The problems in healthcare are not from yesterday, but are the result of a financing model in which the number of patients becomes the main indicator for the work of medical institutions. The inspection at the University Hospital “St. George“ in Plovdiv and the signals of violations in the reporting of clinical pathways raised many questions – about the situation of young doctors and residents, the centralization of specializations, the need to strengthen pre-hospital care and prophylaxis, as well as legislative changes related to public procurement and the prices of expensive drugs. And what else… In front of Lili Marinkova in the “FACT“ studio and the show “Conversation“ Dr. Georgi Petrov, MP from “Progressive Bulgaria“ speaks.
– Dr. Petrov, first of all about the surprising inspection at the Plovdiv hospital “St. George“, the largest hospital in the country. It is striking that this is about long-term monitoring of some vicious scheme. This is very disturbing. What do you think?
– Yes, I heard very briefly part of the briefing that was given jointly by the Ministry of Health together with the Prosecutor's Office and the Ministry of Interior. Indeed, some of the things that I managed to hear are quite worrying. We are talking about a scheme that has been working, I think, since 2021, for more than five years.
And what I heard, without being able to be precise about the figures, is about 3 million euros, which are suspected of draining money from the health fund through effective hospitalizations.
This is really quite alarming information. When I get to know it in detail, we will be able to comment on it, but I don't remember there being such a thing as an action recently, or at least as information that was released officially.
If we are talking about the action of the services for combating organized crime, it seems to be extremely aggressive, radical. Before that, there was no possibility in the system to create a more detailed idea of what was going on.
Now I assume that in order to resort to such a serious showy action, there is most likely quite serious evidence for this. And when we talk about draining and fictitious pathways, it is very important to make a very clear distinction here between when we have hyperdiagnosis, when some clinical pathways are exaggerated, when we are talking about absolutely fictitious patients, that is, people who never set foot in the hospital at all, people who are only in the hospital on documents. Usually these are even healthy people. This is really something that is a crime by law and we cannot remain indifferent to the disclosure of such schemes.
– Do you think about all these levels of control that exist in the system and that should be activated in a similar situation?
– The healthcare system has been oriented a little more in a business direction since 2000, when hospitals became commercial companies. Even then, this bombshell was planted, which in my opinion will continue to explode.
It is about the fact that doctors were put in conditions to work for a standard, and we are talking about a quantitative standard, not a qualitative standard. And it was a matter of time over the years for this system to, roughly speaking, degenerate, because the healthcare system degenerated after these changes.
At one point, doctors literally became merchants who have to trade with the number of patients who passed through the relevant department.
And if morality and the Hippocratic oath are the main thing that should guide the doctor, and this certainly did a very good job in the first years, but going in this direction, the system changes you, because no matter how much you try to be moral, at some point you are forced by directors, by superiors to accept more patients. If you don't have patients, if you don't have enough clinical pathways, you can't earn your salaries and they almost tell you: either accept as many patients as you can, or you won't get paid. As far as I heard, in this particular case, the information that came out of the prosecutor is that there were doctors who didn't want to participate in this type of fictitious activity and received a salary of 1,000-1,500 euros. And others who actively participated received a salary of 6,000-7,000 euros. I'm reporting this unofficially, because I may not be accurate in the numbers. If you have morals and work according to the principle of morality, you can't earn the necessary income to be able to have some kind of standard and literally earn your salary. I say again, this is not from yesterday. This thing has been built, built, accumulated over the years. The system has been slowly changed, changed, to get to this point.
– Do you find it unpleasant that this is the hospital where you spent your internship as a junior doctor?
– I definitely find it unpleasant. I have a lot of colleagues and friends there. And this was quite unpleasant news for me as well. Of course, this is the largest hospital in Bulgaria. I think it has the largest funding from our state resources.
Of course, in this sense it is the largest both in terms of bed capacity in one place, but also in terms of money and funding, but there is no doubt that as it is the largest hospital, it is logical that it has the largest funding. The question is why it has been allowed to get to the point where this funding is not directed directly to the patients, because I know the facility quite well. One part of the facility has been renovated, but basically most of the wards purely visually do not have the necessary facilities. We are even talking purely hygienically and visually against the background of this money that goes to this hospital. I suppose that this has also given some direction to check why this is happening in this hospital.
– You have a very big commitment, a duty and perhaps a somewhat emerging sense of guilt towards young doctors, since according to them you included in your election program to settle the problem of their low pay, which is in some way a very humiliating step in the work of every novice doctor. And now we are beginning to remember the words of Toshko Yordanov in the previous health care committee, which became a mockery of the behavior of legislative circles towards young doctors. What can you suggest and what are your conversations with young doctors?
– I will start from the fact that when I started specializing in medicine, I was on a 700 leva salary. I know what it's like to be at the lowest level and what it's like to struggle to get to the point of getting a specialty.
– How much does a young doctor earn now? 800 euros or something like that?
– Right now, I think that for doctors, for residents, the basic salary is one thing, and what they receive is different. There is a big differentiation between different specialties. There are specialties where young doctors earn much more than specialists in other specialties with many years of experience. But let's start with where the problem comes from. The fact is that in Bulgaria, young doctors are used, they are exploited. Until you have a specialty, the state and the health system do not give you the opportunity to reach any resources, to achieve any real results, on the basis of which you can step forward and say: “I want more, because I work harder.“ Namely, these mechanisms have been invented again over the years, imposed with the aim of some bosses, directors, people who have power, to use these people as unskilled workers. We have even often joked as young doctors that we are actually unskilled workers, and this thing, imposing itself over the years, distorts a doctor's idea of how he should behave with younger people. Continuity has been lost. In many clinics, there are doctors, bosses, who are well past retirement age, who in no way give the opportunity for someone young to take their place. They do not try to pass on to them, so to speak, a craft, because a large part of surgical specialties is a craft. And in these clinics, young doctors really feel desperate, they feel hopeless and accordingly, if they manage to fight back, then they have already taken this bad example and unfortunately this thing has a risk of becoming layered over the years and becoming a vicious practice.
– What do you plan to include in the next budget, if at all, at the level of negotiations with these young doctors who are invited to visit your committees again?
– Yes. In any case, the salaries of young doctors and especially of residents, because there are young doctors who already have a specialty and they, for the most part, manage to reach something more normal in terms of pay. But residents - one of the things that is being worked towards, and here I am glad that the Ministry of Health has also put a lot of effort into integrating this European program, in which for another 15 new residents, already 255 residents, it has been achieved that they receive 2 minimum wages above what they have as an assigned salary in the given hospital. This not only encourages and enables these doctors not to look for any alternative jobs, but to be able to really focus on training, but in addition, this measure also stimulates, encourages doctors in smaller settlements. Because these places are allocated for residents in smaller hospitals, in smaller settlements. According to one statistic that I read, in “Pirogov“ There are currently over 400 residents, which you can assume is not normal. Given that when I was there, they were releasing two places a year. There were no more than 20 residents in "Pirogov", and it was bigger than it is now, right? All doctors at the moment, young graduates, they want to come and specialize in the largest hospitals, in the most modern clinics, thinking that this is the best. And that's where this thing comes from, that when you have such a huge influx of young doctors, you can choose, respectively, you can bully them, as unfortunately is done in some clinics. However, when you go to a small town, to a hospital, where there is a shortage of doctors - and this is true - and you start specializing, there your mentors, your specialists, they will have the desire to teach you as quickly as possible, to make you good as quickly as possible, so that you can cancel them and they can rest a little more. And that's why I say that this centralization that has taken place in recent years is an absolute mistake. An absolute mistake, and a mistake in the management of specializations.
– Now there was a proposal that young doctors be engaged in hospitals and municipalities to pay for their training. At the same time, they would be obliged to specialize there. And there was a ferment, mainly among the young. How can they oblige me to go to work in Vidin, to go to work in Montana or somewhere in the Rhodope Mountains?
– I can tell you that my father worked in a village for two years on a distribution basis and the experience he gained there was invaluable when he went to specialize. And here we are not talking about having to go and move to live, but about going to help the system somewhere, gaining experience and when you already have some experience, then stepping in and starting to build on it. This was not very well received. Everyone wants to be in the most modern clinic, but in my opinion - as a doctor and from the experience I have gained - that in smaller hospitals you gain experience much faster, you learn much faster, you get much better treatment from specialists and the continuity is huge.
– What numbers should change in the budget for next year?
– The Ministry of Finance has not yet provided us with the draft budgets, the ideas in the private fund and the Ministry of Health, but I am very hopeful that what we have given as a request, namely to gradually turn attention from hospital to pre-hospital care, will be clearly advocated. Not only will we give more money to pre-hospital care financially, but we will also have specific measures and specific projects and changes in the laws that will help these funds, which will be given more, to be effectively spent on prevention and to be able to provide serious coverage for Bulgarian patients for preventive examinations. This way, we can catch many diseases at an early stage, which will save many from not reaching the hospital. But this trend cannot be reversed with one budget or one reform. If it were that easy, it would have already been done. It will be quite difficult and it should start from there, that the reform should be aimed at stimulating, encouraging, setting people up so that at the first symptoms they should seek out pre-hospital care, a personal doctor, a medical center, a specialist in pre-hospital care.
Because he can cure them with one procedure, with one medicine, with one diet, instead of them immediately going to the emergency department, being stuck on some expensive clinical path, because the doctor has to earn his salary and in this way we should stimulate more hospital care instead of pre-hospital care. That is, this is the direction that needs to be turned and for me it should start from, so to speak, re-education of the Bulgarian patient, that the first place for help is the personal doctor and pre-hospital care, not the emergency department.
– What happened to your work organizing auctions for these drugs that are the rarest, the most expensive?
– These are the first two initiatives that we took quite seriously by the health committee, which went through public discussions. Of course, there are conflicting opinions. Of course, the interests of some, let's call them lobbies, of some pharmaceutical companies, of some hospitals are affected, because we also included the fact that public procurement should be made for private hospitals, as well as state hospitals. We are aware that we will encounter resistance, but we are looking for equality.
– But are you continuing in this spirit?
– Not only are we continuing. This thing is about to be introduced through a committee this week or next, and, I hope, we have the assurance of our parliamentary group that this thing will also be introduced for first reading.
– What are the amendments...
– These are amendments and additions to the Law on Medicinal Products, on public procurement. Now it passes for public procurement, we are a secondary contractor there. We have submitted it to the relevant committee to submit it, but we are assured that this week or next it will be submitted and in fact this thing will happen and in the shortest possible time.
– List of what?
– The idea here is that the medicines, which are the expensive medicines, the high-cost medicines, which are on a positive medicine list, have not had central tenders for them so far. In fact, we will centralize the tender and try to renegotiate prices at the state level, that is, the state will become a negotiator in these tenders, and not, as has been left until now, for hospitals to be able to negotiate independently. And in fact, we discussed it last time. The overall idea is that when you negotiate for the entire country, the quantities, and in this case the Ministry, the health insurance fund, when they negotiate them, they negotiate for huge quantities and may be able to negotiate a better price. And when a single hospital negotiates for some small quantities, the law has given it the opportunity to choose whatever price it wants. And this is where these huge discrepancies in agreements came from. A medicine in one hospital costs 20 leva, in another it costs 200 leva. This thing will be avoided. Yes, it will not be a huge resource that will be saved, but it will be a reform that no one has ever started, undertaken, and it will be something that will create in Bulgarians a real feeling of equality, that things are starting to be done properly. The same goes for private hospitals and the tenders and public procurements that I mentioned.
– Will this come in within two weeks?
– I hope so, that is the assurance. Of course, things are a bit dynamic in an election campaign, but I hope we will respect this.
– Which ministry is preparing it?
– No, this is something that was prepared by the health commission, on our initiative. So we have the approval, of course, of the ministry with this project of ours. They absolutely support us. Last year, in November, a penal procedure was actually initiated, in which we face a fairly serious fine if we do not do this. Of course, the first motive is that it is unequal, that it is unfair, and this is the main reason for us to introduce it. And the second is that, so to speak, we will kill two birds with one stone, hopefully without fines.
See more of the conversation in the VIDEO.