The government’s fight against “amphibians” in healthcare: too harsh for some, too mild for others

Last week she was the Minister of Health Valentina Prevolnik Rupel sent one of the fundamental laws governing the Slovenian health care system to public debate – the Health Care Act (ZZDej). When we talk about reform, we always mean changing this law. It is therefore understandable that intervention in it raises dust. In particular, an intervention in that part, with which they intend to prevent doctors from earning additional income from private individuals.

The Professional Association of Private Doctors and Dentists of Slovenia wrote that they are horrified by the amendment to the law. They say the core of the changes is to punish and restrict rather than motivate health workers. They are critical because, according to their health workers, the proposal prescribes forced labor in public institutions outside regular working hours, in their free time. They are convinced that it is “exclusively an interference with the labor law situation and a violation of human rights, like no other profession in the country knows”.

A member of the Left submitted their proposal for the same law to the National Assembly Miha Kordiš and an unrelated MP Mojca Šetinc Pašek. The content for it was prepared by the Voice of the People initiative, which is led by the former Minister of Health Dušan Keber. The ministry’s proposal does not draw a clear enough divide between private and public healthcare, they say, as it continues to allow doctors from public institutions to work with concessionaires, but only prohibits it with purely private individuals.

“Amphibians” strengthen the private market

Keber believes that the law continues “the road to privatization and personnel devastation of public healthcare”. He suggests that doctors working in public institutions should first eliminate unacceptably long waiting times in their own and other public institutions and only then apply for permission to work with a private contractor. “Why should a doctor, after finishing his work, provide public services in the afternoon at a concessionaire instead of his own institution? Concessionaires are part of the public network, but they act as entrepreneurs, private contractors in the form of a public-private partnership. As with any entrepreneur, their interest is profit, but they do not bear any responsibility for the sustainable operation of the public health system. The state gives them the authority to implement part of the public program when there is a need to fill a gap in the public network, but it would be harmful if all public doctors were replaced by concessionaires or even freelance doctors, which is proposed by the Medical Chamber of Slovenia. explains Keber.

He agrees that the patient really doesn’t care whether he goes to a concessionaire or a public institution. One of the key objections of the medical union Fides to the draft law is that “radically interferes with the way healthcare services are provided by concessionaires. Patients receive these services as part of their health insurance, without additional payments.” Keber wonders: “Would it then matter if all public doctors were replaced by concessionaires? No way. The system would disintegrate into a multitude of unrelated small contractors who would be neither able nor willing to provide everything that a comprehensive public system must provide. There is already a difference in the fundamental motives: while the public doctor wants to have the healthiest individual possible, the private doctor would like a patient who needs as many services as possible and returns to him often. Not to mention the various tax and other ‘optimizations’ aimed at generating as much profit as possible. For example, today the concessions are being owned by domestic and foreign financial funds, in which doctors are only employees. Do these funds really represent an integral part of our public healthcare? Experience from around the world shows that in public-private partnerships, the most common victim is the public partner, who is exhausted by the private sector. A multitude of private individuals – around two thousand amphibians and 1,400 concessionaires – are expanding the private market at the expense of the public one. In addition to public services, our concessionaires can also provide self-paying services. In Austria, the concessionaire may not provide the same services that he provides for a public insurance company.”

But what would the abolition of “amphibians”, i.e. doctors who simultaneously work in public and private institutions, mean for patients, if there are as many as two thousand of them and they were suddenly banned from working? “The increase in the number of amphibians is increased by the private sector, not the public, where the program is limited by the amount of money from contributions. But in the private sector, services are available only to those who can pay for them. The most disadvantaged patients cannot go there, and the most difficult patients are avoided. Why not have two thousand amphibians work in their own facility for an afternoon? Of course, they must be adequately rewarded for this, but even earlier it is necessary to determine how much work they must do during regular working hours.” says Keber.

Fides is otherwise convinced that doctors will go abroad and to private institutions due to the adoption of the law. “Kader will go where he will not be restricted, and patients will have to follow him, because they will no longer receive appropriate treatment from us,” they are confident in Fides, where they always take the position that they use services in private institutions to shorten waiting lines.

Keber argues the opposite: “Until 2014, we did not have a major problem with waiting times. After that year, we got more than a thousand amphibians and the queues got longer. Amphibians create queues because they need them for their existence. This happened gradually. First, the Fides union ensured the lowest labor standards in Europe, resulting in a shortage of doctors, the appearance of patients without a doctor of their choice and waiting times for most services. All this, even though the number of doctors increased by 30 percent and funding by 40 percent after 2014. We really cannot claim that so many more patients and elderly people have accumulated in 10 years. It is the private sector that creates the needs. This is the legality of every trade.”

Keber is not afraid of too many doctors leaving the public sector: “Those who really want to get rich the American way will leave anyway. But there won’t be many of them. They will definitely realize that the workloads abroad are significantly greater than here, and that there will always be uprooted, eternal ‘guest workers’ who only exceptionally achieve the status, reputation and social position they have in their own country… Ultimately: it will be difficult for them found such a beautiful country as the one they live in now. Would you really sacrifice all that for better pay, if they already have the highest salaries in the public system?”

Sašo Bizjak

Brecelj: a pleasant surprise

The bill was also discussed at the strategic council for health care, which is chaired by an oncological surgeon Erik Brecelj, falls under the auspices of the Prime Minister’s Office and prepares proposals for the Ministry of Health regarding urgent changes in the system. Brecelj fundamentally supports the amendment to the law. “I am pleasantly surprised by what is in the marriage. I’m sorry that the ban on self-paying services for doctors in public health care is the most talked about right now, because there is a lot more to it, from better management to more transparent granting of concessions and rewards. Unfortunately, Fides doesn’t see that we are talking about remuneration and they only care about those who work for self-payers. The new law provides the possibility of tax-advantaged business contracts for all healthcare workers, not just doctors. That way you would be paid better than overtime. Regarding the morning work, the law states that they will measure our effectiveness,” explains Brecelj.

He agrees that some details of the law still need to be re-debated during the public debate. Has the law successfully demarcated public and private healthcare? “We have always tried to ensure that concessionaires are an addition to public healthcare. It will be beneficial for everyone if it is possible to switch between public services paid for by ZZZS,” says Brecelj. He estimates that most doctors in the private sector do not provide self-paying services, but under this law they could work in public health care for more money. “Limits must be set by law, as doctors have shown that some do not have them,” is critical of Brecelj, who says that they will do everything to get the law passed.

He himself observes that the law is strongly opposed by people who work in companies sold to foreign funds. “Now they are worried about what will happen to public healthcare. We are happy about that,” he says cynically. He also believes that there is no fear that many doctors will go to private healthcare. “However, further steps will have to be taken. ZZZS will also have to start looking at where there is interest in the services and where there is not, and where there are long waiting times. And where there is a frenzy of interest in the services, lower the price. The question is whether there will still be such a desire to escape from public healthcare. In the strategic world, we are always in favor of rewarding those who work in public health if they work harder. This is also a matter of management. But the story has to start somewhere.”

Practicum: more harm than good

Robert Balen

President of the union of family doctors Praktikum Igor Muževič considers it welcome that “amphibians” should be banned by law. However, he believes that the law should have been written significantly differently then. “I’m afraid that – as written now – it will do more harm than good,” says Muževič, who encountered in the proposal “a whole bunch of legal awkwardness”. Gives an example of an article that prevents the transfer of ownership of concessionaires. “It says that any change in ownership is prohibited, except for inheritance. But we also have a concessionaire, which is a state-owned company, Zavarovalnica Triglav, which is a joint-stock company. So if I buy one share of Zavarovalnica Triglav, its ownership structure changes. Is that why they will take away their concession? Or if the co-owners are spouses who divorce. Are we going to take away their concession?’ enumerate.–

He also finds it controversial that the institution should hire a doctor full-time, since in some places there is neither the need nor the money for this. “Now they’re going to have to hire him full-time, even if they don’t need him for that much time and don’t even have the money for it, or they’ll be left without him altogether.” illustrates. He cites another example of a problem from his own practice in a home for the elderly. “As a concessionaire, I will not be able to contract with a freelance doctor to replace me when I fall ill or go on vacation. Then people will be without care and may even die. According to this proposal, I can only get a doctor through an undertaking contract from ZD Kamnik, which the doctors there cannot conclude. So the bill is written in such a way that people can die if I get sick. It’s no joke,” warns Muževič. And also that the requirement that the concessionaire must employ as many doctors as there are programs should also apply to public institutions. “It is not right that this is not required of them, but of the concessionaires. So how should ZZZS allocate money for the program if there are not enough doctors guaranteed?” Muževič asks.