Thursday, November 2 2017 15:26
Emmanuil Mkrtchyan

Levon Altounyan: We are building a new architecture of Armenian medicine

Levon Altounyan: We are building a new architecture of Armenian medicine

ArmInfo.The long-awaited comprehensive healthcare reform in Armenia seems to have begun. And, perhaps, it will last for more than one year and will be implemented in stages, accustoming the citizens of the country to the great truth so well described by the authors of the "12 chairs": "the salvation of a drowning man is the work of the drowning man himself". And the famous  quote of Nobel  laureate Zhores Alferov reading  that "anyone who needs such a state, if people, paying taxes, must also pay for education, medical care, independently accumulate on retirement", will remain a purely rhetorical attack. For otherwise - for sure - there will be no education, no medicine, and a normal pension is more than enough. We talked about where and how our medicine will start to talk with the Minister of Health of Armenia, doctor,  insurer and businessman Levon Altounyan.

 

 

Mr. Altounyan, recently you expressed the idea of paying an ambulance. Knowing you for a long time, I'm still far from the opinion that some of my colleagues, who were sensational in sensation, submitted your idea correctly, without bills, without ripping it out of context. Did you mean that the ambulance will be paid for through insurance premiums?

 Of course not.  At a meeting with journalists, I stated unequivocally that the Ambulance Service should be free of charge for both citizens and visitors of the city, but did not rule out the possibility of providing it with a set of paid services. In order that the First Aid to be really fast, that is, it would reach the patient in 5-15 minutes, that is, fit in the standard, we need to calculate the number of urgent emergency cases and divide them by the number of teams. But, very often, these calculated brigades begin to deal with unusual functions, conduct psychological conversations, go on, say, chronic cases, go out, if a person is just scared, then this, sorry, is no good.

 And are there many of such cases registered?

 Real urgent cases registered today are up to 35-40%. All other cases are not urgent.

 And could the understanding of this reality come after the ambulance has been on a call? That is, the patient could not himself assess the severity of his condition.

 We have thoroughly investigated this issue. In cases where a person or his relatives cannot understand, unable to assess the real state of the patient, there are still 15-20 percent. There is no question of this. And it's good when people in such cases just in case pick  up the phone. But if a person knowing that he is a chronic hypertensive person, calls an ambulance every day to keep his hypertensive diary, is this really an emergency service?

 Of course not, but for the sake of justice it is difficult to identify a clear dividing line. Can today not take decisions, but translate such cases into the field of service of insurance medicine, when will it work for us.

 In the framework of general mandatory medical insurance, such cases will certainly not be included. Because keeping a diary of a hypertonic is a function of the patient himself, not of a doctor, especially of an ambulance. This is done either by the patients themselves, or by their relatives, or by social services. So it turns out that almost 40% of cases of ambulance we have are  not  urgent, and   that is because of different reasons. Let's say, fever. That it is possible to tell, if the person of 3 days is sick of a flu, a doctor from an out-patient department goes for that, and in the evening  he arrives fast to make a shot of Dimedrol for the night  so that the patient could fall asleep. Do you want to consider these cases as speedy, unless of course it is not a child or a deeply elderly person, but an adult who called an ambulance at a temperature of 38.2? That's how they do in many countries. An ambulance arrives, serves and leaves. Next, the relevant services are looking at the case itself. If under the protocol this was in fact an early event, then everything is fine, it is credited at the expense of budgetary funds, and if not, these services send appropriate files to the insurance company where the client is insured. Insurance in turn studies whether the case corresponds to insurance coverage. If so, he pays for his First Aid, and, if not, he presents the corresponding account to the citizen. Such a three-step payment system operates in Israel and some other countries, and I think it is absolutely correct. You know, it is much more stupid to try to embrace the vast, diverting money from oncology or cardiology. This is a matter of rational use of available funds.

 I absolutely agree, but how to make sure that First Aid service will not get a  deep temptation to start  earning  money independently? Money has never been  much  to anyone…

It seems to me that with a clear regulation of the issue, there will be no such temptation in the services of the First Aid. Well, on the other hand, if there is a team that stays cool on a standby, why should not have a list of services with appropriate price list and not to go to hypertensive patients?  But for an appropriate  fee.  After all, emergency services also have peak hours, in the morning and in the evening, while in the afternoon. As a rule, many brigades "rest" and this time can be effectively used, providing the population with paid services. Thus, we will have the opportunity to provide additional mobile services to our  population, expand the line of medical services and, in the end, why not, pay extra premiums to doctors. And the range of services can be completely different.

Now I understand why you are accused that you intend to commercialize medicine fully. After all, people have a constitutional right to health care and medical care. And people are perplexed, because our medicine and is deeply commercialized for a pretty long time. Moreover, many of those who privatized Soviet hospitals "for a penny" are doing business today  thanks to the state among others. There are clinics where over half of the proceeds come from state orders. Money and oligarchs from medicine make money on this. If it were not for the existence of a guaranteed state order, I strictly suspect  they would undertake costly repairs of premises and install multi-million-dollar equipment at hospitals. Is this the market for which we are fighting, in the classical sense of it? And thus some clinics become bankrupt. It seems to me that the main reason for these bankruptcies is the availability of relaxing budgetary money and out of control bad management. Although there is another factor - the high cost of services for patients, as we are with you. If you do not mind, we'll talk more about this yet.

 When you say that oligarchs create clinics and sit down on the state budget - this is not entirely true. The best clinics in the country, and large clinics, provide up to 50% of paid extra budgetary services. In this sense, they are paid to the cashier, and from the budget. Another thing is that the statement claiming  commercialized medicine  is initially true, every step in medicine today is money, but take into account that , it's money passing by the cash register and, as a consequence pass around  the budget in the meaning of   taxes. And I subscribe to a study of the world's leading donor financial organizations, which concluded that today's shadow turnover in medical organizations of Armenia is 180% of its official turnover and 250% of the budget. That is, unofficial money in medicine is 2.5 times more than official money. The calculations of our ministry show the same picture. Therefore, we believe that medicine is now commercialized to the limit, and that there is nowhere else to go. There is not a single  service that would be free.

 And here is what we want to do. After all, it is clear that when you pay from one pocket, it is more effective, more targeted and more controllable. That is, we offer to go from a small retail, which is uncontrollable,  to a large wholesale. The state collects this money into one insurance reserve fund and instructs service providers to provide services to the population, pre-bargaining good conditions, good prices and putting quality control in advance. Due to this, it is possible, first of all, to reduce the costs of the population for medicine by 15 to 20 percent, and achieve much better quality, when cheaper, and better, and more. Thus, we will begin to reduce the shadow commercialization of medicine, making it more targeted and rational. Due to this, the population's payments will decrease in many areas. But at the same time, let's not forget that nothing is free, it never happens anywhere. In nature, everything is commercialized, and everything has its price.

 Nobody talks about state charity. The fee is our taxes, so there is no question of something free of charge. We pay taxes for what? In order for our state to fulfill its basic functions, including  protecting  the health of citizens. The taxes are exactly that  payment. And this board has its price. And the state should, it is obliged to  manage our taxes effectively.

 Quite right, and at the expense of taxes, 36 billion drams are now being generated from the budget for medicine, which is only one-third of the needs of   outpatient care and one-seventh of the need for medical services in general.

 Yes, we have a weak economy, and moreover, we have two parallel economies in our country - one formal, which pays taxes and informal, which almost does not pay them. So it turns out a gap. And the one who pays taxes, I think, is not to blame for this state of affairs.

 Yes, but the one who pays taxes must understand – or  he is given 30% of what he needs, or he must pay the remaining 70%.

 Let's talk about 30 for now

Here the state should follow two basic principles - to ensure the maximum workload of medical institutions, and to ensure the principle of temporary availability of the service. If, for example, we are talking about the provision of emergency medical care in the regions, the state is simply obligated within the framework of the adopted standards, that is, for 15-20 minutes in case of emergency, to provide the person with the necessary assistance. That is, emergency services, which are able to provide qualified assistance, should be available within a radius of 40 km. That is, the state is obliged to ensure the availability of a hospital here. In this case, the function of the state can be considered fulfilled. All other types of care, such as complex oncological/cancer, reconstructive and other operations or outpatient studies for which there are no urgent time frames, can be located both in large cities and, naturally, in Yerevan. For example, I will say that 70% of Americans go to Maryland for a liver transplant, where a specialized large clinic is located. So, in our country, the bulk of hospitals, including specialized ones, should be located in large cities, where there is a certain sufficient degree of congestion.

Thus, at the junction of these two principles - maximum workload and temporary availability - we intend to build a new architecture of Armenian medicine. Because spraying  funds and trying   to have a large, well-equipped hospital in every district center, as practice has shown, is senseless, uneconomic, irrational, wasteful and unproductive. Because all these hospital buildings, all this equipment, in fact, remain without doctors. The surgeon can not spend two operations a month. In this case, he goes for  drinks in local restaurants, or becomes an avid gambler and, in the end, loses his qualification, or, at the  best, just escapes.

 Actually, such an architecture lay at the heart of the Russian optimization of medicine. There are certainly huge territories and scales, but judging by the responses and feedbacks, this reform was not so successful. They wanted it better, but they got it as always. Many literate rural doctors were left without work, and patients were deprived of basic medical care. Have you analyzed this Russian experience  not to repeat  such mistakes?

I'm not familiar with the Russian experience, but I want to assure you that unlike the huge Russia, we have everything in the palm of our hand. It is possible to  calculate this efficiency formula in small Armenia correctly. Of course, we will have disputes  and those medical workers, who are underloaded today, will show discontent - and there will be more work and it will be more difficult to get to it.

It's all good, but how does the state intend to fulfill its other function - to do so that it would not be cheated, that is, to reduce to a minimum the level of shadow commercialization in medicine? So that  the money would go into the white cash register, so that doctors would earn a high official income, at least adequate to the level of qualifications? How is it adjusted? Is the insurance medicine capable for assuming the regulatory role?

 To make medicine "white" means to install real prices and control so that the main performers of medical services receive adequate payment. It happens that today we have on a price, let's say, 250 thousand drams for a particular operation, and the doctor is paid 5 thousand for the work done, 2 thousand for the nurse, and for the nurse - miser 500 drams, That is, in fact, this money does not reach the performers , and there is a natural temptation to ask the patient for additional "gratitude". And in the end, it turns out that 250 thousand is a share of the owners of the clinic or head physicians, and the staff is kept at the forage.

I was just talking about exactly this commercialization. You are absolutely right. Nowadays, as a rule, the conflict between the owners of clinics and the personnel lies exactly in this area. Medicine has turned into a super-profitable business of owners and these super-incomes are formed on the basis of savings on doctors and medical personnel, because in the market the offer of doctors often outweighs the demand. Strangely enough, not all clinics present a demand for good professionals, because this is not the main thing for high-paying businesses. Doctors of the average hand, who can be paid a little, are quite fair for  the owners in the context of receiving super profits.

 A much more acute problem is that in the long run, there is no conflict. Doctors and the rest of the staff are quietly patient for this attitude to themselves, to their work, and hope for the generosity of patients. In fact, this is the most sad thing.

 Yes, you are absolutely right. Owners say: "make your money and do not claim even for a percentage". That is, the medicine was turned into a private shop where no laws and regulations work, where informal agreements and rules dominate, for which ultimately the patients pay, both literally and figuratively.

 Yes, they tell the doctors: "do your money, but in a way that  makes  no one  to complain, and if there are complaints - we will take measures."  So  the  staff  gets  between  the rock and the stone .

And the money from the state order and the money that comes to the official in the cash register, weakly reach the doctors. So do doctors have to negotiate with patients?

Quite right, but still I would not talk about this phenomenon today in institutional terms, about everyone. It is possible that there are such clinics, but I do not think that this is a general practice. It was like this about 5-10 years ago. Today the situation is changing for the better. Now doctors receive official salary in the overwhelming majority of clinics, but they receive in absolutely insufficient amount. What is  300 - 500 thousand drams per  month for a good practicing doctor?

 I think that is  nothing for a good doctor. Is it possible to solve this problem by adjusting medicine institutionally, through the introduction of compulsory health insurance?

See what we come to. First, in order to abolish corruption, shadow commercialization, we need to introduce price compliance, that is, we need to calculate both depreciation of equipment, and the profit of clinic owners, and a decent salary for doctors. And after that, we go out to the cost of each patient, the diagnosis or manipulation, in short, to the real price, and the person sees that they take a lot of money from him, and that if he still asks for 3 or 5 thousand drams, he will simply give muzzle. And the one who can potentially ask, also knows and sees it. We came to some rather high prices and in order to make them lifetable for the whole population, the centralization of the funds is needed. Firstly, due to centralization, wholesale buyers always have the opportunity to slightly reduce these prices, and secondly, if the entire population spends 240 billion drams on their medical services per year, then let's divide this sum into 3 million people. And although out of 3 million within a year are treated and receive medical care only 600 thousand, but, nevertheless, sooner or later, it is guaranteed, it will be received all and more than once. This is the essence  of a  general mandatory  medical  insurance.

 And you came out for the sum, that is, as experts say, for an insurance premium of 6 thousand drams per person per month?

Quite right.  But rather, we reached the number of the population from 800 thousand to a million, which will be insured at the expense of budgetary funds. These are those who are included in the social program "Paros" and 100 thousand of our civil servants, for which the state will pay. Although, to be precise, 100 thousand civil servants do not belong here, because the state, like any employer,  also insures its employees. For all the other 2 million people, insurance payments will amount to 6,000 drams per month or 72,000 drams a year under universal compulsory medical insurance. And then the medicine will spread its back, become much more controlled, will feel itself among the developing world's medical people, and the population will not consider themselves infringed.

 Has the MMI mechanism been developed already?  You are talking about the concept.

Since October 1, the mechanism for the social package for civil employees   has already been launched. The mechanism, which will operate for 612 thousand socially unsecured people, has already been developed and will be implemented from April next year. This is a pilot project that will allow, on the principle (law) of large numbers, as they say, "run-in" the program itself. It is another matter that the law on universal compulsory medical insurance (OMI) has not yet been created, it is not in nature, but there is an understanding that everything that has been worked out or already working will be analyzed and extrapolated to 3 million people. We plan to enter the government with the draft law in late 2018. I hope that in 2020 the MMI will work in Armenia.

 How much will the main players who will redistribute money for services, that is, insurance companies, be free in their policy?

Great freedom is not planned. In fact, in this project, insurance companies will have functions not so much of insurers as of service providers. Insurance we delegate as an outsourcing the function of providing the service to the insured and the function of medical examination in terms of the adequacy of assessing the patient's condition and the adequacy of the invoice. All the rest, including the distribution of the market for insurance companies, including the definition of the contract of "insurance company - hospital or medical institution" - all this is determined by the state represented by the State Health Agency. Two things are not yet defined, who will pay insurance premiums - an individual or an employer. In any case, this will be a minus from the wage fund. Secondly, it is not yet determined, it will be a fixed 6 thousand drams a month per person, or a percentage of the salary, which on average will yield the same 6 thousand drams.

 

How do you think the introduction of the MMI will push the market for voluntary medical insurance (VMI)?

I have no doubt. This reform will increase the level of the insurance culture of the population and those who will be able to pay extra for, so to speak, a premium level of medical care, will do it. But voluntary insurance will by no means replace the obligatory.

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Aram Sargsyan: RPA and Serzh  Sargsyan  phenomenal abilities   allowed them to blur  even the brilliant reputation of the new president of ArmeniaAram Sargsyan: RPA and Serzh  Sargsyan  phenomenal abilities   allowed them to blur  even the brilliant reputation of the new president of Armenia
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Giro Manoyan: The status quo coud work in favor of  Armenians only within correct use - an increase  of Artsakh population to 250-300 thousandGiro Manoyan: The status quo coud work in favor of  Armenians only within correct use - an increase  of Artsakh population to 250-300 thousand
Erikas Petrikas: If there are many, very many good examples, then everything around will begin to changeErikas Petrikas: If there are many, very many good examples, then everything around will begin to change
Armen Martirosyan: SerzhSargsyan`s aspiration to play first fiddle deprives him of trusting even his closest teamArmen Martirosyan: SerzhSargsyan`s aspiration to play first fiddle deprives him of trusting even his closest team
Rasim Mousabekov: Earlier appointment for presidential elections in Azerbaijan may allow reaching some breakthrough in Karabakh talks this yearRasim Mousabekov: Earlier appointment for presidential elections in Azerbaijan may allow reaching some breakthrough in Karabakh talks this year
Ashot Manucharyan: Karabakh conflict is the best explosive pulse undermining the fantastic alliance of  Russia, Iran and TurkeyAshot Manucharyan: Karabakh conflict is the best explosive pulse undermining the fantastic alliance of  Russia, Iran and Turkey
Gagik Harutyunyan: Gagik Harutyunyan: "Managed chaos" gradually trends to   change its color from religious to ethnic
Vardan Voskanyan: The purpose of the recent provocations in Iran was the return of Tehran under international sanctionsVardan Voskanyan: The purpose of the recent provocations in Iran was the return of Tehran under international sanctions
Masis Mailyan: Artsakh absence at the negotiation table  impacts negatively  their productivityMasis Mailyan: Artsakh absence at the negotiation table  impacts negatively  their productivity
Arman Melikyan: Russia does not desire at all to share  the resolution of Karabakh issue with Turkish partArman Melikyan: Russia does not desire at all to share  the resolution of Karabakh issue with Turkish part
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NSS Head: expenses of Yerevan fund reached over 2bln AMDNSS Head: expenses of Yerevan fund reached over 2bln AMD
Official Yerevan responds to Moscow`s statementOfficial Yerevan responds to Moscow`s statement
A group of congressmen sent a letter to Donald Trump urging to meet  with Nikol Pashniyan on the sidelines of UN GA Summit A group of congressmen sent a letter to Donald Trump urging to meet  with Nikol Pashniyan on the sidelines of UN GA Summit 
Decision on arrest of second Armenian President Robert Kocharian will  be appealed todayDecision on arrest of second Armenian President Robert Kocharian will  be appealed today
Ara Minasyan was dismissed from the post of director of the medical center Ara Minasyan was dismissed from the post of director of the medical center "St. Grigor Lusavorich"
Republican Party sees Karabakh motivation in charge against Kocharyan Republican Party sees Karabakh motivation in charge against Kocharyan 
Baku reacted to Pashinyan`s statementBaku reacted to Pashinyan`s statement
Nikol Pashinyan and Paola Severino discussed anti-corruption issuesNikol Pashinyan and Paola Severino discussed anti-corruption issues
Balayan: Statement on conflicts in NATO summit declaration reflects  Armenian side`s approach  Balayan: Statement on conflicts in NATO summit declaration reflects  Armenian side`s approach  
Switalsky: 70% of population of Armenia trusts European Union,  meanwhile confidence in EAEU has fallen to 48%Switalsky: 70% of population of Armenia trusts European Union, meanwhile confidence in EAEU has fallen to 48%
Prime Minister: In case of Azerbaijan`s provocation, we must be ready to defend ourselves and shoot back Prime Minister: In case of Azerbaijan`s provocation, we must be ready to defend ourselves and shoot back 
Armenian Prime Minister to pay a working visit to Belgium on July  11-13Armenian Prime Minister to pay a working visit to Belgium on July  11-13
Armenian National Congress is ready to assist in investigation of  events of March 1Armenian National Congress is ready to assist in investigation of  events of March 1
Aram Sargsyan: A certain number of freedom fighters want me to head  Yerkrapah Volunteers` Union Aram Sargsyan: A certain number of freedom fighters want me to head  Yerkrapah Volunteers` Union 
Mass media: Taron Margaryan resigns Mass media: Taron Margaryan resigns 
Stepanakert: If Baku dares to launch a regular military adventure,  Artsakh flags will be hoisted over all Azerbaijani state institutions Stepanakert: If Baku dares to launch a regular military adventure,  Artsakh flags will be hoisted over all Azerbaijani state institutions 
Pashinyan: There are no serious advances of the adversary in  Nakhijevan direction - it is ridiculous to talk about the loss of  territoriesPashinyan: There are no serious advances of the adversary in  Nakhijevan direction - it is ridiculous to talk about the loss of  territories
General Manvel Grigoryan will remain in custodyGeneral Manvel Grigoryan will remain in custody
Newspaper: Early parliamentary elections will be held in Armenia in  September, and before that Pashinyan will resignNewspaper: Early parliamentary elections will be held in Armenia in  September, and before that Pashinyan will resign
Samvel Babayan: Artsakh needs stability before 2020Samvel Babayan: Artsakh needs stability before 2020
Artsakh Defense Army came out with a statement on recent actions of  AzerbaijanArtsakh Defense Army came out with a statement on recent actions of  Azerbaijan
Armenia attaches importance to long-term cooperation with the  Congress of Local and Regional Authorities of the Council of EuropeArmenia attaches importance to long-term cooperation with the  Congress of Local and Regional Authorities of the Council of Europe
Minister: Karabakh conflict settlement was and remains priority not  only of Armenian foreign policy but also all system of state and  securityMinister: Karabakh conflict settlement was and remains priority not  only of Armenian foreign policy but also all system of state and  security
Narek Sargsyan and Martin Sargsyan were dismissed from their postsNarek Sargsyan and Martin Sargsyan were dismissed from their posts
In Moscow on Tverskaya there was a presentation of a new diasporal  organization created in opposition to the Union of Armenians in  RussiaIn Moscow on Tverskaya there was a presentation of a new diasporal  organization created in opposition to the Union of Armenians in  Russia
Atom Janjughazyan: Any criticism of the program of a new Cabinet is  just a matter of personal subjective viewsAtom Janjughazyan: Any criticism of the program of a new Cabinet is  just a matter of personal subjective views
In Moscow they wanted to see Karen Karapetyan in the place of Serzh Sargsyan, but they reconciled with Nikol PashinyanIn Moscow they wanted to see Karen Karapetyan in the place of Serzh Sargsyan, but they reconciled with Nikol Pashinyan
Ambassador: Bulgaria ratifies Armenia-EU framework agreement by the  end of JuneAmbassador: Bulgaria ratifies Armenia-EU framework agreement by the  end of June
Russian Foreign Ministry presented details of agenda of upcoming  meeting Lavrov-MnatsakanyanRussian Foreign Ministry presented details of agenda of upcoming  meeting Lavrov-Mnatsakanyan
Israeli Prime Minister has postponed debate in Knesset about Armenian  Genocide before the end of elections in TurkeyIsraeli Prime Minister has postponed debate in Knesset about Armenian  Genocide before the end of elections in Turkey
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