The hour of truth for afternoon outpatients
Doctors at university teaching hospitals and the Health Ministry are squaring up for more battles as January 1, 2002 approaches, the deadline for the doctors to close their private practices. The doctors have been holding repeated strikes, although without the agreement of the senior professors, while Health Minister Alekos Papadopoulos is determined to open private outpatients’ departments in the afternoons as of that date. The Greek National Health System plan did not get off the ground because of a lack of funds and sufficient space at Athens hospitals, but this time it is hoped the introduction of private afternoon services at the hospitals will provide the hospitals, as well as the doctors, with a considerable income. The fees have been considered extremely high, although they include hospital costs, but are in no way comparable to university doctors’ fees in private practice. Under the new system, only 21 professors of surgery in Athens and Thessaloniki will be able to receive the 44,200-drachma consultation fee, of which only 60 percent goes to the doctors themselves. Opposition was to be expected, as Greek patients are not used to paying for anything officially in hospitals, even though under-the-table payments are the order of the day. In an interview with Kathimerini, the coordinator of the Health Ministry’s relevant committee, Katerina Beriatou, emphasized that there is absolutely no limitation on free access to the hospitals and no patient will be refused treatment, which will continue to be free in duty hours for all emergency cases. Medical treatment and hospitalization are covered by the insurance funds. Afternoon services are only for those patients who do not want to come during regular hospital hours and who want to choose their doctor. Great idea, but hard to put into practice Having private afternoon outpatients’ clinics is a very good system and one which I had 20 years’ experience of in Germany, said Dr Sotiris Raptis, professor of internal medicine. However, in Germany it is only the clinic directors who had private practices in the hospitals. The system has certain advantages, in that in an emergency, there is the hospital infrastructure. But it needs very good organization. You need the space, the infrastructure, the means to monitor the whole system, he added. I hear people on television talk shows asking why Greek patients suddenly have to start paying in the afternoons. They have to pay just as they would if they came to my private practice, where either they themselves or their insurance fund pays. It is separate from free medical care. Of course, in order to attract patients and to treat them you need the appropriate environment. You can’t have them waiting for five hours in a queue to pay. In Germany, the professor’s secretary notes the appointments, the tests and so on, that are billed to the patient and usually paid by the insurance fund, he explained. So the idea is a good one, but in my opinion it will be very difficult to implement, he said, adding that at the Evangelismos hospital, 200 doctors had registered so far for afternoon hours. Personally, I don’t know what space will be allotted to me or whether I will have administrative support, said Raptis. We have the largest diabetics’ center in Greece, with 8,500 patients. Because many of them are working, or students, I have been trying for years to have an afternoon clinic once a week at the hospital, free of charge. I obtained approval from the university to pay the nursing and administrative staff but no one was willing to work in the afternoons. But I have decided to close my private practice, hoping that chaos will not follow, since I am responsible for hundreds of people and can’t just leave them like that. Dr Panayiotis Yiannopoulos, head of the hospital’s medical service and of its second surgical clinic, is more optimistic. As president of the committee set up to manage the afternoon clinics, he suggests that the regular morning clinics be used and if necessary the offices of the hospital doctors. Yiannopoulos told Kathimerini that doctors are favorably disposed toward the new system. Even after years of postgraduate study, their wages are very low in comparison with the private sector. Why shouldn’t they want an additional income, particularly when it has no effect on poorer patients? he said. The challenge: Making proper use of doctors and hospitals National Health System surgeon Katerina Beriatou, the ministry’s coordinator for the system, pointed to three reasons for setting up afternoon services. First of all, patients should have access to the doctor of their choice within the hospital and not outside it by means of irregular, under-the-table transactions. Secondly, we should mobilize the hospitals and ensure that high-technology departments are open all day. They should not close at 2 p.m., or even earlier. This brings us to the third point, in that by ensuring the above, we are also securing income for the hospital. We will be attracting a number of people who usually resort to the private sector, and here I am not referring to doctors in neighborhood practices, but the large, expensive private clinics. I think that doctors at the state hospitals are better and there is a high standard of equipment which should be made full use of, instead of gathering cobwebs after midday. Is there any chance that implementation of the decision might be postponed? The system will begin functioning on January 1 in all state hospitals, although this might not go into effect everywhere. The law gives the hospital governor the authority to implement the provision, according to the capabilities of the hospital in question. That is, as a first stage all doctors might not be able to work in the afternoons – if there are space restrictions, priority will be given to university teaching staff who lose their right to operate a private practice, and to those further up in the hierarchy. The law of choice As many as perhaps 2,000 doctors have the right to ask for an afternoon consulting room in Athens’s hospitals. Is there a demand for so many? What about infrastructure? Patients will be making afternoon appointments with a specific doctor. That doesn’t mean that if someone acquires the right to open a consulting room he or she will keep that right forever with only one appointment per day. The hospital cannot make its support staff available for four or five hours in the afternoon just for one patient. That is a matter for the discretion of the hospital governor, who will set the rules of operation. Infrastructure problems exist, both regarding the amount of space available and the quality of that space. That is, a doctor who closes a private practice in Kolonaki cannot expect the same kind of environment at this stage at the Hippocrateio Hospital, for example. But the space is available, because there are already morning outpatients’ departments fitted out for the purpose, and all doctors will have their own consulting rooms. In any case, each doctor will only have an consulting room two afternoons a week at most, and during the rest of the week the space will not necessarily remain unused. Solutions are being discussed for places where there really isn’t enough space. Some hospitals have other property or can rent space. If the problems are not unsurpassable, we would like the services to remain on hospital premises or next door. We don’t think we will have to look further afield. The greatest problems appear to be at the Hippocrateio and the Laiko. Don’t forget that the university teaching doctors will be moving to Haidari, where they will have far more extensive and better facilities. We are waiting for them to tell us which clinics they want to move there so as to free space at hospitals in the center. But there have been delays and and we have reason to believe that they do not want to move away from the city center. In the provinces there are no infrastructure problems as there is no region in the country without a new hospital. Regional university hospitals, in fact, have asked to implement the system earlier, as they say they are ready. Free emergency care Patients are mostly concerned about what they will have to pay. There will be absolutely no restrictions on free access to medical care and patients will lose none of their current rights. Duty shifts will continue to be free; emergency treatment is free for everyone, while hospitalization and any medical treatment or surgery will be covered by insurance funds. The afternoon service is to give patients who cannot or do not want to use the regular hospital service, or because they want to consult a specific doctor, to do so at their leisure during the afternoon hours (when regular outpatients’ services are closed). Isn’t there a danger of clientelist relations developing within the hospital? There are safety valves; the hospital governor and other administrators will have greater responsibility to regulate the hospital’s conditions of operation. But a patient who goes to an afternoon consultation does not have any priority regarding other tests. By law, priority is designated only at the morning outpatients’ service. Not only the governor, but the head of the sector, who is a doctor but is not head of the department, has the right to check the patients’ check-in list. The Regional Health Systems will give priority to the way in which the afternoon services are to be monitored, and I would like to believe that people will be able to take advantage of this additional opportunity without giving up any of their rights. In addition, having a hospital, particularly the diagnostic sections, open all day will prevent delays of up to a week for tests.