Saturday, July 15, 2006

Perserving it for future generations

I've just become part of Movement for perservation of public healthcare. I think it's worth trying to prove a point this way. Unless in ten years you want to be paying grossly huge amounts of money for every time a doctor dedicates 15 seconds of his precious time to you.

As I said: it's worth a try.

posted by Nadezhda | 16:41


Anonymous marko said...

After reading published "goals and principles" of the movement, I decided not become part of it. I like the idea of showing the government that we exist and want them to listen.

In public health sector, like in every non-profit organization, every institution should be treated equally and fairly, which is not possible without perfect knowledge of the environment. Therefore institions have to compete for funding. After they get it, they have to spend it. If they realize they were given too much, they just spend more, because noone wants to return anything. You could say, that controlling their spendings is the answer, but a possible justification could always be made up.

I strongly believe that every public organization inefficienty spends their money. This system can also very quickly lead to corruption.

Private owners generally like their bussineses to prosper, in other worth they need efficiency and satisfaction of their costumers (or patients). Without costumers there is no bussines.

When lives are at stake, simple economics fails because we tend to find evaluating the "value" of someone's live a bit troublesome. But that argument should not dismiss private health as inferior, on contrary, I think it holds great potential.

I think public health would be much harder to improve than to start something different. Maybe you are just afraid to lose what have.

I'm open to further discussion.

PS: In my opinion good workers (doctors, nurses) are not rewarded enough. For example, a salary of a very good doctor should be at least five (or better, ten) times the salary of mediocre one, which is similarly educated and experienced. That would never happen in public sector, even if their "quality" could be measured preceisly.

Blogger Nadezhda said...

Marko - sorry for the late reply, but here goes:

I agree that whatever's public does not necessarilly spend the money in the most effective/efficient posible way. But with any major purchases the government is involved and competing for funding increases quality of service (to a certain extent). I see your point, but this sword is double-edged. I agree about the corruption, but there's even more potential for corruption in private practices, because in the private sector almost everything is about money. You don't have to wait in the queue as long as you have the little green pieces of paper. This is also corruption, because in the Hippocrates' oath every doctor swears to help everybody regardless of their ethnicla/religious/financial background. And last but not least, corruption is there (in the public sector) because people (doctors/nurses..) are money-hungry and they're willing to break the rules when they benefit from it. A stronger ethical and moral backbone is what I miss the most in the public health sector.

Private sector is not something I despise and I'm not particularly against it, either. I believe the patient has to have the ability to choose his personal doctor. But lately the government has been forgetting that public health sector requires lots more encouragment and governing than they're willing to do. The government seems to support the bloom of private practices over the public sector and here's the major mistake. Let's keep the private practice, but let's never forget that public practice is much more difficult to manage and much more important to sustain in Slovenia (for the benefit of the poor).

I am afraid to lose what we have, because the alternative is the dominance of the private practice and this does not enable proper and much needed access to healthcare for all. You need to note that the poor are generally more disadvantaged and thus more prone to health-risks, so they are the ones that direly need free access to health care. The poor who cannot afford private doctors are also the poor of contagious diseases from tuberculosis onwards and thus present a health risk for other citizens, too. Drop the vaccination rates in a country and you'll get an upsurge of contagious diseases.

This problem is multifaceted and complex and naturally, there can be no single opinion on the matter.

The problem with salaries is how to objectively measure quality. Do you consider the mortality/lethality rate a doctor has, the number of referrals and prescriptions issued in a year, or something else?

Anonymous marko said...

There is another important disadvantage of public institutions. They are subject to our famous public orders law.

We both agree that the problem of our healthcare is very complex. In my opinion privatization is not the best idea, but I despise the stubbornness of "Movement for perservation of public healthcare" which totally denies (in their goals and principles, first paragraph) every improvement (possibly) achievable through private, profit-oriented health practices. To throw away a tool without any serious evaluation seem very narrowmindness to me.

Mortality rate wouldn't be a good classifier, because the sample would (luckily) be to small to posses any statistical significance. :) In other words, I have no idea.

Anonymous Mitja said...

You're saying that free-market prices of healthcare would be higher than the current government-regulated prices? I don't know if that's true and I'm don't know whether you know, but let's say it is. People who are not working in healthcare (the majority) obviously benefit from lower prices. Since government-regulated healthcare prices are beneficial, we can extend the principle to other services: I would be delighted if the government, for example, forcibly lowered the prices of car repairs. And so on. See any flaws in my reasoning? Or should I start campaigning for public car repairs?

Blogger Nadezhda said...

Mitja - certainly the free-market prices wouldn't be lower. Medicine is different than repairing cars in that most people are willing to spend thir last savings on a (supposed) cure, whereas you won't really spend and/or repair more than you need to. One can observe the free-market prices in the field of alternative medicine, where some people are willing to pay grossly over-estimated prices just so they can feel being more healthy. (What if any are the positive effects is arguable anyway.)

And you cannot apply medicine to cars, either. You can do without a car. You can use public transportation, a friend can give you a lift, you can even walk or ride a bike. When your health deteriorates you cannot use someone else's car (=health) and drive onwards. Also, people who have more money are willing to spend more money on either car repairs or doctors. Forcing people who don't have enough money to just pay more (why would a doctor whose clients are majorly the poor charge a smaller fee than a doctor who mainly cures the wealthy?) isn't what I'd call equality. Let's say that having your hair cut can be likened to treating a patient. You have the good hairdresser who charges 15000 sit and a mediocre one who charges 4000 sit for the same amount of work performed. Why are some people still willing to go to the more expensive one is beyond my comprehension, but I think it has to do with how you feel. The staff at the more expensive salon might be kinder and more attentive, but not necessarily more skilled in cutting hair. With a lot of private practitioners you're paying for the kindness. The private docs realize you're paying them and they want to keep that relationship so they're kinder and more attentive, but that does not go to say they treat you better. They might prescribe the same regiment of tratment, but in a public institution you might not get the smily face along with the pills. Now, if you have the money, you might be willing to pay for the smiles and the attentions, but what if you don't? I don't think all doctors would be kinder and more helpful if they all worked as private practitioners. So the really nice ones would quickly fill their quotas and inevitably you might land with the "worse half" of the doctors and you'd be paying the same amount for the bad manners.

Marko - I don't know how to judge the quality of a doctor or a nurse, either. But I think there's too big a hype over the supposedly good doctors. A private doc might be kinder towards his patinets, but he/she might not necessarily be a better doctor. What I'm trying to say is that the public healthcare is the government's baby and has been neglected for too long a time. It's time the present minister of health did something to restore the glory of the public healthcare in Slovenia. Afterall, we all grew up in public health care and were we being neglected? Did we have such bad experinces as to be determined that public healthcare is bad, bad, bad?

I challenge anyone who thinks privatization is a good idea to reminiscence how well off he'd be in the USA health-wise.

Blogger Tess said...

Having just come from the U.S., let me just say that we are all envious of so-called socialized medicine. We pay A FORTUNE for health care, and although it may be good (heavy emphasis on the word "may") it costs an arm and a leg (pun somewhat intended).

There are a few reasons why it is so expensive for us. One of those reasons is because a lot of people cannot afford health insurance (most companies no longer offer it through work), and so they have none. Because of the oath that doctors cannot turn anyone away if they arrive need of treatment, these people are treated at the expense of the hospital or clinic itself (Sure, they are sent bills, but most do not/cannot pay, and one cannot hardly blame them when you see the prices). This expense is then passed on to the insurance companies that deal with the hospital or clinic, and is then passed on to those people who hold policies with those insurance companies. A tablet of aspirin or a band-aid can cost nearly US$20 each. I am not kidding or exaggerating, I assure you.

The other factor to consider is the cost of medicine itself. Pharmaceutical companies in the U.S. spend a lot of money on research, advertising, and FDA approval (read "Washington lobbbyists") for their drugs and they have a dictated number of years (I believe it is seven) in which to recoup that cost, as well as the cost of drugs that failed to make it to market. This cost gets passed directly along to Medicare, the hospital, clinic, or the comsumer who is prescibed the drug and is not fortunate enough to have health insurance. I have stood in line many times at the pharmacy and heard the cost of drugs when customers ahead of me have their bills totalled; I have seen people walk away because they cannot afford to pay it. Many people drive out of the country and purchase their drugs elsewhere because out-of-pocket in another country --plus travel expenses-- is still less than what they would pay in the U.S. I had to pay an amount akin to extortion for my private health insurance when I moved here because I wanted a rider that would cover 30 days a year spent in the U.S. , as well as a pre-existing condition.

I am willing to pay for effective medicine and good care, as are most people, but to force people out of the medical system because of high cost is helping no one. Although there certainly is no panacea, I think that public healthcare is still a better system overall...

Anonymous Mitja said...

Nadezhda, I was hoping to provoke you into producing some good arguments for public healthcare. But the ones you gave don't seem very good to me. If I understand correctly, you gave three:
(1) Health is more important than other things.
(2) Private doctors would only cater to the rich.
(3) Private doctors would be able to trick people into spending more money than necessary.

Let's address them ony by one:

(1) Saving one's live is certainly the most important thing for him, because once you're dead, nothing else matters. But not being homeless is more important than most of the things doctors do. Should government regulate housing prices? And housing is probably not the only such thing.

(2) Sure, most doctors would prefer to cater to the rich. But there are too few rich people, so only the best doctors could actually manage to get only rich patients. The rest would have to lower their prices to have any patients. If some people could not pay even the minimum price that would keep healthcare lucrative, then I wouldn't object to the government subsidizing healthcare for such people.

(3) People may not behave rationally when it comes to healthcare, but insurance companies do. I believe health insurance would solve this one. And I think insurance is a good idea, perhaps so good that it should stay obligatory.

The lack of insurance in USA is also one of the reasons Tess gave for expensive healthcare, so let me repeat: insurance is a good idea. You can have private healthcare and insurance.

The other reason she gave is expensive drugs. But I don't quite understand why are they more expensive in USA. And anyway, what does public/private healthcare have to do with drug prices?

In the end, I still don't see any compelling reasons against private healthcare (although I'm not saying none exist).

Blogger Nadezhda said...

Tess, thanks for your input! I'm very grateful for your first-hand account as it is more valuable than the hear-say. I hope you're well and that the move to Ljubljana went smoothly. I'm looking forward to reading more on your blog now that you seem (almost) settled.

Mitja - one of the best arguments for perserving the public healthcare is control. The current organization with ZDs (zdr. dom) working as the primary healthcare outposts enables doctors and the government control over how many people were vaccinated and control over how many people are infected and present a possible risk for transerring the disease to other people; this also applies to systemic check-ups, which are not performed by private practitioners.

With loosing the local control, presented by zdravstveni dom, we lose a local medical center and increase the possibilities for opening of private biochemical laboratories and other supplementary medical services (ultrasound, Roentgen, and other tests and visualizations).

We also decrease the accessibility of the primary healthcare. The patients are forced to go to place A to see their doctor, place B to give their basic urine/blood sample, then back to place A, then to place C to see their gynaecologist, to place D to see a fiziatrician, place E to see their psychiatrict and place F to get their medications. Then there's the place G where their dentist works. Compartmentalizing medicine leads to lowering the numbers of people that actually take the trouble of going the full circle (unless they're hypohondriacs or very seriously ill, but in the latter case we're stealing the time by making them travel all the way - and time is not what they have in abundance).

And last, but not least, do you really expect the government to continue funding healthcare once (and if) all the docs become private practitioners? Don't you think that once the government doesn't have to pay for their salaries and can sell all the buildings, they'll go further and do the same with hospitals? Don't you think that they won't see the need why they should cover for health-related expenses, but they won't lower the taxes. Also, you might be getting a bigger salary, but you'll sure as hell be spending more on healh, especially when you grow older (over 35). And once the government decides not to cover for healthcare anymore, there'll be an upsurge in the number of private insurance companies offering insurance and the only thing an insurance company cares about is profit.

I'll write more, but currently I don't have time. Probably tomorrow.

Blogger Nadezhda said...

Well, "tomorrow" can be stretched to suit one's need. I'm really sorry I didn't respond earlier, but as already mentioned in a post, I was rather occupied in the last week and didn't have much access to a computer, not to speak of internet.

Mitja - I'm not really sure what's your point in #1. Even if you have everything else and are terminally ill, no amount of wealth will matter; or at least it usually doesn't (because some people realize their time has come and decide to go peacefully, but most people struggle to survive if at all possible). Yes, people who are fortunate enough to be relatively healthy are more concerned with houseing problems etc. than health, but this soon changes when your ehalth deteriorates. I might be wrong, but upon reading your last comment you struck me as a person who's never dealt with a terminally ill or a chronically ill person. And while the government doesn't regulate housing prices, it offers flats at a reduced (non-profit) prices, which is the same as ensuring and perserving the public healthcare.

"If some people could not pay even the minimum price that would keep healthcare lucrative, then I wouldn't object to the government subsidizing healthcare for such people." I'm afraid that at the pace the health minister's going and with the direction he's indicated lately, the government would very much like the keep the financial burden of healthcare on the people's shoulders. I might be wrong, but that's the impression I got.

Take France for example - it has a public health system, but the fault currently lies with the private sector which can afford to simultaneously go on holidays. How would you feel if in dire need you would be treated by a med student or a retired doctor, because your doc can afford to go on holidays whenever he pleases and doesn't have to ensure coverage for the time of his absence.

I'm saying that government should take more care of public healthcare and not abandon it in favour of private sector.

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