How to treat the healthcare system?
Diagnosis to world health: the condition is serious
Dmitry Mungalov, BFM
Due to the intensity of passions around Leonid Roshal's speech at the medical forum, the substantive part of his speech - how to reform the healthcare system – has faded into the shadows? A colossal task in terms of complexity is facing many countries
"It's a misfortune that the Ministry of Health and Social Development does not have a single normal experienced healthcare organizer."
Leonid Roshal, in his speech at the forum, spoke about the uncontrolled and thoughtless spending of funds on medicine.
Photo: RIA Novosti
"Where is the development concept? Where are they taking us? Tell me, please, loudly," Roshal asked the silent audience. A titanic task in its complexity – how to make health care more flexible and adequate to the challenges of our time, without undermining its foundations – is also facing much more prosperous countries. The previous model of financing European health care no longer works – costs are growing faster than sources of funding. So at the end of his speech, Dr. Roshal wished Prime Minister Putin "health and a big bedside table," referring to the health budget. Meanwhile, there are more and more supporters of the opposite point of view in the world: no matter how deep this "bedside table" is, there will not be enough funds from it a priori. Experts believe that those countries are moving in the right direction that are trying to reduce the role of state participation in healthcare, getting rid of excessive bureaucracy, introducing an element of competition there and encouraging patients to be guided in treatment by the principle of "reasonable sufficiency". Russia, on the other hand, is still focused on pumping budget billions into the healthcare sector, while simultaneously increasing the tax burden.
In the first half of the 20th century, when national health systems were being formed in European countries, infections and malnutrition were the main medical problems. Antibiotics, refrigerators and calorie-rich food helped to cope with them. The latter, by the way, gave rise to the opposite problem: doctors from the UK, where the number of overweight people is the largest in Europe, predict a 60 percent increase in obesity-related diseases by 2030.
Now the lion's share of healthcare budgets is being eaten away by the fight against chronic diseases: cancer, cardiovascular and respiratory diseases, dementia, diabetes. The problems are relatively new, and the ways to solve them are the same: since the middle of the last century, the schemes of financing and administration of health protection have changed little. The provision of medical services is too bureaucratic, and their financing is still fragmented and focused on the urgent solution of acute problems, and not on their systematic prevention. Mark Pearson, head of the medical unit of the Organization for Economic Cooperation and Development (OECD), calls the health situation archaic. "European health systems look the same as in 1950: they are focused on the relief of acute conditions. Medical education is concentrated around hospitals. Biomedical research has as a starting point the postulate that a person suffers from a single disease at a particular time, whereas the main challenge is the combination of ailments in one patient. It's time for us to move away from the model of emergency care, and this requires the development of a new funding model."
"You will work for medicines"
The situation with healthcare financing in Europe is far from ideal, and every year this area will require more and more injections. The current 8% of GDP, which, according to the World Bank, is spent on average by EU states on healthcare, will turn into 14% by 2030. Leonid Roshal in his introduction called on Vladimir Putin to increase the financing of healthcare from 3.9% of GDP to at least 6%. In general, this area is underfunded by 2 times, said the doctor, who saw "a clear position of the Ministry of Economic Development and the Ministry of Finance to throw a rope around the neck and limit budget funding."
By the middle of the XXI century, the OECD predicts that pan-European health spending will grow by 350%, while the growth of the continent's economy will be 180%. The situation is similar across the ocean. In 1980, the United States spent $ 253 billion on health care, in 1990 – already $ 714 billion, and in 2008 – $ 2.3 trillion.
In other words, much more money will be needed for healthcare than states will be able to collect with the help of taxes and insurance programs, the main source of replenishment of which are healthy and relatively young people. And there are fewer and fewer of them. Friedrich Breuer, an economist at the University of Constance, Germany, estimated that due to the gap between the number of pensioners and people of working age in Germany predicted after 2020, the share of health care deductions in income tax by 2030 will be 20.7%, by 2040 it will exceed 23%. In 1980, 11.4% of the payroll tax was spent on healthcare. British journalists, for example, are already using the term "crisis", describing the situation with the financing of healthcare in their country.
There are several reasons for this crisis. The main ones lie in two interrelated factors. This is the aging of the population and the resulting surge in chronic diseases. Paradoxically, the health care system in its current form is threatened by the same reasons that have proven its effectiveness in increasing the average life span of Europeans. The UN has calculated that by 2030 there will be 24% of people over the age of 65 on the continent (in 2000 – 16%). Eurostat data show that the average life expectancy of boys born in 2030 will be 10 years longer than those born in 1980. In the USA, by the middle of this century, the average life expectancy will be 83.9 years. In 1950, she was just over 68 years old.
On the one hand, this is good, on the other – bad: old age is accompanied by chronic diseases that are the result of disorders in the work of genes. The failure can be either congenital or acquired under the long-term influence of an unfavorable environment or lifestyle. As soon as the number of defective genes reaches a certain level, a chronic ailment manifests itself: cancer, diabetes, respiratory and cardiovascular diseases, dementia. The longer a person lives, the more likely such a development is. In 2010, according to preliminary calculations, more than a third of Europeans suffered from chronic diseases.
The fact that people live longer does not mean that they enjoy good health until the last day. According to the influential British Medical Journal, the average healthy life expectancy in Europe is 7-10 years less than the average life expectancy. A curious study on how much each additional year of healthy life costs the healthcare system, however, not for a European, but for an average American, was conducted by Peter Neuman from Tufts University Medical School in the USA. His withdrawal is from 100 to 300 thousand dollars.
Returning to Europe. The situation is best in Switzerland, where the average life expectancy is about 80 years, and the average healthy life expectancy is slightly less. Sweden and Italy are in second and third places in the British Medical Journal ranking. Russia, where the average life expectancy is over 60 years, and a healthy life is just over 50 years, the authors of the article placed on the 27th place, after the three Baltic states, as well as Belarus and Ukraine.
Some figures illustrating the situation in Russia in comparison with Europe were made at the All-Russian Forum of Medical Workers. According to Vladimir Putin, despite the obvious progress in the field of healthcare, our life expectancy is 8-10 years lower than in developed countries, infant mortality, on the contrary, is 1.5–2 times higher, deaths from circulatory diseases are 4-5 times more than in Europe.
During the year, 1.3 million Russians die from cardiovascular diseases (CVD), which is comparable to the population of a large regional center. Data provided by BFM.ru Philips, which produces, among other things, medical equipment, demonstrates that mortality rates from CVD in Russia are 7 times higher than in European countries. At the same time, the prevalence of ischemic disease and arterial hypertension with its complications – myocardial infarctions and strokes – is approximately the same. Conclusion: Russians are much more likely to die from ailments with which residents of EU countries live safely for 10-15 years longer.
This gap is a consequence of different approaches to treatment. In developed countries, ischemic disease is treated mainly by surgical methods. Exceptions are only very advanced cases and situations when the operation is contraindicated. In Russia, pills remain the predominant method of treatment. For example, balloon angioplasty and stenting in Russia receive only about 1% of patients. For comparison: in Western Europe and the USA, this figure is 20-30%.
As for oncology, according to 2010 data, about 2.7 million patients with such a diagnosis were registered in Russia. This is 2% of the country's population. A new oncodiagnosis is given every minute. In 2009, the mortality index from neoplasms was 204.5 cases for every 100 thousand of the population, in 2010 it increased to 207.8. Half of the patients do not live five years after diagnosis. The most common malignant diseases in Russia are breast cancer (29%) and circulatory system cancer (25%).
In a year, 2-3 million rubles are spent on one cancer patient in Russia. In the structure of the federal program "Seven Nosologies", designed to provide expensive medicines to Russians with serious diseases, oncology is the most expensive – in 2009 it accounted for 60% of the program budget, or 8.5 billion rubles. Russia spends 2.5 times less on the treatment of cancer patients (in terms of per capita) than in Eastern European countries, and 10-12 times less than in the United States.
Pharmacists were prescribed a sedative
In recent years, European officials and doctors have recorded a curious trend: financial pressure on healthcare is growing due to the development of Internet technologies and greater awareness of patients about modern treatment methods. It is very likely that, having thoroughly studied the topic on the Internet, a person will require more modern – and expensive – treatment and medicines.
The "face" of healthcare has changed over the decades, the principles of financing and management have remained the same.
Photo: uiowa.edu
Materials sciences, genetics, biotechnology, and bioinformatics are developing at a pace commensurate with Internet technologies. The successes they have achieved in recent years have changed our lives and increased the chances of healing. But at the same time, research aimed at the emergence of new drugs, technologies and medical equipment is becoming more and more expensive due to constantly growing requirements and standards. So, in the case of pharmaceutical companies, research and development costs have been steadily increasing over the past two decades. As a result, compared with 1975, the total costs of introducing a new drug to the American market increased 10-fold, to $ 1.3 billion.
Moreover, even such colossal amounts are not a guarantee that the investments will pay for themselves. One example is the story of avastin, an anti–cancer drug released on the American market, and then withdrawn due to the fact that no convincing evidence of its effectiveness was found. About attempts to create a cure for cancer as the best illustration, on the one hand, of people's unwillingness to put up with the incurable disease, and on the other, the effectiveness of marketing moves by pharmacists, BFM.ru and Science Illustrated magazine wrote in a joint series of articles about the most promising medical discoveries that the next decade promises.
Manufacturers are trying by hook or by crook to shift the burden of growing costs to the consumer; the opposing trend is becoming more and more pronounced, expressed in the desire of the state to regulate the ceiling of spending by health officials and citizens on medicines, medical services and technologies. However, the consequences of this regulation are different. When in recession-stricken Greece in May 2009, the authorities announced a 20 percent reduction in drug prices, some manufacturers chose to withdraw from the local market. As a result, medicines produced in Greece could be bought everywhere in Europe, with the exception of Greece itself.
In Russia, after the appearance of the notorious list of vital drugs, on the basis of which plans for the purchase of medicines are formed, they immediately started talking, firstly, that sellers and manufacturers inflated prices for the state-controlled pharmacy assortment, and, secondly, that manufacturers did not get into this list selflessly. Leonid Roshal gave another example worthy of the pen of Saltykov-Shchedrin at the forum of medical workers, telling about the grimaces of the declared struggle for transparency. "An order came from the Ministry of Economy – they sent us a new procurement scheme, in which unconnected things were combined, for example, antibiotics and antifungal drugs. Now we can buy either one or the other for a quarter. Or they made group No. 96, where they combined cotton wool and X–ray equipment," Roshal said. In his opinion, "this is one of those laws that discredit the government." Prime Minister Putin nodded slightly in response.
Healthcare Trends: Saving on Everything
What trends will shape the future of healthcare? In an attempt to answer this question, the Economist Intelligence Unit research and consulting company, part of the same group that publishes the Economist magazine, famous for its quality, interviewed doctors, scientists, pharmacists, officials, politicians and heads of organizations for the protection of patients' rights. Many of the trends identified on the basis of these conversations echo the topics that Dr. Roshal raised in his speech at the medical forum.
Respondents are unanimous: healthcare expects a spiraling increase in costs. This is due not only to the reasons discussed above, but also to the belief shared by an increasing number of countries that good health of citizens strengthens economic power. The first study of its kind on this topic was conducted by economists from the Milken Institute of California, showing what amounts are measured by lost profits due to diseases of the able-bodied population. Cancer, which "costs" American healthcare $50 billion annually, knocks out more than $250 billion from the economy. A similar ratio in the case of high blood pressure – American hypertensive patients could bring almost $ 275 billion, which the US economy does not receive due to the deplorable well-being of workers. The conclusion of the study: the state should treat healthcare not as a heavy financial burden, but as a reasonable investment in a more productive society.
In order for financial injections into healthcare to be as effective as possible, officials will have to improve the system for collecting and processing data on the effectiveness of investments. To do this, it will probably have to make adjustments to the laws on medical secrecy. Marco Steinberg from the Innovation Center of Finland, in an interview with an interviewer from the Economist Intelligence Unit, admitted: "We do not have a mechanism to track the effectiveness of investments, although due to the exhaustion of resources, the development of such a mechanism is becoming an increasingly urgent task. When the amount of funding is reduced, we must take a more careful approach to spending funds." Dr. Roshal, in his 40-minute speech, several times addressed the uncontrolled – and thoughtless – waste of funds on medicine: "It is necessary not only not to be sawn, but also to be used correctly."
Healthcare dispatchers are likely to be general practitioners: they will be responsible for providing urgent care in emergency situations and referring patients to highly specialized specialists. Increasing the role of such doctors implies a simultaneous increase in their knowledge and skills, status and salary. From Leonid Roshal 's speech: "In the primary link, destroying the precinct system is a crime. The district doctor is a center, he should accumulate everything that happens to the patient, but for this he needs to create conditions."
The World Health Organization in 2005 calculated: 80% of cases of cardiovascular diseases, strokes and diabetes could be prevented if the patient changed his lifestyle in time. Therefore, experts interviewed by the Economist Intelligence Unit believe that preventive measures will play a more important role – even people who are not inclined to it will be forced to lead a healthy lifestyle by educational programs, pricing policy and taxes (recall the plans of the Russian Ministry of Finance to sharply increase excise taxes on alcohol and tobacco).
So far, the costs of preventive measures are small; in the EU countries they account for about 3% of the total budget allocated to health protection. Interestingly, Romania is the leader in this indicator (6%). Finland and the Netherlands are in second and third places.
Another trend is connected with the focus on prevention, which was seen by the participants of the Economist Intelligence Unit survey – people will have to abandon the opinion, widespread not only in our country, but also in Western Europe, that the state is obliged to provide the entire population with high-quality and free (in extreme cases, cheap) medical services. Taking care of health will largely become a matter for citizens themselves, and new communication platforms such as medical websites and social networks will help them in this, presenting new opportunities for communication both between patients and doctors and with each other. Leonid Roshal told the participants of the medical forum in Moscow about the benefits of IT in healthcare: "In Orenburg, the children's hospital gave me a password, and I logged in from the office. I looked at the registry, I see what a queue. "Can I have a doctor's office?" – "Can I". - "Can I see how many patients this pediatrician saw last day?" - "You can." - "Or maybe there is a diary, and treatment, and appointments?" - "There is, and a hospital and 8 polyclinics are connected to the network!" What are we making up? See how much it costs and implement it."
Perhaps European countries will come to the idea of some form of consolidation of medical infrastructure. There are already calls for the creation of a prototype of a pan-European health protection system, which will reduce the overall level of costs by eliminating duplication of functions. "We need to move away from the model of medical care near home. It is strategically expedient that we get to the hospital longer, even with compensation for transportation costs at the expense of the state," Richard Sullivan from the London oncological center King's Health Partners Integrated Cancer Center is convinced. Travel for health is gaining an increasing number of supporters in the world. If in 2007 750 thousand Americans went abroad for treatment, then in 2012, according to the forecast of the audit company Deloitte, there will be 1.6 million of them.
So which of the European countries have achieved great success in terms of diversification of funding sources and greater involvement of patients in the treatment process? Health experts name Switzerland, Holland and partly Germany (Germany is a popular place of treatment for Saudi sheikhs and Central Asian leaders). Private health insurance programs are well developed in these countries. The state guarantees support for the poorest strata, the rest can choose between numerous offers from competing companies, of which, for example, 87 are registered in Switzerland.
As a result, despite the decentralized health care (it is clearly cantonal in nature) the Swiss have managed to significantly reduce the time of the patient's meeting with the doctor, which causes burning envy among the British. In the United Kingdom, the health care system is under strict state management and has not changed much in the 63 years that it has existed. Waiting for even the simplest operation lasts for months. The principle of British healthcare "everything and everyone" no longer works.
The dilemma that the governments of many countries will soon have to face was outlined by Dutch Minister of Health Edith Schippers: "If you go too far in the direction of insurance medicine, people with "expensive" diseases and a small amount of money will suffer. The emphasis on budget-funded healthcare will make this area expensive, bureaucratic and insufficiently innovative. There is a very fine line between these two poles."
Portal "Eternal youth" http://vechnayamolodost.ru22.04.2011