Monday, July 07, 2014

How the 2014 Budget can improve healthcare


Everyone has very high expectations from the new budget . Since one of the priorities for the budget is improving healthcare , I’d like to offer a suggestion which would fix a lot of problems which afflict our sick healthcare system today.

Most traditional approaches towards improving healthcare consist of spending more money on medical colleges to create more doctors; building more hospitals;  or on providing subsidies to make drugs and healthcare available to the poor.

While these universal health care policies and " health insurance schemes for all " look great on
paper , in reality they have been able to achieve very little . This is why a new scheme needs to be launched with great fanfare, every 4-5 years. However, like all the rest, it fizzles out . Sadly, the money is usually siphoned off , as a result of which very little trickles down to the poor patients.
The " fashionable " modification being actively promoted these days is PPP - Public-Private Partnerships, with the hope that these will improve sustainability, but I think these are doomed as well.

Part of the problem is that these grand projects are developed by health officials and senior doctors who live in ivory towers. They are out of touch with reality because the doctors who deliver the medical care on the ground and the patients for whom these schemes are designed are not involved in designing and implementing these schemes. Just providing more inputs will not help, unless the inputs are utilised more effectively by the end-users.

As Einstein pointed out – The definition of stupidity is to repeat the same actions and expect different outcomes.  Trying to subsidise healthcare has failed all over the world, but we seem to have learned precious little from the experience of the USA. The huge amounts they are spending on healthcare is progressively spiraling out of control, which is why they are now looking for disruptive and innovative solutions.

One problem is that we have always treated the fact that we don't have enough doctors to treat 1.2 billion Indians as a major bottleneck.  We confuse health care with medical care and believe that providing more hospital beds is a sign of delivering good healthcare . This is flawed thinking ! We should want to keep people out of hospitals – and full hospital beds are a useful metric only of an illness care system.

We need to reinvent the way we approach the problem . Patients are actually the largest untapped healthcare resource , and we need to explore options which give patients more voice, so that they can become active partners in the healthcare system

Can a healthcare system work well without doctors controlling it ? Just like war is too important to be left upto the generals, healthcare is too important to be left upto only the doctors. Now I am not saying we need bureaucratic meddling – this just makes matter worse. We need to learn to put patients first , and everything else will fall into place over time.

There are enough real life success stories which show this works well. An excellent example is the work done by David Werner , the author of the book, Where There is no Doctor. Just because there is no doctor does not mean people are not healthy ! Measuring the health of the community by using medical metrics such as number of doctors per 1000 citizens ; or the number of hospital beds in a community makes no sense. 

We need to take off our blinkers and stop thinking that we need to focus on doctors in order to provide effective healthcare solutions . While an optimal amount of doctors are essential, sometimes it’s the doctors themselves who create more problems. Senior doctors, who are often specialists , want to spend money on the latest medical toys and build 5 star hospitals for themselves , because they enjoy treating patients with complex and rare problems. They hijack the budget and create shining “centers of excellence” because of their personal prejudices. In any case, creating more doctors just seems to exacerbate the problem. Most doctors refuse to go to underserved areas ( where they are needed the most ). They flock to the large cities, and having too many doctors in a town just sets up competitive forces which end up in increasing healthcare costs !

So how do we put patients first ? The solution is surprisingly simple – empower them with Information Therapy. The problem is that this is such a simple and obvious solution, that it’s often overlooked completely.

Information Therapy – the right information for the right person at the right time – can be powerful medicine. Patients are increasingly going online these days, and thanks to the growing penetration of smartphones and the internet , the number of patients who are going to be able to access information if it is provided to them online will grow exponentially. The minister needs to think of clever ways of incentivizing doctors to proactively and routinely prescribe Information Therapy.

We know doctors are homo economicus and respond to incentives . In the USA, EMR adoption went through the roof only after Obamacare provided financial incentives to doctors to invest in EMRs.. One way the minister can encourage doctors to prescribe information is by providing doctors with a small financial carrot to publish their own websites , so that they could digitally prescribe information .
Here’s a simple suggestion – the Finance Minister can give a tax break of Rs.5000 for every doctor who publishes their own website.  This is easy to implement; and this simple intervention can help to catalyse a major change in the healthcare system.

It is my hypothesis that everyone will benefit as a result of this – doctors, patients, health insurers and the government. Let’s see how this would work.

A doctor’s personal website will result in: 

  • more patients . It’s much easier to find a doctor who is online, thanks to google !
  • improved patient satisfaction, because patients are happier when their doctor has educated them about their problem;
  • increased productivity , because a lot of patient queries and follow-ups can be done online, so the doctor can see more patients more efficiently;
  • better risk management , because the doctor can prove that patients were informed about possible risks and complications .

Once doctors see the positive impact of having a website on their practice, this will set up a virtuous cycle. Because doctors are competitive , they will start investing even more resources in order to ensure their website is better than that of their colleagues and competitors.

Patients would rather get their health information from a person they trust – their personal doctor. If they can access information 24/7 on his website, they would be able to trust him far more, because he is being open and transparent.

Well-informed patients are treated with much more respect by doctors. They would be able to push back when they are advised unnecessary medical tests and treatments. This will help to keep medical costs under control, and make sure health insurance companies can finance cost-effective healthcare services

The government could take the lead by providing authoritative, updated, reliable health information in local Indian languages on the Health Dept website. Doctors could link to this from their own website; and create even more personalized resources, by adapting and improving them.

This simple step would ensure that patients would no longer remain passive participants in their healthcare; and could actively help to heal the healthcare system.

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