Imagine if your inpatients had to wait two weeks to undergo MRI scans, and individual laboratory tests were capped each month at 15 per outpatient. That's the current situation for physicians and their patients in Greece, where the debt crisis that began in 2010, culminating in the current bailout discussions and austerity measures, has placed the nation's health care delivery system on the brink of collapse.
Health care spending in Greece has dropped annually since 2009, driven by a steep reduction in public outlay as part of government efforts to reduce the large budgetary deficit. Greece experienced double-digit percentage reductions in health expenditures in both 2010 and 2012, leaving the overall level around 25 per cent below its peak in 2008. And physicians and their patients are feeling the pain.
Neurology Today spoke to neurologists practicing in Greece to learn more about how the economic crisis has affected their professional lives and patient care.
THE ‘BRAIN DRAIN’
There are about 940 neurologists and 240 neurology residents currently practicing in Greece, according to Konstantinos Vadikolias, MD, PhD, an associate professor of neurology at Democritus University of Thrace and president of the Hellenic Neurologic Society. And many of the challenges they face pre-date the current economic woes.
For one, there was a steady “brain drain” of physicians even before the financial crisis, affecting many of the nation's medical students. Antonis Kerasnoudis, MD, PhD, was one of them. In 2008, he faced a five- to six-year waiting list for a neurology residency training program opening. There was no exam or other mechanism to distinguish himself to move up the list, he said, adding: “The doctors simply resigned and went abroad.”
He left to train at the University of Bochum in Germany. He subsequently returned in 2014 for family reasons, practicing his subspecialty of neuromuscular ultrasound and immune-mediated neuropathies.
Many physicians elect to stay in Germany and other European Union (EU) nations. A July 1 New York Times article, “Pressed by Debt Crisis, Doctors Leave Greece in Droves,” reported that approximately 3,500 doctors have left Greece to practice medicine in Germany alone.
Dr. Kerasnoudis, who is a supervisor of an outpatient ward at St. Luke's Hospital in Thessaloniki and maintains a private neurology practice, explained that normally every Greek citizen is covered by civil insurance, and is required to pay a contribution unless they are on social welfare. (Those who were financially well off had historically purchased private insurance, as well.)
In the past, most hospitals in Greece paid little attention to finances; people were treated, but there was little effort to bill for inpatient or outpatient services, said Nikolaos Scarmeas, MD, an associate professor of neurology at Columbia University who specializes in aging and dementia. Dr. Scarmeas, who went to medical school in his native Greece but left to do his neurology residency at Columbia, is very familiar with the country's health care system. “Even if you were a tourist visiting Greece and suffered an accident, you would get full care and your private insurance would not be billed,” he said. Moreover, he added, citizens were lax in paying their premium contributions to health care and enforcement was nonexistent.
That has all changed, but now there is a 27 percent general unemployment rate and a 50 percent youth unemployment rate, the highest in the EU. Typically, insurance pays 75 percent of medication costs and 80 percent of testing charges. The demand is so great and waiting lists are so long for the public system that people with elective problems such as headache, dizziness, or ataxia cannot be seen for three to four months, Dr. Kerasnoudis said. “Another problem for the unemployed is that they are often unable to pay the balance for diagnostic tests or their treatments unless they can borrow money.”
Neurologists face tight controls on ordering diagnostic services. “I can order a CT for dementia, but not an MRI, and I can order an x-ray for low back pain, but not an MRI, unless there is sensory loss or paresis,” Dr. Kerasnoudis said. Recently, he saw a patient who experienced a rapid onset of memory loss, prompting his suspicion that there might be a cerebral mass, but he was only able to justify a CT scan. Stretching the rules by citing a gait disturbance, he was ultimately able to get approval for an MRI, which revealed a glioblastoma.
There are also limits on treatments. “Civil health insurance has a low budget, requiring us to limit medication cost to 100 euros per patient per month,” Dr. Kerasnoudis noted. If those limits are exceeded, the ordering physician faces sanctions (monetary fines run between 500 and 5,000 euros) and potential legal problems, even risking their medical license, he reported.
That means he cannot write multiple prescriptions at the same time, he said. “It also puts me in the position of trying to find a low-cost drug, such as amitriptyline rather than gabapentin or pregabalin for neuropathic pain, for example, and to rely on a cost reference list that changes every two to three months.”
Patients are required to cover 25 percent of generic drug costs, Dr. Kerasnoudis explained, as well as the difference between the cost of the generic and brand, if the latter is needed. Indeed, spending on drugs dropped by 32 percent since 2010. And the country owes international pharmaceutical companies 1.1 billion euros, according to the European Federation of Pharmaceutical Industries and Associations.
The drastic reductions in drug spending are the result of a series of governmental measures aimed at reducing the price of pharmaceuticals, as well as lower volumes due to costs shifting to consumers. According to a July 15 report in Forbes, “Greece Is on the Verge of a Health Catastrophe,” a drug shortage has already begun. Biologics have been unavailable for the ordinary citizen for quite some time, and it's now a question of time for generic medications and other commonly used drugs. Denmark's Novo Nordisk, the world's largest maker of insulin, suspended shipments of insulin to Greece in May 2010, and only resumed shipping after prices were raised. Some expensive treatments like IVIG and plasmapheresis are in short supply, neurologists told Neurology Today.
PUBLIC HEALTH UNDER STRAIN
People are visiting their doctors less frequently, even though there is no co-pay for primary care physician visits. Greece's 132 public hospitals had a budget of $735 million for the first four months of 2014. This year, the budget for the same time period was slashed to $50 million total.
Dr. Vadikolias said the number of patients in public hospitals is increasing, as Greeks are no longer able to pay for private care.
“The rising volume of patients in hospitals translates to better training,” said Konstantinos Charalambopoulos, MD, a third-year resident in neurology at a university hospital. But so too has it resulted in more burdensome administrative hassles with ever more forms to complete.
Along with the rise in use of public hospitals, there is a correspondingly significant drop in demand for private practice neurologists, Dr. Vadikolias noted. After June 29th, the day that the “banking capital controls” were activated with a 60 euro daily limit, this shift became even worse due to the shortage of cash, he added.
Christomos Bairactaris, MD, PhD, a private practitioner in Kastoria, a provincial town in Western Greece, has experienced a 30 percent drop in neurologic patients. “These patients try to get an appointment in the closest hospital's neurology department, but there are considerable delays, and this backlog, together with a shortage in diagnostic supplies and treatment, has degraded neurologic services.”
There are no neurologists left in some provincial hospitals, so there is the added hardship for those who lack the financial means to travel to cities with an operational neurology service, he explained.
There has been a significant reduction in neurologist income, said Dr. Vadikolias. Greek salaries in public health care were already lower than other EU countries, but since the beginning of the financial crisis, this has worsened. “For example, a doctor employed by a university and in a public hospital has typically seen a reduction of 10-20 percent of his university salary and a 30-70 percent reduction in his hospital salary,” he said.
Dimitris Artemis, MD, PhD, a Thessaloniki private practice neurologist who just returned from Germany in April of this year, said, “Two other factors negatively impacting physician take-home salary are the delays in Social Security payments to doctors, as well as extreme taxation.”
PATIENTS AT RISK
Many financially disadvantaged patients have reduced or ceased their medical treatments, according to Dr. Vadikolias and others. Noncompliance with treatment regimens is not a new phenomenon, but nowadays, a greater number of patients and caregivers cite economic distress as the reason for this behavior, he noted.
“Just yesterday, we saw a patient with epileptic seizures who had stopped her medications [because she could not afford them],” he said. “A 45-year old diabetic patient with a history of multiple strokes, who had stopped his diabetic treatments and aspirin, was transferred to us in a comatose state and died.”
Dr. Vadikolias also suspects, although the analysis has not been completed, that an increase in the number of cases of intracerebral hemorrhages in the EVROS-INTRA and EVROS-SAH registries is due to noncompliance with antihypertensive and antithrombotic medication.
There is a notable change in patient morale, said neurology resident Dr. Charalambopoulos. “Many patients are on edge and unforgiving,” resulting in poor doctor-patient relationships and a loss of trust and respect. “Due to lack of resources, residents are forced to work harder and longer and are therefore more prone to judgment errors and burnout,” he added.
The Hellenic Neurological Society (HNS) is trying to ease the training shortages. Every year, for the past four years, the HNS has awarded grants to four neurologists — two each at 16,000 euros and 8,000 euros — for training abroad. These funds enable trainees to take advantage of educational programs in the US and in other European countries. Now, there is a delay in next year's grants because of the “capital controls” and difficulties with bank transfers.
Over the last two years, educational courses, monthly seminars, and summer and winter educational programs were provided without charge to active members of HNS. The annual fees for the membership have been decreased to 30 euros, including the subscription for their official journal, Neurologia (www.jneurology.gr). HNS also pays annual fees to the European Academy of Neurology (EAN) in order to offer to its members the benefits of EAN e-subscription.
For more information about these and other programs, contact the HNS Secretariat by email at email@example.com.