Julia Gáti

Healthcare Under the Knife

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The task of slimming down a healthcare system that was wasteful in its overall functioning and ill-adapted to changing needs was left to the second term of the Socialist-led coalition government under Ferenc Gyurcsány, re-elected in April 2006. In less than six months the Minister of Health put five bills before the National Assembly and the government displayed unprecedented political resolve to have them passed into law. The aim of the restructuring all this legislation kicked off is to reduce the geographical inequalities, both qualitative and quantitative, in access to healthcare. Today most hospitals are geared to meeting medical needs over a wide spectrum; however, data demonstrate that care should be provided by specialist centres, with state-of-the-art equipment. In such hospitals, the chances of survival are practically doubled for heart attack victims, for instance, and the survival rate for stroke victims is 30 per cent higher. Another goal is to reduce the number of hospital beds and improve standards with the money saved. To this end, it is necessary to create more facilities for caring for the aged and for treatment at home; a whole range of examinations and treatments can be supplied perfectly well on an out-patient basis or by day surgery. The alignment to the needs of the elderly is warranted because with the expected increase in life expectancy, more treatment and care will be needed during that increased life span. In 1995, the over-60s comprised 14 per cent and the under-19s some 27 per cent of the total population; by 2050, those proportions may be almost reversed. The number of hospitals will have to be reduced for reasons of sustainable development and cost efficiency. At present Hungary's provision of hospital beds per 10,000 inhabitants is some 30 per cent above the European Union average, and whereas the number of hospitalised cases in most EU countries is stagnant, in Hungary it is actually growing. Even so, as many as 25 per cent of available hospital beds are unoccupied at any given time. Under changes in effect from 1 January 2007, healthcare provision in Hungary will be on four distinct levels. Of the current total of 170 hospitals, 39-seven of them in Budapest- have been designated as centres of excellence. These centres will dispose of the highest level of specialist medical expertise, offering round-the-clock emergency care and equipped to the highest possible standard. District and regional hospitals that cater for the less serious but more common diseases will now be able to contract with the health insurance service to obtain funding for half of the available beds (the centres of excellence get the other half).

How these are to be distributed within a given region depends on decisions taken in March 2007 by councils made up of the local authorities in that region. The number of available acute beds is due to fall from the present 60,000 to 44,000, while the number of chronic beds will rise from 20,000 to 27,000. One major priority is the further development of outpatient centres, as well as the introduction of quality and quantity controls on the work of general practitioners-in other words, to ensure that medical care should be provided at the adequate level. For most hospitals all these changes will mean closing down departments, pruning revenues and, in some towns, complete closure or "downgrading" to chronic care institutions. That the country should be up in arms about all this was to be expected. Since the vast majority of hospitals are owned by local authorities, and each is one of the biggest, if not the biggest, employer in its locality, substantial numbers of auxiliary workers, as well as doctors and nurses, are likely to lose their jobs. Even large national institutions that are still state-owned and under ministerial supervision will not escape the slimming-down, which in some cases is going to mean amalgamation with other units. They too are seeking to preserve their status and professional privileges by bringing all possible pressure to bear on the distribution of capacities. One of the measures is going to directly affect patients' pockets. Medical care that hitherto has appeared to be "free" at the point of delivery-paid for by social security deductions, with any deficit being made up from tax revenue-will be subject to charges. A token fee of 300 forints (little more than €1) will have to be paid per consultation with a general practitioner or specialist, with this money going directly to the individual doctor. An identical fee will be charged for each day spent in hospital. Many fear that even this modest charge will prove a major burden for the chronically ill and/or the elderly, those likely to be in most need of frequent medical attention. The government has pledged that all children under 18 will receive medical care free of charge, while for those in receipt of social assistance the charge will be only Ft100. Emergency care and screening will remain free to all. The ending of "free" provision of medical care is intended, first and foremost, to have an educational role. The hope is that patients will learn that it is not worthwhile turning to a doctor for every trivial complaint, as provision of service does have a very real cost and value. The consultation fees will constitute a legal (and taxable) source of income for doctors which, it is hoped, will help squeeze out the practice of "tipping".

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The Grateful Patient

It is one of the most popular social pastimes in Hungary and it is called "How much to put in the envelope". Players-either at home or already in hospital-try to guess how large the sum of money that they slip into the doctor's pocket should be. In the case of elective surgery the deliberations would start at home, well in advance of the appointed day, with a string of friends and acquaintances being grilled in the hope that they can shed some light, either because they themselves underwent surgery not so long ago, or because they have a doctor in the family, or simply because they are generally reckoned to keep themselves au fait about such matters. The point of interest is that no-one is able to give a sure-fire tip, but at least the range of error is narrowed. Before making a final decision, it is always worth listening to the bids that are suggested by patients who are currently in the hospital as some of them will be returning "guests" and so count almost as insiders. The removal of kidney stones by an experienced, reliable but not top-notch surgeon in one of Budapest's hospitals would in this way come to something like Ft30,000 (about €120, around the minimum monthly wage in Hungary). It is important that the amount should not be less than others give, because that downgrades the donor; it is also important that the doctor should remember how grateful his patient was if one has to return to see him again.
With decent doctors that sum just puts a smile on their faces, because they treat their patients to the very best of their ability whether the patient is grateful or not-at most they will smile more or less, their manner will be more or less pleasant. Well-known professors or top consultants running hard-pressed departments in high-demand specialities (e.g. cardiology, rheumatology) leave nothing to guesswork: the tariff for even the simpler kinds of interventions can easily be one-and-a-half times the minimum wage, while the sky is the limit for more complex affairs. Just how much it will cost if a patient seeks their beneficent care, a bed in their ward, or an expensive diagnostic procedure they will not be shy about disclosing. Gynaecologists too belong to this magic circle, and they function essentially as if they were in private practice, with set tariffs (while they work hours that are already paid for and in facilities funded by the national health insurance system). There are, of course, more discreet techniques as well, and junior doctors have those down to a T. They pretend that paying any attention to a patient is a special favour, as though the use of certain medicines, procedures or tests was out of the ordinary. Then, of course, the horror stories also go round by word of mouth, just like the appropriate gratuities. A general practitioner tells a female patient who has just been scared to death over a diagnosis of early-stage colorectal cancer exactly how much, down to the nearest forint, she will have to pay to have the necessary treatment (radiation and chemotherapy) started immediately along with the number of weeks she will have to wait if she doesn't want it started immediately.

J. G.

By-Passes: The Disability Benefit Scam

Rózsi and Marika. Two middle-aged women, one had qualified as an agronomist but was now a shopkeeper, the other made pasta for sale. The two of them were key figures in one of the biggest bribery scandals of recent years, which took place in Miskolc, Hungary's second city.
Ninety-three persons were suspected, including thirteen Miskolc doctors. The doctors were bribed in the hope of being able to draw the dependable monthly income that a disability allowance provides. Rózsi and Marika were the go-betweens putting patients in touch with doctors-for a substantial fee. Initially, potential clients came from the waiting rooms of doctors' surgeries; after a time the women's telephone numbers became widely known in the city. Their 'fixing' assumed a quasi-industrial scale in the years 2001 and 2002. Our own sources suggest that it was still 'business as usual' even after the police investigation was started; one of the accused even interviewed clients when already under house arrest.
In all, there were 211 counts of bribery, 100 of trafficking influence, 53 of forgery of official documents, 63 of fraud and 324 of forgery of personal documents. The police have questioned almost 800 persons and legal opinion has been sought in 115 instances. It has been established that around Ft7 million in bribes changed hands, while the state has been defrauded of 93 million (about 1365,000). Those sums, however, were just the tip of the iceberg. The police had uncovered pointers to a good many more instances, but they had been unable to obtain evidence of these within the time available. As it is, they had submitted to the county prosecutor some 15,000 pages of written evidence to back their recommendation to prosecute.
It is unclear exactly when and how the whole affair began. According to a senior physician at Saint Francis's Hospital in Miskolc, for many unemployed men in their forties and fifties in those slump-stricken areas of north-eastern Hungary, obtaining disability benefits is often the only way of securing a regular income until they reach pensionable age. Although a 50 per cent disability brings in little more than Ft20,000 per month-about 180, disability assessed at 67 per cent or or more means the allowance is calculated on the basis of the claimant's length of employment and previous salary: in some cases this may come to Ft 100,000 per month. (For 100 per cent disablement the claimant is entitled to a full pension.)
Getting yourself written off as disabled is accepted in Miskolc as an everyday escape route out of the slump. After the change in regime, it was Party apparatchiks who were the first to present themselves at hospitals, and they were followed by the officialdom of bankrupt state enterprises. Local panel doctors who were trying to be helpful would sign for people who were in serious financial difficulties to receive sick pay then send them off to hospital for further investigations, saying that the thicker the patient's file, the more likely he or she was to secure a disability allowance. As the practice spread, it was inevitable that people should come along who saw a business opportunity in all this, and it did not take them long to locate the doctors who were ready to cooperate.
The two women had no healthcare qualifications but they managed to build up a highly lucrative business. The procedure was the following: the two women might have eight, ten or fifteen people waiting to see them at a prearranged time in the hospital car park. Those patients would be told to bring along the results of previous medical tests and Ft 30,000. Out of that the two women deducted Ft5,000 each and the remaining Ft 20,000 was slipped in among the documents. One of the women would then escort the whole group to a chief consultant, knock on the door and send them in with a farewell "We're here, doctor". The consultant would then arrange for the patients to have the necessary tests. There were even individuals who on paper were in-patients at the hospital but who in fact were at home. They were differentiated from other patients by an asterix in the nursing records so meals would not be ordered for them as they were not actually occupying a bed.
The departmental head and his deputy were questioned by the police. They claimed in their defence that the sums of money they accepted were not prepaid bribes for medical examinations but 'gratuities' for treatment received for which they had not done any favours. The investigation indicated that Rózsi and Marika were in direct contact with three of the assessment board's administrators, who would always know to which doctor the client's file should be handed. The younger and healthier the individual seeking disabled classification, the higher the price that had to be paid. As the go-betweens used to put it, it was costlier the more the medical assessor had to have his palm "greased".
"After a while, the ramifications of the affair became incredibly complex," says one officer who has been involved in the case. "The names of other hospitals and new doctors kept on coming to light as the strands spread right across and even beyond Miskolc. We were under immense time pressure because the law requires an investigation to be concluded within two years of an individual's first interrogation after being charged with an offence, otherwise the charge has to be dropped. We had to wait months to get some expert opinions and were afraid that all our work would have been for nothing so we did not take in more institutions and doctors. The evidence recorded on those 15,000 pages is just the tip of an iceberg."

(From the press)

Julia Gáti
is on the staff of the political and economic weekly HVG.