“We have enough money in healthcare, we just spend it irrationally”

Why private clinics benefit from free patients, how it turned out that dialysis for kidney patients is done mainly in non-state clinics, and what lessons our medicine received during the pandemic – Ilya Shilkrot, President of the National Association of Non-Governmental Medical Organizations (NANMO), told Profile about this.

– Ilya Yuryevich, who is a member of the National Association of Non-Governmental Medical Organizations and what is its purpose?

– Today, NANMO includes 20 largest medical organizations in our country and three associations (Moscow, St. Petersburg and Nizhny Novgorod), which represent the majority of private clinics in their regions. At the same time, clinics of members of our association are present in more than 70 constituent entities of the Russian Federation. The mission of our association is to develop the national healthcare system, creating equal opportunities for all participants and caring for the welfare of the patient.

– We have two medicines – public and private, but, as we see, there are enough problems in both …

– When the NANMO was created, we came to the unanimous opinion that we do not have public and private health care systems, but only a national one, which our previous and current ministers of health of the Russian Federation also spoke about. Alas, so far this remains only a slogan: a universal understanding and acceptance of such a position has not been achieved, and the attitude towards public and private medical organizations is different. At the same time, the national health care system itself has unresolved problems and tasks. They are connected both with the organization of medical activity and with the processes of providing medical care. Moreover, these two issues at the legislative and everyday levels are often mixed. On the one hand, it is legislated that medical activity is the provision of assistance, and on the other hand, the provision of medical services, and this is a completely different legal regulation.

In general, there are several groups of problems in the national health system, and they are all different. For example, related to the planning of medical activities and planning the need for medical care. The fact is that we often lack planning for needs and there are a lot of so-called “politics” in the healthcare system. Medical organizations are often built not where they are really needed, but where they, in someone’s opinion, will bring possible “political” or other dividends.

– What do you mean by the phrase “political dividends”?

Not formed and opaque: why the CHI system needs to be adjusted

– For example, there is a functioning medical organization, and a new one is being built next to it, without first analyzing who will be treated there and what will happen to the already operating clinic, regardless of its form of ownership and departmental affiliation. We have private companies with a large network of medical organizations. Their power can be used very profitably. That is, order medical care from these clinics, and they, under an agreement with the Compulsory Medical Insurance Fund and with insurance companies, can provide assistance to the population that lives in the territory where the clinic or hospital is located. What happens to us most of the time? For example, in the city of N there is a large private clinic, and instead of using it, a state polyclinic is being built on the same street for huge budgetary funds. Why spend that kind of money? Here it should be taken into account that the heads (as a rule, the chief physician) of state hospitals and polyclinics in the regions are appointed by the regional ministers of health. Of course, all the regulations are observed, but in fact it is very rude, and they get full control over the activities of the organization. And in a private clinic, they can only control the quality of medical care, collect complaints from patients, and so on, but they cannot appoint a chief doctor there or order any actions, including financial and economic ones.

– Interesting…

“Moreover, when we had municipal health care until 2012, the work books of the chief doctors were not in the personnel department of hospitals and polyclinics, but in a safe at the head of the administration of the municipality, and he could order them. The head physician could not refuse, because he was a subordinate. I may surprise some, but this is a real case. However, this is not the point. The main problem is that crazy money is spent on construction, and then the search for personnel begins. Very often there are difficulties with this, as private and public clinics begin to poach doctors and medical staff from each other. If doctors go to work in a private clinic, then insults and talk begin that private traders have lured away. And the fact that the specialists themselves went there for some reason, no one takes into account.

– What are the current challenges facing NANMO?

– As an association, we strive for equal participation of all medical organizations, regardless of their form of ownership, departmental affiliation and location. We are working towards full participation in the implementation of the program of state guarantees, free medical care, the CHI program, federal projects, and the national project. We do not want any preferences or privileges, but only equal participation. After all, state organizations, along with private ones, can provide paid services, and there is equality in this regard. For example, we have a huge number of excellent private clinics and hospitals with branches in many regions of the Russian Federation. There are even statistics that commercial clinics use medical equipment more efficiently. If we want to participate in the implementation of the CHI program, then why not provide us with such an opportunity? Many already partially work in the CHI system, but, in my opinion, this is not enough.

– Why, then, in the country, almost all dialysis centers are private?

– There was a period when the state could not provide dialysis centers for kidney patients. This procedure was given to private traders who were in the CHI. Subsequently, it turned out that all our dialysis centers turned out to be private. Only now our health officials began to claim that commercial clinics took away patients from them and carried out all dialysis procedures. There is an opinion that for the most part health care leaders only like to build and buy, and they don’t really want to organize.

– And in general, it is profitable for private clinics to work within the framework of compulsory health insurance?

– Of course. Although the state accuses private companies that they do not want to work in primary care, but want to take away only the most “tidbits” and expensive pieces, for example, oncology or cardiology. We have enough money in the healthcare system, we just spend it irrationally. Moreover, I am convinced that until the health authorities prove that they can rationally and competently spend the funds allocated from the budget, it is not necessary to allocate them in a larger volume. We now have a difficult situation in our country, and for some reason the state prefers to purchase equipment, instead of purchasing compulsory medical insurance services. Then, to work on this equipment, it will be necessary to train personnel, maintain, buy spare parts, and this is all with the current problems with logistics. And private capacities will be used poorly.

– But at the peak of the coronavirus pandemic, private clinics were actively involved in the treatment and diagnosis of COVID-19…

– Indeed, during this period, almost all private laboratories conducted tests, and many of them, within the framework of compulsory health insurance, just like the state ones, did computed tomography, opened their own hospitals. By the way, they made a significant contribution to the fight of the entire healthcare system against the pandemic. But it remains a mystery to me why all this is required only in emergency situations and why it is impossible to plan in advance and consider the entire healthcare infrastructure, regardless of the form of ownership, as a single entity.

– Do you think that outside of emergency situations, it is difficult for state clinics to cope with the workload?

– Of course. This is not denied on any level. After all, they are very busy, and patients have to wait. And in order to speed up the process, people resort to paid services in public clinics.

In preparation for the interview, I conducted a survey among several of my acquaintances. It turned out that only one person managed to receive medical care in a private clinic under the MHI, despite the fact that they work in this program. Why are patients denied?

– The fact is that a small amount of volumes is allocated to private traders. For example, 50 CT scans per year or 50 angiographies and coronary stentings. They do this volume in one or two weeks and can no longer, because they are not paid in excess of the allocated volumes. A person comes, and he is told that it is impossible for free, because we have run out of volume. The patient is confused and begins to swear. It turns out that private clinics refuse medical care to the patient, without wanting to.

Plus, with us, OMS money can only be spent on what the fund says. In addition, our state is afraid that they will transfer patients to private clinics, and they will close. For example, my colleague Grigory Roitberg, the head of Medicina JSC, said more than once that if we suddenly leave, we will not take the building with us. We can give a bank guarantee, and in the event of our departure, the bank will pay all possible compensation. The state will retain the building, equipment, and employees.

– That is, a private clinic cannot write a request for residents to be attached to them?

– There are clinics that do not want to provide outpatient care, but there are those that are happy to do so. Of course, they can write such a request, but residents will not be attached to them. I practically do not know such cases, except for clinics in Novgorod, Chelyabinsk and in several other cities. For example, in Chelyabinsk there is a private polyclinic that works only on compulsory medical insurance and does not provide paid services at all. At the same time, it is profitable for them, and they guarantee quality. In general, primary care provided in a polyclinic is unprofitable for a medical organization from an economic point of view, but this company proves the opposite. It’s all about getting organized and saving on inefficient spending. Alas, our regulatory documents force us to such expenses. It sounds strange, but at the peak of the coronavirus pandemic, doctors had to distribute medicines to patients. Why doctors and not nurses or couriers? Fortunately, now we are at least switching to electronic sick leave, and before, patients came to doctors to open or extend sick leave. This is one of the examples of irrational use of premises and personnel. At the same time, health care has only two answers to many questions: “this is how it happened historically” and “this is how it is accepted”.

Our medicine is one of the most advanced in the world in terms of the availability of equipment and personnel, and, alas, far from the most advanced in the field of healthcare organization.

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