Questionnaire of Survey on Costs of Medical Manipulations and Funding of Medical Staff across the European Countries

Elīna Ozola1, Ronalds Mačuks1,2, Jekaterina Vasiljeva3, Inês Vasconcelos4, Tanja Nikolova5, Natasha Nikolova6, Sotir Nikolovski7, Ignacio Zapardiel8, Kamil Zalewski9, Sara Giovannoni10, George-Marios Makris11, Chene Gautier12, Patriciu Achimas-Cadariu13, Rene Laky14, Milena Mitrovic15 1Rigas Stradins University, Riga, Latvia 2Department of Gynecology, Latvian Oncology Center, Riga Eastern Clinical University Hospital, Riga, Latvia 3Department of Gynecology, Charite Clinic, Berlin, Germany 4Department of Gynecology, Berlin Breast Clinic, Berlin, Germany 5University Clinic of Obstetrics and Gynecology, Skopje, Macedonia 6Skopje Medical School, Skopje, Macedonia 7Department of Gynecology, Bitola clinical hospital, Bitola, Macedonia 8Gynecologic Oncology Unit, La Paz University Hospital, Madrid, Spain 9Gynecologic Oncology Depratment, Holycross Cancer Center, Warsaw, Poland 10Oncology Unit BPoliclinico Umberto I, La Sapienza University, Rome, Italy 11Gynecologic Oncologist, Ampelokipoi, Athens, Greece 12Department of Gynecology, Hospieces Civils de Lyon, France 13Gynecologic Oncology Unit , The Oncology Institute “Prof. Dr. Ion Chiricuţă” Cluj-Napoca, Romania 14Division of Gynecology, Medical University Graz, Austria 15Department of Gynecology and Obstetrics, Clinical Center of Serbia, Serbia


Introduction
The European Union clinical University hospitals are providing medical services according to today's quality standards; it also relates to the new member states of the European Union, however, there are significant differences in medical service payment by the state.
There are also some differences in the amount of the payment of medical services, also in ambulatory and hospitalization stage.
According to World Bank's assessment a number of new European Union member states are ranked as high-income countries alongside to old European member states, but the payment gap of medical services, between these EU member states, is very significant.
The survey was carried out to compare the differences of gynecological surgical manipulation costs, medical payments that are covered by state and salaries differences between Eastern and Western Europe countries.

Aim
To analyze the gynecological service payment covered by state, costs of different surgical gynecological manipulations and salaries across the European countries.

Methods
Questionnaire was established that included 14 questions about gynecology manipulation costs, state funded medical services and medical staff payment.The questionnaires were sent to 37 European countries.Thirteen questionnaires were received from Romania, Denmark, Greece, Macedonia, Spain, Austria, Germany, Italy, Serbia, Poland, the Netherlands, France and Latvia from which eight were considered to be adequately completed and five were not fully completed.

Limitations
During our research we did not receive questionnaire answers from 54% of the countries it was sent out to.This could be explained with many doctors being overworked and not having enough time for these types of questionnaires or by the fact that in countries where payment and medical costs are well covered by state this subject is not topical.Accuracy of these questionnaires may vary because there is no way of telling if the person is understating, overstating or telling the truth.This study was focused on payment covered by the state so it did not include information about bonuses (except academic degree bonus), additional work in private sectors and other income therefore it does not reflect physicians total salary.

Results
In most countries health insurance provides a complete health care package, only in Italy in order to get better service or if medical service is not emergency aid, you have to pay additionally.As well as health insurance in most countries is compulsory public insurance, but in some countries patients have the possibility to choose private or public insurance, such possibility is provided, for example, in Germany and France, but in the Netherlands only private companies provide insurance.
Insurance costs differ significantly in various countries, in some countries they are fixed, in other countries they are calculated as a percentage of income.In Denmark health care system is for free, but the taxes are above 50%, and if patient wants faster treatment, there is possibility to buy additional insurance from private insurance companies, so patient does not need to wait for an open time in the public free system.The highest insurance rate is in Germany and it is equal to 15.5% of revenues, followed by Poland with 9% and Romania with 5.5% of revenues, while in Latvia percentage is calculated based on Gross Domestic Product (GDP) and total tax revenues that are not fixed percentage value.Some countries specify the sum that has to be paid per year, the highest is in Serbia and it is equal to 1200 EUR per year, followed by Spain with 1000 EUR per year, followed by Greece with 800 EUR per year, followed by Macedonia, where annual insurance is equal to 200 EUR, and the lowest insurance is in France, where it is 100 EUR per year.
In six of surveyed countries, the patient has no possibility to choose health care institution for money provided by state or insurance company, the patient can choose services only in the specified hospital.However, in other surveyed countries the patient can choose, where he wants to get medical care and these services will be covered by compulsory public insurance or private companies` insurance.
Only in Netherland of surveyed countries payment for medical care in state hospital is specified for the patient with gynecologic cancer.In Latvia fixed sum is 7.5 EUR per night; this sum has to be paid by the patient, it is a co-payment, because State pays remaining 28.25 EUR per night.In Greece, the patient does not need to pay for stay in hospital; public insurance covers 60EUR per night for patients with malignant gynecological diseases.In Serbia, State pays 150 EUR per night for a patient staying in hospital.In the remaining surveyed countries, state average payment is equal to 60 -150 EUR per night.
In most surveyed countries, the patient with malignant gynecological disease does not have to pay medical costs, but in Latvia in such cases the patient has to pay 13.5 EUR per night, but State pays 38.25 EUR per night.Also in Macedonia the patient with malignant gynecological disease pays 10% of costs, for example, if maximum costs are 705 EUR, the patient pays 10 EUR per staying in hospital per night and maximum sum that has to be paid by the patient is 70 EUR per all period staying in hospital.Thus, State pays the remaining 90%; the maximum sum is 635 EUR.In Greece the patient with malignant gynecological disease does not have to pay for staying in hospital, because State pays for each patient staying in hospital in amount of 60 EUR per night.
In nine of surveyed countries, the patient do not need to pay for surgical manipulation costs, they are paid by State.But in Macedonia the patient has to pay 10% of surgical manipulation costs, payment varies from 12 EUR (dilation and curettage) to 70 EUR for simple hysterectomy with bilateral salpingo-oophorectomy.In Latvia, the patient has to pay fixed payment for surgical manipulation that is equal to 43 EUR.
In surveyed countries, surgeon does not receive percentage or fixed payment for the manipulations they have carried out.
In three of surveyed countries, state or insurance company does not cover the patient's out-patient consultations.In Denmark, Spain, Germany, Greece, Austria, Poland, the Netherlands and France, State pays all out-patient consultations costs.In Macedonia, State covers 25 EUR of out-patient costs, but in Latvia, State covers only 11.5 EUR of out-patient visits costs.
In all surveyed countries, patient costs for the first and further visits differ significantly, if the visit is related to the same gynecological disease.In six countries, visiting gynecologistoncologist, the patient does not need to pay for the first and further visits, if the patient comes to the physician with the same diagnosis.In Germany, costs depend on the procedure that had been carried out, thus consultation payment is 61.20 EUR, physical examination -21.45 EUR, ultrasonography -111.26EUR, etc.In Greece payment for the first visit is 5 EUR and for further visits with the same gynecological disease is the same price, similarly it is in Latvia, but cost is 4, 27 EUR for visits, and also in Greece, where payment for the first visit is 28 EUR and it is the same also for further visits.Although in Italy first visit cost is 23 EUR and further visit with the same gynecological disease is 18 EUR.And in Macedonia first visit is only for 2, 50 EUR and further visits are for free.
In 12 of surveyed countries, radiological costs are paid by State, but in Greece the patient has to pay for service additionally.
In all surveyed countries, monthly payment for 160 working hours (full time) is specified for physicians.
In surveyed countries, full-time wages differ significantly; the amount of monthly payment is shown in Figure 1.As the figure shows the highest wages of gynecologists' oncologists are in Western European countries, it can be equal to 4000 EUR.The lowest wages of physicians are in Eastern European countries.The lower incomes of physicians are in Macedonia, Romania and Latvia as shown in Figure 1.The data of salaries in figure are without any benefits and excluding the night shifts.
There is no specified premium in four of surveyed countries depending on the academic degree (for professor, assistant, etc.), but in most countries premium are specified (shown in Figure 2).As can be seen the highest premium are set in France, if the treating physician has professor`s degree.France followed by Poland and Italy.The lowest premium is set in Latvia and Macedonia.

ISSN: 2469-3138
To compare differences in gynecological surgical manipulation payment that is covered by state, survey included table with few of the most common surgical manipulations.These countries were divided in two groups -countries with well covered manipulation costs, which are Spain, Germany, Denmark and Italy and countries with poorly covered manipulations costs -Latvia, Romania, Macedonia, Poland and France.Table 1 shows average manipulations costs.

Discussion
According to the new classification of the World Bank the Baltic countries are in the category of the high-income countries (income above 12.746 $) [1], but data of our study do not support this statement.The income of Latvian physicians' is considerably lower than those calculated by the World Bank classification.
An Average income of a physician in the Baltic countries is 600 EUR (732 $) after the payment of taxes for one workload.Also, the income of physicians in Macedonia, Greece and other countries do not comply with the data published in the World Bank classification.
In order to become a physician one needs to continue developing skills and gaining new experience by visiting various conferences and congresses on regular basis.The average cost of attending conferences in a foreign country varies from 1000 to 2000 EUR.Thus in countries where a physician's income is around 600 EUR per month, they can only visit one or two conferences per year.That significantly decreases the possibility of improving their knowledge, and gaining experience from other countries` representatives.Also according to Piek J et al. [2], the educational climate between Western Europe countries and Eastern Europe countries did not differ significantly by region and is similar between Western or Eastern European countries.However, scores did differ by country income, with higher income countries having apparently better overall educational climates than middle-income European countries.
The state has to be responsible for providing an appropriate income to the physician practicing in this country so they have a possibility to improve their knowledge and skills.It is also a benefit for the country because it gets highly qualified and competitive specialists.
First of all, the state has to calculate physician's expenses related to a doctor's degree (accommodation, learning fee, transport costs, conferences, etc.) and secondly has to estimate their work and obtained remuneration.It should also create opportunities to continue improving one's skills during the practice period.
According to research conducted by Reginato E et al [3], that compared physicians` wages to an average income in the country, in most countries the physician's lowest wage is equal to an average wage in the country (Finland, France, Germany, Italy, Poland, Slovenia).However, in Belgium, Denmark, Italy, the Netherlands, the physician's average wage is higher than an average income in the country.However, in some countries, such as Latvia, Greece, Macedonia, Romania, the physician's wage is lower than average income in the country.Although the study of Reginato was conducted in 2011, this assumption has not changed.Also, today in Eastern European countries such as Greece, physicians' income is often lower than the average income in the country.
In Eastern European countries physicians' income is so low that physicians having obtained the education in their country often choose to work in another country, where they can get higher wages.It leads to a situation where the country at their own expense provides the education for professionals that choose to work in other countries.In this case the state does not receive their tax and do not get returned the invested funds.
Several tens of thousands of physicians and nurses from Romania [4] and Hungary [5] have gone to work in England to carry out their work and get higher wages in the last year.Similarly the representatives of the Baltic countries completing medical schools in their country go to work to other countries.Often professionals from the Baltic countries go to Germany or England, because of higher wages.A Research conducted by Michael Day [6] also confirms the high wages of a physician in England.The Research shows that in England physicians' average income per year is 150 000 EUR.
Not long ago in post-Soviet countries the following problem was common -informal payments [7]  indisputably caused low physician wages.Many patients would choose it as it was like a guarantee of the quality of provided service.For example, the new law, coming into effect in 2007 in Latvia, prohibits physicians to get any premium for providing services.Today wages have increased slightly, but without informal payments physicians income is not sufficient.

Conclusion
The purpose of this paper is to draw attention of public officials to physicians' wages in different European countries, taking into consideration that the quality of the service is similar.It is necessary to think how to approximate service costs to average wages in Europe.The increase of physicians` revenue will improve qualification, participating in international medical conferences, plenaries, congresses, etc., thus expanding the range of contacts and gaining new experience.
Other important fact is the possibility to stop physicians` emigration to countries where physicians` wages are higher.As well as to eliminate the situation when relatively poorest European countries at their own expense prepare professional physicians for countries where economic situation is at higher level.

Figure 1 :
Figure 1: Average wages for a full time job (160 h in a month) after

Table 1 :
or envelope wages" that Average premiums in different European countries for academic degree per month.Financial coverage of surgical manipulations from the governments across the European countries (*Western Europe countries -Spain, Germany, Denmark, Italy, France, **Eastern Europe countries -Latvia, Romania, Macedonia, Poland).