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How the coronavirus changed the organization of medicine

How the coronavirus changed the organization of medicine

The COVID-19 pandemic has become a crash test for world medicine and an incentive for large-scale investments in the development of tests, vaccines and medical technology in general. Developed countries will learn from this shake-up useful lessons to modernize their health systems. Perhaps another round of reforms will take place in our latitudes. The conversation is mainly about Russia, but there are comparisons with Georgia, Belarus and Ukraine.

The first question is – could the collapse of regional health care be avoided, given its state? Apparently not, since the throughput and medical productivity of primary care and hospitals was limited not so much by the number of beds as by the lack of qualified and motivated personnel. And they cannot be purchased by state purchases in a month – neither with a competition, nor without a competition. Especially in the conditions of obviously unequal competition with Moscow.

Second, what health care reforms can be implemented as a result of the fight against the pandemic? The political situation has changed, influential private players have appeared in Russian medicine, the government of Mikhail Mishustin is set to optimize costs and introduce information technologies. The experience of dealing with the pandemic has shown that the Russian health care network, left over from the Semashko system, can be completely reformatted in a couple of months. Friends of Vladimir Putin and the court oligarchs are tempted to participate in the development of $ 60 billion a year – the amount of the consolidated state budget for health care – and about the same amount, made up of official and unofficial public spending on medicine. In today’s Russia, the captains of the medical bureaucracy – the chief doctors of regional and federal hospitals and health officials – are unlikely to be able to keep such a large piece of the pie.

grazing corporations

Let’s make a reservation right away that in the post-Soviet countries, the medical systems of which we are analyzing, Georgia stands apart. In Georgia, public health services died in the 1990s, as Dr. Irakli Dartsmelia aptly put it, just as the central heating system in Tbilisi died. At a time when residents of the capital of Georgia were drowning their houses with stoves, doctors switched to private practice: the per capita expenditures of the Georgian budget on medicine in 1999 amounted to $ 0.8 per year, the share of healthcare in GDP (which amounted to $ 2.8 billion) fell from more than 4% in 1991 to 0.59% in 1999. Half of these several million dollars went to the departmental medicine of the Ministry of Internal Affairs. The first steps to reform health care in Georgia began in 1995-1996. With the adoption of the new constitution, the state abandoned full and free medical support for citizens, and the Soviet hierarchical model of a network of medical institutions, which died anyway, was replaced by a free network. The development of medicine in the future was based on the privatization of most hospitals and clinics and the attraction of private funds. Georgia is the only post-Soviet country in which citizens, insurance companies and the budget buy medical services from private medical organizations. In an interview with Dmitry Gordon, Alexander Kvitashvili, the ex-minister and one of the main reformers of the Georgian healthcare already under Mikhail Saakashvili, said: “Why did it work? I think because we started from scratch … In Georgia, everything has really been destroyed. As paradoxical as it sounds, I think it was good, in the sense that it was easier to build something new. ” In Russia in 1999-2000, government spending on health care fell to a minimum of 3–3.2% of GDP, but it was almost $ 6 billion. In Ukraine, in 1999, total health spending was 4.5% of GDP, with a share of government spending at 65% – it was almost $ 1 billion. In Belarus, where at a minimum in 2000, total health spending was 6.1% of GDP, the share of government spending remained high, 75.5%, or about $ 585 million – 100 times more than in Georgia.

As a result, having lost as a professional medical community (someone left the profession, someone went abroad, medicine ceased to be a prestigious field of activity), the health care systems in Belarus, Russia and Ukraine survived as bureaucratic institutions. The attempts to get rid of Semashko’s legacy, which began in the 2000s, rested against the resistance of the corporation of medical bureaucrats. The same club, consisting of the chief doctors of thousands of hospitals, heads of regional health departments and national leaders of medicine, did not allow the privatization of the health care network, this source of administrative rent, growing along with the budgets, did not allow foreign medical and insurance companies to enter its market.

With a very small stratum of the rich who were ready to pay for qualified services, the role of the bureaucracy distributing budgets grew, and the role of the professional medical community declined. By 2014, government spending on health care in Russia increased slightly in percentage terms, according to the OECD, to 3.7% of GDP. But GDP in 2014 was $ 2.06 trillion, more than 10 times the 1999 GDP. The state spending on the industry alone amounted to almost $ 80 billion, and the total (state, corporate and private) reached $ 150 billion, that is, increased more than 10 times compared to the minimum in the late 1990s. After 2014, due to the devaluation of the ruble, the dollar turnover of the industry fell by about 25%.

Institutional reforms were built around the dispute between the budgetary and insurance models and were, in fact, reduced to an apparatus war for financial flows. Under the budget model, the role of the relevant ministry and regional health departments remains; under the insurance model, it is easier for federal technocrats and the Ministry of Finance to create the right incentives for market participants; in addition, large insurance companies and national medical networks can count on their share in the budget pie.

Doctors are not market participants, although their monthly earnings in Russia have grown from $ 50-60 in 1999 to $ 500-600. Of course, working for wear and tear, you can earn $ 1000 or more, and the income of Moscow doctors is fundamentally different from the earnings of their colleagues in the regions. Nevertheless, the weak dependence of remuneration on qualifications and labor costs in post-Soviet medicine (excluding Georgia) remains one of the main conditions for the formation of a medical professional environment. In Belarus, a similar situation – with a part-time job at an average of 1.36 rates, the average salary of a doctor in 2019 was $ 560 per month. For the most part, the incomes of doctors in Ukraine remain low.

To understand the peculiarities of the reaction of our health care as a corporation to the challenge of the pandemic, it will be enough to state that by 2020, Russian, Belarusian and, to a large extent, Ukrainian medicine are managed as bureaucratic systems, in which neither economic incentives nor the institution of professional reputations work. This makes it difficult to fully fight for the patient’s life, and sometimes makes it impossible.

Do not forget that only practicing doctors directly treat people and take responsibility for their lives in this entire cumbersome healthcare system. These are those who remain “dry” after subtracting numerous officials from the Ministry of Health, regional and local health authorities, federal and territorial compulsory health insurance funds, Roszdravnadzor, FMBA, Rospotrebnadzor, insurance companies. The employees of the Investigative Committee, the Prosecutor’s Office, and the operatives of the Drug Control Department of the Ministry of Internal Affairs cannot help patients either. Honestly, even the medical staff of polyclinics, who are more involved in writing meaningless certificates and logistics, which the primary care absolutely did not cope with during the pandemic, cannot help the patient in any way. Responsible and meaningful medical practice, according to our research of medical teams, is engaged from 10–20% of medical personnel in therapeutic hospitals to 50% of surgical ones. That is, according to a very rough estimate, out of 700 thousand doctors in Russia, this is about 100-150 thousand specialists. They are forced to work under total bureaucratic pressure, in the status of lower-level civil servants. They turned out to be privates in the war against the pandemic.

Doctors on the front lines 

In medical practice, it becomes impossible to make bureaucratic decisions as soon as the patient’s condition goes beyond the instructions. And this, to one degree or another, almost always happens, and often the Hippocratic Oath contradicts the protocol. Even the application of the best protocol is impossible without regard to the task of healing and saving.

That is, the requirements of insurance companies and supervisory authorities may directly contradict the interests of the patient. Even in Georgia, where citizens are treated by private clinics and private practitioners, a conflict of interest is not excluded. If a large insurance company owns a clinic, it can demand that doctors, essentially their employees, save on medicines and consumables, limit their earnings, and refuse expensive, highly qualified specialists. If the customer of the medical service is the state budget, whose share in the Georgian healthcare market has been growing in recent years, the interests of the patient are contradicted by the corrupt interests of the officials distributing funding.

In the current “wartime” the doctor almost every day faces a morally and legally difficult choice. From interviews with doctors who worked with severe covid patients during the peaks of the first and second waves of the pandemic in Russia and Ukraine, it can be seen that a situation often arises when there is a patient who will almost certainly die without mechanical ventilation, and a patient who will die almost 100% and on ventilator:

“A patient, 87 years old, was admitted in a critical condition. I have all the ventilators busy – if I turn off one of them, he will die. I will connect a new entrant – he will almost certainly die with artificial ventilation, judging by his condition. And two hours later, my grandfather died in the corridor ”(interview, pulmonologist, 52 years old, Ukraine).

On whose conscience is this death? Nature, for we are all mortal? A virus caused by which pneumonia may have accelerated this death? Bureaucrats who did not organize a sufficient number of equipped intensive care beds and did not train a sufficient number of specialists? A specific doctor who made a choice between two patients applying for a ventilator? Relatives of the patient himself, who, despite the obvious collapse of the healthcare system, “shoved” the old man into the hospital “to certain death”?

Ideally, this is a question between the doctor and the patient or his responsible representative. But it works when there is a high level of professional ethics and reputation in the medical community. In reality, the head, the insurance company and the investigator breathe in the back of the head of the doctor, reduced to the status of a municipal official. There is no moral or professional choice for them. Moreover, they are “obligated” to ask for violation of instructions, not for death or life.

A doctor sometimes works in two registers – in the corporate, when he is under the control of the administration, and in the informal, when his main interest is to save the patient, for whom he, for some reason (financial, related, reputational), was personally responsible. It is precisely this split personality that is associated with the various strategies recorded during research in Russia, Belarus, Ukraine, and even in Georgia, which doctors practice in an informal and formal, even conditionally formal status. Patients feel this: after a meeting with a doctor in an official space, they are sure to seek informal consultation, sometimes from the same specialist, only in a different setting. And doctors play these different roles, easily moving from the jurisdiction of the prosecutor’s office to the jurisdiction of Hippocrates.

I will retell a conversation-consultation with a doctor professionally and responsibly engaged in private counseling and routing of patients with coronavirus pneumonia in one of the regional centers in the eastern part of the country:

Question: Our patient is 62 years old, type 2 diabetes mellitus, temperature 38–39 for the last five days, saturation 87 in the prone position. Hospitalization was denied due to negative PCR test. Recommend us a protocol for taking anticoagulants and dexamethasone, and how to control blood sugar in such a situation?

Answer: Dexamethasone and low molecular weight heparin should not be used on an outpatient basis, especially in diabetes. Hospitalization required.

Question: Hospitalization was denied, the patient is deteriorating critically. If we buy an oxygen concentrator, glucometer and pulse oximeter, we will monitor sugar and saturation by the clock. We will try, as far as possible, to donate blood for clinical and biochemical analyzes from home [in medical institutions at that moment the blood test was not done promptly even to hospitalized patients] and will we inject dexamethasone and clexane? What blood sugar should we consider critical?

Answer: All this can be done only in the conditions of hospitalization in the intensive care unit of the “covid hospital” (from a conversation between the author and a doctor, man, born in 1974).

As a result, the patient had to be treated on an outpatient basis; his daughter, who did not have a medical education, took all responsibility for the appointment of intensive care. She bought an oxygen concentrator through Avito from a retired ambulance doctor, traveled to all pharmacies in the city in search of dexamethasone and an analogue of clexane (she bought the last packages), monitored the preservation of the pron-position, sugar and saturation. And she did it. And the doctor, who gave advice by phone as a representative of the system, also went to treat his patients with hormones, low molecular weight heparin and oxygen at home.

The ambulance team, which they managed to call “through Moscow” for another patient (the regional services did not accept calls, but managed to get through to 112. The dispatcher, after explaining the symptoms, connected to the region, the car was in half an hour), could not hospitalize the patient, an X-ray was taken , gave a certificate and refused inpatient treatment: “There are no beds, no oxygen, he will be better at home.” Prescribed ceftriaxone, klacid, arbidol, influenza, paracetamol with fever and chest collection No. 4. According to the 7th or 8th recommendation of the Ministry of Health in force at that time.

Experts say: “after this epidemic of coronavirus, we will have a very big problem with the resistance of pathogenic flora to antibiotics, because people, firstly, drink everything on an outpatient basis. When they get sick, they just start taking it on their own … They don’t understand that the virus cannot be treated with antibiotics … Now this ceftriaxone and levofloxacin are drugs that have been lost for many, many years “(Surgeon of the highest category, woman, born 1971).

When asked why all patients with a presumably viral infection are prescribed strong antibiotics, local doctors and ambulance doctors either do not answer anything, or they honestly say that this is the instruction and they do not want to be held liable either to the insurance company or to the prosecutor’s office. In an informal conversation about the effectiveness of such treatment, 80% of doctors will answer the same: “Antibiotics for viral pneumonia are not indicated, their appointment” for prevention “is illiterate, arbidol is a drug from the category of” fuflomycins “, its effectiveness has not been scientifically confirmed.”

“I see how my colleagues, three months ago, the smartest people, they turned off the brain and … follow the patient’s logic, they inject everything that falls into their hands – these are people who three months ago gave lectures on how we need to do evidence-based medicine. [The process is controlled] by some bloggers with large subscriptions, some foreign, local articles, and so on … ”(male, doctor, born in 1985, Moscow). During a pandemic, an ordinary civilian doctor in the status of an ordinary employee finds himself in a situation similar to the position of a military surgeon at the “Pirogov” sorting of the wounded, when he has to choose who to save lives and who to let die. And the civil doctor is forced to make this professional and moral choice, knowing that a bureaucratic and police hunt is open for him. If in 2016 878 criminal cases were opened against doctors, then in 2018 there were already 2229.

System collapse 

At the federal level, the political leadership adequately responded to the epidemic – by mobilizing beds, rewarding medical workers for working with covid patients, purchasing resuscitation equipment, and involving private medicine in the fight against the pandemic. All of these decisions involve allocating decent budgets. Already on April 8, at a meeting with the heads of regions, Vladimir Putin announced the allocation of 33 billion rubles from the federal budget for the deployment of additional equipped beds in hospitals, 13 billion for the purchase of medical equipment, including ventilators, more than 10 billion rubles for additional payments to doctors: 80 thousand rubles each per month for doctors, 50 thousand rubles for nurses, 25 thousand rubles for orderlies, 50 thousand for ambulance doctors, 25 thousand for paramedics and drivers. According to the estimates of “Project”, as of July 29, federal and regional budgets signed contracts worth 210 billion rubles.

All this sounded and looked good as long as it remained at the level of political decisions of the federal center and wealthy Moscow.

In almost all regions, “red zones” were organized in covid hospitals with doctors in anti-plague suits. The Moscow Mayor’s Office spent 250 billion rubles on the fight against the pandemic by the end of the summer. They launched the famous hospital in Kommunarka, where the President visited, reconstructed several hospitals, hooked up private traders, even put beds in shopping centers. Several dozen CT centers in the capital were engaged in sorting patients according to the degree of lung damage.

But already at the next level of routine work, everything turned out to be much worse. The lack of qualified personnel in a system in which medical work has been replaced by paperwork for the past 20 years cannot be corrected by any mobilization billions. Back in early 2010, while working in pilot regions to switch to single-channel financing, we analyzed the state of medicine in remote regions of Western Siberia. The central district hospital, a fund holder, according to documents payable for treated cases, exposes about 600 operations a year – as in the 1980s and 1990s. Only, for example, in 1995 at least 60% of these operations were abdominal (appendectomy, cholecystectomy, amputation, resection of the mammary gland, even resection of the stomach according to Billroth 1 or 2), and in 2010, with more than 80% of operations increased several times – minor surgery on the subcutaneous fatty tissue. There is no one to work, although according to the list of surgeons there are no fewer, the same five units (interview with the chief physician, male, born in 1959, and a comparative study of operating journals, Tomsk region, 2011).

Outside the regional centers, this situation was widespread. In large cities, of course, health care is better, but there are also not enough qualified personnel and equipped hospitals. The same specialists known throughout the city work in both the public and private sectors. And the opening, for example, of the FEFU multifunctional medical center on Russky Island was accompanied by the enticement of the best personnel from the regional and city health care of Primorye and Vladivostok.

The collapse began during the first wave, in April-May 2020. The most equipped and equipped hospitals were converted into covid hospitals in the regions. Of course, “It is easier and more convenient – to take and make a covid hospital in a ready-made hospital and take there the most severe patients from all over the city … if the infectious diseases hospital has only 6 beds in intensive care … and the veterans hospital [also redesigned for COVID] does not have trained personnel” (Surgeon of the highest category, woman, born in 1971). And a million residents lost an ambulance hospital and emergency vascular surgery. 

Not only regional medical centers, but also federal ones were reequipped for covid purposes. The preliminary list of 51 clinics, approved by the government on April 25, includes military hospitals, departmental hospitals and federal specialized

medical centers, including those focused on cardiovascular surgery, traumatology and orthopedics. You can add beds, there is nowhere to take doctors. This is a typical for Russian regions history of displacement of other functions by covid beds: “All surgery of the city [a large regional center in eastern Russia] was kept in our hospital, because we were on ambulance duty all days a week around the clock, every day … Can you imagine what happened when we became COVID … the only surgical clinic in the city fell out of work, the load fell on the regional and railway hospitals. They choke “(surgeon of the highest category, woman, born in 1971)

Infected patients appear not only in covid hospitals, but the staff works without protection and additional payments, doctors and nurses fall ill, entire departments and huge hospitals are quarantined. Or they don’t close, they just don’t feed data to keep working.

“COVID is everywhere that is hiding. … The regional hospital submits data that no one fell ill with them – neither the staff, nor patients with COVID – and in our hospital there are married couples of their doctors, patients come to the red zone of the dynasty … from the regional hospital, from the city hospital, from the Institute of Orthopedics , from the medical unit, from the railway, all the hospitals in the city are on fire … And when we left for COVID, after a while we realized that it’s easier for us than everyone else – we work in defense, but they don’t, they pay us money, but they no ”(surgeon of the highest category, woman, born in 1971). Often doctors have no choice but to go to work in the red zone. Because in the regions “the volume of work and, consequently, the financing of medical institutions is falling by at least 50 percent, because all planned hospitalization is being stopped … Some hospitals are closed due to covid outbreaks” (head of regional health, male, born 1970) … They close, open and close again. “There will be very grave consequences in terms of financing and the survival of medical institutions … They suspended medical examinations, and this is a certain profitable part, stopped all medical examinations, and this is also a profitable part. Some of the staff are trying to go to the private system. Some go nowhere ”(head of regional health care, man, born in 1970). As soon as the head doctor asks a question about money, he becomes uncomfortable. In the past few years, regional health care has already been replaced by “inconvenient” professionals with bureaucrats. There are strong-willed and resourceful leaders who are trying to save their teams. For example, in the same Primorsky Territory, as soon as planned hospitalization was banned, the head physician of the City Diagnostic Center forced his doctors to write an application for unpaid leave and go to work in a covid hospital. Accordingly, 14 people received their salaries (and federal bonuses) ”” (head of the regional health department, male, born in 1970).

With covid allowances, an interesting experience is obtained – before, outside of Moscow, doctors did not see such money, but thanks to COVID-19, they realized how much their work could cost.

“Now we are just shocked how we will continue to live. … We now earn somewhere 250 thousand a month … we now understand that for us this work is much easier than what we did before. And they pay 6 times more for it ”(surgeon of the highest category, woman, born in 1971).

But not many doctors work in the red zone. The rest of the regions went to Moscow in teams, because there is work there. Some part of the medical staff went from Ukraine and Belarus to Poland. But much of this professional migration is yet to come if European countries begin to strengthen their health systems. 

In Russia, neurosurgeons, traumatologists, and cardiologists, in order to survive, went to “covid hospitals” to fill out medical records in anti-plague suits.

“I survived for two days (in the red zone) and returned to the emergency room … because I drowned in the papers that I need to fill out … for 16 hours of work I did not master them … The second point – … no need to watch whether the treatment works or does not work – you spank the protocol, and smart people have already thought about what to treat ”(doctor, man, born in 1985, Moscow).

Doctors are unnecessarily afraid to work in a covid hospital “not because we do not know whether we will get sick or not … the question is that when everything is over, they will come to judge us, the Investigative Committee will start twisting its hands, (not according to how they were treated) , but by the way the pieces of paper are written. And everyone understands this ”(doctor, man, born in 1985, Moscow).

Due to the distortion of statistics, we will never know whether this mobilization was able to significantly reduce mortality from complications in coronavirus pneumonia and how many people died due to the lack of care for other pathologies. But even logistically, the system collapsed.

At the beginning of the first wave, due to the propaganda and readiness of administrators for various reasons, including the promised money, it is easy to give beds for coronavirus patients, there was a boom in unmotivated hospitalizations. On television, they showed queues of ambulances in Moscow, there was a collapse in St. Petersburg, Dagestan and some other regions.

“Then they put everyone in a row … just so that people would not be hysterical, to take bunks. They also said that there was a direct command to keep the hospital beds occupied … at the very beginning of this declared pandemic, more than 50% were patients who did not need hospitalization ”(doctor, woman, born 1979, Dagestan).

But the real collapse in most regions came in October-November 2020, when the number of patients in need of resuscitation exceeded the capacity of regional healthcare.

Experts in both Russia and Ukraine said back in April that an extensive increase in bed capacity and general hospitalization without educational work, the introduction of adequate outpatient protocols and the organization of effective triage would lead to the fact that beds would be occupied, doctors would run out, and the number of patients would continue grow (interviews with doctors from Moscow, Kiev, Vladivostok).

The collapse left two scenarios for patients. The first is open. When, for any reason, a patient with an oxygen saturation even less than 90 is denied hospitalization. One of the common options is a negative PCR test. If we take into account that there is a noticeable (from 20 to 40) percentage of false negative results when testing, then this is something like biological discrimination. Moreover, the doctor who makes the verdict, in most cases, understands this perfectly, but cannot violate the instructions. 

Or, more honestly, they explain that hospitalization is only possible sedentary (and in some regions in October-November 2020 it was a harsh truth), that the hospital has no oxygen and there is not enough staff, and that the patient is better off being treated at home. In the corruption market, the cost of hospitalization in some regions was estimated at one million rubles.

The second scenario is very dangerous for people in serious condition. You are hospitalized, but the bed is not equipped with oxygen, there are no qualified personnel. You are dying in the hospital. The magnitude of latent collapse varies by country and region.

Other manifestations of the collapse of the system are interruptions in the supply of drugs and oxygen concentrators, the active release of “fuflomycins” on the market – drugs that are quite expensive, the effectiveness of which has not been proven, but there are direct or indirect recommendations for their appointment from the Ministry of Health.

Rush demand and the introduction of a unified drug labeling system in Russia, which worked with failures, led to a shortage of medicines in pharmacies. It was during the second wave that the problem with oxygen came to the fore, and the state system was not completely solved either in Russia, or in Ukraine, or in Belarus.

Bureaucratization and centralization, appealed to in some expert studies, in Russia, Belarus (which adheres mainly to Russian recommendations) and Ukraine, for several months held back the use of effective treatment protocols in public health care, especially on an outpatient basis. In Russia before the publication of the 9th recommendation of the Ministry of Health in October 2020

anticoagulants and glucocorticosteroids could not be used “officially” in outpatient treatment, which unofficially relatives, on the basis of informal consultations with specialists working in public hospitals, saved serious patients even in the Dagestan villages.

The mobilization of Russian health care to fight the pandemic did not reveal anything new about the work of Russian officials and top managers of corporations with state purchases. The process is well documented and predictable.

Adaptation signs 

Already in the summer there were signs that the system was beginning to adapt to martial law, elements of triage appeared, a symbiosis of public and private medicine arose, by the fall, not only had been developed, but also began to spread to the outpatient link, effective treatment protocols had been reduced, and unmotivated hospitalizations had decreased.

The pandemic has given additional patients to private medicine, which has picked up the flow of non-coronavirus patients – their services have been drastically cut by public health. 

Planned surgeries and examinations in many regions were suspended, and since August, private clinics began to offer them for those who are able to pay. In most cases, these are, of course, federal medical networks, like Vladimir Yevtushenkov’s Medsi or Evgeny Shilov’s EMC. In Irkutsk, the Expert clinic expanded its activities. In all regions, blood tests could be done at a reasonable time only at Invitro or other private network laboratories. The same can be said about Ukraine or Georgia.

In addition, private medical companies were able, mainly in large metropolitan areas, to become part of the general system for treating covid patients. Back in late March, Medsi launched a full-fledged covid hospital with almost 500 beds in Otradnoye near Moscow, where up to 40% of patients were admitted through the compulsory medical insurance system, and the rest through voluntary medical insurance and for cash payments. In addition to Medsi, Moscow patients with coronavirus were treated by Medinvestgroup (K-31 and the clinic at 22 Akademika Pavlova Street) and the Lapino Clinical Hospital of the Mother and Child network. The Moscow tariff for the treatment of covid pneumonia is 200,000–205,000 rubles. Treatment with resuscitation and mechanical ventilation is more expensive – 1 million rubles or more. Even receiving up to 2 million rubles from paid patients, private clinics complain about losses. At the same time, there were no free places at the peak of morbidity in them, as well as in state hospitals.

Federal “covid” surcharges, payments for duty in the red zone and on covid calls made the labor migration of doctors to covid hospitals in regional centers and Moscow more economically feasible than connecting private clinics to compulsory medical insurance. But private medicine has proven particularly effective in bottlenecks such as triage and laboratory diagnostics. In St. Petersburg, where there were significantly fewer CT centers than in Moscow (where by mid-April there were already 47 CT centers organized by the city health care), specialists from Arkady Stolpner’s MIBS rapidly worked out the protocol for ranking covid pneumonia by the area of ​​lung injury and passed it through two of their sorting rooms. center with up to 400 patients per day, working 24/7 and covering 60–65% of the needs of the northern capital. Arkady Stolpner himself, in an interview with Elizaveta Osetinskaya, speaks of a significant influx of budget money into the market for MRI, CT and radiation therapy of cancer this year. Private laboratory networks – “Invitro”, “Gemotest”, “Helix”, have worked effectively in partnership with the state. They were attracted to work on government orders and both sides liked this experience, the heads of private laboratories hope that this cooperation will continue.

Another type of participation of private companies (and professional private initiative) in the fight against the pandemic, although it does not look large-scale, seems to be at least equally important. An example is Yegor Burdanov’s Medliner microenterprise in Irkutsk, who in “peacetime” worked as a physician coordinator accompanying a solvent patient in the maze of the global medical market. In the context of the collapse of the healthcare system, frightened patients naturally began to seek help from their consultant, whose main assets are reputation among the informal network of potential clients and the respect of the medical community for adequacy, reliability and professionalism. This challenge turns a private medical coordinator into a highly motivated healthcare organizer. During peak loads, Burdanov led up to 25 patients at the same time, organizing diagnostics, consultations, dragging oxygen concentrators from patient to patient, agreeing on hospitalization in a hospital in which the patient will be provided with qualified and responsible care.

A similar role was played by “familiar good doctors” who were taken out through instant messengers, forced to maintain permanent advisory pages on Facebook and organize Telegram channels. If someone did not have a network of patients and a reputation, it appeared. Because people needed expertise. But this is how society adapted, not the state, and this is the topic of the next article.

It is noteworthy that even the most advanced in terms of distance traveled from Soviet healthcare to conditionally European Georgia did not avoid the activation of informal networks that have arisen around good doctors, immigrants from the republic or just acquaintances living around the world. Their expertise helped to expose, firstly, the corporate collusion of insurance companies and clinics trying to save money on drugs. Secondly, there is a corruption conspiracy of bureaucrats who distribute budget money for the treatment of uninsured citizens and “their” private clinics.

If some adaptive decisions in the field of healthcare management are extrapolated to the possible direction of reforms, then in Russia as a result of the pandemic the importance of private medical networks and insurance companies will increase, they will rely on patrons from the political leadership and occupy an increasing share of the federal and regional CHI market, especially in parts of the VMP. Medicine will turn from state to corporate. This will optimize both management and costs, but will make healthcare the same business of the political elite, which is today the chain retail, the construction of infrastructure facilities, and the banking system. Changes in the leadership of the FFOMS, transfer of financing of federal medical institutions from regional MHIFs directly to the competence of the Ministry of Health, admitting and expanding the participation of large private medical networks and corporate clinics in the MHI program, consolidation of medical insurance organizations are only the first symptoms. We will wait for an increase in the presence in the healthcare market of such bison of public-private partnerships as Rotenbergs, Timchenko, Chemezov, Gref, etc.

Will this bring happiness to doctors and patients? To some, of course. A layer of privileged highly paid professionals and managers, a good level of services for the solvent Moscow, St. Petersburg and, for example, Sochi, public. The question is where the border will be between those who can qualify for modern treatment, and those who will be left with herbal collection number 4.

The text was prepared within the framework of the Reforum project. 

Denis Sokolov, publication of the Republic portal