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.