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JUDr. Katarína Belešová, MPH: Je zdravotnícke prostredie na Slovensku patologické ?


 | 27.8.2013 | komentárov: 296

Slovenské zdravotníctvo, ktoré je výsledkom koncepcie štátnej politiky zdravia a prostredníctvom stratégií, priorít by sa malo zameriavať na starostlivosť o zdravie, jeho podporu, ochranu, rozvoj celého obyvateľstva, pripomína vyhladovaný roj včiel, ktorý v stave ohrozenia rabuje svoj vlastný druh s jediným cieľom prežitia. Prežíva naše zdravotníctvo krízu ekonomickú alebo aj morálnu? Na jednej strane poskytovateľ, ktorý sa čuduje, že pacient chce mať všetko zadarmo a na strane druhej pacient, ktorý sa tiež čuduje, čo všetko zadarmo nemá. Poskytovateľ chce mať zaplatenú cenu bodu, ale už neprizná, že je pre neho veľmi výhodné byť vo zmluvnom vzťahu so zdravotnou poisťovňou, s ktorou sa dohodol na zmluvnom objeme. Zmluvný objem je rôzny, a teda tento vydelený počtom skutočne ošetrených pacientov patriacich do spádových oblastí, spôsobuje, že cena urobeného výkonu je pre každého poskytovateľa nižšia. Je to cena dohodnutá medzi dvomi podnikateľskými subjektmi, „ber alebo nechaj tak“. Mať zmluvu so zdravotnou poisťovňou je istota príjmu.

Na trhu služieb v oblasti zdravotníctva má takýto poskytovateľ výhodnejšie postavenie oproti nezmluvnému poskytovateľovi zdravotnej starostlivosti. Výhoda spočíva v pravidelnom príjme za vykonávanie všeobecne užitočných hospodárskych služieb (názov používaný EÚ), ktoré sú financované z povinných odvodov verejného zdravotného poistenia. Niektorí poskytovatelia sa však správajú ako „nezmluvní" a inkasujú poplatky, o ktorých legálnosti a spôsobe vystavenia  príjmového dokladu sa dá pochybovať. Faktúry zdravotnej poisťovni však posielajú. Povedzme si konečne na rovinu, že spôsob komunikácie s pacientom, poistencom poisťovne je úplne rozdielny ako v nezmluvných zdravotníckych zariadeniach. V nezmluvnom zdravotníckom zariadení si to poskytovateľ nedovolí. Dokonca si nedovolí ani prehnať cenu nad rámec nevyhnutnej a neodkladnej zdravotnej starostlivosti, ktorú z verejných zdrojov preplatenú má i bez zmluvného vzťahu s poisťovňou. Uvedomuje si, že jeho zdrojom príjmu je pacient, a tento sa už nemusí vrátiť. Niekedy môžeme povedať, že zdrojom príjmu je pracujúci a zarábajúci pacient.

Môžem uviesť príklad, ktorý ma osobne robí veľmi smutnou, pretože si dobre uvedomujem, čo znamená a koľko stojí solidárnosť v zdravotnom systéme. Podnikateľ radšej investuje (väčšinou do príbuzných), vykoná daňové odpisy na drahé autá, aby nemusel uhrádzať vyššie odvody do systému. „Nič tomuto štátu nedám“, znie odpoveď. „K lekárovi chodím za vlastné, pretože vidím, za čo platím“. Silné reči nás vedú k dvom zamysleniam. K absolútnemu ovládnutiu egocentrizmu jednotlivca.
Človek človeku vlkom :„Ja bohatý a zdravý, čo ma po Vás, chudobných a chorých“. Druhé zamyslenie je okamžitý prerod hrdinu pri zistení závažného ochorenia. Tam je už dobré aj štátne zdravotnícke zariadenie, pretože jedna chemoterapia stojí toľko, za čo si hrdina robil odpočet dane za jeden rok. Na to by určite aj ten bohatý a chorý nemal.

Poskytovateľ si musí uvedomiť, že nemôže brať z dvoch kôpok. Kto na toto skutočne dopláca? Pacient. A kto je pacient ? Aj lekár sa jedného času stane chorým. V konkrétnych prípadoch boli moji priatelia lekári zdesení z prístupu voči nim alebo voči ich blízkym príbuzným, ktorý bol niekedy zvolený. Pacient - lekár, ktorý „nastúpi“ rolu pacienta mimo  obvyklý priestor, v ktorom vykonáva pracovné činnosti, stráca aj možnosť vykonávať svoje sociálnu rolu „ja lekár“ napríklad pri hospitalizácií. Na jednej strane, môže nadobudnúť skúsenosti, ktoré ako lekár predtým nevidel aj vo vzťahu voči kolegom ( vyťaženosť, stres, prepracovanosť a nedostatok všetkého), a na druhej strane pocíti nerovnovážne postavenie seba ako pacienta. Aj on môže zažiť pocit, že sa stáva „prípadom“ alebo „diagnózou.“

Nie je potrebné viniť len zdravotné poisťovne z nedostatku financií. Je to otázka voľby a každá voľba má svoju cenu. Budem mať istotu, ale zarobím menej alebo to idem risknúť a možno budem taký dobrý, že zarobím viac. Buďme úprimní, niektorí poskytovatelia zdravotnej starostlivosti, patria medzi vyššiu strednú vrstvu, ale odvody majú z minima. Peniaze zo systému sú dobré len keď ich platí niekto iní?

Aby som začrela aj do svojich radov, u nás je to rovnaké. Keď elita tejto spoločnosti pohŕda zákonmi, ktoré si odhlasovala, čo máme robiť my?  Vieme všetci dobre, že lekári sú len ľudia, niektorí nemajú manažérske zručnosti, ale sú výborní odborníci, a naopak iní  sú skôr obchodníci. Spoločnosť si vždy urobí mienku na základe negatívnych skúseností a odsudzuje celú stavovskú skupinu. Je to podobné ako s kňazmi, stačí jeden negatívny príklad, ktorý zmarí snahu a skutočne užitočnú prácu celej väčšiny. S lekármi je to rovnako. Ide o stavovskú skupinu, tak poriadok by mala urobiť stavovská organizácia. To som myslela úprimne a vážne. Neskrývajme, čo sa v spoločnosti šušká. Patologické sociálne javy ako alkoholizmus, závislosť na omamných a psychotropných látkach, vysoký vek  a  „všimné“ spôsobujú následok, ktorým je patologická komunikácia s pacientom. Táto následne zle vplýva na compliance. Prežívanie kariéry pacienta významne závisí od komunikácie s pracovníkmi v zdravotníctve, kde sa mu zdravotná starostlivosť poskytuje. Psychologické a sociologické štúdie zistili, že pri poskytovaní zdravotnej starostlivosti pacient prichádza do zdravotníckeho systému s problémom, ktorý sa obvykle týka choroby alebo zdravia a dostáva sa  do kontaktu s pracovníkmi zdravotníckeho systému. Kontakt s pracovníkmi zdravotníckeho systému ovplyvňuje názor pacienta a postoj pacienta ku compliance. Je treba si uvedomiť, že on je ten, kto nerozumie, kto sa obáva a chce vedieť.

Na konferencií „Aké princípy vládnu v zdravotníctve,“ vyšlo najavo, že slovenskí lekári nevedia s pacientom komunikovať. Pacient má podľa Európskej charty práv pacientov právo na informácie, právo na prístup k všetkým druhom informácií týkajúcich sa jeho zdravotného stavu, zdravotníckych služieb a ich využívania a všetkého, čo je dostupné na základe vedeckého výskumu a technickej inovácie.  Rovnako má právo na to, aby jeho  diagnostické a liečebné programy boli čo najviac prispôsobené jeho osobným potrebám. Táto komunikácia závisí od vlastnosti prostredia a organizácie poskytovania zdravotnej starostlivosti, od vlastností pacienta ale aj vlastností pracovníka  zdravotníctva.

Zažila som rozhovor lekára na OAIM, ktorý na lôžkovom oddelení  informoval o stave pacienta po mozgovej porážke. Príbuzní sa ho opýtali, prečo otec nechodí.  Pacient bol v umelom spánku. Ako mohol tak im to vysvetlil, ale sestričke sa sťažoval, že namiesto toho, aby boli radi, že ich otcovi zachránili život, sa pýtajú, prečo ešte nechodí! Sestrička mu jemne vysvetlila, že ide o medicínsky nevzdelaných ľudí, ktorých otázka nesmerovala priamo k pohybovému ústrojenstvu, ale že sa len jednoducho chceli opýtať, čo otcovi vlastne je. Otázka, prečo nechodí v ich prípade vyplývala z domnienky, že kto nechodí, teda leží, a teda mu niečo je. Zaskočené teda zostali obe strany. Príbuzní sa dozvedeli niečo, čomu vôbec nerozumeli a lekár bol nahnevaný ako málo si vážia jeho prácu. A pravda? Tá bola len niekde veľmi inde.

Pred 20 rokmi som sa smiala na americkej brožúre, ktorá presne určovala ako má lekár vyjadriť príbuzným ľútosť nad stratou blízkej osoby. Prišlo mi to skutočne hlúpe, aby slušnosť bola  v brožúre. Odporúčania zneli  pre zdravotníka asi takto: „Pravú ruku položíte na ľavé plece príbuzného, nadýchnete sa a pri priamom očnom kontakte mu poviete vetu: „Je mi to veľmi ľúto“.“  Neviem, či aj my nedospievame do tohto štádia, hoci sme sa tomuto mali naučiť v rodine.

Ešte jeden poznatok z komunikácie pacient a lekár. Na Slovensku, ak už sa má lekár rozprávať s pacientom tak, ako to vyžaduje jeho profesia, pacientovi sa dostanú odpovede najmä na otázky, ktoré sa nepýtal. V období prepoisťovania  august až september okrem liečby dostanete aj odporúčanie, do ktorej poisťovne sa máte prepoistiť ako prvý krok pre úspešné zaradenie do čakacích listín. Samozrejme, že ide o nekalý nábor poistencov, ktorý môže preskúmavať ÚDZS.

Ako príklad vzájomného neporozumenia medzi pacientom a lekárom, nakoľko ich rozhovor rozdeľovali diametrálne odlišné ciele, Vám poskytnem nasledujúci príhodu. Pacientka vo veku 74 rokov bola v ordinácií so svojou dcérou a riešili s lekárom možnosť transplantácie bedrových kĺbov. Bol rok 2012 a po počiatočných odporúčaniach na zmenu poisťovne im ošetrujúci lekár oznámil termín transplantácie - máj 2018. Babička sa úprimne rozosmiala a povedala. „Pán doktor, to sa dovtedy o mňa postará už niekto iný!“. Lekár  zo strachu pred stratou koristi znervóznel, začal jachtať niečo o tom, že nikto by to lepšie neurobil, že možno by sa to „nejako“ teda dalo urobiť. Keď sa už potil, dcéra sa zmilovala a povedala: "Prepáčte pán doktor, vy nepoznáte humor našej babičky, ona myslela a ukázala prstom do neba, toho hore !“.
 
Na záver by som už len chcela poďakovať a podporiť tých zdravotníkov, ktorí to takto nerobia, priať im, aby sme ich mali  sviežich a vyspatých, aby sme na nich ukazovali konkrétne, hovorili o nich konkrétne, aby ich práca skutočne bola ohodnotená. A hlavým indikátorom je tu  nie poisťovňa, ale pacient !


AUTOR: JUDr. Katarína Belešová, MPH- právnička, venuje sa problematike verejného zdravotného poistenia a zdravotníckeho práva






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