Question: Ms Skvortsova, two years ago Ms Golikova cited a terrible number referring to the shortage of medical personnel – about 160,000 doctors. You say 40,000 doctors. How did you manage to cope with this enormous gap so quickly, or is this difference due to the methods of counting?
Veronika Skvortsova: Of course, the methods matter. However, we did manage to increase the number of primary level medical personnel and doctors by 7,000 people over the last two years. This is a considerable achievement, but above all the figure has to do with methodology, a different approach to different regions. We are continuing to improve these methods. According to the plan that was approved today, in early 2014 we will have a multi-parameter model for calculating the number of doctors and paramedics required in each region.
To date, we have made a preliminary re-calculation depending on population density, on the proportion of the rural population in each region, on some basic demographic indicators, and we see that the requirement differs. We can roughly divide these regions into three categories. The first category has a population density of 20 people per square kilometre and includes 38 regions; the second category comprising 39 regions has a population density between 20 and 80 people; and the third category – with a population density over 80 people – includes Moscow, St Petersburg and six other regions. The demands for medical personnel are absolutely different in these categories.
Today in my report, I cited the numbers that we currently have for Russia in general: a shortage of about 40,000 doctors and about 280,000 nurses. But the situation is very different in various regions and in different medical professions, even depending on the level within the healthcare system – that is, it prevails at the primary level, of course. It concerns not only district internists, pediatricians and, to a lesser degree general practitioners, but also specialists working at the primary level. The shortage is considerably lower in hospitals, however it also exists in some professions, in particular phthisiologists, narcologists, neonatologists and some other professions.
Question: Recently, State Duma Deputy Valery Seleznyov introduced a draft law on a complete ban of fee-based medical education. What is your opinion on this issue? The motive behind this draft law is that higher education institutions take enormous efforts to help paying students, and so the quality of education falls.
Veronika Skvortsova: In 2016, we will introduce certification for all medical personnel. This means that six-year and five-year students of some departments will receive their first certification – these are graduates from medical institutes and universities. The criteria for this certification will be unified both for medical institutes of the Ministry of Healthcare and for classical universities – both for regional universities and private institutes. This certification will be carried out not by the teachers who have taught the students, but by a professional medical community. This will be a special commission on certification in all basic areas. Institutes can be under various forms of ownership, they can be controlled by different departments, but the criteria and standard programmes taught there should be unified.
Today in my report, I spoke about the features of medical education including the large proportion of mandatory practical training that is part of the last two academic years. I am referring to reducing the variety of education programmes in the last years, and linking the sum of knowledge and educational programmes to professional standards and healthcare standards in those basic areas in which we train young doctors, young specialists.
Question: Ms Skvortsova, annual medical checkups are planned to be reintroduced in the Russian healthcare system in the near future. It's known that a third of the population is scheduled to have these checkups the very first year they become available. It seems like a heavy burden (at least, on the face of it) for doctors, particularly the ones in the primary care system, which is anyway weak. How can this be accomplished?
Another question. You said there’s a shortage of 40,000 doctors: how much is that percentage-wise?
Veronika Skvortsova: We have 740,000 doctors working in the system and we need 40,000 more; 780,000 doctors will pretty much cover our needs, if job balancing is done in line with the needs of the healthcare system. Since we are talking about real people, not chess pieces, we won’t be able to avoid certain negative processes where experts go to areas that are of more interest to them. Our job is to provide personnel to rural and remote areas, and so on. So, we should have some leeway in this regard.
As for your original question, regarding annual checkups, we have carried out a substantial amount of work with each of 83 Russian regions. Indeed, re-introducing annual checkups and changing the way they are organised (enlisting large numbers of professionals and instrumental and laboratory methods), is a major burden for regional healthcare systems. However it’s a prerequisite in order to have an advanced healthcare system. In this regard, we have added annual checkups to the state guarantee programme and have laid out the standards for routine checkups in primary care. They are paid for through the compulsory health insurance system. Each region has provided us with its regional annual physical checkup programme focusing on remote and rural areas.
In such regions that are prone to certain risks, local authorities form mobile preventive screening teams. Generally, they are based in the regional, territorial or republican multi-purpose hospitals or large municipal hospitals. So far, we have bought 187 mobile systems, and plan to acquire several thousand of them in total. They are staffed with properly trained multidisciplinary teams and equipped with labs and medical instruments.
We have conducted a pilot project to introduce medical checkups in the Moscow Region and have carefully analysed this experience. This is a fairly complex region due to its ring-shaped location around Moscow. The Moscow Region is affected in particular by the outflow of personnel heading to Moscow, along with some other problems that are associated with a large rural population. Therefore, it was an enriching experience for the entire country.
We have held several video conferences with the regions based on this analysis. The all-Russian conference on annual checkups, rural health care and advanced health-saving technologies in rural areas will be held on May 31 in the Belgorod Region. This is an important topic. We believe we can get this programme on its way.
Just a reminder: we will have children annual checkups. Children will see different specialists depending on their age. Adults will have these checkups once every three years, and they will also be based on age groups: below 40, 40-70, and over 70. Of course, we will strive to diagnose diseases in the early stages. In such cases, patients will be treated and have routine screenings at specific medical institutions. Diagnosing diseases is not an end. All patients should be entered into our record systems. We have developed customised treatment and wellness programmes for everyone.
The ministry performs onsite inspections of such work in the regions together with the Federal Service for the Supervision of Healthсare and Social Development and the Mandatory Medical Insurance Fund. Just like you, we don’t want regular medical checkups to become a formality.
We analysed the experiences of the 1980s, and I specifically discussed this issue with then-Minister of Healthcare Yevgeny Chazov. The Soviet medical system was notorious for the liberal use of doctored numbers in statistics concerning medical checkups and services. We are doing our best to avoid this now in the new Russia. We realise that a lot depends on the regions, which will have to do all of the organisational work. We, in turn, perform cross-checks, do onsite inspections, and encourage public oversight over this work. We have opened a special hotline to callers... In other words, we are doing everything to obtain information about existing distortions, if there are any, and to take quick action to remove them.
Question: You mentioned that the industry is short of 270,000 nurses, and the shortage is on the rise. How does the ministry plan to attract professionals to the industry? What benefit packages do you have for them?
The second question concerns salaries. What salaries will doctors and nurses receive by late 2013?
Veronika Skvortsova: I gave the numbers today regarding the nursing staff. We have an unmatched, wide network of 244 medical schools and colleges in the regions. We also have 26 higher medical educational institutions with special departments for training nurses. We also have a dedicated research and methodical centre at the Ministry of Healthcare and three federal colleges that also engage in research, methodology and capacity-building activities.
Every year, we train 59,000 nurses. The problem is not that this isn’t sufficient. The problem is that by far not all of them go to work in the healthcare industry. On top of this, about 90,000 nurses leave the industry yearly, and of them only about 15,000 retire due to their old age, while others simply leave for better jobs.
Actually, I brought up these figures to let you know that we do not need to expand our educational network. In order to improve the attractiveness of education, together with the board of directors of higher medical institutions and colleges, we have held the Russian Congress of Nurses and updated all of the programmes in all of the key areas. Nurses also have a large number of specialties, and they are highly skilled workers, too, with a specialised secondary education, and they come in three skill categories. Paramedics are part of the fifth category near doctors. Doctors are the sixth category. We should bring nurses’ salaries up to standard with the average wage in the region by 2018. However, their salaries will vary depending on their skill level. Thus, paramedics should receive about 120% of the average regional salary as a minimum, while some nurses with lower skill sets may have salaries that are somewhat lower than 100%. As for doctors, the figure is well known. They should receive 200% of the average regional salary by 2018. These figures are included in a presidential executive order dated May 7.
In late 2012, doctor salaries were estimated at 123% of the national average. Nurses, as far as I can remember, had about 78% depending on the region.
I would like to call your attention to the fact that statistics show salary rates whereas executive orders use the average wage concept, which is not the same thing.
As we see it, the flawed system of work rate setting for medical professionals is a problem, and revising and making changes to the work rates of doctors and medical personnel is a major part of the measures we have been discussing today. If the average pay differs so much from one job rate, while the work hours are about the same, obviously, something is wrong here.
We have set up an interagency working group together with the Ministry of Labour and Social Development, the trade unions and our medical professional community to revise the rates for various doctors and nurses proceeding from the time the doctor spends on one patient if he or she is not acting as a mere operator (you know what I mean). Naturally, a psychiatrist, a neurologist or a cardiologist need different times for examining their patients. These things are well established in international practice. We will proceed from the rates used in the majority of countries. Based on these rates we will recalculate the number of patients an outpatient doctor can and must see if they are working a single time rate and then their pay will be justified and their professional activity will be dignified.
The same is true of nurses. There is one important thing to bear in mind. Nowhere else in the world do nurses just sit copying papers while doctors see patients, because nurses, as we have mentioned, are highly qualified workers. They should work as operational, rehabilitation, visiting nurses and so on. Especially since the current policy is to develop rehabilitation in the regions and to develop palliative services which are mainly administered by nurses. Therefore we pin great hopes on modern information technology in healthcare.
We have developed the doctor’s workplace and presented it to the Communications Ministry at our joint meeting yesterday. I am referring to the workplace of any outpatient doctor, be it a general practitioner or a specialist in the primary sector. The workplace is in fact designed to provide access to various systems. It comprises first of all an information block, access to an electronic medical library we completed in late 2012, to the main information sites, reference materials and guides. It provides access to clinical protocols and standards. We have developed a decision-assistance system, which is going through pilot tests, to help doctors, especially at the primary level, to decide which drugs to prescribe because there are considerable irregularities in this matter in our healthcare system.
Polypragmasy, that is, prescribing handfuls of mutually exclusive drugs is a scourge of our healthcare system, so we have developed a system to prevent this from happening by warning doctors that certain drugs are incompatible and providing recommendations on changing the dosage and so on. The system will contain a block of all the standard documents a doctor needs, including prescription forms and referrals in which only the name will need to be written and all the other information is entered at the click of a mouse without the services of mid-level medical personnel. This is important because firstly, it cuts down on paperwork and it saves doctors time which they can use to work with patients, and also, given the shortage of mid-level medical personnel in our country, it will enable more efficient use to be made of mid-level medical personnel, who are vital for the sector.
Another theme connected with the electronic workplace is the ease of fixing up appointments to see a specialist. This is an important point because if a therapist examines a patient and sees that they need an otolaryngologist, they can enter that system at once. We locate all the otolaryngologists within a certain radius of a particular institution, see their opening hours and the waiting list, and patients who find that in the outpatient clinic where they have come there is a long waiting list can say, I want to see a specific doctor. These information resources related to management and organisation greatly facilitate access to medical assistance.
We very much hope that with the help of these modern technologies we will be able to get rid of queues and the humiliating procedures of registration for an appointment and so on. That should be very helpful. But of course in parallel we need to provide enough primary level personnel and we are making every effort to do that. And the fact that from 2016 we are introducing accreditation enabling medical university graduates who have received good practical training in the final two years to start work as primary care physicians should help us achieve this goal. We hope the situation will improve in the near future.
Question: You said in your report that a register will be introduced. I would like to know what it will contain: simply a list of doctors or some data about them? I am told that in America they have a public database where people can look up how many operations of a certain type a surgeon has performed. Will we have something similar?
And my other question is about doctors’ liability insurance. When will that system start working and how will it operate?
Veronika Skvortsova: Regarding your first question. The information-analytical base has been developed, and it contains several segments. On the one hand, it’s information on all medical workers – physicians and nurses – who work not only in state and municipal institutions, but also in private healthcare institutions. Information on their level of competence, qualifications, the training courses they have taken, repeat accreditation, medical rating (we still have it) and some other things, including demographic indicators: age (because we will have to plan the retirement of some of our staff), gender and so on, i.e. the information needed for planning and forecasting. This database also includes all the medical schools and colleges, and all the medical higher education institutions and medical faculties. The database contains information on the reserve that will join the system after a certain period of time.
Actually, we developed this database in 2011. I was involved in it myself from the beginning of 2010, forming that base and determining what information should be protected from external users (only people who do analytical and information work should have access because for them the personal data of individual specialists do not matter). Some segments should be open to the public because they effectively form a competitive environment for improving the quality of healthcare and offer choices.
What is the problem? Why, having basically filled that system, can we not use it in full? Because when the subjective human factor comes into play and these data are entered for each person from outside... We have found a lot of distortions and we identified these information distortions during the course of the checks that we conducted in several regions. We need to apply that system to all the clinical institutions, and ideally the system will work when information is read straight from the human resource department at every institution without any intermediate records. In fact the register will contain a staff chart plus any necessary additional information.
We plan to complete this work by the end of 2013. During the whole of 2013 there will be intensive computerization work and we hope that a large chunk of this register will be accessible directly, which will greatly facilitate the situation and make the information reliable, which is the key factor.
Considering that we are simultaneously developing open information zones that will be on the sites of every district, healthcare department or municipal healthcare organisations, where they exist, with indicators that make it possible to assess the performance of every institution, there will be information on the medical personnel. But the volume of that information is currently being discussed by the professional medical community so as not to infringe on the rights of the medical personnel, of course. So much for your first question.
The second question is about insurance. The ministry has developed a draft law on malpractice insurance. This subject was raised at a meeting in Rostov-on-Don between representatives of the Popular Front and Vladimir Putin. The draft law is ready and we are planning to initiate an open discussion with non-governmental organisations, with patients’ organisations and with the professional medical community. We think this is the right approach because medical errors are very difficult to define. They are sometimes systemic because the organisation delivering emergency care does not have the equipment to provide the appropriate assistance lege artis, that is, properly. There could be many reasons, for example, unavailability of the proper specialist at the right moment, when for example a general practitioner has to treat a heart condition. The rules specify in which cases a therapist should refer a patient, say, to a cardiologist (a therapist can treat some heart conditions, but more specific treatment that calls for a very high qualification, should be provided by a cardiologist), but sometimes the cardiologist is out of reach and the therapist has to do what he can because doing nothing is an even greater failing. But assistance like this may fall short of professional standards.
Why am I giving you these examples? Malpractice is not always committed knowingly, and a lot of errors are systemic. The range of definitions that define malpractice is currently being developed in various parts of the world, including the German Medical Chamber and especially the American Doctors Association which leads in terms of the number of malpractice suites against doctors. They have left everyone far behind: America leads the world in terms of the number of complaints against doctors. There are special organisations you could call a patients’ organisation only by a stretch, which make a profession of it and make money that way. We should keep that in mind because we have the advantage of developing this system later and we can avoid the mistakes of other systems. When I meet with my American colleagues and with US Health Secretary Kathleen Sibelius (we are constantly in touch, exchanging information and we are benefiting greatly from this cooperation) her big headache is how to keep all this from snowballing because that genie had been let out of the bottle before her time. It is a controversial subject… At this point the subject under the law is not the doctor but the hospital or the medical organisation because we are talking about a combination of the available equipment, the way medical care is organised and the competence of specialists.
We would like to insure the patient against medical malpractice and to have the medical organisation insure patients. This is our approach.
Question: With your permission, could we go back to the question of salaries. Some regions are already reporting that they are paying decent salaries to doctors and middle-level personnel: 37,000 roubles, 24,000 roubles, respectively. But if you have ever visited internet medical forums, the doctors there cite much lower figures. My question is, do you have feedback from the grassroots, from the people on the ground? Because the regional administrations of course are interested in making things look good.
Question: And a follow-up question…
Veronika Skvortsova: Yes, of course.
Question: Everybody understands that the reason there is a shortage of doctors is the appallingly low salaries. I know, for example, that in the Tver Region a doctor’s salary is 8,000 roubles. From what you said, it will increase to 200% over two years, which means that it will be 16,000 roubles, or even less if today it is 123% of the average regional wage. Doctors won’t settle for such a salary and the regions will still be without specialists. My question is, why is a doctor’s salary made up of numerous components? If the personnel shortage is so serious why doesn’t the state ensure a normal transparent salary for doctors so that the sector can work properly?
Veronika Skvortsova: You are right of course that in some Russian regions, not everywhere, but in some regions (it is a common situation in the Central Federal District, in some Siberian regions and some signs are coming from the Urals Federal District) doctors and nurses have very low salaries at some medical institutions. I would like to explain the methodological situation today. For the first time in the second half of 2012 the Ministry together with the professional community came up with documents, mainly financial documents, setting standards for medical care. We have developed 797 standards of which, as of yesterday I think, 781 have been registered by the Justice Ministry. These documents are thus becoming binding, no longer recommendatory. These standards are necessary to determine the overall cost of medical care. Every standard for treating a given disease is essentially a price list of all the medical services that may be potentially used to treat a certain typical case of the disease as well as the drugs and medical implants, plus blood preparations, diet management, etc. The standard spells out all the main blocks and indicates how many times on average an element can be used in a standard. It is basically a check that helps to determine the average cost of treating a patient with a specific disease. Knowing the average cost and knowing the statistics of incidence of the disease we can assess the total amount of money required for all the country’s citizens to treat a certain disease and then calculate the cost of medical assistance assuming that the diseases selected for the standard account for 90% of morbidity, that is, all the main classes of diseases, plus separate standards for orphan diseases that are very costly to treat. They are rare, but their cost is high and that is also taken into account. For the first time since the demise of the Soviet Gosplan (State Planning Committee) we did this in 2012. For the first time we made a case for the amount of money that must be in the system to finance the standards which our professionals, our medical community have written up.
The money is then distributed among the regions, each of the 83 regions proceeding from the budget situation in every region, the morbidity and mortality rates, and certain regional indices and coefficients. This is a special methodology handed down to us by the Ministry of Economic Development and the Ministry of Finance. The money is distributed among the regions, and is then distributed among the clinical and preventative institutions, medical organisations.
For this money to be distributed in a more targeted way, depending on the type of the institution, plans and urgency, the Ministry together with the World Bank did some research in 2012 and, drawing on the best international experience, developed a special method of directing resources to a specific medical institution based on what is called the Diagnosis Related Group (or DRG) concept, connected with a diagnosis made in a group of diseases).
Each group uses specified rates because there are groups where the cost of medical assistance is determined by the cost of, say, an artificial joint or an expensive implant, and accordingly, the cost of the medical labour makes up only 20-30% of the rate. In another disease group, for example connected with abdominal surgery, salaries make up about 80% of the rates, because the main thing there is the ability of a given surgeon.
The DRG system was invented 40 years ago in Australia and is now the main method for determining rates and targetedly allocating money to institutions used around the world: it has been perfected in Australia, they have been refining it for 40 years now; in Germany it was first adopted 25 years ago. It was also introduced in America and everywhere else. We have also adopted this method, and in November it was approved on our order and, accordingly, circulated to the regions as a recommendation in December.
How are things organised in the regions? Each region has its own rate commission which includes representatives of every region’s healthcare department, of the medical professional community, of the regional administration, the trade unions, patients’ organisations, and so on. Law No. 323 On the Basics of Health Protection for Citizens (the system law) and No. 326 On Mandatory Health Insurance prescribe how these rate commissions should operate. To begin with, all the money allocated to a region goes to this tariff commission. Next the commission (it enjoys some independence) determines the mechanism whereby this money is to be distributed to institutions. There are three basic mechanisms. One is the most outdated, which no one uses anymore, although some regions still use it; this is when the allocation is based on the number of bed-days or the number of out-patients. These methods are from the 1950s and 1960s; they don’t show how efficient the system is but are merely added to the formal indices of treatment given to in- and out-patients. Then there are methods that we describe as modern. Everyday I talk with the regions, separately and collectively, in video conferences and otherwise – addressing governors and deputy governors, as well as ministers – to explain how the tariff commission is to operate. The point here is that this authority belongs to the regions themselves. Methodwise, the federal centre can help them, and we issue recommendations, suggesting some approaches to rule-setting and so on, but they do everything themselves.
Our concern is to not step on the authority of the regions and be accused of misbehaving, because every region prizes its autonomy and what the law empowers it to do.We just want to lineup a kind of monitoring. And we have provided one: starting on April 15 we will be receiving monthly information from each region on the average salaries of doctors and paramedical personnel at every medical institution, not municipality. I want to draw your particular attention to this point because the municipalities can mix the two things together and arrive at an index which looks right in every respect. But when it concerns specific medical organisations we can see what salaries are being drawn by doctors and nurses. This monitoring system is now in place. On the fifteenth of every month we will receive data about the previous month. What’s more, the Ministry’s spokesman Mr Salagai, who is here, has set up a hot line to receive information in the form of open letters to me or complaints about irregular practices in some region or other, not across the board, yet at a specific institution.
I wish to remind you that each institution has been following these special rules for payroll since 2010. In each department or unit, the department head has a lot of authority – he decides, for example, how many people he should employ in a particular unit, what salaries to pay employees; in fact he distributes the wage bill inside every institution. This independence, when first introduced, was designed to enable the medical staff to work with maximum effect and savings within concretely specified conditions in every institution. But, of course, if a dishonest person heads an institution, he has the opportunity to abuse his power to detrimental effect.
So we all should … First, we would appreciate it if you, too, would inform us of any negative developments in specific areas. This is not an all-pervading situation everywhere. In many regions and at many institutions, things are really improving. But the fact that such disgraceful practices occur calls for a rapid response, especially since, in some cases, those who work are still treated badly despite a shortage of personnel.
We are planning to work with the Mandatory Health Insurance Fund. The Fund, too, has a right through its field branches to monitor finances. Likewise we will cooperate with the Federal Service for Supervision of Healthcare and Social Development to exercise what is known as government control and monitor each organisation. We hope that we will be able to prevent many abuses in this way. But human nature is human nature. Human presence always presupposes some risk, so please work with us. We will only be grateful to you.