The President of EurAsia Heart Health Fund (Switzerland) and CEO of the Swiss International Medical Group, cardiac surgeon, professor - Paul Vogt, who visited Astana with proposals for cooperation, described how the system of universal health insurance was experiencing problems in his country, how important it was to implement effective medical care quality control levers and containment of ever-increasing health care costs, reports Zakon.kz.
- How does the health insurance system work in Switzerland? And how much does it satisfy the population's requests for accessibility and quality of medical care?
- Swiss health care is based on compulsory health insurance. Since 1996, every citizen of the country, regardless of age, social status and nationality, must have a compulsory health insurance policy. The basic policy includes almost all medical services, which are necessary for a person in the event of illness. In addition, health insurance funds render voluntary health insurance services, under which patients can get additional medical services, such as massage, acupuncture, homeopathy, psychologist visits, and sanatorium treatment and so on. A premium policy can also be bought and comfort at hospitalization can be increase (for example, a separate ward in a hospital), as well as free unlimited choice of visiting doctors and clinics can be got. Everything is perfect!
And now let’s see what happens in practice. A consumer of medical services, paying an insurance premium, tries to use it in full, sometimes going beyond insurance guarantees. Having even a minor health problem, the patient immediately goes to the largest and best hospital, subjecting himself to an extended expensive examination, since he can afford it on account of insurance. In pursuit of customer satisfaction, the amount of insurance premiums, in turn, is increasing immeasurably. Unfortunately, for a certain group of population, insurance payments have reached a critical level, posing a threat to family budget, and very soon someone will not be able to afford health insurance and these costs will come upon the state, which is obliged to compensate insurance payments for poor people.
Figuratively saying, our insurance medicine can be compared to a large shopping center, where people choose services themselves, spend money unlimitedly, and there is practically no control over consumption: no one can assess the quality of services rendered, the need to provide it, and how much it corresponds to the cost, no one can verify the correctness of recommendations.
Continuous increase in insurance premiums creates a rather tense situation in the society and in response the Ministry of Health is trying to find some levers allowing reducing the costs of medical care by taking them under control.
- How much does the average health insurance cost in Switzerland?
- From 200 up to 1000 US dollars per month per person. A half of payments is made through insurance premiums, the other half is covered from taxes paid by population. The cost of basic policies is regulated by the state and does not depend on the incomes of citizens, but depends on the type of insurance chosen, the age and gender of the insurer, also on the place of residence as well (it is higher in cities, as doctors' services are more expensive in large settlements and people are ill more often than in rural areas).
- What can be done to restraint the costs of health care? After all, traditionally, Swiss medicine takes the leading place in the world, both in quality and in cost of services.
- The quality of medicine in Switzerland is indeed the highest one in the world and we have the lowest death rate for cardiovascular diseases, besides Switzerland is the second largest in the world in terms of life expectancy (after Japan), precisely because of the quality of medicine. But as for the high cost and expenses for health care, Switzerland is very expensive and is second country after the United States in these terms. The life expectancy in the United States is 6 years shorter. But despite the fact that the most expensive product in Switzerland is medicine, patients are quite satisfied with the result of the doctors' work.
But every year it is increasingly difficult to control the unrestrained growth of spending in this industry. The system has become so complex, and politicians have to enter the “game”: they are trying to "screw up the valve” somehow in order to regulate the balance of value and volumes of services rendered. But, honestly, it is a very difficult task, or it will need about 20 such “valves” simultaneously.
Actually, the quite understandable trend towards higher medicine costs is alarming in many countries, including budgetary financing systems, as in England, for example. They also experience similar problems, and maybe even are in a more difficult situation. The British people cannot stand the deliberately created long waiting lists for health care and go abroad to get at least some treatment. But there are incredibly expensive private clinics, which provide guaranteed support for health until old age. We initiated an independent research campaign and offered our program to improve the insurance system in the country, it received high approval in the parliament and our recommendations are being gradually introduced.
But reconstruction of a house is always more difficult thing than constructing of a new one. That is why it is very important to arrange the right foundation of the insurance system at the very beginning and Kazakhstan has such a chance. There are many factors determining availability and quality of insurance medicine. It is very important to set clear indicators: what you pay money for and what result must be achieved, in order to get effectiveness of any model of health financing.
I will give an example of not very successful optimization of expenditures in our country. The government seeks to save money all the time and introduces various kinds of regulation. This has led to closing of private medical practices, which particularly affected the population residing in small towns and remote settlements. Applying to large city clinics is not convenient and expensive both for the patient and for the state. Effectiveness of care by family doctor, who visits the patient and his family for many years, is higher and better.
We have nearly destroyed the “family doctor” institute, but stopped at the time, when it became clear that the harm from such savings is more than goodness. Now this model is actively developing again. The training of such specialists requires resources, and this cannot be done without help of the state. In addition, it is required to use social packages in the form of housing, good salaries and other conditions to make the profession of a family doctor attractive.
The Western European countries want to put the whole system of health insurance into a clear financial framework and create supervisory agencies. But the expenses in healthcare sector are distributed not only directly to medicine, IT-technologies, soft-programs, rent of premises, utilities, personnel maintenance and so on. On the one hand we are trying to cut costs, on the other hand - we are creating some other mechanism that increases them by creating of an additional controlling structure. As a result, all health care involves 20% of financing, and everything else absorbs 80% of the budget. It is the effect of the inverted pyramid. In fact, keeping the costs of accompanying expenses is required, and the medicine itself needs to be free from frames.
If we talk about the growth of costs rates in the industry, then we can give the following comparison. The cost of living in Switzerland is growing by 3% per year, spending on health care – by 2 times more. There are 8.3 million people in the country, the entire health care system spends 75 billion Swiss francs. In Kazakhstan, there are 18.5 million people for which 5-7 billion US dollars are provided, or 3.5% of the state's GDP. We have an average of 10,000 Swiss francs for each person's health care.
- The ratio of the price and quality of the product or service is the basic principle in marketing. How successful is this principle in medicine?
- In fairness, quality control in medicine is very important, because it is directly related to costs. In principle, the quality control system should control not the “family doctors”, that occurred in Switzerland, but the more complicated part where surgical interventions occur, complex minimally invasive and intervention manipulations, where the risk of incorrect actions can subsequently provoke huge costs. And strange though it might sound, there is no proper quality control system for medical services in the health care practice of Western European countries and in Switzerland.
It is assumed that the control should come from the doctors themselves, from profile associations. The government cannot establish a quality control process. For example, the industry with which I am connected to is cardio surgery. Here, quality control can play a huge role. Of course, doctors themselves do not want to be controlled, and want to “dilly-dally” in their work. But, nevertheless, a group of experts should be established, which will monitor the work of hospital and monitor the results. Stripped of fine words, in order to control the sphere of cardiovascular diseases, 5 components of control are enough: who dies; how many people die; who brought the infection, or from what it occurred; how many patients had a heart attack during the operation (sometimes this is provoked by surgery and preoperative actions); how many patients have neurological losses, and how many patients have come to re-operation because of the same problem.
The next important thing is to understand immediately whether there are indications for surgery, or indications for any medical action or therapy. Ideally, you must first establish control over one of these aspects and the effect will not take long time. And after that, go on to the next part.
As for effectiveness of the insurance system - it does not matter who pays the fees, it should be paid for the medical service. Insurance should pay only for medicine, services from related fields - massages, sanatoriums and others at the expense of the patient. Of course, other factors should not be overlooked: preventive campaigns, promotion of healthy lifestyles, etc.
Performing operations in 20 different countries, in Western Europe, as well, comparing of dozens of positions, I was convinced of the very high quality of our medicine. But, in terms of price, the system needs to be made more optimal.
- Is there a system of penalties for mistakes made by doctors or complaints of patients in Switzerland?
- Hardly ever. It is the lack of quality control, which does not reveal the mistakes of doctors. Patients can complain and sue, but in very rare cases the process is given a course. Most complaints are resolved in arbitration court. In the United States, for example, numerous litigations are being conducted for millions of US dollars, in Germany it is a little bit rarer, and we have a big rarity and such cases are widely publicized. In Switzerland, despite the lack of control, relationship between the doctor and the patient is trustworthy. Patients trust to whom they come to. Of course, the state should maintain this relationship with all its forces; this is a very important factor of success.
- How does the payment of doctors’ labor affect for the final result of their work?
- Our system allows the doctor, if he works well, is talented and promotes qualification, to have a high income. But I'm still sure that the only incentive for a doctor when choosing a profession should be a vocation, not material wealth. The other variant should not exist, in principle. If someone wants to make money, quickly rise up - there are other areas of activity where it can be done faster and easier. A doctor is not a profession. For the most of them this motivation remains decisive for their career.
I also observe this tendency event in our country: most of my colleagues have this motivation throughout their career; the other part lost their way, and went in another direction in order not to worry about a good result, but make money. The introduction of quality control should weed out this second group.