/ world today news/ Hospitals in the country continue to collapse one after another. After Lovech and Vratsa, those in Vidin, Pomorie, St. Zagora. Why did we get to this point, what problems lead to these results, is there a solution, why so far no one dares to reform the healthcare system, we asked Dr. Tanya Andreeva, MD. She was the Minister of Health in the cabinet of Plamen Oresharski.
– Dr. Andreeva, hospitals started closing their doors, why?
– This is a very old problem, since the time of Dr. Ilko Semerdzhiev. And I’ll tell you what I mean. When the new health insurance model is created with one fund, for which the financing rules are determined by the Minister of Finance, then it should be calculated how many hospitals it can work with. In Bulgaria, since then, the number of hospitals has grown by a third and is now over 360. This means three things. The first is that since 2006, despite the increased prices of equipment, medical supplies and medical supplies and the labor of doctors, the prices of clinical pathways, which are a very outdated way of working in hospitals, have not been updated. Second, this reform that began then did not provide for the balance between outpatient and hospital care, because over the years our health care has become the health care of hospitals, and it should be the other way around. Prevention must be developed, minor illnesses should be treated in outpatient care, chronic conditions should be monitored there, so that they do not end up in a hospital. The out-of-hospital system should be the gatekeeper of the hospital, but the opposite has happened. The larger flow goes to hospitals, where everything is much more expensive.
– Who is to blame for this proliferation of medical institutions, can a minister simply refuse to give permission for the emergence of a new one?
– No, that is why the necessary rules and policies must be created first. There are many ways to determine how many medical facilities and for what diseases there should be. I wonder how 20 years ago there were 260 hospitals, the budget was much smaller, and people were treated normally in them. Now the budget will be close to 4 billion and it will still not be enough, because the control over the hospitals is not good either. It can also be seen in the Public Procurement Agency at what prices they buy their materials and equipment. And thirdly, it is very important for the ministry to introduce rules for the operation of hospitals, regardless of who is their principal, because in state and municipal hospitals every patient is accepted, and that is correct. There is selectivity in some private hospitals. To return emergency cases, severe cases, which cost the resource of the medical facility, is unacceptable, to say the least.
– Shouldn’t there be changes in their financing then?
– With these contributions and the resource that the state gives to the NHIF, without it being clear whether it pays at all, it can be done in several ways. The first, which works in many places in Europe, is that the cashier pays something and the patient pays more. The second is to proceed to a new model of funding from the funds, then patients will choose where to invest their money, and hospitals will be able to work under certain conditions with the different funds. There will also be shared control, at the moment this cannot be done. At the moment there is a doubt that those who work pay for everyone. But this is a matter of political decision.
One thing is clear – with this resource, this system cannot work. And I expect bankruptcies of many more hospitals. In 2013, I took over medical institutions with 390 million BGN liabilities, today they are over half a billion. In 2014, our government updated the budget of the NHIF with BGN 230 million. This gave the hospitals a breath of fresh air, I’m not saying that this is the right thing, but this is how we managed to keep their debts down, while under the management of Dr. Petar Moskov they increased by BGN 100 million.
– Why, however, no government wants to take a decision to change the health insurance model?
– Recently, the governments in Bulgaria change very often, and a serious reform requires good preparation, a very difficult discussion in the parliament, dealing with the lobbies, because for many people this option is extremely profitable and works well. The best is the situation where there is no particular control and everyone takes what they want from the cash register.
– What are the lobbies?
– I know they will be very unhappy with my words, but first of all it is the pharmaceutical industry. In the new budget, the money for medicines will reach BGN 1.09 billion, which is very startling and the logical question is, are we very sick? Because if that’s the case, the ministry has a much bigger problem than failing hospitals, and that’s missing out on prevention and the opportunity to keep people healthy. This means that in 30-40 years with such a “serious” increase in morbidity, which fortunately is not the case, we will disappear. It is true that there are many expensive new medicines, innovations that cannot be replaced by anything else, but there are also generic drugs that can be used for some diseases, the question is why this is not done. I remember when I spoke about more generics, what a serious media attack was organized by some of the representatives of the pharma industry. So here we need a full mandate and a serious team in the Ministry of Health to bring about change.
– And what are the other lobbies?
– In hospitals, this is less pronounced, although if one sees the reference to the funds paid from the fund, it will become clear that 15-17% of the hospitals spend about 50% of the resource of the fund. And one wonders who they are, outside of the large university and district hospitals, where it is logical to have such a large flow. It will be seen that there are some private hospitals that operate with an unreasonably high resource. I will give just one example with the large hospital in Panagyurishte, where there are almost no patients anymore, teams of doctors and nurses are leaving. Why then does she continue to work with such a large resource.
– Which are the next hospitals at risk of bankruptcy?
– If urgent measures are not taken to support the medical facilities that are worth existing, I expect by the summer large hospitals, such as those in Targovishte, Blagoevgrad, Razgrad, Burgas, will follow the example of the ones in Vratsa, Lovesh and Stara Zagorje. But here I have to open a big bracket – all regional hospitals will not be able to survive if they do not have additional support from the state. Because put on a common basis with hospitals that selectively admit patients, and have additional income and funding, they cannot fight. There is no bankrupt private hospital, because for everyone who enters there, in addition to giving the path, something else is always paid. Either this practice should be stopped, or state and municipal ones should be allowed to work in the same way. Same rules and then let’s see who survives how.
Also, what does it mean – stealing from public hospitals? Yes, it is stolen, procedures are carried out under the Public Procurement Act (Law on Public Procurement) and materials and equipment are bought at incredible prices, but where is the place of the state? She is the owner, why doesn’t she control them, why doesn’t she change their directors. I will give you an example with ISUL. I left this hospital with 1 million BGN liabilities, but within three years they have reached minus 16 million. What is happening – it is not managed well, there are no patients? At the same time, the salaries of doctors and medical teams have not changed, staff are being chased. That is, a very serious analysis and control is needed by their owners – municipalities and the state.
– We say that the state must take measures, but can these hospitals be saved piece by piece?
– No, various changes are needed – from the hospital level, starting with looking at their staffs, because there is a huge staff working there and very often only the “Wage Salary” Fund is as much as the income from the cash register. This means that the funds for all other expenses must come from somewhere else. If this is not done, hospitals have a negative financial result. This is an extremely wrong approach. The other day I found out that the health fund will give more money to the hospitals in Lovech, Vratsa, Vidin, but this is not a solution. Because there is a problem and a situational decision is made, and a cardinal one is needed, which applies to all hospitals, so that they do not fall into this situation. Besides, a few hundred thousand given to clinics with tens of millions of liabilities will not help permanently.
– Restructuring of hospitals is the solution?
– First we have to start with how many hospitals our country needs with this population. Even if we were all sick, theoretically speaking, there are still a lot of us. Thank God that VAS canceled the national health card of Minister Petar Moskov because it was not appropriate. But a new health map must be drawn up to determine what medical facilities the country needs and then think about how they will be financed.
– With 360 hospitals, of which 100 are private, is there already a useful move?
– Of course there are many countries. In the Czech Republic and Slovakia, for example, the operation of many municipal hospitals is given to someone else to manage. During my mandate, while I am not claiming that this is the best solution, we discussed under the umbrella of the regional hospitals to include the municipal ones, because there are many places where there are many of them. Take for example Lovech region, there are hospitals in Lukovit, Teteven, Troyan, why are there so many, some of them can be restructured into emergency centers. And here I will say one big criticism – since 2014, no work has been done on the strategy for reorganization and modernization of emergency aid. There is only talk about ambulances, but when we presented the concept in Brussels and the funding was secured, no one talked about ambulances, they approved the creation of a network of emergency centers.
There can be one in Lukovit, Teteven, and Pomorie to take in emergency patients. They can even have inpatient beds and provide first aid and then transport the patient to major hospitals if needed. Municipal hospitals can be united under the umbrella of regional hospitals. This can lead to a restructuring of activity, not necessarily every 15 or 20 km. to have all kinds of activities. And this could also help in solving the personnel resource in the country. What prevents a doctor from Lukovit from being on duty in Teteven or Lovech! This will also save financial resources. It is one thing to hold a large auction and achieve lower prices for drugs or consumables, it is another for each hospital to make small orders and buy at whatever prices it wants. So with such a merger, the number of medical facilities will be reduced, activities will be restructured, there will not be cardiology, surgery, eye departments on every corner, and what not, the administration will be reduced. In addition, the personnel problem will be solved. Then doctors can safely take higher salaries and not work in a hundred places, not go around some diplomas, and the financial resource will be able to be distributed more efficiently.
– And new hospitals should appear only if there is a need for them?
– If you ask me, it is best to introduce a moratorium on the opening of new hospitals. I think the needs are met at the moment and the ministry can focus on fixing its hospitals. The fact that there are no private structures in some areas of the country is not a problem.
– Moratorium for how long?
– First, it should be stopped until a health card is made to see where and what we need, such as medical facilities. Secondly, this restructuring should be done when the map is ready, then it should be seen how this system will be financed, whether there will be only one health insurance fund or if there will be room for additional health insurance, for demonopolization and the emergence of many tills. This is a matter of political decision, and only then can we think about whether we need new hospitals and whether this moratorium should fall or not.
#Tanya #Andreeva #moratorium #hospitals
