Insurance Medicine: Favored by All Except Legislation

The bill on universal compulsory social medical insurance rates a special endurance award – or rather its authors do. Its long-suffering history beats even the constitution and the criminal code. The first draft was worked out at the dawn of independence and has since been constantly amended and restated, so that now the text is entirely different. The bill has sustained two readings in parliament (June 2001 and January 2002), but the controlling health care interest is still in the hands of the state.

True, some headway has been made. Whereas at the beginning some factions in parliament rejected the very idea of insurance medicine in Ukraine (since it denied the citizen’s constitutional right to free health care), nowadays the debate is centered on some rather essential clauses. The Verkhovna Rada Health Care, Maternity and Childhood Committee, for example, is accused of leaving out of the text (actually prepared for the third reading) corrections and amendments introduced by the previous parliament, after two readings. Oleksandr Chernov, medical executive of the private joint stock company “European Insurance Alliance,” claims that raising the medical insurance fund at all costs and securing immediate receipts remains the authors’ key target, adding that they did not bother to think of how that fund would function without having insurance schemes and tariff system – and of that fund’s liability as an insurer. In other words, passing this bill the way it is would mean simply an additional tax burden on the employer; money would be entered on the account of an entity that would not have to report on how that money was spent, just as its bureaucrats would assume no responsibility for violating any of the stated rights. In other words, it would be corruption made legitimate that would undermine the population’s trust in any insurance transactions.

As for such transactions, their number is on a steady upward curve in Ukraine (408,401 registered in 1997; 3,003,500 thousand in 2001). In contrast, the number of personal insurance transactions is going down at almost the same rate (16.6% of all insurance transactions in 1997; 7,08% in 2001). There are 60 companies operating on the insurance market, offering various voluntary medical insurance schemes, of which the most popular envisages indemnities paid directly to the medical institution being party to the insurance contract. In other words, the insurant and his relatives should not worry about money for the treatment or where to find a doctor. Some insurance companies make things even easier for the insurant, organizing and running control stations that are contacted if the insured accident occurs. They must call the ambulance, arrange for medical consultations and even hospitalization. Here the interests of the company and its customers coincide, for both want treatment to be less expensive. True, an effective company-hospital tandem is made only with a private hospital.

Insurers say (and it can be corroborated by whoever has visited state-run hospitals of late) that policy-holding patients are met with little enthusiasm, regardless of whether the insurance company pays that hospital, because the only interested party is that hospital’s management.

By the way, the same scenario is prognosticated in the case of universal compulsory medical insurance. Academician Lubomyr Pyrih, M.D., believes the only beneficiaries will be bureaucrats along with head physicians. Unless state-run hospitals and polyclinics can compete among themselves, trying to get most patients (naturally by improving health service and personnel), any law on compulsory medical insurance will remain on paper. It could be made effective if enacted with a simultaneous restructuring of health institutions. Volodymyr Rudy, head of the secretariat, VR Health Care, Maternity, and Childhood Committee, for example, proposes to make these institutions noncommercial entities, meaning that they will remain state-run but will abide by the economic code. In that case, he says, there will be a “natural selection” of medical personnel; given money supplied by the universal compulsory insurance fund, these people will eventually guarantee quality and timely medical service.

The interrelation of universal compulsory medical insurance and the quality of health service worries Mykola Polishchuk, chairman of the said VR committee, the most. Will anything change for the better after the health care purse is filled with extra millions of hryvnias? Off the record, he said that he had recently received a call from a Kyiv hospital. They had complained that they hadn’t been able to diagnose a patient for two weeks. It would soon transpire that they had done nothing except routine tests. Time had been wasted and the patient died. So there is another problem, having nothing to do with finance but everything with professionalism.

Quantitative statistics look normal, even good. There is an average of 40 physicians per 10,000 residents of Ukraine (compared to 30 in France, 35 in Hungary, and 29 in Poland). True, about 60% physicians in the West specialize in primary health care, compared to 20% in Ukraine, with an increasing number of surgeons and other particular specialists idling: an average of two surgeries a week; 35,000 family physician vacancies. Universal compulsory medical insurance will not change the situation one bit.

At the same time, Ukraine is placed 111th among 191 countries by per capita health care budget spending. Improving these ratings and securing adequate health service at all levels requires at least $150 per capita a year – 7.5 times the current amount. People in the province are dead serious, saying they have no health service whatsoever. Local polyclinics lack elementary diagnostic equipment, let alone medications. Patients are sent to district and regional polyclinics where they are bluntly charged three-digit sums (at best) for an examination.

Practically all European countries at one time saved their medicine by instituting universal compulsory medical insurance. Russians followed suit, although their health care reform is regarded by experts as a failure (owing to jumbled funds). The fact remains that it is way ahead of Ukraine. Here experts are also convinced that universal compulsory medical insurance is badly needed. Otherwise straightening out national medicine will take decades. It is just that many suspect that money channeled in the insurance funds free from any liabilities will appear to have been spent for some administrative purposes; that nothing will change in the health care system, and that people will finally distrust both compulsory and voluntary medical insurance. Also, putting off the bill any further appears simply impossible, considering that health care appropriations in the 2002 state budget bill are even smaller than this year. Some propose to put the bad situation to good use, adding to the health care budget alcohol and tobacco excise returns. Volodymyr Rudy, however, says it is clear even now that the matter will remain at the level of debate in the nearest future. Both the VR committee and people from insurance companies agree that there is no turning back. The long- suffering bill must be passed. Vadym Zahrebelny, CEO, private stock Kyiv Insurance Company, believes that Ukraine could solve problems relating to both medicine and insurance if the state helped by enacting the required laws.