Κυριακή 25 Νοεμβρίου 2018
Gesy is the Titanic and in real danger of sinking
Gesy is underfunded and the limitations it is placing on the private sector will severely impact the quality of healthcare By Dr Theodoros Potamitis As we near the implementation of the new health care system in Cyprus (Gesy) there are an ever-increasing number of media reports regarding its funding and viability. Most of them give the impression that implementing Gesy is being obstructed because doctors are demanding more money in return for taking part and providing services. The fact is many in the medical profession are deeply worried about the proposed structure of Gesy. It is fair to say that most of us agree that currently Cyprus has a high standard of medical care that is primarily driven and maintained by the private sector. No one doubts that Cyprus as a European nation has an obligation to its people to implement a healthcare system that will provide a service at least equal to today’s standards. This needs to be state funded because no individual should have their wellbeing dependant on their ability to pay. The problems we are facing today have arisen because the Health Insurance Organisation (HIO) – responsible for managing Gesy – and the Cyprus Medical Association (CMA) disagree over the amount of funding required to provide this level of healthcare. The basis of this disagreement are two studies, one undertaken by HIO which suggests that healthcare can be provided with approximately one billion euros of funding, and the other, commissioned by the CMA, which suggests that funding requires closer to 1.5 billion euros. Logic dictates that one of these studies is wrong. It is important to understand the consequences of an erroneous calculation and the impact it will have on the healthcare system. Let us assume that the HIO study is correct and the healthcare system is implemented. It will work perfectly harmoniously, all these arguments would have been meaningless and no harm will come to any user of the system. But what if the CMA study is correct? To answer that question, we need to look at the way the system will work. Once implemented every person living in Cyprus will be financially contributing to Gesy whether they want to or not. On needing healthcare they will visit their general practitioner who will either provide treatment or refer them for a specialist opinion. If they are referred to a specialist opinion through the general practitioner they will be charged six euros as a co-payment for their treatment. Patients will, however, have the option of bypassing the general practitioner and directly visiting a specialist, but in this instance they will incur a 25 euro co-payment charge. In both cases the fee is not paid to the doctor but to Gesy. Although the doctor will collect the money, it will be credited to their account and be deducted from their overall payment at the end of each month. Specialist doctors will be paid by ‘credit units’: medical treatments will not have a monetary value but a unit value. At the end of each month HIO will have collected all the credit units from all the doctors across Cyprus and divide their fixed monthly budget by the number of units in order to determine the unit value. In several media releases HIO has stated that they are confident that the unit value will be 15 euros. However, they have failed to make clear that the unit value is not fixed nor does it have a lower limit. The same will apply for payments to clinics and hospitals for operations and in-patient treatments. This will of course, include the current state hospitals which will also join the system, the difference being that state hospitals, if they have a shortfall at the end of their financial year, will be bailed out by extra funding from the ministry of health. The estimated 15-euro value of the unit is based on what HIO has calculated to be the current healthcare spending in Cyprus. The biggest objection from the medical community to this system is that only at the end of each month will they discover what their income will be. If in a particular month there is a high demand for healthcare then the value of the unit could drop to any amount since it has no safety cut off. Running a clinic or medical office is no different from running any other institution. Running costs for salaries, buildings, equipment and utilities are there every month, not just on good months. Since the value to the unit of payment has no lower limit, then it is difficult for anyone to ascertain whether they will be viable in such a system of funding. A second, very important issue concerns the absence of guidelines and protocols for the treatment provided. In very simple terms any doctor can perform any procedure with any method since there is no minimum standard of care required by Gesy. What invariably happens if you squeeze spending but set no quality standards is fairly obvious. Clinics will be forced to cut spending in order to survive and invariably quality of care will be at risk. State hospitals of course will be rescued, running the risk of only those surviving financially, leaving us and them in a worse state than we are today. To give just a simple example from my own specialty, the average cost of a good quality intraocular implant used for cataract surgery is €150. There are however, implants available for as little as €10. Although, using such an implant in a cataract camp in the middle of nowhere in a developing country is common practice and accepted as better than nothing, it is totally unacceptable in a modern European state. The issue of private practice is also widely debated with no conclusion. In any system the need for private healthcare will always exist. It is the right of any individual doctor to practise privately and the right of any individual patient to choose to privately fund their healthcare so that they receive their treatment at a time most convenient for them with the luxury that a private room offers. It is not in any way immoral to practise privately any more than it is immoral to fly business class. It is only immoral if in your private practice you provide better healthcare than in your Gesy practice, the same way it would be immoral if only first class passengers had oxygen masks and life jackets. On this subject HIO states that allowing doctors who are in the Gesy to practise privately in their free time, will create a two-tier system. Considering that by design Gesy is a two-tier system, since patients who have money can bypass their GP by paying €25, this is an argument with no substance. In addition even though somebody may elect to visit their specialist privately, and thus save Gesy money, if that doctor then prescribes drugs or tests they will be unable to undertake them within Gesy. This discriminates against patients who have after all paid their full contribution to Gesy and more by saving it money and attending a private physician. In the end the questions you need to ask about the problems with implementing Gesy are very simple. When undertaking a task such as building a house, almost without fail by the time the construction is finished there is a 10 to 20 per cent increase in expenditure due to unforeseen circumstances. Is it possible that the HIO has estimated the cost of this monumental project we call Gesy so accurately that no unforeseen circumstances will occur? Secondly if you were to build your house and the construction company offered you a contract that had in no way described the quality of materials to be used would you sign it? Lastly, do you think that you could find a contractor who agreed to build your house, with you having a fixed budget and promise to give him a share of the total after you have decided how many houses you were building? Implementing Gesy as it stands will almost immediately run into difficulties and plans need to be made from now to preempt this happening. We need an additional source of funding to cover the short falls and not wait for the system to collapse and then decide we need more money. We need is to dictate minimum standards of care before complications and treatment failures begin to stack up. Doctors want more money put into the healthcare system not because they want to line their pockets, but because we truly believe that its design and its funding structure are fundamentally flawed. By ignoring the warnings and simply saying we don’t need extra funds, the system will work, our calculations are right, the HIO is basically saying we don’t need lifeboats, this ship is unsinkable. And we all know where that attitude leads.
Dr Theodoros Potamitis is a consultant ophthalmologist who runs the Pantheo Eye Centre in Limassol
How Gesy is penalising the private healthcare sector
In its present form the National Health Scheme will continue
to reward state incompetence while assuming all private doctors are out
to cheat the system
By Dr Marinos Soteriou
The entire philosophy of the National Health Scheme (Gesy) is based on a fixed budget divided by a finite number of medical procedures, resulting in a unit price to be paid per procedure. It is a mechanism to avoid abuse of the system by doctors tempted to perform unnecessary procedures to increase their gains.
Unfortunately, as a consequence, the system creates an unfair
situation where upright doctors could suffer financial consequences from
renegade physicians who unnecessarily try toincrease their revenues by
performing an increased number of procedures, thus reducing the unit
prices. The Health Insurance Organisation (HIO), which will manage Gesy,
will define the unit prices in retrospect, namely at the end of the
month and often long after the medical procedures have been completed.
This ensures the medical world does not refuse to provide medical care
because reimbursement is low. In reality it is a way of cheating doctors
and hospitals into performing procedures without knowing their true
reimbursement. I find this completely unfair and unacceptable.
The problem of course is the variation of the unit price, which may be dangerously low, or even below cost. It has to be understood that even a small variation in the unit price – say five to ten per cent – could result in below cost reimbursement and thus in major financial losses. Obviously the public hospitals will be shielded from such outcomes through government subsidies. In contrast, the private sector will receive no such financial assistance.
The HIO is claiming that armed with the Mercer study – which provided the blueprint for Gesy – and specially designed software that cost tens of millions of euros, it will be able to introduce and monitor protocols, guidelines, results, quality, payments and budgets. In addition we are told that the Mercer study is very detailed and precise, and that it made predictions for all variables. In that case it is reasonable to conclude that the HIO should be in position to introduce a stable, easily monitored unit price that does not exceed the budget. But the HIO is not willing to accept this responsibility and just chooses to penalise the doctors as a group in case of increased demand. In reality doctors who perform their duties with care and caution will be penalised for the abuses of renegade colleagues or hospitals which abuse the system.
In principle all doctors in Cyprus, both the private and public sector, will become employees of Gesy. Yet private physicians will not be granted any benefits associated with such employment, such as working hours, maternity or sick live. If physicians fall sick or shortly after delivery of a child, they will simply have no income. This is an unacceptable development in a “European country “.
Gesy is heavily weighted in favour of the state hospitals, which will continue to be inefficient and uncompetitive because they will be subsidised by the state for between three to five years, or even longer if needed, after Gesy is introduced.
Public hospitals may be paid the same rates as private hospitals, but if there is a big financial hole at the end of the year the state will cover it with additional taxpayer money. What incentive would a state hospital have to keep costs down and improve quality? It is the same anachronistic system that always favours state organisations and state employees.
The unfair competition will continue because the public employees at state hospitals will receive their pay rises every year, pushing up the costs in private hospitals as well, because we will have to follow suit to keep our staff. But we will not receive a state subsidy at the end of the year to cover any deficits caused as result.
If a private hospital runs an accident and emergency department operating 24/7, there will be a copayment charge fee of €10 per visit for the user. Once Gesy is introduced, there will be no charge for visiting the state owned outpatient clinics that will operate until midnight which puts us as at a disadvantage. So in reality up to midnight people are incentivised to use the state owned departments.
There is even a special law for private hospitals that dictates minimum safety requirements. Take an intensive care unit as an example. Private hospitals are obliged to have one bed every 12 square metres to reduce the risk for infections. The state hospital usually have multiple patients in the same area. All these things, plus many others add to costs. The state sets minimum standards for the private sector in order to safeguard patient safety, but the state-run hospitals are not required to meet these standards.
By default this results in major quality differences in the healthcare provided by the two sectors and inevitably results in “double standards“.
For example Gesy will pay €7.50 for an electrocardiogram. A manicurist receives €20 to do someone’s nails. I believe that it is unreasonable for society to accept that a doctor is paid less than a manicurist. We have to keep in mind the responsibility associated with reading the electrocardiogram and the risk to the patient and most certainly the financial consequences of malpractice costs if the doctor misses something. There was a relevant case recently in which a private hospital and a doctor were ordered by court to pay €750,000 in damages.
It is of paramount importance to understand that if the doctors are not properly rewarded, very soon the system will not be in position to recruit well trained, competent and experienced physicians, based on the dictum “if you pay peanuts you get monkeys “. The system will deter good physicians and attract incompetent ones. Similar developments have been recently observed in Greece, Germany and elsewhere.
There are other issues as well. For instance, the case of new therapies that are very expensive. For metastatic lung cancer there are two different therapies: chemotherapy that has very low chance for survival beyond one year and immunomodulation therapy that has kept a significant percentage of patients disease free and alive up to eight years so far. Immunomodulation is much more expensive (€100,000). If Gesy cannot cover the cost of immunomodulation, the doctors or the hospitals affiliated with Gesy are not allowed to accept co-payment from the patient to cover the extra cost. The HIO prohibits co-payment and makes the doctors liable.
We have invested in equipment that carries out mammography examinations for detection of breast cancer. At the rates Gesy will reimburse per examination, it will take 30 years to make our money back. How can we invest in the latest technology under such circumstances?
HIO is reimbursing all the doctors and all the hospitals at the same unit price. Sophisticated tertiary care centres with complex and expensive infrastructure and quality certification will receive the same reimbursement as smaller units that do not have the complexity and the expenses of the larger units. Quality care and patient safety for the patients and become a disincentive.
When we challenged the HIO about its practices, it cites the Mercer Study, but refuses to release the full study to be reviewed. There is only a summary on the health ministry website. The assumptions and other details of the study are still treated as a state secret. It is highly likely that the study contains a lot of information, principles and assumptions that do not correlate with what is about to be implemented through Gesy.
I am very concerned that the preparation for Gesy is very superficial, incomplete, unfair and biased. There has been an organised media campaign to blame and stigmatise doctors and push them to accept Gesy . Yet, it is now more than obvious that Gesy is poorly planned, poorly funded and will be badly executed with far reaching financial, accessibility and quality implications.
The authorities are in full denial of the imminent disaster and are not willing to address the situation. Only if the majority of physicians and private hospitals refuse to join Gesy will the authorities be forced into action
Dr Marinos Soteriou is a cardiothoracic surgeon and founder of the American Medical Center
The entire philosophy of the National Health Scheme (Gesy) is based on a fixed budget divided by a finite number of medical procedures, resulting in a unit price to be paid per procedure. It is a mechanism to avoid abuse of the system by doctors tempted to perform unnecessary procedures to increase their gains.
The problem of course is the variation of the unit price, which may be dangerously low, or even below cost. It has to be understood that even a small variation in the unit price – say five to ten per cent – could result in below cost reimbursement and thus in major financial losses. Obviously the public hospitals will be shielded from such outcomes through government subsidies. In contrast, the private sector will receive no such financial assistance.
The HIO is claiming that armed with the Mercer study – which provided the blueprint for Gesy – and specially designed software that cost tens of millions of euros, it will be able to introduce and monitor protocols, guidelines, results, quality, payments and budgets. In addition we are told that the Mercer study is very detailed and precise, and that it made predictions for all variables. In that case it is reasonable to conclude that the HIO should be in position to introduce a stable, easily monitored unit price that does not exceed the budget. But the HIO is not willing to accept this responsibility and just chooses to penalise the doctors as a group in case of increased demand. In reality doctors who perform their duties with care and caution will be penalised for the abuses of renegade colleagues or hospitals which abuse the system.
In principle all doctors in Cyprus, both the private and public sector, will become employees of Gesy. Yet private physicians will not be granted any benefits associated with such employment, such as working hours, maternity or sick live. If physicians fall sick or shortly after delivery of a child, they will simply have no income. This is an unacceptable development in a “European country “.
Gesy is heavily weighted in favour of the state hospitals, which will continue to be inefficient and uncompetitive because they will be subsidised by the state for between three to five years, or even longer if needed, after Gesy is introduced.
Public hospitals may be paid the same rates as private hospitals, but if there is a big financial hole at the end of the year the state will cover it with additional taxpayer money. What incentive would a state hospital have to keep costs down and improve quality? It is the same anachronistic system that always favours state organisations and state employees.
The unfair competition will continue because the public employees at state hospitals will receive their pay rises every year, pushing up the costs in private hospitals as well, because we will have to follow suit to keep our staff. But we will not receive a state subsidy at the end of the year to cover any deficits caused as result.
If a private hospital runs an accident and emergency department operating 24/7, there will be a copayment charge fee of €10 per visit for the user. Once Gesy is introduced, there will be no charge for visiting the state owned outpatient clinics that will operate until midnight which puts us as at a disadvantage. So in reality up to midnight people are incentivised to use the state owned departments.
There is even a special law for private hospitals that dictates minimum safety requirements. Take an intensive care unit as an example. Private hospitals are obliged to have one bed every 12 square metres to reduce the risk for infections. The state hospital usually have multiple patients in the same area. All these things, plus many others add to costs. The state sets minimum standards for the private sector in order to safeguard patient safety, but the state-run hospitals are not required to meet these standards.
By default this results in major quality differences in the healthcare provided by the two sectors and inevitably results in “double standards“.
For example Gesy will pay €7.50 for an electrocardiogram. A manicurist receives €20 to do someone’s nails. I believe that it is unreasonable for society to accept that a doctor is paid less than a manicurist. We have to keep in mind the responsibility associated with reading the electrocardiogram and the risk to the patient and most certainly the financial consequences of malpractice costs if the doctor misses something. There was a relevant case recently in which a private hospital and a doctor were ordered by court to pay €750,000 in damages.
It is of paramount importance to understand that if the doctors are not properly rewarded, very soon the system will not be in position to recruit well trained, competent and experienced physicians, based on the dictum “if you pay peanuts you get monkeys “. The system will deter good physicians and attract incompetent ones. Similar developments have been recently observed in Greece, Germany and elsewhere.
There are other issues as well. For instance, the case of new therapies that are very expensive. For metastatic lung cancer there are two different therapies: chemotherapy that has very low chance for survival beyond one year and immunomodulation therapy that has kept a significant percentage of patients disease free and alive up to eight years so far. Immunomodulation is much more expensive (€100,000). If Gesy cannot cover the cost of immunomodulation, the doctors or the hospitals affiliated with Gesy are not allowed to accept co-payment from the patient to cover the extra cost. The HIO prohibits co-payment and makes the doctors liable.
We have invested in equipment that carries out mammography examinations for detection of breast cancer. At the rates Gesy will reimburse per examination, it will take 30 years to make our money back. How can we invest in the latest technology under such circumstances?
HIO is reimbursing all the doctors and all the hospitals at the same unit price. Sophisticated tertiary care centres with complex and expensive infrastructure and quality certification will receive the same reimbursement as smaller units that do not have the complexity and the expenses of the larger units. Quality care and patient safety for the patients and become a disincentive.
When we challenged the HIO about its practices, it cites the Mercer Study, but refuses to release the full study to be reviewed. There is only a summary on the health ministry website. The assumptions and other details of the study are still treated as a state secret. It is highly likely that the study contains a lot of information, principles and assumptions that do not correlate with what is about to be implemented through Gesy.
I am very concerned that the preparation for Gesy is very superficial, incomplete, unfair and biased. There has been an organised media campaign to blame and stigmatise doctors and push them to accept Gesy . Yet, it is now more than obvious that Gesy is poorly planned, poorly funded and will be badly executed with far reaching financial, accessibility and quality implications.
The authorities are in full denial of the imminent disaster and are not willing to address the situation. Only if the majority of physicians and private hospitals refuse to join Gesy will the authorities be forced into action
Dr Marinos Soteriou is a cardiothoracic surgeon and founder of the American Medical Center
Τετάρτη 14 Νοεμβρίου 2018
Εγγραφή σε:
Αναρτήσεις (Atom)
