Hungarian healthcare in the grip of a corrupt medical aristocracy

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.”


Illustration: Szarvas / Index

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.”

April 18, 2016
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April 18, 2016 6:49 pm

“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.”

I am not sure who these healthcare experts are, but in the state of Oregon there are 66 hospitals for a population of about 4 million. In New York State I was too lazy to count, but on this site one can see the list, my guess is that it’s above 450 for a population of about 20 million.

April 19, 2016 1:33 am
There is a need for more doctors in Hungary because of a few unique practices. For example, if your child is ill, you cannot simply write a note to the teacher saying that. You have to take the child to a doctor to get a doctor’s note for the school (n.b. parents are allowed to let the child off school for three days, total – more than that and they need a doctors’ note). If you do not provide a note from the doctor, the teacher is required to enter the child as absent without leave (igazolatlan), and if the child gets enough of these (it doesn’t take money) there will be consequences up to the removal of the family support payments. That, alone, creates a great and unnecessary demand on doctors. Another example – in the US, you can go to a pharmacist to get a flu (etc.) vaccination. In Hungary, only a doctor can give you a vaccination. So, everyone must go to doctors for this – and the process here, too, is ridiculous. You go to the doctor to get the prescription. Then you go to the pharmacy to get the vaccine. Then you go back to… Read more »
April 19, 2016 1:33 am

I meant to write “(it doesn’t take MANY)” above, not “money”

April 19, 2016 4:42 am
It’s probably easier (and more appropriate …) to compare the Hungarian health care system to other European systems because they have a similar base – everybody is insured … We’ve had a concentration of hospitals in Germany – smaller hospitals were closed but the number is still much higher than one for a million patients, maybe one for a hundred thousand would be appropriate. And of course the time a patient spends in hospital can and has to be reduced – that’s the modern idea. My last operation e g (after a hernia inguinalis) was in the early afternoon and in the evening I was lying in my bed at home – the nice thing was that the doc called at around ten and asked if I felt ok …) – that would have meant a week in hospital some years ago. “Minimally invasive” is the code word. And my doc sent me directly to the specialised hospital that does these kind of operations – not the giant university hospital cpmplex that we also have which serves around a million people! Of course the bosses in the hospitals are not really interested in that – they would lose money! So… Read more »
April 19, 2016 4:53 am

I would just like to add two things to today’s excellent post:

1. Even if there are enough doctors in Hungary in aggregate, this doesn’t mean that they are evenly spread in terms of specialization or on a geographic basis.

For example, there has been a critical lack of GPs (háziorvosok) for several years now, and unsurprisingly the lack is more pronounced in rural areas. See:
among one of many articles on this subject.

2. I once asked a doctor who left for Britain the major difference (besides pay) between practicing in Hungary and practicing in England. Her response? “In Britain the doctors admit it when they make a mistake. In Hungary they don’t.” She is certainly not the first person I’ve heard this from either.

It would seem to me that any reform of the medical system here would also have to include introducing accountability into the system for medical professionals.

April 19, 2016 5:15 am

It is interesting to note that the private hospital whose director is the author of the article works is actually owned by Csaba Lantos one of the most trusted and loyal supporters of Orban (and probably a Strohmann for Orban as well).

These oligarchs like Lantos may complain (after all the health care line is not as profitable as MET AG is) but they will still support Orban no matter what.

April 19, 2016 5:47 am

Today’s post is an eye opener.

The surgeons make unnessarily large cuts in order to augment their gratuity.
For the same reason they keep surgical patients longer than necesseary in deadly infected hospitals.

They are not only violating the moral code of their profession, the Hippocratic oath. They are also breaking the law against inflicting bodily harm. They see themselves as the salt of the earth. In reality they are simple criminals. No wonder that they support Fidesz.

April 20, 2016 3:02 am

Something I noticed when spending time in Hungary is the amount of people with big scars on their bodies. Obviously, endosurgery is not common in the country indeed.

Ndy - Healthy Pannonia
Ndy - Healthy Pannonia
April 19, 2016 8:24 am

I been lucky – though I could complain – but choose not to.
The walls around here are NOT caving in though the average life expectancy is approx 10-12 years under that of Western Europa.

No wonder they say in the US: You get what you pay for… Well, my monthly Health insurance cost (full hospital and doctor care and very substantial medicinal state drug subsidies (Western Drugs!) All comes to 7,050 Forints, that is: 25 us Dollars i.e. 22 Euros…

How the state manages to keep the system functioning and keeps paying for it is beyond my comprehension.

A little thank-you money here and there but many doctors do not accept it at all. Of course there are occasional exceptions. No question the quality of attention you get is in relation to your means but the needy are indeed provided for.

Whichever way you look at it – the fact that it FUNCTIONS at all is a miracle in itself.

And I speak from much experience… !

April 19, 2016 11:10 am

London Calling!

This article for me seems hard to fathom.

I don’t doubt its veracity – but how does the medical profession allow its hospitals to be in such a terrible unclean state?

And how does it allow a situation where patients have to bring their own AA and AAA batteries for basic necessary physiological measurements?

And how can they allow their working environments be so life-threateningly filthy?

And how can they allow their hospitals to be so life-threateningly cold?

And how can they perpetuate a state of such self-serving self-interest at the obvious expense of their patients?

The only conclusion must be corruption, unprofessionalism and ignorance of the Hippocratic oath.

This story of ‘surplus’ doesn’t compute with the experience of neglect.



April 19, 2016 11:23 am

…and a related story of British naivety and abuse of our health system.

And another nail in the coffin of our continuing EU membership.

(It was the EHIC card that allowed me to have such fantastic treatment in the Wurzburg University Hospital.)

April 19, 2016 1:02 pm

Rather OT but funny in a way – two news items today:

O visited ex-Chancellor Kohl – for a private visit:
And I found in our letter box the latest issue of the Jobbik magazine: Hazai Pálya
On the first page a picture of O and some of his minions with the text:
A Keresztapa …

April 19, 2016 1:32 pm

And here’s a short analysis of O’s visit with the rather frail Kohl – it doesn’t mean much more than a gesture, Kohl is no longer important.

April 19, 2016 1:45 pm
In relation to tomorrow’s teachers strike. Magyar Nemzet today has an article explaining the impact of PSZ’s agreement with the government in relation to Fidesz strike law’s provisions on minimum services that will be required to be provided to all children. Emmi (Ministry of Human Resources) is telling parents they do not need special care for children and – every school in Hungary will open and will operate normally. Minister of State for Education László Palkovics told M1 TV that the areas of disagreement between PSZ and the government are down to four points: (1) The authority and autonomy of school principals. There is agreement but it has not been agreed upon in written format; (2) the restoration wage supplement; (3) the evaluation system for teachers; and (4) the numbers of compulsory lessons required of teachers. Istvánné Galló indicated on M1 TV that the union was not in agreement with how the Minister of State summarized the outstanding issues. Laszlo Mendrey has asked PDSZ members to “hogy vegyenek részt a Pedagógusok Szakszervezet (PSZ) szerdára meghirdetett egésznapos, országos sztrájkján” (to strike also on the 20th). What is also interesting is that the PSZ has adopted blue ribbons for teachers to signify… Read more »
April 20, 2016 3:02 am

My wife just told me about a joke she found in the Jobbik magazine – it’s really good! (The joke, not the mag).

It’s titled “Health Reform” and you see a sign being erected: Hospital

The old sign is carried away: Cemetery
No comment necessary …