Marie Pelcová is afraid. Since undergoing a mastectomy after she was diagnosed with breast cancer two years ago, the 59-year-old retiree has been taking Arimidex, a costly drug that has helped her battle the disease.

Now she worries the medication will be harder to obtain and that her insurance provider — Všeobecná zdravotní pojišťovna (VZP) — might no longer cover it.

"If I had to pay for [Arimidex] myself, my pension wouldn't suffice," she said. "A one-month supply costs nearly 5,000 Kč [$200]."

Pelcová has good reason to be concerned: The Czech healthcare system is in crisis, staring at a massive deficit, and dealing with that shortfall could translate into significantly reduced care for the thousands of people who depend on it.

Recently appointed Health Minister David Rath plans to curb healthcare spending within the next few months in order to lower the deficit, including closing some small cancer clinics and hospitals around the country. Other hospitals across the country will need to limit their services by as much as 20 percent — bad news for people waiting for hip replacements and other elective surgeries.

But perhaps most worrying for patients like Pelcová is Rath's war on VZP, the country's biggest health insurer, which insured 6.5 million people in 2004. Rath blames poor financial management at VZP — some estimates put the insurer's deficit at 15 billion Kč — as the largest contributor to the current crisis in the healthcare system. He says the insurer has caused the entire system to plunge into financial shortfalls that only significant cost-cutting measures can now fix.

Rath's first move as health minister was to put VZP under forced state administration, a move that essentially places the Health Ministry in charge of the company. Rath proposes, among other things, to limit the prescription of costly drugs to save money, and under this pressure VZP could begin to cut back on how much it covers such drugs in favor of cheaper, generic ones.

But as Rath says targeting VZP will solve the country's healthcare woes, experts say the Health Ministry, with just months to go before the next general election, has made VZP a scapegoat in an effort to deflect attention from bigger, structural problems within the Czech healthcare system.

Care vs. cost cutting

Medications swallow up about a quarter of the state's healthcare budget, and Rath argues that doctors over-prescribe expensive drugs covered by VZP when they could have prescribed cheaper, generic ones.

Some experts worry that if doctors feel they are under pressure to prescribe cheaper drugs, they may not tell patients that other more expensive options exist.

But not all drugs are replaceable, especially when it comes to cancer treatments for people like Pelcová, health experts say.

Pelcová has tried Tamoxifen, a similar, less expensive drug than Arimidex. It made her feel ill, she said.

Cost cutting, Rath said in a recent press statement, is "not a measure that will affect patients."

But is it really possible to sustain high-quality care and save millions of crowns at the same time?

Many doctors are skeptical.

"Every reform aimed at curbing healthcare spending will inevitably have some sort of impact on patients," said Jiří Vorlíček, president of the Czech Oncologic Association. "And it will necessarily affect some patients more than others."

Luboš Olejár, president of the Patients' Union, an organization that aims to promote patients' rights, is even more critical of the cost-saving measures.

"It's a very unfortunate solution that won't resolve anything at all," he said.

Decisions for hospitals

According to Olejár, hospital directors will now be in a difficult position: On the one hand, they will need to comply and limit their services as the Health Ministry dictates or they run the risk of not being paid by VZP. And on the other hand they must still try to offer the best service possible to their patients.

"So far we haven't limited our services, but it may come to that beginning next year," said Leoš Heger, director of the Teaching Hospital in Hradec Králové. The hospital, he says, will get only 2 percent more funding than last year from the state when it needs at least another 4 percent.

"We might need to fire a few people," he said. "We might also need to start turning away patients that come to us from outside our region."

Another measure aimed at saving money will be to limit the number of cancer centers across the Czech Republic.

Cancer treatments that require high-tech equipment, such as the linear accelerator used for radiation therapy, are very expensive. According to the Health Ministry, limiting the number of centers will not only save money but also lead to better quality care.

And some oncologists agree. "It's unsustainable to have 200 different [cancer] centers in this country," said Vorlíček. "Centralizing cancer care is a worldwide trend."

But many cancer patients worry that a sparser network of centers will mean long, costly commutes to clinics in unfamiliar cities.

"For me, traveling to a remote center wouldn't be a huge problem," said Soňa Novotná, 44, a nurse who was diagnosed with breast cancer six years ago. "But I know patients for whom commuting would be a big discomfort. Just imagine: traveling all day to a treatment and back when you're feeling weak and ill from chemotherapy."

Václav Pecha, head doctor at a private oncology clinic that specializes in breast and gastrointestinal cancer at the DTC Praha center, can see her point.

Pecha's clinic treats 40 women daily on average. Each year it admits 1,000 new patients. Pecha, who is a former cancer patient himself, has been treating breast cancer since 1978.

"For cancer patients, a well-established support network is very important. Suddenly having to transfer to a bigger clinic from a more familiar environment could have an adverse effect on some people," he said. "What's more, the big state-run clinics wouldn't be able to handle a sudden influx of patients from the smaller centers."

But because the clinic at DTC is relatively small and doesn't have all the necessary equipment on site, it might not fulfill all the requirements that the Health Ministry will set and use to determine which centers will stay open. Pecha fears his center may be shut down.

No overnight solution

Most doctors say the Health Ministry's proposed cost-saving measures are just a flimsy bandage that Rath has hastily applied to an ailing healthcare system.

"All of these changes are only superficial. What Czech health care needs is a massive reform," said Tomáš Cikrt, executive head of Czech Health Media.

According to Cikrt, it's farcical that Rath is suddenly pushing to save money. When he was president of the Czech Medical Chamber, he never proposed cost-saving initiatives, Cikrt said.