Why doctors increasingly hide the existence of modern drugs from patients. – Has procurement always been structured this way? – What gives a hospital the status of an autonomous institution?

On New Year I gave myself a gift - a quadcopter with a video camera. Well, I think: it’s time to test the device in action, take pictures of the beautiful Istra forest, where Cancer Hospital No. 62 is located.

The adventures began as soon as a local resident approached me. The conversation went something like this:

What are you doing?
- Yes, I’m photographing your beauty. What places!
- Why take it off, the forest is the same everywhere. You better house take off our rich man.
- What is this?
- Well, the director of the hospital, there are no other rich people here.

Even then I could not imagine that the story would become a post about how a unique hospital became the domain of a single chief physician. I couldn’t get close to the house; I was barked at by two very large shepherd dogs. Well, okay, I’m not a real intelligence officer, I decided not to risk it. But it was possible to stop the unscrupulous active deforestation, which, according to documents on the fence, is being carried out by a certain “Society of Plastic and Reconstructive Oncology” (OPRO). The main activity of the company (registered at the address of cancer hospital No. 62) is logging! Agree a little strange...

Please note: the red line on the map indicates a section of forest that has already begun to be cut down for a new cottage community.

According to local residents, in order to obtain permission to cut down, someone first introduced a bark beetle into the forest. I don't think it's hard to guess who did it...

Well what can I say, friends? I googled it on the Internet and it turned out that Anatoly Nakhimovich Makhson and his close relatives have perceived City Oncology Hospital No. 62 as their patrimony since the 90s.

I’ll continue the investigation: where are Anatoly Nakhimovich and his beloved wife registered and living? The answer will be given by any site with databases of Muscovites. For example, this http://nomerorg.com/moskva/

If you type in Makhson Anatoly (you can try it yourself), we will see that a person with such initials is registered in an apartment in the village of Istra and in a cottage in the village of Stepanovskoye (next to the territory of hospital No. 62). Now let’s look at where Anatoly Nakhimovich’s wife officially lives?

The address is even more interesting: she lives in the “village of Gorbolnitsa No. 62.” Just a song! Everything around is collective farm, everything around is mine)

What is remarkable about the territory of hospital No. 62, the reader will ask me, why live there? I will be happy to answer!

The oncological hospital is located on the territory of an old noble estate, built in the 17th century and belonging to the Dolgoruky family. Machson himself actively praises the environmental advantages of its location in his interviews: "For recent years The unique oncology hospital began to look more like a sanatorium in appearance. This is an entire architectural ensemble that combines traditional classical style and modern high-tech. I never tire of admiring the forest park and the healing air on the territory.”

In general, almost every material about Makhson reveals in one way or another his passion “for the unique architectural ensemble of the 17th century.”

“Almost all of Anatoly Nakhimovich’s childhood is connected with Moscow Hospital No. 62, on the territory of which his family settled”- from here http://oncodome.narod.ru/Makhson/Makhson_2009.htm

And here it is very good and convex about family ties Makhson himself says: “And we encourage family ties. My parents worked here. My wife Valyusha works here - she’s in charge. computed tomography. Yes, Misha is my son sister, but he is a very good surgeon and computer expert. My deputy, a unique oncologist, Professor Nikolai Pavlovich Zabazny, has a daughter, son-in-law, and nephew working at the hospital. Is this bad?

It’s bad, Anatoly Nakhimovich, very bad, especially when all these family ties develop into a clan!

It turns out that with the permission of chief physician Antalya Mahson, residential cottages were built on the territory of the city oncology hospital No. 62, which may also have become the property of “daughters, sons-in-law, nephews.” They are marked with red rectangles on the map.

Now the entire hospital complex is a whole sanatorium-resort town with its own boiler room, treatment facilities, three apartment buildings where people close to the hospital administration live... Almost communism reigns here - they pay for electricity according to the tariffs of the medical institution. Complex, expensive and modern infrastructure complex, surrounded by beautiful forest. For which ordinary Muscovites paid (and continue to pay)! How can you not imagine yourself as the King of the Hill?

What surprises me is that everyone knows about everything, but chief physician City Hospital 62 refuses to leave his post and writes denunciations against the leadership of the Moscow Department of Health to the FSB and the Investigative Committee. Agree, the situation is not ordinary!

P.S. When this story just began, I had no idea what could be answered by Machson’s defenders, grateful patients, etc., who want him to run the hospital for life, and then hand over the reins to inheritance. The answer was suggested to me by one of the Istra residents: “Maybe, of course, he is a doctor from God, but he is also a decent bark beetle!”

I suggest that at least someone take an interest in these miracles in and around the hospital and answer a number of questions:

1. Who lives on the territory in their own houses and on what basis?
2. Who pays for utilities and at what rates?
3. What did Makhson officially declare of his income as the head of a large institution?
4. Why is there no publicly available information about the hospital’s procurement activities? Who does the hospital buy from? expensive medicines and other materials?
5. Or maybe Makhson is just a puppet in someone’s big game? And with his hands does a larger predatory fish “wage a fair fight”?

By the way, leave your insights in the comments! Although I’m not a conspiracy theorist, I think pharma may be involved here, and even big politics!

The authoritative Telegram channel Nezygar, which is suspected of being associated with the presidential administration, reported that Leonid Pechatnikov, in the recent past the Deputy Prime Minister of the Moscow government, who oversaw the social block, was under investigation. According to the channel, he is accused of embezzlement in the amount of 3.5 billion rubles. In addition, the mayor of the capital, Sergei Sobyanin, is already aware of the conflict that has arisen.

Actually, if the information is true, Pechatnikov became the second vice-mayor of the capital, risking joining Ulyukaev, Belykh and other “illustrious prisoners.” But if Luzhkov’s deputy Ryabinin did not work in the government for long and was quickly caught in a bribe, without having time to become completely part of the capital’s elite, then Leonid Pechatnikov is a completely different figure in scale.

He came to the first government of Sergei Sobyanin as head of the health department from the post of director of the European medical center. Therefore, he was known as a specialist in advanced, in the terms of the present time, medicine, that is, moving to self-sufficiency at the expense of the patient. Actually, it is with the name of Pechatnikov that the very controversial reform to optimize the capital’s healthcare is connected, built on reducing the number of doctors and merging (enlargement) medical institutions. This reform met strong condemnation both patients and doctors themselves. A prominent State Duma deputy and former social minister, Kalashnikov, compared it to genocide.

Leonid PechatnikovEvgeniy Samarin/RIA Novosti

Meanwhile, the activity of the “optimizer” was marked by his elevation to the rank of Deputy Prime Minister for social issues. And it must be said that for a very long time Leonid Mikhailovich was, as they like to say, absolutely Teflon, that is, the waves of scandals that arose around his name did not cause any harm to his career.

It began with the fact that his chosen successor as Moscow Minister of Health in urgently emigrated to Switzerland, smelling something fried. In a distant country he had a solid reserve airfield. But Pechatnikov behaved as if nothing had happened. However, the next minister Khripun did not show himself in any way. Doctors even began to remember with longing the times of Luzhkov’s minister, famous surgeon Seltsovsky.

Somehow, inopportunely, it turned out that introducing himself everywhere as a doctor medical sciences, Pechatnikov cannot document his high scientific achievements. In the end, the cornered doctor of science said that he had defended his dissertation in France, but there was no formal confirmation there either.

Meanwhile, signals were multiplying that not everything was in order in the sphere of capital medicine. The culmination was a public showdown between the vice mayor and the famous oncologist Anatoly Makhson, who accused the capital’s healthcare management of inflating the cost of purchasing drugs. There was even a figure for overpayments of almost 200 million rubles. Pechatnikov responded by accusing his opponent of economic abuse. In general, there was a lot of noise. But at the center of the showdown between medical husbands was the same “optimization,” which seemed especially egregious in the field of oncology.

Pechatnikov was also known for his unexpected support of the liberal Leonid Gozman, who compared the NKVD and the Gestapo. And when the KP journalist recalled that the Nazis made lampshades from the skin of Gozman’s ancestors, Pechatnikov said that he would no longer have anything to do with Komsomolskaya Pravda. However, he quickly came to his senses.

It must be said that when dismissing Pechatnikov after his next election, Mayor Sobyanin made a heartfelt speech about the merits of Leonid Mikhailovich and his irresistible desire to return to practical medicine. All decorum was observed. Although everyone understood that the emerging information about strange suppliers of the largest metropolitan hospitals registered in Cyprus and other offshore countries did not remain without some consequences. After all, among their official founders there were, for example, people from the same European Medical Center, which Pechatnikov headed for a long time.

Now, if you believe Nezygar, they could unwind the entire chain through which government billions went to offshore companies. We are waiting for details.

There is a picture circulating on social networks with a quote from Gogol’s “The Inspector General”: “We do not use expensive medicines. The man is simple: if he dies, then he will die anyway, if he recovers, then he will recover anyway.” The words of a classic almost two centuries ago are relevant again. In Russian hospitals, employees are given an unspoken instruction: not to chat. If new treatments for a disease or effective medicines are not included in the state guarantee program or the medical institution does not have the opportunity to provide them - they simply will not tell the patient about them. Doctors gloomily joke that as the list of shortages grows, saline and iodine will soon remain the most widely available. Lenta.ru tried to figure out how the lack of money in the healthcare system affects medical ethics.

Habit for the worst

Maya Sonina, Chairman charitable foundation"Oxygen", helping people with cystic fibrosis ( genetic disease, which destroys the lungs), assures that the conspiracy of silence has become commonplace. Mucus accumulates in the lungs of the foundation's residents. To prevent it from rotting, we need good antibiotics. In some cases, the course of treatment costs hundreds of thousands of rubles. Generics (analogues of original drugs) often do not help and cause complications, since they are often made from insufficiently purified raw materials.

In clinics, patients are prescribed imported cheap generics,” says Maya. - If doctors see that the medicine does not work and the patient’s respiratory functions are increasingly impaired, they do not care.

According to Sonina, at first people tried to complain, demand good drugs, then they reconciled:

The hospital administration intimidated them that if they wrote somewhere, they would not receive anything at all. This is what they tell patients: it’s difficult for everyone now, they should be happy with what they have. Doctors' salaries are small, there is a lot of work, and we won't waste time on you.

And they don't spend it. Oxygen receives many letters from “neglected” patients. Newly diagnosed cystic fibrosis patients simply do not know what treatment options exist.

We recently transported an 18-year-old boy from Rostov to Moscow. He was given antibiotics dating back to Soviet times, which were extremely ineffective in his situation. Brought to terrible condition. Now that my mother is in a federal clinic, she is surprised to read the list of prescribed medications. And she says that she didn’t even think that such pills existed.

Patients who need expensive treatment suffer the most from the “don’t talk” principle. For example, it is used to fight breast cancer modern drug Herceptin. The cost of a bottle in pharmacies is up to 80 thousand rubles.

For a certain type of oncology, Herceptin is mandatory, says the president of the association of cancer patients “Hello!” Irina Borovova. - Even when the patient has achieved remission, the drug must be taken for at least a year. Otherwise, the cancer almost always returns. Despite the fact that medicine is required to be purchased, there is not enough of it. In the regions, women are not even told about this drug. And if patients find out on their own, local oncologists convince them that this is unnecessary.

The less you know, the better you sleep

Doctors do not deny that they are forced to play a silent game: for disseminating “closed” information, management can reprimand or fire them. The patient or his relatives, having heard about the existence of a life-saving remedy, write to the prosecutor's office and demand that the Ministry of Health provide it free of charge.

The necessary medicine may even be included in the compulsory medical insurance state guarantee program, says oncologist from St. Petersburg Alexey Nikolaev (last name changed). - However, the hospital doesn’t have it - they didn’t buy it due to lack of money. Situations are different. It happens that a doctor looks at a patient and understands that there is no point in prescribing him an expensive treatment that the state will not provide and he himself is unlikely to be able to buy. That's why he doesn't talk about such possibilities. Or vice versa - the doctor sees that the patient can afford an expensive drug that is not available in the hospital, which means he can be recommended something. However, the doctor is still a “partisan”. Because the experienced one imagines: if he says so, the grateful patient will leave the office, get into an expensive car, take out an expensive phone and call: “Listen, Mikhalych! I was told that I had to purchase the medicine at my own expense. Why don’t you supply hospitals with them? What the hell is this?” The next day the head physician will call the doctor and scold him: “What are you doing? Such people come to you, and what do you offer them? The health committee called me about this. I'll punish you now. And in the future, if you have such patients, bring them to me.” So today the chief physician, by august decree, decides who is worthy of modern treatment and who is not.

According to Alexey, many in the medical community believe that the principle of dosing information is for the benefit of the patient: the less you know, the better you sleep. And few people think that keeping silent takes away a person’s chance of salvation. Medicine adapts to military field conditions.

The system is configured to medical practice adapt to your capabilities,” explains Lenta.ru’s interlocutor. - And they are now very limited. And when you cannot prescribe the optimal treatment, you convince yourself that it seems to be unnecessary. It seems so good. How long and how a person lives is no longer your concern. One compromise, another, and then you start recommending to people not what is done in the leading clinics in the world, but what you have. If furatsilin remains, they will treat it. Unfortunately, many of our doctors, and even entire hospitals, have already gone down this path.

Be like everyone else

Compared to the regions, Moscow remained an island of prosperity until recently. However, here, too, medical ethics have become somewhat distorted due to a shortage of funds. City Oncology Hospital No. 62, which the professional community and patients consider the best in the country, became a participant loud scandal related to medications. The clinic receives some of its chemotherapy drugs centrally; they are purchased by the city health department. But since there are not enough of them, the institution purchases some drugs on its own - using the funds it earns.

We had a patient who was not from Moscow,” says the head physician of the hospital, Anatoly Makhson. - We operated on him and treated him under the compulsory health insurance policy (CHI). But in Moscow, chemotherapy is not included in the compulsory medical insurance tariff, since the drugs for it are purchased by the city itself, that is, nonresidents must pay for it. Our patient agreed to this condition, but when he was told how much he had to pay for it, he grabbed his head and left: he was counted 90 thousand rubles. I was very surprised, because usually our cost for such a cycle of chemotherapy was about 30 thousand. They began to look into it - and it turned out that the hospital was now using a drug purchased by the Moscow Health Department. In the same dosage and from the same manufacturer, we purchased this medicine for 7.5 thousand rubles per bottle, and in the centralized supply it was already 25 thousand.

After this, the doctors, out of curiosity, analyzed other procurements within the department. We used open data from the website zakupki.gov.ru. The difference is shocking. In 2016, the city paid for a package of zoledronic acid from 4,135 to 17,125 rubles. The hospital purchased the same medicine in the same packaging for 1,019 rubles. The hospital got a package of 100 mg of Oxaliplatin for 859 rubles, and the city managed to buy the same medicine with prices ranging from 5,839 to 13,580 rubles per pack. From the end of 2014 to 2016, the cost of many domestic medicines, acquired through a city tender, increased 11 times!

We tried for ourselves, so we negotiated directly with manufacturers,” Anatoly Makhson explained the price metamorphoses to Lenta.ru. - Another secret: pharmaceutical companies agreed to give us big discounts on drugs that were about to expire. But our medicines did not remain unused and were quickly put into circulation.

City Clinical Hospital No. 62 sent the results of its “research” to the Moscow City Hall. There, apparently, guided by the “don’t talk” principle, since November they have deprived the clinic of the right to independently purchase drugs. Now the hospital will receive all medications at general principles- so that no one will be tempted to compare again. Moreover, rumors spread in the professional community that the hospital would be restructured, optimized, or even closed altogether.

However, the Moscow Department of Health resolutely denied these rumors. They told Lente.ru that there were no plans, much less administrative documents, to close Cancer Hospital No. 62. On the contrary, the department “plans to further strengthen and develop this clinic, which is rightfully considered one of the leading oncology clinics.”

Speaking at the city clinical-anatomical conference, Moscow Vice-Mayor for Social Affairs Leonid Pechatnikov devoted a separate speech to the situation in the oncology hospital. According to him, the transfer of the clinic to centralized procurement can in no way be considered malicious intent.

In 2015, in accordance with the law, we loaded inpatient care in oncology to the compulsory medical insurance system, knowing full well that the cost of treating cancer patients, to put it mildly, is not fully covered by these tariffs, explains Pechatnikov. - And then Anatoly Nakhimovich Makhson came to me with a proposal: for the period of such adaptation, as an experiment, transfer the hospital to the status autonomous institution. He argued this very clearly, and I thought it was reasonable. The autonomous institution, in particular, had the opportunity to purchase drugs not according to Federal Law No. 44, but according to Federal Law No. 223, that is, in fact, from a single supplier. He convinced me that he could negotiate with suppliers so that he could get the drugs cheaper. We made such an exception - it was the only hospital in Moscow; no other hospital working with cancer patients received such a privilege.

However, from January 1, 2017, according to Pechatnikov, Federal Law No. 223 ceases to apply in Moscow. The fact is that some enterprises abused the right to purchase from a single supplier and committed violations of financial discipline. And although there were never any complaints against Anatoly Makhson in this sense, the mayor decided to transfer all state unitary enterprises and autonomous institutions to procurement in accordance with Federal Law No. 44 in 2017. And this, according to the vice-mayor, means that the conditions of autonomy are becoming meaningless and even dangerous.

Pechatnikov explains the jumps in prices at the competition by bureaucratic conflicts, which have now been eliminated.

Until 2015, during centralized procurement of medicines, the initial maximum price was set to the minimum price registered with the Ministry of Health, explains the vice mayor. - But on January 12, 2015, all regions received a directive letter from the Ministry of Economy, which obligated them to set the maximum registered price so that absolutely all suppliers could take part in the auction. They took everything seriously, did it, and the prices of medicines really went up. But now we have returned to the method of determining the price that was before this letter. Even if there was no malicious intent in it, this stupidity, of course, was incredible.

Pechatnikov promises to carefully study the clinic’s experience in drug provision and adopt it.

We try to talk to our patients about how their cases are treated in the world,” continues Machson. - And not only talk, but also buy innovative drugs. We bought, for example, at the expense of the Beyodaym hospital. A course of treatment costs them about 2 million rubles. It helps young women with Her-positive breast cancer. If we use only Herceptin, which is available in government procurement today, we cure 40 percent of these patients. With the new drug - 75-80 percent. And most importantly, the medicine can be used during pregnancy. We bought this drug for 20 million. It's good if there is enough for everyone. And if not, how can a doctor choose? We had enough for now. I don’t know what to do next. Probably everything will be like everyone else.

According to Makhson's forecasts, Russian medicine everything will change only when the Minister of Health starts telling the truth, and not repeating that everything is great with us and will be even better.

How can everything be wonderful when the healthcare budget in Russia is 3.5 percent of GDP, and in developed countries - 8-16 percent? - he sums it up. - If there is no money, then the health insurance system needs to be changed. Modern one doesn't work.

Former head of staff of Mayor Sergei Sobyanin Anastasia Rakova will now oversee social direction in the renewed Moscow government. Previously, this post was held by Leonid Pechatnikov; his name does not appear in the current government.

Sobyanin, whose inauguration took place the day before, on September 18, announced this on his blog. The decree on personnel changes also appeared on the city hall website. “He [Pechatnikov] is a practical person, a wonderful doctor, and he didn’t quite like bureaucratic work, which he told me more than once. I am very grateful to him that he agreed, albeit with great difficulty and reluctance, but still agreed to work for some time in the Moscow government. Over the years, he has done a lot for the city's health care. We have gone through the most difficult and sometimes very painful, but necessary changes. As a result, the industry has become economically more stable and better motivated by clients,” wrote the capital’s mayor, clarifying that Pechatnikov’s resignation is also related to his transfer to another job. At the same time, Sobyanin hopes that Pechatnikov will remain “at least” his advisor.

Anastasia Rakova has headed the Moscow Mayor's Office since 2010. Before that, she worked in the Tyumen region together with Sergei Sobyanin, and also held the posts of Deputy Secretariat of the Head of the Administration of the President of Russia and Deputy Minister of Regional Development.

Leonid Pechatnikov is a graduate of the First medical institute them. THEM. Sechenov, he graduated from the university in 1979. Then in 1981 he completed his residency training in the specialty " internal diseases" Until 1994 he worked as the chief therapist of the Central Republican clinical hospital Ministry of Health of the RSFSR, and from 1994 to 2001 he served as chief therapist of the diagnostic and treatment association of the Ministry of Health Russian Federation, from where he moved to KGB No. 67 in Moscow as chief therapist. In 2004 he became president of the European Medical Center (EMC).

In 2010, Pechatnikov headed the Moscow Health Department, and two years later he moved to the social bloc of the Moscow government. In this post, he repeatedly found himself embroiled in various scandals - from the purchase of medical equipment and drugs to questions about the education of the vice mayor himself. The name of Pechatnikov is associated with the optimization of the Moscow healthcare system, which began in 2014 and was associated with large-scale layoffs of the capital’s doctors and the consolidation of medical institutions. Pechatnikov himself said that optimization “has been completed good performance”, and to the then head of the State Duma Committee on Health Protection, Sergei Kalashnikov, who called the reform “genocide”: “It makes no sense to comment on Kalashnikov’s statements. I found the answer to the deputy from Faina Georgievna Ranevskaya: “I blurted it out like a p****l in a puddle.”

At the end of 2016 - beginning of 2017, Leonid Pechatnikov took an active part in the high-profile conflict between the then chief physician of the Moscow City Oncology Hospital No. 62 (MGOB No. 62) Anatoly Makhson and the Department of Health. The department issued order No. 963 dated December 1, 2016, changing the status of MGB No. 62 from an autonomous to a budgetary institution. Then, by order of December 5, Anatoly Makhson was dismissed from the post of chief physician of the Moscow City Hospital No. 62.

Makhson made a statement to the FSB and the Investigative Committee with a request to check the purchases of the Moscow Health Department and bring officials to criminal liability if violations are identified. The statement cited examples of the department purchasing five oncological drugs and two units of medical equipment, the prices for which were inflated by 217.8 million rubles. Leonid Pechatnikov refuted Makhson’s arguments, tried to convict the hospital of illegal business and, in the end, announced that inspections of the procurement activities of the Health Department did not reveal any violations.

In 2017, representatives of the Dissernet community Vademecum said that they were unable to find the deputy mayor’s doctoral dissertation in the available sources. Representatives of the Central Scientific Research Center also failed to find her. medical library at the First Honey and All-Russian certification commission(VAK). The Department of Certification of Scientific and Scientific-Pedagogical Workers of the Ministry of Education and Science responded to Vademecum’s request that “there is no information about the award of the academic degree of Doctor of Medical Sciences to Leonid Mikhailovich Pechatnikov... in the department’s registration and accounting database.” In response, Leonid Pechatnikov said that he defended his doctoral dissertation in France, but his doctoral dissertation was also found in the databases of the Bibliographic Agency for higher education France, whose archives contain information about all scientific works defended in the republic.

The chief physician of the Moscow City Oncology Hospital N62, Anatoly Makhson, explained why, in his opinion, the Moscow authorities decided to optimize the capital’s most successful hospital and what consequences this will lead to for patients.

“The department buys at an inflated price”

What is the cause of the conflict between Hospital No. 62 and the Moscow Health Department?

The fact is that Moscow is trying to centralize all purchases under the pretext of saving budget funds. But in reality there is no saving. So that you understand, we have been an autonomous institution since 2014. Our only difference from a budget hospital is that we have more freedom for financial and economic activities, and we also conduct trade and procurement activities in accordance with Law 223. A budgetary organizations conduct trade and procurement activities in accordance with Federal Law 44 - there is complete control and centralization.

Before the transfer to compulsory medical insurance, the hospital had no problems at all. There was enough budget funding for almost everything. The patients did not buy anything from us, I say this responsibly. Muscovites did not pay for anything. Were paid services only for out-of-town patients. We conducted our own trading and purchasing activities. We bought what we needed, and we had enough for everything.

In 2015, the hospital was transferred to single-channel financing under compulsory medical insurance; the level began to fall, because much is not included in the compulsory medical insurance tariffs. There was significantly less money. In 2015, we treated 1 thousand more people (we still had a supply of medicines and supplies from 2014), and in 2015 we already earned 40% less than we received from the budget. By the end of 2016 it became impossible to work - they were running out consumables and medicines, money ran out. I know that in other Moscow hospitals it has long been like this: acute shortage medications, many consumables are missing, patients are told: buy this, buy that. We've never had this before. And now we are on the brink.

This year, consumables and medicines worth 590 million rubles were centrally purchased for us, but not everything was purchased - there will be a shortage. If they had given us the money, as it was before, we would have fully provided ourselves with everything we needed with these 590 million rubles. There are many disadvantages to centralized procurement. We cannot influence purchases, but we know better what drugs and consumables we need.

Why would you buy more drugs 590 million than the Department of Health at the auction?

Because the department buys at an inflated price. We learned about this last year. The hospital wrote a request for chemotherapy drugs, they are always purchased centrally. We wrote it in July. We were told that the application would be fully satisfied. But in November our truncated application was returned - the department (without agreement with the hospital) threw it out a whole series drugs that our hospital cannot live without. But the most important thing is that they not only revised our application. They also redrawn the application for the entire city under the DLO (additional drug supply) system, there were more than 5 billion rubles, and within this amount they increased the purchase of some drugs and did not buy others. I refused to sign our application. This is where it all started.

How did they explain the reduction in your application?

The main reason is lack of funds. And the result of such formation of the application is a critical shortage important drugs in hospitals and more than 3 thousand unsecured prescriptions only in the Northern and Northwestern districts of Moscow with a delay of up to 46 days (this is data for 10 months of 2016).

Well, since we had a conflict, we began to understand the situation. And it turned out that there are no budget savings with centralized procurement. That our hospital buys a whole range of drugs at two, three, four and even seven times cheaper than through centralized procurement.

You know, I have been working at this hospital since 1972, and for almost 27 years now I have been the chief physician. When I became the chief physician, we had nothing. There was no endoscopy, ultrasound, or monitors in the oncology hospital. We had two or three old X-ray machines. I don’t know how we worked. But they worked, and not badly. True, the mortality rate was 4.5%. At that time, we had 700 beds throughout the state, we treated a maximum of 5.5 thousand patients and performed 1,800 operations per year. And now - for comparison - we treat 15 thousand people in the hospital, 6.5 thousand operations per year, the mortality rate for many years does not exceed 0.7%. And in day hospital We are treating another 6 thousand patients. Many operations are not performed by anyone in the city except us. We have the only integrated 3D operating room in Russia. And we did it ourselves. Now we are no different from any good European clinic. We have three computer and two magnetic resonance imaging scanners, the only molecular biological laboratory in the city healthcare system, and much more.

And all this is thanks to autonomy?

Thanks to normal budget financing, the desire to work and autonomy, among other things, because autonomy makes it possible to lead economic activity independently, including purchasing medications and consumables. Over the years, we have formed a very strong team. By the way, the team chose me. Because the hospital was dying. And I had an idiot's dream - to work in normal conditions. And I did everything to create these conditions. I worked at the hospital for 17 years as a surgeon, headed the department for a year, then became the chief physician. He continued to operate. The hospital was home.

“Our task is to treat the sick, not to buy more expensive things”

Tell us how centralized purchasing works? Who determines the price?

The pharmacy department of the health department is responsible for the purchase of drugs. They own a central pharmacy warehouse, which supplies medicines to pharmacies and hospitals too.

The formation of initial prices for auctions begins at the registration price. The registration price of a drug is the price that the manufacturer declares when registering the drug on the market. And it is the maximum. At one time, the Ministry of Health came up with it as maximum price For this drug. During trading it should be reduced. Often, for many drugs, especially generics (drugs that are not original, reproduced under license), the cost has nothing to do with the registration price. They prescribe it, let’s say, 10–15 percent cheaper than the original drug. And the cost can be 30 times less. And if the seller set a price of 8 thousand, and the real cost is 300 rubles, then he may well sell for 4 thousand. And the customer then says: “The original price was eight, we bought it for four and saved half, we’re great.” And if the hospital buys it itself, according to Law 223, then we can buy more drugs at a lower price, because we are interested in it.

There was an auction this year where the drug anastrazole was sold. The total auction amount is 480 million rubles. How much do you think the price of the drug can fall at auction? She fell 27 times. The auction price was announced - 8 thousand rubles. per package. And in the end, the company won the auction at a price of 300 rubles. for a package or the entire lot - 18 million rubles.

Why such a high price for cheap drug originally?

The secret here is very simple. The auction is formed according to the international generic name- INN - “anastrazole”. And the price was set according to the cost of the original drug, which once cost just 8 thousand rubles. But now there are a lot of generics of anastrazole, and original drug by definition, cannot win the auction. So the generic won. And it happens that companies participating in the auction agree among themselves and reduce, for example, not to 300 rubles, but to 3 thousand. And they receive a colossal profit.

And how often does this happen?

Happens. There are very interesting auctions. Do you think it is possible to buy the same drug at different prices within one auction?

Probably not.

That's right, with a reasonable approach. But in practice it is possible. And this happens when the firms participating in the bidding come to an agreement. Here we had a case - we bought a generic at a price of 7.5 thousand rubles. per package, and then received the same generic from one auction at a price of 25.3 thousand rubles. And when they began to look into it, it turned out that four generics were purchased as part of one auction, with a cost ranging from 17.9 thousand to 26.7 thousand rubles. per package. This is exactly what happens: an auction is announced, the price is inflated, firms negotiate, and within one auction there are several generics with a wide range of prices.

How did you buy this generic for 7.5 thousand?

Just. We buy with our own money. Our task is to treat the sick, and not to buy more expensive things. We buy on our own, we announce the auction ourselves. As an autonomous institution, according to Law 223, we find a company, bargain, lower the price. Our auction prices drop slightly, but there is always competition. One time it was very interesting - we held an auction where the price dropped by 70% because two dealers fought. We bought more of the drug and paid less. All this is possible when there is no centralization. But if we become a budget hospital, all tenders will be according to the 44th Federal Law, and this is centralization, this high prices. We will no longer be able to influence anything. This means that we will receive less medicine, we will treat fewer people, and patients will be forced to buy what they should receive for free.

If you remember, Pechatnikov said that our hospital is not only the best in Moscow, but also the best in Russia. But nevertheless, he petitioned the mayor to transfer us to budgetary institution, in violation of the law. For what? Why improve if we are already the best?

Why in violation of the law?

Because according to the law, an autonomous institution main body- This is a supervisory board. It is formed according to the principle: one third is the owner of the property (health department), one third is representatives of the public, one third is representatives of the hospital (but not the hospital administration), one person is a representative of the Moscow property department. The Chairman of our supervisory board is Khripun, the Minister of Health of Moscow. Every year, the chief physician of the hospital (who is not a member of the supervisory board) makes a report on the results of the hospital’s work, reports on financial and economic activities, medical indicators, and so on. The Supervisory Board hears him and accepts or does not accept his report. Approves the plan of financial and economic activities for next year. And if something is not going well in the institution, the supervisory board can petition to change the type of institution - for example, from autonomous to budgetary. Our supervisory board did not meet whole year. Nobody listened to me. And we work well, every year we increase our throughput and maintain quality. So it turns out that our transfer to a budget institution is illegal. With the sole purpose of returning us to the centralized procurement system, after which it will be impossible to see their inefficiency.

Typically, centralization is needed to optimize costs.

Correct, but in this case this optimization is not in favor of hospitals and patients. With centralized procurement, you cannot predict when you will receive the drug or whether you will receive it at all. Because the actual delivery can begin in June, in August, and it happened that we were supplied with the drug in October.

That is, at the end of the year? What did you use for treatment all year?

Well, we treated ourselves through independent purchases. We were autonomous, and according to the law, an autonomous institution cannot have centralized procurement at all. And other Moscow hospitals in such a situation will be left without medicines.

“The larger the auction lot, the less competition”

So why then are you being deprived of your autonomy?

Here we come to the essence of the conflict. When we become like everyone else, there will be nothing to compare auction prices with. Everyone will buy at the same price. There will be no 62nd hospital, which bought four and sometimes seven times cheaper, and then showed this price to the whole world.

Here in my hospital there are two absolutely identical devices for pathological anatomy. I can show you the invoices. We bought one ourselves for 9 million rubles, we really needed it, and we decided to spend the money we earned from the hospital. But one was not enough, we have 150 thousand biopsies a year, all the devices are overloaded, and if one stops, it’s a disaster. And we ordered more. And we received the same device through the department, through centralized procurement, for 20 million rubles. We bought another device for this laboratory for 5 million rubles. and received exactly the same one through centralized procurement for 13 million rubles.

While we are an autonomous institution, we can buy three times cheaper. And when we become a budgetary institution, we will be bought at the prices of centralized procurement. From my point of view, this explains a lot.

In addition, there is something to interest the antimonopoly agency here. The larger the auction lot, the less competition. Imagine an auction for 500 million rubles. There will only be 50 million worth of security, very complex logistics. And it is precisely these auctions that the department conducts. That is, only very large companies can participate in this auction. All small companies they won't go there. The whole system is set up to kill competition and support monopolists. Our hospital had about 20 suppliers, we knew which of them was the most profitable to buy which drug. Now there will be no competition. Moscow officials are lobbying the interests of one or two companies. And the drug market is simply being destroyed.

Mayor Sobyanin has already signed a decree on transferring the hospital to the status of a budgetary institution, when will this actually happen?

We are still autonomous for now. We will become budgetary when we register the charter of a budgetary institution with the tax office, and then we will need to change a number of legal documents. These are colossal costs and colossal headache, because all the seals, all the forms, all the signs change.

What will happen to the hospital after the status change?

We will go back ten years in the treatment of patients. The hospital will not be able to carry out a whole series modern circuits chemotherapy that requires many days of continuous administration of the drug, which requires special consumables (which are not paid for under the compulsory medical insurance system). A whole range of diagnostic and therapeutic techniques will become inaccessible to our patients. If we were centrally supplied with everything we need, we wouldn’t mind. Do you think I want to buy? I want to provide modern treatment to our patients. And to provide it, I know how much and what I need. Centralized procurement is crazy for oncology. Every year new drugs, new methods and consumables for them appear, treatment regimens change, and the department wants us to submit applications one year in advance, but there have been attempts to make such applications 2-3 years in advance. How is this possible? The composition of patients is changing, and unpredictably. We had a queue at the gynecology department, suddenly for some reason it disappeared, but grew up in another department. A flexible approach is needed here. You can buy something simple centrally. For example, syringes, dressings.

Why are there not enough drugs in public hospitals today? For example, there is the drug bevacizumab. It is registered for many indications in oncology, normal drug, good. But the drug aflibercept appears on the market, which is twice as expensive as bevacizumab, has a similar mechanism of action, and is registered only for colorectal cancer in the second line of chemotherapy and only with the FOLFIRI regimen. And with centralized procurement they buy aflibercept. At the same time, it has been proven that it helps only with a certain chemotherapy regimen, which is actually done only here; it is quite complex, because it requires a two-day continuous administration of 5-fluorouracil. If this FOLFIRI regimen is not used, then the drug aflibercept has no advantage at all. But bevacizumab is bought in insufficient quantities, but they buy aflibercept for the whole of Moscow, despite the fact that it is twice as expensive and, in accordance with the indications and a clearly defined administration regimen, cannot be used practically anywhere.

Or another example: the drug cabazitaxel is purchased, good drug, used for cancer prostate gland, but very toxic, causing grade 4 neutropenia. Therefore, the consumption of the drug is minimal, it is used very little in clinics, and elderly patients tolerate it very poorly.

We are practically the only institution that uses it, so we use seven bottles a month. But in our clinic at the end of last year pharmacy kiosk there were 300 bottles of this drug. They will last us for four years, but the expiration date has already passed, and they bought more. It would seem, why did they buy us so much of this drug? And then, there is a manufacturer, and you need to buy from him. Do you understand? If you are interested, you can now go and look at the stock of this cabazitaxel, which has been centrally procured. It is impossible to use it up. I don’t know how they will write it off, but this medicine is worth hundreds of millions of rubles.

Why did they buy it?

It was necessary to buy from this company. And no one cares about how much the drug is needed.

The department accuses you of buying drugs with an expiration date.

Here I show a certificate for the control department of the presidential administration of the Russian Federation: the drug irinotecan. We bought in 2016 for 1023 rubles. per package, it has an expiration date of September 2018. And centrally we received the same drug with an expiration date until March 2019 - at a price of 5121 rubles. per package. But we used up this drug in 2016. What does expiration date have to do with it? It happened that in the summer of 2016 we bought a drug with an expiration date until March 2017. So it doesn’t last until the end of the year, we use everything. We ourselves know how much we need. We are not interested in overpaying or buying more than we can use.

The department also says that some drugs you buy are more expensive.

They show that someone bought antibodies for the immunohistology laboratory for 10 thousand rubles, and we for 35 thousand. But we buy 250 tests, since we have a very powerful laboratory, and it is profitable for us to buy a lot, we still buy them We'll use it up. And for 10 thousand they have 50 tests. Thus, one test purchased centrally with a total purchase of 10 thousand rubles turned out to be a third more expensive than one test purchased by us in a purchase of 35 thousand rubles. And most importantly, it would be normal if, with centralized procurement, prices were even 30% lower. This is normal, this is why centralized trading was invented. But the department does not explain why it centrally bought the same thing at two, four, and sometimes seven times more expensive. They are silent about this.

Your doctors say that the hospital is checked a lot and often. And now there is a new test. What are they looking for?

Previously, there were checks as checks. Many, different ones, but they checked and left; no significant violations were ever found. And now an unscheduled inspection has come from the Moscow Department of Health, the 18th one this year. And these inspectors have been sitting with us for a week, digging, destroying all the work. Every day 10–12 people come. Their task is to find something. They wanted to prove that we don’t change gloves for every dressing. The chief epidemiologist looked at how many dressings there were, then dumped all the used gloves on the floor and counted them. Everything coincided. He says: “This cannot be, you are prepared.” Their task is to find at least something. Every day the department holds a meeting to discuss who has dug up what.

There are two ways to resolve this conflict. You could sort out the procurement, restore order there and revoke the decision to transfer the hospital to budgetary status, or you could try to prove that the hospital was to blame for everything and that it was making noise unreasonably. Although the questions raised by the hospital concern the entire Moscow healthcare system. They chose the second path.

Interviewed by Olga Allenova and Rosa Tsvetkova