Transcript:
Dmitry Medvedev: This meeting will focus on hi-tech medical care. Everyone here understands how important this is. People’s health and lives depend on access to this kind of care. Those requiring advanced surgery involving complex and expensive equipment depend completely on the timely provision of this care.
I remember what it was like before these medical centres were established. I started to look into this issue in 2006, if I’m not mistaken, as part of my work on the Health national project. One of the project’s measures was to introduce, on a broad scale, these medical centres, and, despite certain difficulties, I think that it was a good idea that has resulted in a number of medical centres that is close to the number required. As you know, federal funding for hi-tech medical care has increased since 2005 and you can see that the figure is substantial. It has grown eight-fold and reached 52 billion roubles. So the funding totalled just seven billion roubles seven years ago. Consequently, the number of patients who receive hi-tech medical care every year has also increased eight times over. This is quite a good indicator. As many as 1.5 million patients, including 250,000 children, have received hi-tech care during this time. This is a brilliant result. To be honest, the figures are good. This doesn’t mean that we can relax and not do anything more. That’s why we’re holding this meeting.
Why can’t we relax? Because, according to experts and the Ministry of Healthcare, less than half of the demand for high-tech medical care is being met. Surveys, which we can more or less trust, show that only a third of our citizens are satisfied with the level of access to such care. There is still a really significant gap between regions in the levels of providing such care. For example, in the Northwestern Federal District the provision of such care exceeds by 2.5 times that of the Volga Federal District, which is not too far from us, and the situation in the Central Federal District is better than in the Southern Federal District. We will have to balance out this disproportion and irregularities. We will have to increase the accessibility and quality of high-tech care, to expand its geographic reach to meet current demand. I would ask that the Ministry of Healthcare analyse what technology is lacking in Russia and develop measures to introduce such technology in the work of healthcare institutions. Currently eleven regions have these high-tech medical centres (some of their heads are attending this meeting), which have been created under the Health national project. But they have been created not only under this project and not only with federal funds, which is also not bad. Remember that these are the centres that have been opened in Penza, Astrakhan, Krasnoyarsk, Khabarovsk, Chelyabinsk, Perm and Kaliningrad – centres of cardiovascular surgery, neurosurgery in Tyumen and Novosibirsk, centres of trauma surgery, orthopaedics and endoprosthetic replacements in Cheboksary and Smolensk.
We are in one such centre in Kaliningrad. Of course, it is very well equipped, and it creates a certain impression: there is no ornate architecture, no expensive furniture, and indeed, the centre does not need such things. But the centre has magnificent equipment and excellent doctors. This is what is needed here. And we should not spare funds for this. It’s time to stop pursuing those hospital construction projects, and not only hospital construction projects which require excessive costs, those Soviet standard construction projects with enormous premises whose maintenance requires enormous costs while only 30%-40% of the premises are used. But here everything is rational. We hope that in the future we will have such specimens of the construction and medical industries, let me put it that way. The centre is well equipped; we have just inspected the equipment. It is state-of-the-art equipment. Although I have told Mr Shneider (Yuri Shneider, Chief Doctor of the Federal Centre for Cardiovascular Surgery in Kaliningrad), that currently this equipment is the most modern equipment available, in ten years it will be completely common and even obsolete equipment, and we will have to take a new decision on updating the high-tech centres. This is a state programme, and I think we will have to continue it. This is an issue of the methods of its implementation. We will think about it, how and what financial instruments we should use here. Once we extended direct budget allocations, and so we can continue to do this in the future; or we can do it differently, using medical insurance and other forms of financing. We will think of the best way to do it.
This year we are concluding this programme entirely. The last centre, as far as I remember, will open before the end of 2012 in Barnaul. The more intensive their operation, the better: the waiting list is long. All those here, all the heads of medical institutions and the best doctors, are aware of this.
What else is important? The equipment looks good. It looks like a spacecraft cockpit. And everything here is of foreign make, including gloves, bandaging material and packaging. Of course, we should think about creating a national industry to produce medical equipment and products for high-tech care. A short while ago I held a meeting on Russian medical equipment. The situation is better than it was ten years ago; we have had some success. Some Russian enterprises have gained strong positions on the market; some Russian enterprises export their products. But the situation with high-tech medical equipment is still not very good in Russia. Therefore, we should advance in this area. I have held a meeting in Penza and issued instructions; but this is a two-way road, this is not only about state support, this also involves the decisions of businessmen, because this is a business, this involves risk-taking. One should find his niche and seek a space for development in harmony with foreign suppliers. But in any case we expect that in the medium term, before 2020, the Ministry of Industry and Commerce and the Ministry of Healthcare should take measures to localise production of foreign medical products in those segments of the sector where they are currently not produced or are insufficiently produced, including those expendable materials that I have mentioned and therapeutic agents – this is part of the programme for developing high-tech medical care.
And one more priority. Besides the equipment, nothing is possible without the right personnel. This centre, similarly to other hospitals, has a good team, because as a rule these people come from different places. This is a team of professionals, and this is a true team, always, because it does not work otherwise. First, I’d like to thank all doctors who have taken such difficult decisions. It is not often easy for a top-grade expert to move to a different place: you have a reputation and contacts in, say, your native town where you were educated and where you worked. On the other hand, this is a challenge for every person and it needs an answer, and it is very good that you have given such an answer. But then the responsibility is on the receiving party, that is, on the region, on the municipality, because they have to offer a job and ensure normal living conditions for high-quality experts. These are basic things: on the one hand, this is a flat, a home in the region; on the other hand, this is an option to take part in various programmes including educational internships and so on. I’d like to highlight this point for all those present here including the new Minister of Regional Development Igor Slyunyayev who is on his first official trip today. Please, take your seat, Mr Slyunyayev, I wish you success. I hope you will supervise all issues under federal jurisdiction on the development of our regions, and I hope you will attend to construction projects, deal with support for regions and coordinate relevant federal targeted programmes. I wish you success and I hope that you have strong nerves. The experience shows that the Minister of Regional Development needs strong nerves.
Igor Slunyayev: Thank you.
Dmitry Medvedev: And the rest of you, don't let up on this. Let’s start discussing problems. Ms Skvortsova, please go ahead, keeping in mind what I have said.
Veronika Skvortsova (Minister of Healthcare): Thank you very much, Mr Medvedev. Colleagues, in 1993 the Russian health care system focused for the first time on the development of innovative, effective and resource-intensive technologies for treating certain diseases. However, as Mr Medvedev mentioned, the actual work only began in 2006 when funding and high-tech health care became increasingly available.
From 2005 to 2012, spending on high-tech medical care increased nearly eight times, as did the number of patients who received this type of care. Children account for 17% of high-tech medical care recipients. Notably, the Russian regions have been providing high-tech medical care through co-financing programmes since 2008. They did such a great job that the number of patients receiving high-tech medical care increased from 40,500 to 134,900 in 2011 alone, which indicates that we have chosen the right course of action.
Much of high-tech medical care is related to various types of surgery, such as cardiovascular surgery, traumatology, orthopaedics, oncology, ophthalmology and brain surgery. The percent of pediatric care has significantly increased over the past two years after neonatology and neonatal surgery were introduced in 2011. Approximately 64% of the high-tech medical care provided in Russia focuses on three major groups of diseases with high fatality rates.
Importantly, new types of high-tech medical care that make use of the most advanced, complex and resource-intensive technologies become available every year. As a result, the cost of providing high-tech treatment has doubled since 2006 from 72,000 to 144,000 roubles per patient on average.
In 2006, 93 federal healthcare institutions engaged in the provision of high-tech medical care in Moscow, St Petersburg and Novosibirsk. In 2012, the number of these institutions grew to 336, of which 221 reported to regional authorities and another 115 institutions reported to the federal authorities but were also located in the regions.
The supply of high-tech medical care has increased by five times on average from 2006 to 2011, from 41.6 to 223.8 per 100,000 people. However, average supply numbers vary considerably across regions. This number stands at 361.5 in the Northwestern Federal District, which is 61.5% higher than the Russian average, with St Petersburg accounting for as much as 551.6.
Notably, St Petersburg is the only Russian city that shows numbers that are comparable with the average European standards in this regard. The situation in the Central Federal District and Moscow is somewhat similar. This suggests an inadequate supply of high-tech medical care in most regions which is further corroborated by the comparison with Eastern and Western Europe and the United States (shown on the next slide.)
The construction of 12 federal high-tech medical centres is also among the priority projects listed in the national Health programme. This has significantly contributed to the overall success in this area. Eleven centres have opened since 2008, including seven cardiovascular surgery centres, two trauma and orthopaedics centres and two neurosurgery centres. Four of them, including federal cardiovascular surgery centres in Perm and Kaliningrad, a federal trauma, orthopaedics and prosthetics centre in Smolensk and a federal neurosurgery centre in Novosibirsk were opened in 2012. The twelfth centre - the federal trauma, orthopaedics and endoprosthetics centre in Barnaul - is scheduled to open in late 2012. A meeting chaired by Deputy Prime Minister Olga Golodets to discuss the completion and commissioning of the federal centres in Smolensk, Novosibirsk and Barnaul was held on 11 October.
A sufficient number of qualified professionals had to be trained for this high-tech medical centre. Over 800 doctors, including neurosurgeons, cardiovascular surgeons, trauma surgeons and orthopaedists have been trained. Leading federal research and medical institutions played a major role in this training. Importantly, industry leaders continue to oversee the continuous operation of high-tech medical centres, provide specialty training and simulation training programmes, send teams to new centres and perform surgery along with training new surgeons. Federal centres provide the necessary conditions for efficient and creative work by the staff. The centres commissioned before 2012 are 90% to 100% staffed whereas others hire additional staff on an as-needed basis as they become fully operational and perform anywhere from 3,000 to 5,000 surgeries a year. Doctors’ salaries range from 85,000 to 90,000 roubles; nurses are paid anywhere from 30,000 to 34,000 roubles, which is higher than the average salaries for most medical personnel in Russia. In accordance with the agreements, the specialists working at the centres have been provided with over 170 flats, and we hope that the staff of the centres to be commissioned in 2012 will also be provided with proper housing and social support.
Federal high-tech medical centres are located in different federal districts which makes high-tech medical care readily available across Russia. Each federal centre supports over 12 Russian regions. The Cheboksary-based centre provided care to patients from 38 regions in 2011 alone, which makes it the top performer in this regard. More than 72,500 high-tech surgeries have been performed from 2008 to 1 October, 2012, including 25,324 in 2011. Therefore, the capacity is growing progressively. Federal cardiovascular surgery centres in Perm and Kaliningrad started performing surgeries in 2012. The federal centres in Smolensk and Novosibirsk obtained licenses in October 2012 and are now providing advisory and diagnostic services in preparation for performing surgeries in the near future.
The federal cardiovascular surgery centre in Kaliningrad deserves a special mention given its particular geographic location and the number of patients in need of high-tech medical care. Since this centre employs leading specialists from this region, we believe that the centre will be more than a one discipline institution and will eventually include other related specialties, such as vascular and endovascular surgery, some transplantology and some vascular neurosurgery on an as-needed basis.
The development of high-tech medical care to 2020 will require us to change organisational and financial arrangements. Under the federal law on mandatory medical insurance (MMI) and basic health care in Russia, primary types of high-tech medical care will be covered by medical insurance beginning in 2015. Notably, rapid development of biomedicine and the introduction of innovative medical technology on a yearly basis will maintain the level of funding requirements in 2015 and later that are not included in the MMI system. The industry will need this additional funding in order to continue to provide innovative treatments and eventually make them standard medical practice. Major organisational efforts will need to be made in order to ensure uninterrupted and rapid development of innovative medical treatment in 2013-2014, including the establishment of a special pool of federal institutions that will not only provide complex and exclusive high-tech medical care, but also serve as fundamental and translational medicine centres to develop and introduce innovative technologies, organise multicentre clinical studies, train specialists from all regions and update clinical protocols, practices and standards of care on an annual basis. Thank you.
Dmitry Medvedev: Thank you, Ms Skvortsova. Colleagues, I don’t really want to have to point my finger at anybody, but if anyone has anything to say, please go ahead and do so.
Nikolai Volobuyev (Deputy General Director of the Rostekhnologii State Corporation): May I, Mr Medvedev?
Dmitry Medvedev: Please go ahead.
Nikolai Volobuyev: My name is Nikolai Volobuyev. I’m Deputy General Director of the Rostekhnologii State Corporation.
Mr Medvedev and colleagues, I would like to remind you that in accordance with the presidential executive order in March 2009, the Rostekhnologii State Corporation was designated the customer for the construction of federal high-tech medical centres. By 2010, the corporation along with regional authorities built and commissioned four federal centres, including three cardiovascular surgery centres in Khabarovsk, Krasnoyarsk, Chelyabinsk and a neurosurgery centre in Tyumen. As was already mentioned, these four centres are now fully operational and provide high-tech medical care. In 2011-2012, the corporation completed and launched four federal high-tech medical centres, including two cardiovascular surgery centres in Perm and Kaliningrad, a traumatology, orthopaedics and prosthetics centre in Smolensk and a neurosurgery centre in Novosibirsk.
In cooperation with the Altai Territory government, we are about to complete the construction of a traumatology, orthopaedics and prosthetics centre in Barnaul. The construction and assembly of the visible part of the building has been completed, the utility hook-ups and the start-up of the utility systems are underway as is the installation of the medical equipment. The construction of the basement and work on the utility lines, as well as the landscaping, are nearing completion. The centre is scheduled to open in early November as it takes time to install and commission complex medical equipment. The assets will be put on the centre’s balance sheets and a license obtained in December. The opening of the federal centre in Barnaul will complete the corporation’s mission to build high-tech medical centres under the Health national priority project.
The corporation has gained extensive experience in building healthcare facilities and equipping them with high-tech medical equipment as it participated in this ambitious government programme.
The latest offsite construction techniques made it possible to open medical buildings that will improve the availability and the quality of healthcare within a short period of time. The centre where we are now is a case in point. It took us just 12 months to build and open the building and obtain the license. Therefore, we believe that the corporation is capable of fulfilling the tasks assigned by the Russian Government in the area of healthcare, such as building and equipping medical facilities, particularly perinatal centres, modular rural feldsher-midwife stations (health posts) and mobile diagnostic units for rural areas. We can do entire projects from design to finishing.
Mr Medvedev, we would therefore like to request the Government and the Ministry of Healthcare to take our experience into consideration and issue new assignments in this area to us.
Thank you.
Dmitry Medvedev: Thank you. Was it 2009?
Nikolai Volobuyev: Yes.
Dmitry Medvedev: I did sign an executive order to transfer all projects to Rostekhnologii, because, unfortunately, the previous arrangements did not work out the way we wanted. We learned from this experience, because the challenge was huge: we have never built that many high-tech medical centres in this country at the same time before. Frankly, even the equipment suppliers failed to deliver on such a large order. This lesson needs to be learned because our work doesn’t stop here. We ended up with an arrangement in this process where we have a major state-run corporation as one of the participants and where financial and organisational responsibilities are divided among three participants, including federal authorities, industry-specific agencies and regional authorities which were supposed to hook up utility lines and fulfill other obligations. Rostekhnologii served as a large operator in this work. Eventually, the programme ended on an upbeat note. I hope that we will be able to commission everything we need in Barnaul and that the issue will be closed.
I agree that your experience should be used in the future. However, I do not rule out the possibility that some other forms of coordination and cooperation may arise, including other sources of funding. Frankly, I do not see anything wrong with the regions and private investors, with or without the participation of the federal authorities, building high-tech medical centres using the expertise that we now have. Colleagues, you all have your own ideas about this.
Alexander Baranov (Vice President of the Russian Academy of Medical Sciences): May I?
Dmitry Medvedev: Please go ahead.
Alexander Baranov: I am the director of the Paediatric Medical Research Centre and Vice-president of the Russian Academy of Medical Sciences.
Mr Medvedev and colleagues, the use of high-tech medical care in recent years has helped reduce infant, child and the overall mortality rate and has stabilised the disability rates at least among children.
What we need to do today (based on our previous experience) is to clarify our approaches to organising high-tech medical technology. I believe that we should base our approach on the concept presented by prominent Russian physician Matvei Mudrov whereby we focus on the patient not the disease. High-tech medical help is intended for patients with complex disorders. Usually, these are cases of concomitant multiple organ pathology that require a multidisciplinary approach to treatment. Clearly, treating such patients requires us to go beyond a single standard and make use of clinical guidelines based on medical technology. Such an approach makes it possible to treat the patient, not the disease based on the concomitant pathology that occurs in 80% of such patients.
That begs one important conclusion: high-tech medical services should be mostly provided by multi-disciplinary clinics with the use of an interdisciplinary approach. Take, for instance, the cerebral palsy where orthopaedic, neurological, neurosurgical, ophthalmology and rehabilitation techniques are used to treat one patient. Cochlear implants are another case in point: the child will not start speaking unless you complement the surgery with rehabilitative, medical and psychological treatments. In expanding the list of facilities providing high-tech medical assistance we need to keep in mind that both the facilities and their doctors need to be accredited. Quite often, medical facilities meet specific requirements for providing high-tech medical assistance but lack skilled doctors with the necessary qualifications to operate the advanced technology.
It should also be noted that due to the biological specifics of each individual, and owing to major shortcomings in the system of clinical trials, up to 40% of medicines being marketed in Russia have no proven efficacy, so we need to work out a concept of personalised medicine based on molecular-genetic research. This will make it possible to assess individual tolerance and sensitivity to medications. Federal research centres are expected to play a more important role in this regard. These centres should focus on the following three very important aspects. First, they must conduct fundamental research, assess various mechanisms of disease pathogenesis and search for molecular markers and their diagnostics. Second, they have to study the effectiveness and safety of medicines. Pediatrics faces special problems in this respect. Today only 1.5-2% of clinical trials assess the quality of pediatric medicines. We once proposed simplifying the registration of medicines for pediatric patients, for those that had undergone clinical trials, particularly in the United States and in other countries. Mr Medvedev, this instruction was issued, but, unfortunately, it has not yet been implemented. And, third, we must assess the results of fundamental and clinical trials and convert them into new technology for use by the healthcare system. But we still have no idea of how these projects will be financed within the system of compulsory medical insurance.
The effectiveness of high-tech medical assistance largely depends on how the provision of medicines is organised, especially for children. I would like to draw your attention to the fact that if they are in remission children with severe health disorders are no longer classified as disabled, which means they lose the right to preferential, reduced-price medicines and subsidised travel to medical facilities for treatment. As a result, they no longer receive any treatment, which aggravates their health disorders, and so they once again end up on the disabled list. Although this issue has been raised repeatedly, it has not yet been resolved. In our opinion, subsidised medicines should be issued because of someone’s illness rather than their status as disabled.
In conclusion, I would like to note that the clinical centres of the Russian Academy of Medical Sciences are ready to double the number of patients receiving high-tech medical assistance, from 50,000 to 100,000. They are also ready to take the lead in developing innovative high-tech medical centres for diagnosis, treatment and rehabilitation.
Thank you.
Dmitry Medvedev: Thank you, Mr Baranov. Who would like to go next?
Yury Slyusar (Deputy Minister of Industry and Trade): May I say a few words?
Dmitry Medvedev: Yes, go ahead.
Yury Slyusar: My name is Yury Slyusar, from the Ministry of Industry and Trade. I would like to talk about the role of the medical industry in providing high-tech medical assistance.
Dmitry Medvedev: Okay, go ahead.
Yury Slyusar: Tomorrow at the Government meeting we will examine the State Programme “The Development of the Pharmaceutical and Medical Industry.” In drafting this programme we have taken into account all the comments and suggestions that were made, including those voiced at two important meetings in Penza and Skolkovo. We tried to include measures in the context of the challenges facing the Russian healthcare industry, including the provision of high-tech medical assistance … We can single out four aspects here, and I would like to discuss them briefly.
The first is the modernisation of the existing production facilities based on new technologies and making sure they conform to international quality standards. We launched this work last year. It is being financed in accordance with the schedule and in principle we can already talk about the initial results we have obtained.
Secondly, as you said, we need to have localisation. In those areas where there is a significant technological gap we believe it is possible to encourage localisation and make it attractive. We have already drafted a government resolution to develop standard, common regulations for those wishing to localise production and we believe that by making progress in this direction with the involvement of Russian healthcare companies, it will become possible to meet demand to a considerable extent. What’s important here? We need clear and understandable long-term forecasts. Here we are cooperating with the Ministry of Healthcare. The information we receive is very important for the economic agents planning to work in this market. We are currently implementing several projects, you know about the most important of them: The Russian Technologies State Corporation is developing stents in conjunction with GE Healthcare and Renova. In fact we believe that some general ideas and a common approach in this situation will make this area more attractive.
Third, this year we have launched about 30 projects worth over 700 million roubles to develop new products at the level of components and of finished products. In our opinion, this area also needs to be supported and encouraged as far as possible. Some aspects of our potential and achievements have to be expanded. In this situation, the financing of similar projects in the medical industry will provide us with that level of independence in critical areas that is so important to us.
And fourthly, and in our opinion the most important area is the attempt to create a new industry landscape. Participants in the Penza meeting spoke of the need to solve the problem of the consolidation and strengthening of companies, and I agree with you completely: this entails the search for and development of global international partnerships and alliances. In this situation, we believe that our rapidly growing market and specific measures of state support make these projects very attractive. Given the high business activity, our state support and clear market-demand assessments, we believe that we should aspire to these types of projects. We are ready to fully support these projects, which is why tomorrow we will have to examine the programme. We very much hope that it will be approved, and we have tried to reflect all these aspects in it. That concludes my report. Thank you.
Dmitry Medvedev: Thank you. I will of course be making comments on the speeches at the end. Please, colleagues, over to you.
Alexander Shchukin (Head Doctor of the Voronezh Regional Clinical Hospital): Alexander Shchukin, Head Doctor of the Voronezh Regional Clinical Hospital.
Mr Medvedev, Ms Golodets, Ms Skvortsova, colleagues and meeting participants. I would like to outline the development of advanced technology in the Voronezh Regional Clinical Hospital, which reports to the regional authorities. The Voronezh Regional Clinical Hospital is the region’s largest multi-disciplinary medical facility and provides specialist and high-tech medical care. The in-patient department has beds for 1,757 patients. The hospital consists of 42 clinical and 16 diagnostic departments; the outpatient clinic treats over 200,000 patients a year. The hospital also provides training for 14 departments of the Voronezh State Medical Academy. In 2011, over 56,000 patients were treated in the hospital, with over 31,000 operations conducted and over 4,500 babies delivered.
Our hospital specialises in providing and developing hi-tech medical care for the residents of the region. The medical care is coordinated at different levels in the region and is provided by the seven regional advanced medical centres, all branches of our hospital. The hospital also deals with performance analysis, development of telemedicine and maintenance of patient records.
The Voronezh Regional Clinical Hospital started to grow as an advanced inpatient clinic in the late 1970s when the first heart surgeries were conducted. Since 2007, the hospital has been participating in a government programme to develop the following three areas, funded out of the federal budget: cardiovascular surgery, neurosurgery, and traumatology and orthopedics. In 2009, the hospital specialised in four areas. This year the hospital is working in 15 areas as part of the government programme and will add four more high-tech specialisations next year, bringing the total number up to 19.
The total capacity of the hospital has not changed drastically. The quality of the care provided, however, has changed as a result of the Health national priority project. The number of beds in the cardiovascular surgery and neurosurgery departments has increased to make hi-tech medical care more accessible. Due to the growing number of advanced surgeries, the number of beds in the intensive care unit has practically doubled. The number of operating theatres fitted with the latest equipment has increased from 34 to 43 over the past three years.
These measures enabled 31,000 surgical procedures to be carried out in 2011, which is 38% more than in 2005. The number of technology intensive surgeries has increased by over five times over the same period and in 2012 will increase by another 200% on the 2005 figure.
In 2008, the region was one of the first to start implementing the federal programme on improving medical care for patients with peripheral vascular diseases. Today we can boast an effective system of advanced treatment for stroke patients and patients with acute coronary syndrome. There are 10 new primary care centres coordinated by the regional centre for cardiovascular diseases based in our hospital. This enables all the residents of the region to be given equal access to timely, specialised and high-tech medical care, regardless of their location. The heart surgery centre was reopened in 2011 after undergoing reconstruction and is now equipped to international standards. The heart surgery centre has three innovative operating theatres, one of which is a hybrid operating room, one of the first of its kind in Russia. Additionally, a cardiac intensive care unit was opened. The centre for cardiovascular diseases provides treatment to both adults and children. Over 2,500 heart surgeries are conducted every year, including over 700 using the cardiopulmonary bypass technique. The number of heart surgeries has increased by 90% and the number of surgeries using the cardiopulmonary bypass technique has increased by 50%. The neurosurgery department has received a powerful boost as part of the Health national priority project. In the past four years, some of the latest hi-tech treatments, including endovascular therapy, have been implemented for acute stroke patients. In the past three years the number of surgeries has increased by a factor of five compared to 2007.
The Voronezh Clinical Hospital is one of the leaders in hip and knee replacement operations in the Central Black Earth Region. In the last two and a half years alone 1,668 major joints have been replaced, resulting in a three-fold increase in the number of surgeries, from 303 in 2010 to 924 in 2012.
The multipurpose perinatal care centre, which opened in 2011, is offering a new level of quality to pregnant women and newborn babies, including babies with extremely low birth weight and congenital heart and vascular disorders. We have been able to conduct more heart surgeries on children and emergency surgeries on newborn babies with critical heart defects starting from the very first days of their lives.
Dmitry Medvedev: Mr Shchukin, sorry to interrupt. What you are saying is great. But are there any problems? We are not here to boast even though so much has been achieved in the past years. I am not embarrassed about this programme because I have been directly involved in it for the past seven years. It is good these projects are based in the regional hospital. Do you have any suggestions for the Healthcare Ministry, the Finance Ministry or the Government? Does anything need to be changed?
Alexander Shchukin: No. Government Resolution 1062 is quite successful at allocating funds and providing help to the regions’ residents on an equal basis. It means the direction the project is taking is producing positive results.
Dmitry Medvedev: I remember quotas were our biggest headache. Now we have moved away from this system. Everybody was talking about this ad nauseum. Whatever medical facility I visited I heard suggestions that the quotas be redistributed. Federal quotas, regional quotas… It’s a far too familiar issue. What is the current situation?
Alexander Shchukin: It has become easier this year because the method is now transparent. Regions are actively preparing because everything depends on us.
Dmitry Medvedev: I see. Thank you.
Now the governor (Nikolai Tsukanov), please, would you take the floor?
Nikolai Tsukanov (Governor of the Kaliningrad Region): Mr Medvedev, let me thank you on behalf of the residents of the Kaliningrad Region for your timely decision to start the construction of this centre. This really is the best, most modern centre in the Kaliningrad Region. We need it because we live in an enclave and it is a burden on family budgets to send children or adults for diagnosis to other medical centres in the country. The fact that we at last have this centre is very important to us.
We understand that we share responsibility with the Ministry of Healthcare for utilising the capacity of the centre. We understand that we will cater to our residents for two or three years, because our children, inhabitants of the Kaliningrad Region and possibly people from surrounding regions need this assistance. We also understand that the problem may come to a head two or three years from now and we may yet ask for quotas. But we might work for it on our own and negotiate with the other countries in the surrounding areas. We have borders all around us. The Poles, Lithuanians and Germans all enjoy hi-tech medical services, but they are extremely expensive compared with ours.
We have good specialists. As we saw and heard today, our specialists can provide highly competent assistance. We are doing our best to attract top specialists to come work here. I asked the head doctor to invite the country’s leading specialists. The Region’s Government is renting 38 flats for specialists; we pay for them out of the regional budget. We have started building a block of 60 flats and will be ready to hand over these 60 flats to the Cardiology Centre by the middle of 2013. We understand that this is very important because a specialist will only take a job where a benefits package is provided. As for the foreigners, they will only come to work at places with a good reputation, good surgery and good specialists.
Now the question of visas. Can we introduce a simpler visa-issuing procedure for foreigners who buy contracts for surgery from the Cardiology Centre or maybe do something else? Could they obtain their visa in a simpler way or directly on the border perhaps? This would help the Cardiology Centre to work with foreign patients.
Dmitry Medvedev: My mood always plummets whenever the question of visas between the EU and Russia comes up. I feel like saying what I think about some of my partners. But I won’t do that. This is a peaceful meeting about healthcare, after all. Nevertheless, we must do all we can to simplify the visa regime with the EU. You know, I have done a lot in this regard. We have a visa roadmap with them but its implementation is being dragged out. Many aspects still lack coordination. Actually it has stalled, I regret to say. The ball is in their court, because visa issues are always reciprocal. For our part, there will be no delays, if we can come to terms, including the issue regarding rapid visas for this kind of surgery. In fact, it’s a humanitarian matter, if you come to think of it.
Nikolai Tsukanov: Thank you.
Dmitry Medvedev: …on medical grounds.
Please, colleagues, doctors or non-doctors. Please, Mr Shlyakhto.
Yevgeny Shlyakhto (Director of the V.A. Almazov Federal Centre of Heart, Blood and Endocrinology, St Petersburg): Mr Medvedev, Ms Skvortsova, Ms Golodets, colleagues, it so happened that our Centre (the V.A. Almazov Federal Centre of Heart, Blood and Endocrinology in St Petersburg) is the same age as the Health national project, which as we know was launched in 2006. You may remember, Mr Medvedev, how you opened our Centre. We began as a single-field facility; today we are a multi-disciplinary facility and a lot has been achieved. What would I like to say? There are three things we have implemented at the Centre, which may be useful for the modernisation and for the general development of hi-tech medical assistance.
First, is the fact that we are a multi-disciplinary organisation, as Mr Baranov said (we haven’t coordinated on this). There are many reasons involved, but comorbidity is one of the main factors. Patients with cardio-vascular ailments have more than 90% complex comorbidity as they prepare for major surgeries. This determines the multi-disciplinary approach. Since 2006, when we started operations, we have managed to expand to 19 fields and increase the number of surgeries by a factor of 20 compared to 2005. What is important in this sense? As well as increasing the number of surgeries, we have also reduced surgery-related death rates for open-heart surgeries from 4.2% in 2005 to 2% last year. That’s the European level.
The second area which I see as very important for the future development of hi-tech centres is the model of phased assistance. Ms Skvortsova showed the data for St Petersburg. We have a very favorable hi-tech situation. We have achieved a great deal thanks to the Ministry of Healthcare and the Government.
But we see that there is room for improvement of the quality of care. Even with the money currently available to us, we can increase the number of interventions if instead of phased financing, we fund the medical assistance service as a whole. Today, we carry out the main phase, and then the patient moves to the network, after which we have very little information about what is happening.
We suggest two phases of medical care for adults and children. For adults, surgical procedures are provided during the first phase, and then patients are transferred to less expensive wards for after-surgery rehabilitation. We would like to have a third phase for physical rehabilitation. This is currently not available, but I believe it is very important. Therefore, we strongly support the concept aimed at the development of physical rehabilitation medicine that has been declared by the Ministry.
In line with this concept, as you know, we have opened a children’s perinatal centre. We are currently completing the construction of a physio-therapeutic complex for this perinatal centre. Bad, severe children (97% of cases when mothers had pathologies) come from all over Russia and they need additional rehabilitation treatment that has to be longer than a month or two. Therefore this area of medicine is very important.
As part of the phased care approach, outpatient care is also very promising. Today, with the two-phase medical care system we save about 15% of the allocated resources by transferring patients to less expensive bed... But if we use outpatient services -- by involving our specialists and centres, perhaps through accreditation of municipal outpatient clinics and centres, which will participate in this process, along with us -- we can save almost 50%.
We examined patients two years after they had surgery, and came to the conclusion that we can reduce the cost per patient from 144,000 to 68,000. This means that can save almost 50% of expenditures by ensuring that patients see their doctors and take their pills on time.
And this active drug therapy will help improve the patient's condition and reduce the direct and indirect costs due to less frequent hospitalisations, heart attacks, strokes, emergency calls, sick leaves (it's all been calculated). This is a very important and promising direction.
And the third thing that I wanted to mention is that we have created a great number of centres. It really is a different kind of medicine. Believe me, it is a modern, rapidly established European-style of medicine. But I would also like to see all the achievements in this area helping to develop science and education. We need to create an integrated system of science, therapy, and education.
And it is very important to ensure that the new high-tech medical centres are involved in the system, and in the development of new medical technology, in close partnership (perhaps even closer than today) with major research centres. Only with a multi-disciplinary and phased system, and using the latest achievements in translational medicine, can we achieve serious results. Thank you.
Dmitry Medvedev: Thank you Mr Shlyakhto. Colleagues, please, any other comments?
Nikolai Nikolayev (Chief Doctor at the Federal Centre of Trauma Surgery, Orthopaedics and Endoprosthetics in Cheboksary): May I take the floor?
Dmitry Medvedev: Go ahead please.
Nikolai Nikolayev: Mr Medvedev and meeting participants, I would like to brief you on the first results of the work of the Federal Centre of Trauma Surgery, Orthopaedics and Endoprosthetics in Cheboksary. The centre opened in 2009 and over the past three years we have treated over 16,000 patients; of these, 14,500 patients were given high-tech care. Surgery accounts for 99%. Last year, the Centre was certified to comply with the ISO 9001 quality management system, including the IQNet certification. In the future, we are ready to export medical care. 70% of our medical care is the endoprosthetic replacement of joints, all types of joints, large, medium and small. We carry out complicated operations with the use of unique technology and computer navigation. We also give spinal operations, some with the use of robotic assistance.
The centre has successfully introduced an information system which calculates the expenses for a patient in any sector of the Centre. Essentially, we have introduced a patient-specific registry of all medical services offered by the centre. We know the expenses for a first-time patient, for a second-time patient, and we can calculate which stage will entail lower cost treatment. Some time ago, a rehabilitation department for 60 patients was opened for our centre in a multi-field hospital in Cheboksary. However, this department cannot cope with our volume of medical care now, and this year we are sending only 30%-35% patients there for primary rehabilitation. So the other patients continue to occupy expensive hospital beds. The general view is that these centres would develop successfully if other multi-field hospitals offered adequate rehabilitation, or if rehabilitation buildings or facilities were built for centres like our one. Why? Because our patients are in great need not only of passive rehabilitation, but active rehabilitation with the use of modern rehabilitation technology, including biofeedback. And a 50% reduction in the average stay of a patient in hospital will make it possible for us to increase the volume of medical care by at least 30 times, based on our existing capacity. Given the module structure of our centres, if in the future we extend our buildings and erect two additional operation rooms, then volume of medical care will increase. And if you look at the statistics, as you rightly said, Mr Medvedev, the number of endoprosthetic replacements in Russia has at least doubled over the last three or four years, but there is still quite a high demand for this treatment. At the moment, we carry out 55,000 joints implants per year, but we need to be doing 120,000 to 130,000. Thank you.
Dmitry Medvedev: Thank you very much. Mr Vinnichenko, go ahead please.
Nikolai Vinnichenko (Presidential Plenipotentiary Envoy to the Northwestern Federal District): I’ll be brief, Mr Medvedev. Naturally, we would like this centre to be a key centre for treating Russian citizens and residents of the Northwestern Federal District. Of course, it can treat foreigners, and it must treat them, but primarily it should treat Russians. One problem that has not been solved as yet (and I know there have been requests filed in this regard, not only from the Northwestern Federal District, but also from Smolensk and Central Russia) is the higher cost of travelling here from Central Russia as compared to travelling across Russia in general. This is due to the high prices of railway tickets and to the high prices of plane tickets. Perhaps we should think about compensating travel expenses for Russian patients from Central Russia. Regional budgets could cover these expenses. Kaliningrad residents receive certain discounts for travelling to other Russian regions, and they make good use of them. Perhaps Russian patients coming here for treatment could be entitled to similar compensation. Thank you.
Dmitry Medvedev: I’d like to reply to this right now. If regions decide that they need a certain kind of medical care offered, for example, in the Kaliningrad centre, and not by a different centre in its territorial location, they can decide to include this in their budgets. This is a possible option. In any case, it should be discussed with them. Please go ahead.
Mikhail Kotyukov (Deputy Minister of Finance): Mr Medvedev, very briefly from the Ministry of Finance, just one request, a proposal to colleagues. The slide with which Ms Skvortsova ended her presentation shows in detail the tasks which the Ministry has set for the next few years of high-tech care development. I think the point on the economic foundation needs further elaboration. The heads of medical organisations and regional representatives have said that issues of tariff formation are our priority. When determining the conditions for private investment in the sector we will have to answer the question on the tariff’s economic foundation – whether this is a uniform tariff in terms of the Mandatory Medical Insurance or some kind of additional sources that should be formed in some way?? And work on this should be completed before forming the next year’s budget.
Dmitry Medvedev: Thank you. This is information from the Ministry of Finance. All those present should pay attention to what has been said. Ms Golodets, please, go ahead.
Olga Golodets (Deputy Prime Minister): Thanks, Mr Medvedev, colleagues. I’d like to briefly comment on the establishment and functioning of these centres. This is an important subject for our country and the regions not only for medical purposes. Today we can see that the quality of life in the regions is changing. The employment structure is changing in the regions also. We try to bring in high level technologies in some regions, we discuss where this may be possible, and put in great efforts over this, often involving foreign specialists. But here we can see a unique example of creating a hi-tech enterprise using specialists from Russia. The entire infrastructure is changing.
We’ve discussed how the personnel are trained, and we know that these medical faculties are created on the basis of the local medical university. We talk with school children and they say: “I’m going to be a doctor because that’s the job I want.” This is really where Russia can be strong, this is our competitive advantage. We have good schools, we have very serious potential and creating these kinds of centres changes the economy of the region and its social and cultural atmosphere. And, in this sense, we must approach this not only as a social aspect, but we must try to provide services to our people on a very high level. It is needless to say that all residents of the Kaliningrad Region must have access to all services available in the centre. And today we saw examples of people who used to roam the country for an operation, who have now just undergone surgery, and today it is an absolutely different story for them. This must become the basis for the development of the region’s economy, and here we must show our involvement. We must make use of the region’s unique geographic situation.
This is why I found Governor Nikolai Tsukanov’s suggestion very interesting. We must consider possible forms of bilateral agreements with our neighbours with regard to medical tourism. We have established a unique enterprise involving specialists who are also in a certain sense unique, and now, I guess, we must work out how to make it function at the highest economic level, as we won’t get anywhere without economics. If we just start providing compensations for people from Smolensk to go there now, it will fail. People do not just want to go to the nearest clinic to be treated, but they also want to be able to stay with a family member who undergoes treatment. The family must be near. This is why hi-tech clinics have been built all across Russia. And this is why each clinic must have both a medical and economic range of its own. And we must act promptly, we must sell services. We can do this. We have a unique example of this: the Mother and Child Russian medical company was offered for sale via the IPO. This was last week. So today we are strong in medicine and in the economy of medicine, so I suggest we work on this issue.
Dmitry Medvedev: Thank you very much. So, shall we conclude? Or is there anything else anybody wants to add? All right then, let’s sum up.
Like I said, I would like to make a few comments. Naturally, I agree with the statements of our colleagues, the heads of national healthcare organisations. This has been mentioned by Mr Baranov (Alexander Baranov) and Mr Shlyakhto (Yevgeny Shlyakhto), and I cannot argue with this. Of course, we must create opportunities for the correct provision of consultations and treatment to patients and for their subsequent rehabilitation.
Actually this is included in the draft instruction which I will sign after today’s meeting. The multi-disciplinary approach… Of course, health disorders are always complex. As doctors are fond of saying, they are of a “combined nature.” It goes without saying that we will have to address these issues during the treatment-planning stage and during the development of high-tech medical assistance. This assistance is expensive, and we don’t like to count every penny we spend. We are not accustomed to doing so, unlike those who prepared and built all this, by that I mean the Germans. We must count the money because one day here is much more expensive than one day at some other medical facility. And this is absolutely normal because different institutions provide different kinds of services. In the long run, as the speakers correctly pointed out, this means a phased approach. At any rate, it implies financing the entire medical service being provided to the patient. Frankly speaking, the patient does not care who is providing the financing, or how much it all costs, and anyway, our specialists are still not very good at counting all the costs. All the patient cares about is getting comprehensive medical treatment. But this is all the more important if you take into account that we are planning to set the prices for the services provided, so accordingly these services will be funded out of the mandatory medical insurance budget, and this is an entirely different system of medical care. And I would like everyone to be prepared for this. By everyone I mean of course the medical facilities and the Ministry of Healthcare. My instruction will state that the Ministry of Healthcare and executive bodies, in conjunction with the Federal Mandatory Medical Insurance Fund, will have to draft measures to transition to payments for high-tech medical assistance coming from the mandatory medical insurance budget, ensure an increase in the provision of high-tech medical assistance at regional healthcare facilities and develop the required methodology for formulating the prices of high-tech medical assistance, as outlined by the Ministry of Finance.
Of course I also have no objections to supporting the integration of science and education. Representatives of the Ministry and educational institutions are present here and it is clear that you cannot have one without the other. We have a lot of substandard medical education institutions. To be honest, some of them provide extremely primitive training. On the other hand, we have some bright spots on the map, like this centre and other centres, which are represented here by hospitals and other healthcare facilities. We need to combine all this. We realise that education, especially the education of doctors, is a continuous process. I understand that a humanities student can learn by reading textbooks. Vladimir Lenin managed to take an external degree, and look what he did afterwards… He studied at home. But you cannot train a doctor like that. He will also get up to all sorts if he only reads textbooks, or if he trains at some obsolete clinic that is part of a medical education institution. These are not the kind of specialists we need. People today expect a lot more. Colleagues, I am counting on you to come up with suggestions on how this objective can be accomplished. We will try and help you in this respect.
We really need to look at common approaches regarding the organisation of high-tech medical assistance. I have already said this. We must do this in the context which our colleagues were talking about. At the same time, Government members will examine a programme regarding production of pharmaceuticals. You could argue this isn’t really what this current meeting is about, but these issues are related. We have made a number of decisions on localising production, and we have compiled certain forecasts. We are developing partnerships with our foreign colleagues… In the long run, we must also promote this aspect in Russia because we have done what we have done: we obtained funding from budget revenues by taking advantage of the favourable market situation. To be honest, we bought these centres, and we invited skilled Russian doctors. But it would be incorrect to buy them all the time. We need to create the required national potential because we realise that these are two sides of the same coin. The manufacture of this high-tech equipment means we also have specialists who can operate this equipment. If you pardon my rudeness, there is no way that all the equipment we saw at the operating room was made by morons with no medical knowledge. These people work at the crossroads of medical knowledge and technical expertise. Why am I saying all this? Of course, it is very important that we address the issue of localising production. That’s true. At the same time, we need to buy some advanced equipment models abroad. There is nothing to be ashamed of here.
As for the subsequent operation of this centre and other centres, we have to plan the budget and address the economic issues. Our colleagues have correctly pointed out that the centre is a business, albeit a unique one, so that means they need to count the money. We have to do this.
I don’t know about the future dominant aspects with regard to the Kaliningrad Centre, but it is obvious we must all do our best to provide and deliver medical services to the people of the Kaliningrad Region. That is our main objective. This issue is not up for discussion. We have to do this if Russian citizens, those living in other regions, are to receive such services. But this may prove rather expensive. We have discussed this issue with Ms Golodets (Olga Golodets) who mentioned so-called medical tourism. People going to Germany have to pay travel and accommodation expenses, so why not travel to the Kaliningrad Region instead, which is after all their home country. Let them come. As for support, such support is always individual. We have never planned this support within the framework of the federal budget. If the region has money, it can go ahead. If there is some private fund, let it pay, that’s not a problem. If this clinic, this Centre picks up momentum and gains a reputation on the international market, then it might also treat foreign patients. We have no objections to this. But we must give priority to Russian citizens, first and foremost. Judging by current trends, and we talked about this on our visit today, the new team must first treat all the prospective patients who are now in a queue. I believe that lots of new patients will be coming to the Centre for treatment over the next few years. After that, we need to have a look and find a balance between local residents, those arriving from other Russian regions and patients from abroad. Actually, this is a very good issue.
In conclusion, I would like to go back to the beginning. I believe that we eventually took the correct decisions at that time. It has not been very easy to implement those decisions. Ms Golodets had to do all the hard work. But we will close this issue in 2012, and these are our flagship projects. It is very good that we have accomplished this, but we will have to accomplish even more in the future.
Thank you very much, everybody.
