Hungarians Bribing Doctors Increases Health Spending (Update1)
By Alex Kuli
Aug. 28 (Bloomberg) — For Magdolna Vincze, free health care was never so expensive.
When giving birth to her second son in 2004, her payroll contributions into the state insurance system weren’t enough to guarantee the medical care she needed, she said. So Vincze did what she said is expected of patients: She bribed staff at Budapest’s Szent Margit hospital more than 100,000 forint ($522), about a month’s take-home pay for the average Hungarian.
“Everyone knows it’s unethical,” says Vincze, a 34-year-old telephone company worker. “People feel pressured. They’re afraid they won’t get personal attention, the doctor won’t even look at them, the nurses won’t go into the room, they won’t tell them about the newest treatments.”
Hungarians grew up giving communist-era doctors what they call “gratitude money” to secure comforts not provided by the state. Hungarians now pay doctors as much as 100 billion for int under the table a year, Health Minister Agnes Horvath says. The practice inflates Hungary’s health budget as doctors prescribe unnecessary procedures in hopes of maximizing illicit income, she says.
The debate over bribery comes as the government proposes changes to the way health care is funded and paid for. Medical spending affects the country’s battle against the European Union’s widest budget deficit, which reached 9.2 percent of gross domestic product last year.
The shortfall forced Hungary to abandon plans to adopt the euro as its currency by 2010. Overspending on health alone last year was equivalent to about 2 percent of GDP, according to the Health Ministry’s Web site.
Acceptable, But Unfair
About 60 percent of Hungarians consider medical bribery acceptable, though nearly all of them say it’s unfair, according to an opinion survey published July 24 by Median, a private Budapest polling agency. More than a third would ban it, the poll showed.
Horvath’s measures to fight bribery include a 300-forint fee for doctor’s visits, which used to be free. Patients who pay a fee are less likely to slip cash to the doctor, she said.
Ferenc Odor, a member of the main opposition party, Fidesz, instructed hospitals July 31 to post Horvath’s picture on machines where patients pay the fee, according to a party Web site.
“People should know who to thank,” the statement said.
Horvath’s party, the Free Democrats’ Alliance, responded by asking Odor to provide patients with bribery envelopes bearing a picture of Fidesz leader Viktor Orban.
Stay Awhile
Some doctors prescribe unnecessary hospital stays because overnight patients are more likely to hand out cash, Horvath said. Slightly more than 2 percent of surgeries were performed on an outpatient basis in Hungary in 2004, compared with 53 percent in Britain and 48 percent in the Netherlands, according to the Health Ministry’s Web site.
Doctors hate taking cash and prescribing unnecessary treatments, says Geza Gyenes, chief secretary at the Hungarian Doctor’s Chamber. The problem is, doctors are underpaid, with some earning a base pay near minimum wage, he said.
“An assistant bricklayer gets paid better than a doctor,” Gyenes says. “If we didn’t have gratitude money, not one doctor would have stayed in this country” after communism collapsed, he said.
Still, many doctors are well paid, and bribes exacerbate income differences, says Finance Minister Janos Veres.
“Who gets the most gratitude money? The professor at the clinic, whose income isn’t low,” Veres says. “Who gets the least? The coroner in the mortuary, even though his salary is low.”
Commonplace
Medical bribery remains commonplace in the east 17 years after communism collapsed, former Dutch Health Minister Hans Hoogervorst, who served as an adviser to Hungary’s health ministry earlier this year, said at a June 14 press conference.
Latvian President Valdis Zatlers, a surgeon, told the Diena newspaper in May that he’d received under-the-table gifts from patients during his 27-year career. He didn’t specify when, or how much he’d received. He was fined 250 lati ($495) in July in connection with an incomplete tax declaration, state revenue service spokeswoman Agnete Busta said.
The city of Budapest, which owns Szent Margit and other hospitals, doesn’t have the wherewithal to eliminate gratuities, Deputy Mayor Csaba Horvath said July 20.
“It’s impossible to change a 40- to 50-year-old practice from one day to the next, that’s why banning it wouldn’t be effective on its own,” says Horvath, who is no relation to the health minister.
Options
Criminalizing the practice will only drive it underground, Health Minister Horvath says. Instead, the ministry has implemented rules to ensure patients don’t bribe their way to the front of a waiting list, she said.
In June, she awarded 3.3 billion forint to institutions to build outpatient surgery facilities. Hospitals can save an estimated 814 million forint a year by not requiring patients to stay overnight for certain operations, Horvath said at an Aug. 9 press conference.
Hungary’s program to overhaul health insurance may help to eliminate bribes, says Mihaly Kokeny, a member of Parliament who heads the Health Committee. By 2009, the state will break its single health insurer into several funds with minority private ownership. The funds will choose which hospitals they’ll contract with and may stay away from the ones they deem corrupt, he says.
Competition between providers has eliminated coercive tipping in other formerly communist industries, such as gas stations, said Zsombor Kovacsy, president of the Hungarian Health Insurance Supervisory Authority.
“Without gratitude money, they filled your car with petrol, but didn’t clean it at all,” he said in a May 21 interview. “Now, I never give gratitude money to the petrol station guys, and they do everything. So I think that the mentality of competition and well-regulated procedures can help a lot.”
Polling data shows that Slovakia discouraged bribery after it introduced visit fees similar to Hungary’s in 2003, said Tomas Szalay, a partner at the Health Policy Institute in Bratislava, Slovakia.
Patients “pay cash and feel that it isn’t for free,” he says. “Why should they give something more?”
To contact the reporter on this story: Alex Kuli in Budapest at akuli@bloomberg.net
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