A revelatory opinion piece appeared in today’s Index, written by Gabriella Lantos, managing director of the Róbert Károly Private Clinic, which specializes in women’s medicine. Lantos lays out in a convincing way “what is wrong with Hungarian healthcare.” Of course it is a complex issue, but the main reason for the close to hopeless situation of Hungarian healthcare is the hold of a corrupt medical aristocracy (orvosbárók), the top few thousand of the 30,000 practicing physicians in Hungary. Gabriella Lantos, who is safely ensconced in a private hospital, felt free to sign her name, unlike the author of an opinion piece on the same subject that appeared in HVG back in 2012 who remained anonymous, fearing consequences. Interestingly enough, the author of that article also talked about the corrupt medical aristocracy as the source of the problem. He also described them as “orvosbárók” who rule hospitals like personal fiefdoms.
The common wisdom in Hungary is that there are not enough doctors because about 10,000, mostly young doctors have left the country for British, Swedish, German, and Austrian hospitals. Even twenty years ago when there were about 44,000 doctors in Hungary one could hear the same complaint. At that time I countered that there was an overabundance of physicians in comparison to wealthier western countries. That is still the case. There are fewer doctors in the United States per 1,000 inhabitants than in Hungary (2.6 versus 3.3). A couple of months ago I heard Péter Mihályi, a professor of economics specializing in healthcare issues, give a talk in which he claimed, just as Gabriella Lantos does in this article, that there are enough doctors in Hungary. The mostly liberal audience was up in arms. They simply refused to believe it.
It is unnecessary to bemoan yet again the abysmally low pay of both doctors and nurses, which is not enough to keep body and soul together. But Lantos’s description of ways a doctor can make extra money is educational. First, and most obviously, after his shift is finished the doctor can sell his services to the hospital as an entrepreneur for the market price of 5,000-6,000 forints per hour instead of the 1,200-1,800 ft. he gets as a state employee during regular hours. In some provincial hospitals one can get even 8,000-10,000 per hour or 50,000 for a day.
Another way for a doctor to boost his income is to join a private practice. There are at least two dozen private clinics and practices in Hungary, mostly in Budapest. There, depending on his expertise, a physician can easily make 5,000-20,000 forints an hour, or he may work for a decent commission. These private hospitals and practices do a brisk business. According to Forbes, their turnover is about 80 billion forints per annum.
Finally, there is the gratuity system (hálapénz) which, according to estimates, amounts to 70 billion non-taxable forints in the pockets of certain doctors. At the top of the “gratuity pyramid” are the hospital directors, heads of departments, and star physicians. About 20% of all doctors are in this category, and they receive 80% of the “tips.” That is about 50 billion forints, which breaks down to a monthly non-taxed income of 1-8 million forints a month. The other 80% of the doctors have to share the remaining 20 billion forints, amounting to about 1-2 million forints per year. According to Lantos, these “physician barons make three times more than their colleagues in western Europe, where the average salary is 25 million forints after taxes and social security payments.”
So, if there are enough doctors, why do people believe there is a shortage? One reason is that there are not enough nurses in the system, so doctors perform tasks that in other countries are done by nurses and physician’s assistants. The reason for the shortage of nurses is the incredibly low pay. The average pay is no more than what a cleaning lady makes elsewhere (100,000-130,000 forints or €420). Highly qualified surgical nurses with years of experience make only 170,000-200,000 forints, or about €640 a month, while the average salary of a nurse in western Europe is €2,500.
Another reason for the seeming shortage of physicians is the incredible number of hospitals and hospital beds. Let’s start with the beds. In Hungary there are 7.1 hospital beds for every 1,000 inhabitants as opposed to the United States and the United Kingdom where that number is under 3.0. Because of the way government payments for healthcare services are structured, a longer hospital stay, whether the patient needs it or not, benefits the hospital. Therefore once a person finds himself in a hospital bed he will not be released for over five days. In the United States 64% of all surgical procedures are done on an outpatient basis; in Great Britain and the Scandinavian countries 50% are. In Hungary only 8% of procedures are done that way.
Apparently, many Hungarian doctors are qualified to use the more modern procedures that don’t require protracted hospital stays. Some are already using such procedures when working abroad. But they cannot replicate them in Hungary because hospitals would go bankrupt without the longer hospital stays. Administrators who code medical procedures for government reimbursement use every trick in the book to make them seem as complicated as possible to milk as much as they can from the government. There is also an interesting twist to this story. If the head of the department uses old-fashioned methods, his younger subordinates cannot use more modern procedures. It’s no wonder that young doctors leave in droves to go abroad.
There is another reason that the medical establishment prefers the older surgical procedures. As Gabriella Lantos puts it: “The longer the scar and the longer the time for recuperation the higher the amount of the gratuity. If someone after an endoscopic procedure with a half-centimeter scar can go home the next day, he most likely will not pay 150,000-300,000 forints to the surgeon.”
Finally, moving on to the number of hospitals. Believe it or not, Hungary has 160 hospitals, if you can call them that. According to healthcare experts, one well-appointed hospital nowadays can serve one million people. So, Hungary would need 10 “real” hospitals, as Lantos puts it, with 5,000 beds each. If that is too radical given Hungarian circumstances, Lantos offers a compromise of 25 hospitals with 2,000-3,000 beds.
Apparently the Hungarian definition of a hospital at the beginning of the twentieth century was a building that could accommodate at least 100 persons in wards with 12 beds each. Today that definition has been whittled away. Of the 160 Hungarian hospitals 90 have at least 80 beds while the rest, that is 70 of them, look after even fewer patients. Yet these facilities are not only called hospitals but their financing is based on their being full-fledged hospitals.
According to another definition, a city hospital must have at least four departments: internal medicine, surgery, obstetrics, and pediatrics. Only 62 hospitals have a department of obstetrics, and in 24 of these fewer than 700 babies are born a year, that is fewer than two babies a day. These medical institutions should, Lantos argues, be closed. They are neither medically safe nor economical. The institutions that remain (about 35) are real hospitals and as such deserve modernization and investment in improvements.
Yesterday I reported on the incredible popularity of Mária Sándor, the nurse in black. When this modern Joan of Arc began her crusade, she struck me as naïve. She was hoping to get help from Viktor Orbán and Fidesz politicians in parliament because she was convinced that they simply don’t understand what’s going on in Hungarian hospitals. After a few months, disillusioned and disappointed as well in the trade unions that are supposed to represent her and her colleagues, she has become bolder and a great deal less charitable. She now talks freely about the incredible corruption of the top echelon of the medical hierarchy and even made a fleeting remark about the kickbacks these hospital directors and the top doctors receive from companies providing essential supplies to the medical facilities. She made no bones about her contempt for these people. She is convinced that as long as they are in charge nothing will ever change.
The anonymous article from 2012 I mentioned at the beginning of this post bore the title “Members of the medical aristocracy must be convinced.” To convince in Hungarian is “meggyőzni.” My first thought was that “convince” was the wrong verb. Instead of “meggyőzni” one should use “legyőzni,” which means “to defeat.”