07.25.09

THOUGHTS FROM AFAR

Posted in Personality, Contributors, CBT, Stress, Anxiety, Depression, Uncategorized at 2:41 am by admin

THOUGHTS FROM AFAR

I know almost noting about he American health system. But I am an Israeli, UK educated physician working in management dealing with mental health care reform.

So here is my twopenneth of thoughts.

I do know that no one buys a pig in the poke. Today’s medicine is expensive, incoherent and economically unsound. These conditions make a ‘tax led’ expansion nigh on impossible. 

I think that we should consider what can be done and how?

The driving force for change may be political. But change has to encompass both delivery and payment.

I will develop a theme that states basically that costs and delivery can and must be altered before payment can be tackled.

Payment is pivotal in the making of universality.

REFORM:

There is no such thing as reform in medicine. There are far too many vested interests, preconceived ideas and established practices.

To make life easy lets call the involved parties shareholders.

Shareholders must want change. The change has to be as a constructive evolution and not a threatening revolution.

There can only be small, graduated and, hopefully coordinated incremental changes.

All reform has to have both a strategy and tactics.

Each change must be seen as being beneficial to most and detrimental to none.

In other words every shareholder must see some befit before he will take some risk. The benefit must be tangible and the risk less than such. It cannot be the opposite.

DESIRES:

What do we want to do?

Most encouragingly all the shareholders agree about what they want and do not want.

They want comprehensive, coherent professional care.

They do not want to have their economic status threatened. The user does want affordable health care. The industry member wants to maintain their income level. 

So far so good.

So let’s take the first step that is accepted by all.

Lets just save money.

FISCAL PRUUDENCE:

 We’ll examine but two issues.

 

  1. Litigation:

    The cost of insurance coverage is enormous.

    We could offer an alternative coverage. The choice would be of the individual but the premium would be affected accordingly.

    We would need to set up a State Quality Monitoring Board[SQMB]. The SQMB initially would have the following powers:

    1. Arbitrate in all litigation concerning mal-praxis.
    2. Set maximum sums to be paid according to misdemeanor.
    3. Set and monitor accepted practices in utilization of ancillary medical diagnostic services.

  2. Reduced expenses:

    On signing to being in a program that is under the aegis’s of the SQMB the premium could be reduced if the patient also agrees to:

    1. Wherever possible, as the treatment of choice, use generic medications.
    2. That all laboratory services would be done in accordance with absolute, medical needs. Put bluntly, not because I may get sued or it would be nice to have the tests but because I need this test to do good medicine.

If we get this far, and we can, we will see savings.

So we can move to the next step.

EFFICIENCY:

Medicine is a system of services. More often than not the patient is not doing what he should. Quite often he is doing what he should not be doing, or could be doing it somewhere else cheaper.

As a rule of thumb the patient:

 

  1. Should know what he is to do.
  2. Be followed up to ensure that he is doing, as he should.

This means evolving a system of care that has a case manager.

This involves profound conceptually and structural changes in the delivery of medicine. 

As the patient is liable to have many needs his medical needs are holistic and should be dealt with at the community or primary care level.

The care manager should know:

 

  1. What is needed?
  2. Where is it best done?
  3. Has it indeed been done?

This means several things:

 

  1. We resort to the idea of the centrality of the Family Doctor.
  2. A nurse does the case working.
  3. Case management is a ‘medically based decision’. It is not fiscal. It is an essential part of an efficient delivery.

  4. Cases are managed at the level of the family Doctor.

    1. Referrals and recommendations are from and to him alone.
    2. The ‘specialist’ is redesignated  as a ‘consultant’.   

For this stage to work effectively the Family Doctor Practice should be reasonably large so that it can negotiate with experts and providers in the field. THE FAMILY DOCTOR IS THE TEAM LEADER .

The enlarged family practice should subscribe to the SQMB.

The setting up of the family practices would be the corner stone of health reform

I would consider favorably:

 

  1. That subscription to a practice would be:

    1. Per annum at a fixed fee with a basic health basket [Number of visits, hospitalization days, lab costs] per family.
    2. FFS above the basic basket. This aspect would be monitored and authorized by the SQMB.
  2. That the SQMB would offer assistance in negotiating between the Family Practices and between both insurers and other health providers [hospitals, labs and etc.]

IN THE FULLNESS OF TIME THE ENLARGED FAMILY PRACTICE WOULD BECOME THE CORDINATING BODY IN CHARGE OF THE PATIENTS COMPRHENSIVE NEEDS.

In other words we now have three well-delineated bodies:

 

  1. The professional hub – based firmly on the Enlarged Family Practice
  2. The administrative hub- based firmly on the state based SQMB.
  3. Payments – Private and non-private insurers.

UNIVERSALITY:

Only when medicine has been rationalized can it become universal. We cannot expect the State to foot the bill when the medicine is neither rational nor cheap. Medicine has to become professionally and fiscally rational. Only then can further decisions be made.

This decision is UNVERSALITY OF SERVICE.

The decision is twofold:

 

  1. Political.

  2. Fiscal:

    1. What is the State paying for?

      By my proposals the Sate would know what are the expenses involved.

    2. How does the State pay?

      This decision is purely fiscal. Medicine, as such, has no part in this discussion.

    3. How will the State know that I got what it paid for?

      By setting up and developing the SQMB we have the basis for an answer.

Universality has a temporal dimension. The SQMB should also be placed in charge of evaluating, developing and training professional man power so that future needs will be met.

In summary:

I suggest series of changes none of which threaten any one. A clear distinction should be made between means of payment and means of service. Limiting expenses in medicines, procedures and insurance coverage should initially reduce costs.  Service should be rationalized by developing in tandem the ‘Enlarged Family Practice’ and the ‘State Quality Monitoring Board’ [SQMB].

When costs and services have become coherent and rationalized the cost of universality of care and the political implications can begin.