radical for the MSZP MPs.

Another reform: membership in the Hungarian Medical Association is no longer compulsory for every practicing doctor; apparently the association lost 25% of its membership. Needless to say, the leaders of the association are furious. The association fiercely opposes all of the government’s health care reforms, and one has the distinct feeling that the association’s stance encourages the doctors’ opposition. There were some pretty ugly scenes in hospitals where doctors refused treatment and told the patients that if they didn’t like it they could go complain to the minister. Perhaps the ugliest affair at the Hungarian Medical Assocation occurred only a few days ago, when an article appeared on its homepage in which the author called the minister of health a murderer. Moreover, because the minister was present at the gay pride parade he made some disparaging remarks about her and the gays. If interested, here is the "masterpiece" in Hungarian:

The Hungarian health care system was and, alas, still is highly unfair. If one lives in Budapest, especially in certain districts in Buda, the health care one receives is as good as anywhere in the West. If, on the other hand, one lives somewhere in the northeastern corner of the country, the situation is pretty grim. In Budapest there are twice as many doctors per capita as elsewhere, even in larger cities. In order to remedy this situation a certain number of doctors and nurses were let go in Budapest. The outcry is not surprising. Just as the constitutional court judges didn’t want to go to Esztergom, the doctors don’t want to go to the "countryside," as Hungarian usage calls everything outside of Budapest.

And finally on an optimistic note. Yesterday I heard a gentleman who was admitted to a new, very large hospital center, created out of three older ones. The old gentleman was elated: a gorgeous place, he is in a single room, there is television, there is everything. They clean the room three times a day. The food is wonderful. The ministry claims that what they want is many hospitals like this one.