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Pohled LPR k současné reformě zdravotnictví v ČR - 6 chyb


 | 6.10.2011 | komentárov: 335

Občanské sdružení Lékaři pro reformu (LpR) se znepokojením sleduje nedůsledné a pomalé reformní snahy ministerstva zdravotnictví. Opakovaně ukazuje jako vzor reformu holandského zdravotnictví, ale nemá odvahu ji prosadit.

Obrazok Pozorně sledujeme schvalování reformních zdravotnických zákonů. Tak je nazývají autoři z Ministerstva zdravotnictví ČR (dále „MZd“). Netají se snahou inspirovat se holandským systémem zdravotní péče, který je v současnosti asi nejlepší na světě.

Pokud však srovnáme holandský systém s navrhovaným systémem u nás, je na první pohled vidět, že se mu podobá pouze vzdáleně – a to je špatně.
Celý holandský systém má pevnou strukturu, která musí být důsledně akceptována v plném rozsahu. Nejhorší, co může nastat, je situace, kdy se několik prvků zavede a k jiným chybí odvaha. To už je pak lepší nechat celý systém v režii státu – bohužel i se všemi negativními důsledky.

Holandský systém má zjednodušeně tuto základní strukturu:

- Stát definuje co nejjednodušeji péči hrazenou z veřejného zdravotního pojištění, pravidla při jejím poskytování a základní spoluúčast.
- Konkurující si zdravotní pojišťovny musí tuto péči zajistit pro své pojištěnce nákupem u poskytovatelů zdravotní péče. Cena vzniká dohodou mezi plátcem a poskytovatelem.
- Zdravotní pojišťovny získávají zdroje z odvodů z mezd a přímo od pojištěnců formou prodeje pojistek (nominální pojistné). Právě cenou této pojistky si konkurují.
- Nad vším dohlíží stát cestou úřadu a nijak finančně nezasahuje ve prospěch jakékoliv pojišťovny či jakéhokoliv poskytovatele.

Naše MZ se, dle našeho názoru, dopouští několika zásadných chyb.

1. Definuje nadstandard, místo aby standardizovalo péči a určilo jasně to, na co mají pacienti nárok.
2. Špatně mění systém spoluúčasti.
3. Nezvyšuje podíl soukromých zdrojů správnou cestou – tedy zavedením nominálního pojistného.
4. Nepodporuje ambulantní sféru, tedy čerpání péče u praktických lékařů na úkor ambulantních specialistů a péči ambulantních specialistů na úkor nemocnic.
5. Nepracuje na změně systému úhrad z úhradové vyhlášky na cenu za péči, kterou si mezi sebou dohodnout plátce a poskytovatel.
6. Chybně zvyšuje úlohu monopolního plátce v systému.

Naše výtky vycházejí z informací o tom, jakým způsobem byl a je realizován zmiňovaný holandský systém.

I. Definice péče hrazené z veřejného zdravotního pojištění, pravidla při jejím poskytování a základní spoluúčast

Stát musí definovat základní rozsah péče hrazené ze zdrojů solidárního veřejného zdravotního pojištění. Definuje pravidla poskytování, práva občanů, lékařů i pojišťoven. Definuje spoluúčast na péči a také stanovuje pravidla, která je nutné dodržovat při diagnostických a terapeutických postupech – to je tzn. standardizace péče.

Chyba MZd č. 1: Definuje nadstandard, místo aby standardizovalo péči, a určilo jasně to, na co mají pacienti nárok.
V této části se současné ministerstvo upnulo k čemusi, co nazývá „nadstandard“ a dochází k medializaci něčeho, co je z hlediska reformy naprosto nepodstatné. Mnohem důležitější je definovat standardní péči tam, kde je to možné, a odlišit ji od péče NEstandardní.

Je to náročný, ale naprosto zásadní prvek celé reformy. (např. jaká léčba je standardní u pacienta s DM I a DM II typu, jak často se mají dělat odběry, kdo je má právo dělat, jaké léky je správné podávat, má se začínat hned těmi nejdražšími a nejmodernějšími nebo je správné začít základní řadou perorálních antidiabetik, kolik diabetologů může pacient navštěvovat, patří do standardní péči i pravidelné návštěvy chirurgie, ortopedie, revmatologie či neurologie a kdo tato vyšetření má indikovat, …).

Takovéto postupy je nutné postupně zpracovat pro většinu zejména chronických onemocnění jako je revmatická arthritida, ICHS, hypertenze, epilepsie, deprese, Alzheimerova demence, Parkinsonova nemoc, dna. Prostě je potřeba stanovit, co je péče standardní a co nestandardní. V Česku však hledáme nadstandard - což je naprosto marginální část péče, a mediální humbuk kolem toho ukazuje reformu ve špatném světle. Jako bychom dělili péči na tu pro chudé a pro bohaté.

Chyba MZd č. 2: Špatně mění systém spoluúčasti.
Další chybou je trvání na současném systému spoluúčasti pacientů a pokus o jejich úpravy. Zvýšení doplatků za pobyt v nemocnici nic neřeší a chybná změna poplatku za recept povede k tomu, že pacienti budou na každý recept požadovat 2 léky. Je nutné zvýšit podíl financí, které přicházejí přímo od pacientů. Jednak je potřeba celkové zdroje ve zdravotnictví navýšit na standardních 8–10% HDP, a hlavně – soukromé zdroje zvyšují tolik potřebnou regulaci celého systému.

Platby občanů je třeba rozdělit na dvě skupiny:
A) Soukromé zdroje, které by měli občané platit v okamžiku, kdy jsou zdraví, kdy nepoptávají žádnou zdravotní péči, a tedy se nerozhodují pod tlakem nemoci. Jedná se o tzv. NOMINÁLNÍ POJISTNÉ – jednou za rok si vyberou a zaplatí pojistku dle vlastního uvážení u libovolné zdravotní pojišťovny.
Nominální pojistné je opravdová pojistka, kterou si klient kupuje u zdravotní pojišťovny. Aby to nebyly pouze peníze navíc, je možné přiměřeně snížit současné odvody zaměstnanců na zdravotní pojištění a tím jim poskytnout zdroje na koupi této pojistky – nominálního pojistného. Zdroje pro sociálně potřebné musí zajistit stát.

Chyba MZd č. 3: Nezvyšuje podíl soukromých zdrojů správnou cestou – tedy zavedením nominálního pojistného.
B) Vlastní spoluúčast placená v okamžiku čerpání zdravotní péče, tedy v době, kdy pacient má zdravotní problémy a je často ochoten zaplatit cokoliv, aby o něj bylo postaráno. V Holandsku je tento systém řešen formou SPOLUÚČASTI (odpočitatelné položky) na konci pojistného období do určité stanovené výše.
Pacient by na konci každého roku zaplatil zdravotní pojišťovně z celkové roční čerpané ceny péče prvních 2500 až 5000 Kč a zbytek by hradila pojišťovna. Preventivní prohlídky, péče o děti do 15 let, péče v těhotenství a péče praktických lékařů se do té do sumy nepočítá a je tedy pro občany zcela zadarmo.

Chyba MZd č. 4: Nepodporuje ambulantní sféru, tedy čerpání péče u praktických lékařů na úkor ambulantních specialistů a péči ambulantních specialistů na úkor nemocnic.
V ordinacích ambulantních specialistů a v nemocnicích by pacient dostal účet, aby věděl, co si dané zdravotnické zařízení účtuje zdravotní pojišťovně. To podstatně zvyšuje přirozenou kontrolní funkci pacientů a současně upřednostňuje péči praktických lékařů.

Oboje by efektivitě zdravotnictví velmi prospělo. Výběr poplatků v ambulancích a nemocnicích by se mohl zrušit a pojišťovny by si spoluúčast vyřešily se svými klienty po skončení roku. Odstranila by se nespravedlnost mezi praktickými lékaři pro děti a dorost a ostatními ambulantními lékaři a také mezi těmi, kteří mají velké procento pacientů v sociální nouzi – ti totiž poplatky platit nemusí.

Celková suma spoluúčasti by se zvýšila (MZd by zajistilo další zdroje do systému, mj. i na dorovnání cen lékařům o snížené poplatky), aniž by pro kohokoliv byla finančně nedostupná, a zvýšila by se efektivita systému. Vznikl by konečně i nový fenomén, kdy by pacienty opravdu začala zajímat cena zdravotní péče, a požadovali by vždy účet za poskytnutou péči. Nejednalo by se o jakoukoliv výraznější administrativní zátěž, protože každý program to dnes umí automaticky.
Je také důležité si uvědomit, že tato spoluúčast nesmí v žádném případě podléhat možnosti připojištění. Jinak se zvyšuje tzv. moral hazard (platba 3. stranou – „vezmu si co nejvíce, když to platí někdo jiný“) a efekt spoluúčasti mizí do ztracena.

Současně má tento systém velký význam ve vztahu k nominálnímu pojistnému. V Holandsku, kde je nominální pojistné již několik let úspěšně zavedeno, je možné si spoluúčast i dobrovolně zvednout a současně snížit cenu pojistky (nominálního pojistného). Klienti, kteří se rozhodnou pro tuto možnost, ušetří a současně se jistě ke svému zdraví budou chovat jinak, než ti, kteří mají téměř veškerou péči zadarmo.

II. Zdravotní pojišťovny a poskytovatelé

Nyní se na hřišti objevují zdravotní pojišťovny a poskytovatelé. Na úvod je nutné jasně deklarovat, že v případě zdravotních pojišťoven se nejedná o ústavy tak, jak je známe dnes a současně je naprosto nepředstavitelné, že by některá z nich mohla mít dominantní postavení. A je úplně jedno, jestli by to byla státní či soukromá. Vlastně není: v tomto případě by byla monopolní soukromá pojišťovna mnohem větším zlem.

- Pojišťovny znají objem péče (standardní péče x počet pojištěnců) a dokážou si vypočítat potřebu prostředků na její zaplacení. Tento objem péče budou muset pojištěncům ze zákona zajistit pod přísnými sankcemi (místo toho MZd chce pokutovat lékaře naprosto likvidačními sumami).
- Zdravotní péči si pojišťovny musí kupovat u poskytovatelů za tržní ceny, tedy za takové, jaké si spolu domluví. Tak to funguje všude jinde na trhu a nejedná se o vyjednávání ceny v ambulanci mezi lékařem a nemocným. Musí skončit nesmyslná úhradová vyhláška.

Chyba MZd č. 5: Nepracuje na změně systému úhrad z úhradové vyhlášky na cenu za péči, kterou si mezi sebou dohodnout plátce a poskytovatel.
- Právě pro fungování konkurenčního prostředí je potřebné omezit až zrušit monopol jedné pojišťovny. Pouze pluralitní systém s konkurencí jak na straně plátců (pojišťoven), tak na straně poskytovatelů (nemocnic, léčebných ústavů či ambulantních lékařů), umožňuje udržet náklady na rozumné úrovni (i když jistě budou stále vysoké a rostoucí) při dostatečné kvalitě péče. Současně ale zajistí proplacení reálných nákladů poskytovatele (poskytovatel nepřistoupí na smlouvu, která mu nepokryje náklady).

Chyba MZd č. 6: Chybně zvyšuje úlohu monopolního plátce v systému.
- Zdravotní pojišťovny musí mít volnost při vytváření smluvní sítě a základním kriteriem bude zajištění (nasmlouvání) dostatečného počtu zdravotnických zařízení, která budou schopna poskytnout zákonem stanovený standardní rozsah péče v požadované kvalitě i objemu. Tím se zajistí, že prostředky půjdou pouze těm, které systém opravdu potřebuje. Je pravděpodobné, že ne na všechny nemocniční kapacity se dostane, stejně jako na některá ambulantní zařízení v místech jejich velké koncentrace.

III. Pojistné a jeho přerozdělení

Po navázání smluv pojišťovny zjistí, kolik zdrojů opravdu potřebují. Větší část získají z odvodů na zdravotní pojištění, včetně odvodů za státní pojištěnce. Tyto prostředky je nutné lépe přerozdělovat, nejen podle věku a pohlaví, ale také podle závažnosti zdravotního stavu pojištěnců. Na tomto, podstatně sofistikovanějším způsobu přerozdělení, již ministerstvo pracuje.

Dalším zdrojem se musí stát nominální pojistné, které si budou pojišťovny vybírat přímo od občanů a jehož výši si budou stanovovat sami na základě finanční situace - konečně normální pojistka. Právě výše nominálního pojistného bude ukazatelem hospodaření zdravotní pojišťovny a jedním z nejdůležitějších kritérií, podle kterého si pojištěnci budou zdravotní pojišťovnu vybírat.

Výhodou nominálního pojistného je jeho možnost recipročního svázání s ročním limitem spoluúčasti. Pokud si pojištěnec dobrovolně zvedne roční limit spoluúčasti, může mu pojišťovna snížit nominální pojistné. Tedy ti, kteří se ke svému zdraví chovají správně, ušetří. Současné „pseudopojišťovny“ se stanou opravdovými pojišťovnami.

IV. Role státu

A jako poslední bod je nutné zajistit kontrolu toho, zda zdravotní pojišťovny opravdu zajišťují standardizovanou péči v rozsahu stanoveném zákonem a zda mají dostatek prostředků (včetně rezerv) na zaplacení této péče zdravotnickým zařízením.
Dále je nutné důsledně zamezit vzniku jakýchkoliv monopolů, ať mezi pojišťovnami tak mezi poskytovateli a také přestat s finanční podporou státních zařízení. Daně se nevybírají pro to, aby dotovaly neschopné.

MUDr. Roman Flašar, předseda o.s. Lékaři pro reformu
MUDr. Ivan Sucharda, místopředseda o.s. Lékaři pro reformu

zdroj: LPR, zdn.cz, pôvodne tu.
foto: metrolic.com


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