Tag Archives: hospitals

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.”

orvosbarok

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

Inadequate hygiene in Hungarian hospitals

Today I’m venturing into the world of healthcare, specifically hygiene or rather the lack of it in some Hungarian hospitals. A discussion of the high rate of infections contracted in hospitals began when the movement “1001 physicians without gratuity” called attention to the problem. According to the statement of these doctors, the problem has been known for years. But not only is nothing being done to try to eradicate the problem, the number of reported cases has also been kept secret. The doctors complained about the quality of the sterilization machines, a lack of diapers, not enough disinfectant, etc. The group demanded the release of data about the number of cases of hospital infections and the death rate from such infections. That was at the end of February. Since then a fair number of articles have appeared on the subject that further highlighted the terrible conditions that exist in Hungarian hospitals.

Nothing, however, elicited a greater outcry than a news story published a couple of days ago by Index, which claimed that the department of dermatology, venereal diseases, and skin-related cancers at the hospital of the Budapest Medical School ran out of “rubber gloves” and therefore the unprotected staff must use “nylon gloves,” which are not as effective. The “rubber gloves” must be saved for operations.

Well, this is where my definitional problems began. I have heard of “rubber gloves” (gumikesztyű), the kind we use when washing dishes, but I had never heard of “nylon gloves” being used in hospitals. I suspect that Index’s reporting was not precise. The gloves we see in doctors’ offices and hospitals are “nitrile non-sterile single use” gloves. I assume that this is what Index called “nylon gloves.” These same gloves also come in a sterile form, which is more expensive, but the non-sterile gloves (which retail for $7.99/100) “pose no higher risk of infection for non-surgical procedures when compared to sterile gloves.” In fact, I read that even doctors and nurses dealing with HIV patients are well protected wearing these gloves.

Latex gloves used to be common in operating rooms because they fit more snugly (though they also puncture more easily). But a fair number of people are allergic to them, so many hospitals have opted for alternatives, admittedly more expensive.

If we’re dealing here with the distinction between latex and nitrile gloves, the hospital’s director was correct in explaining to the journalist that these two kinds of gloves have nothing to do with one another. That is, a shortage of one wouldn’t affect the other. No operation had to be postponed because of a possible shortage of nitrile gloves in the wards. However, the likelihood that the department did run out of ordinary nitrile gloves is very high. Tímea Szabó (PM member of parliament), who is currently working in a hospital as a volunteer to experience first hand conditions in Hungarian hospitals, has been reporting shortages of all sorts of the most basic necessities.

disinfection

Quite apart from this particular case, the fact is that hygiene doesn’t seem to be a high priority in Hungarian hospitals. One reason is the shortage of money, which unfortunately cannot be eliminated by “loving care” as Zoltán Balog, the minister of charge of healthcare, suggested. And because of this shortage hospitals try to save on items they consider non-essential. Here is one example of what is considered to be a “luxury” in Hungarian hospitals. The World Health Organization suggests the use of at least 20 liters of hand sanitizer for every 1,000 patient days. In Hungary hospitals use only 6 liters. They try to save money on disinfectant as well. Moreover, according to one man who worked as a sterilization machine operator, hospitals often sterilize equipment that should be discarded after each use. According to the whistleblower who no longer works in a hospital, he was instructed to resterilize equipment used in laparoscopic surgery as many as fifteen or twenty times. The interesting thing is that it is more expensive to resterilize equipment than to purchase new equipment. In fact, it can be twice as expensive. But since sterilization is done “in house,” the management can put in a request for new equipment but use the money for something else. As he said, “the money simply disappears.”

Meanwhile, the Állami Népegészségügyi és Tisztiorvosi Szolgálat (National Public Health and Medical Officer Service / ÁNTSZ) steadfastly refuses to release details about hospital infections and the resultant number of deaths even as it claims that its reporting is among the most comprehensive in the European Union. The website of the Országos Epidemiológiai Központ (National Epidemiological Center / OEK) does provide countrywide numbers, broken down by year, although its website is so user unfriendly that I didn’t even try to find them. It seems that Társaság a Szabadságjogokért (TASZ), the Hungarian equivalent of the American Civil Liberties Union, did look at their data but found them totally useless. What the doctors demanded and TASZ now demands as well is not aggregated numbers but a breakdown by individual hospitals. ÁNTSZ refuses to release this information. As one of the department heads of ÁNTSZ explained, if they published the data they would create panic. People would avoid hospitals where the number of infections and the resultant death rate is high and would go to hospitals where the danger of infection is low. But this could have grave consequences. Some patients might end up in hospitals that are not equipped to handle their problems. TASZ is not satisfied with this answer, and the organization will sue ÁNTSZ for the data. TASZ usually wins its cases against government authorities.

The stories of infections and death continue to multiply in the Hungarian media. A few days ago Index reported another serious infection, this time in a hospital in Pécs. The infection, called “methicillion-resistant Staphycoccus aureus” (MRSA), is caused by a type of staph bacteria that has become resistant to many of the antibiotics commonly used to treat staph infections. This sounds bad enough in English, but I’ll bet that Hungarians were petrified to read that “meat-eating bacteria are at work in a Pécs hospital.”

Infections picked up in hospitals are a problem worldwide, but according to some Hungarian doctors who came forth lately, the Hungarian situation is worse than that in most developed countries. One doctor I heard being interviewed claimed that the number of deaths as a result of these infections is twice as high in Hungary as in the U.K. According to one of the sources I consulted, the disparity is even worse. The British figure is 6.4% per 100,000 while in Hungary it is 14.7%.

It is ironic that in the country of Ignác Semmelweis, the pioneer of antiseptic procedures, hospitals are not using enough disinfectant, doctors and nurses don’t wash their hands often enough, toilets don’t function, and hygiene is altogether neglected. Devotion and hard work on the part of the staff is simply not enough, although admittedly it would start to address the problem. How often members of the staff wash their hands is not a question of money.

Hungarian healthcare needs more funding and an entirely different attitude on the part of hospital managers and staff. One of the early tasks of the post-Orbán administration should be to break the stranglehold on Hungarian healthcare by hospital administrators, trade union leaders, the Hungarian Medical Association, and those doctors in high position who are the beneficiaries of this corrupt system. Otherwise healthcare in Hungary will never improve.

April 9, 2016