A good friend of mine has lived for many years in the Czech Republic. In 2013, Phoebe was strolling down a busy street in Prague when she slipped on a patch of ice. In a split-second, every bone in her right ankle shattered. Had the accident happened in the U.S., Phoebe says, she might never have walked again. Instead — while it took many months of casts, canes and rehab — her ankle healed perfectly.
An ambulance had rushed Phoebe to the emergency room of General University Hospital, a massive brick edifice built by the Austro-Hungarian emperor Joseph II in the late 18th century, around the time of the French Revolution.
Joseph was a reform-minded monarch. He established a system that gave free health care to thousands of the poor in exchange for their donating their bodies to medical research in the event of death. German chancellor Otto von Bismarck expanded the principles of universal health care in the next century. He invented health insurance and social security. A pragmatist steeped in Enlightenment ideals, Bismarck believed that healthy workers with a financial stake in Germany's new industrial economy would be more productive. Health care must be regarded as a right, not a privilege, he argued, in any civilized society.
By 1900, state-subsidized health care was the norm in most European nations. Czechoslovakia's system became one of the best. That Czech citizens paid according to their ability made it affordable for all.
After World War II, the Soviets sickened the system by attempting to centralize it under Moscow's control, but not incurably. The Velvet Revolution in 1989 allowed the country to return to the basics, set forth in what the Czechs call their five pillars of health care. These emphasize equity through efficiencies derived from a decisionmaking process that is bottom-up, not top-down. They call this "self-administration."
Czechs are free to choose their own general practitioner (everyone must have one), and to consult with a specialist without a referral, as long as the health care is delivered in their own backyard. It's like neighborhood public schools in the U.S., with one key difference: The national government ensures that the quality of health care is excellent in each region. It is the law that everyone in the republic is entitled to the same level of care.
Czech doctors and hospitals don't have to compete to prove their competence. Money is awarded or withheld based on the medical results. The Czech system takes it as a given that the first priority of nurses and doctors — their calling, if you will — is not to get rich but to make sick people well.
After 1989, Western scientific advances were eagerly embraced in the Czech Republic. The CR's democratically elected leaders privatized and localized health care delivery. A predictable shakeout followed, as less-efficient insurance providers failed. Competition strengthened the surviving companies by rewarding sound practices over bells and whistles such as expensive tests, equipment and advertising campaigns. In the 1990s, the number of insurers shrank from 40-something to eight.
Beginning in 2005, the Czechs embarked on a new phase of modernization aimed at tightening controls on drug pricing and adding more doctors.
Phoebe was struck by the lack of paperwork required in her emergency admittance to General University Hospital. She was spared the intake ordeal that has become routine in American hospitals. No one mentioned insurance or made her sign privacy and malpractice related forms. "They didn't even ask to see my passport," she recalls.
She expected to spend hours parked in front of a flat-screen TV, as one might be in the States. Instead, a doctor was waiting for her when she arrived. In the corridor outside the emergency room he looked her in the eye and asked if she'd ever had a baby. Incredulous, she tartly replied, "Yeah, why?"
He grabbed the foot that dangled off jagged shards of exposed bone and pulled until the bones rearranged themselves, guided into place by the soft tissue still intact — muscle, ligaments, tendons and cartilage.
Then the doctor wrapped the leg to stabilize the bones and stop the bleeding as Phoebe was hastily readied for a surgery that was now all but an afterthought, the real "operation" having been initiated even as she was still in the wheelchair. All that remained was to cast the leg and attend to her general condition — blood pressure, fluid and pain levels, and the like. In less than an hour, she was dozing comfortably in her hospital bed, her ankle already well on its way to recovery.
Phoebe's awakening to the marvels of medicine, Czech-style, had only begun. She spent four nights in the fine old brick building that was almost as comforting as the pain meds. What impressed her were not the amenities, of which there were few in the American sense of the word. General University Hospital's website proudly states that it features 45 clinics, institutes and independent departments; 1,603 beds; and 4,549 employees, of which 703 are physicians and 35 pharmacists.
This no-frills summary speaks volumes about how the Czech health care system sets priorities — especially that reference to beds. Phoebe shared a large, sunny space — "ward" is the correct, if unfashionable, term — with six other patients. Each was recovering from an orthopedic event. The patients compared notes and traded advice, symptoms, sympathy. Visitors pulled up folding chairs or sat on the patients' beds and conversed with anyone who felt up to it. Those who didn't kept their bed curtains closed.
This arrangement, Phoebe says, stimulated the healing process. Misery loves company, after all. And with everyone sharing an open space, no one ever felt abandoned by busy staff.
A remarkable feature of General University Hospital that didn't make it onto its website is the architecture. Phoebe remembers that each morning a nurse would enter the ward and open the large windows to let in sunlight, the sounds of the bustling city and, best of all, great gusts of fresh air, which was then circulated by ceiling fans.
This exhilarating routine (patients were given extra blankets when it got chilly in the ward) had benefits beyond its uplifting emotional effect. Czech hospitals are not hermetically sealed against potential viral and bacterial threats. Instead they rely on nature to keep bugs at bay by pitting them against each other. It seems to work. Staph infections are far less common in the Czech Republic than they are here. Super bugs like MRSA are unheard of.
General University Hospital is not a luxury hotel. Czechs don't expect or even want it to be "fun" to be sick. This, too, is calculated, Phoebe says. "They want you out as soon as you're able. Hospitals are expensive."
The system can't afford private accommodations for every patient, or an MRI when an X-ray will suffice, as Phoebe learned on another visit to General University Hospital. She showed up desperately ill. Her symptoms pointed to a kidney stone, and an X-ray confirmed its location. Once her pain was brought under control, Phoebe was sent home with instructions to drink lots of water and wait for the stone to pass.
In lieu of the brand-new hospitals that are de rigueur in a consumer-driven system like ours, the Czechs boast the highest ratio of physicians to citizens in the world — 3.5 to 1,000. In the U.S., the ratio is one doc per 1,000 people. The CR's nursing numbers are even more impressive.
"The Czechs revere their medical providers," Phoebe says. Professional reputations carry more clout than marketing campaigns. There is no malpractice industry, because the Czechs know their doctors personally and trust their judgment. They accept that there's a degree of uncertainty in any medical treatment and do their homework up front to protect themselves from choosing an incompetent surgeon, for example. Those savings, too, are plowed back into caring for the sick.
Not only are indigents and retired seniors subsidized by the system, but so are foreign visitors like Phoebe. Dental care is also fully covered. That vaccinations are mandatory reflects the system's underlying premise that in matters of public health, individual freedom is subordinate to the general good.
Nevertheless, some Czech doctors have threatened to organize an exodus to countries like Germany that pay four times what Czech physicians make at home. Many young graduates clever enough to have mastered a second language as well as organic chemistry take their training elsewhere.
The pay problem has been exacerbated by an influx of dollars from abroad that raise the cost of living for all Czechs. Few Czechs are property owners. Rents have soared in Prague as its beauty and quality of life have attracted tourists and wealthy Europeans, who relocate there or buy second homes. Incomes of workers who cater to these newcomers, such as flight attendants and cabdrivers, have eclipsed those of workers living on fixed salaries set by the government.
Boosting physician pay to stem the exodus will raise the cost of Czechs' health care, which represents a mere 6.03 percent of GDP, far less than half its cost here in the U.S. The Czech government is determined to push back against the widening wealth gap that polarizes societies that are being shaped by global supply and demand with little government intrusion. But this may be a losing battle. Critics say the Czechs are developing a two-tier system. So far supplemental "private" insurance plans focus mainly on elective procedures like face-lifts and better-looking teeth.
But these aren't the procedures attracting more and more Americans with real health problems to Prague. The Czech Republic is one of the world's fastest-growing "medical tourism" destinations. The lure is efficient and affordable knee replacements, cancer treatment and much else.
Polls show that most physicians and nurses in the U.S. believe that the Affordable Care Act doesn't go nearly far enough. Better delivery models that emphasize continuity of care for "the whole patient" are being implemented by major plans like HealthPartners, with excellent results. But until we engage in reform that begins with an honest discussion about priorities and incentives — and what's really driving up the cost of health care — the current trickle of health care dollars to other countries will swell to a flood.
Simply because it's affordable, effective, efficient and available to all, health care, Czech-style, is on its way to becoming a growth industry.
Bonnie Blodgett is a writer in St. Paul. Reach her at bonnie@gardenletter.com.
