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Is High-Quality Public Medicine Possible?

The headline I’ve chosen for this article is a bit strange, as it focuses not on medicine, as such, but on healthcare. However, healthcare is so firmly associated with the «impassible» bureaucratic system, while I would like to focus on the content aspect – treatment and prevention which, as a matter of fact, people need.

Problems in healthcare are brewing. Everybody is worried about the modern healthcare system’s capability to provide the society (or at least its largest part) with high quality «medicine» (treatment and prevention) and the possibility of offering such medicine to citizens free of charge.

 

High quality medicine


Evidently, «High quality medicine» is a very capacious notion. We can evaluate it to a full extent relating to the aggregate health of all members of society and dynamics of its change during a sufficiently long period of time. Such «public medicine» consists of many rendered services. It is not necessarily that «high quality services» automatically result in «high quality medicine», while definitely «high quality medicine» is impossible without «high quality services».

How do we define «high quality services»?  Probably they are medical services which are well chosen, which provide maximally successful results, for an acceptable price, delivered in comfortable conditions. Each of these statements, considered individually, doesn’t seem to be an excessive requirement. Why all these components altogether represent an insoluble task? The healthcare minister of one well-off Central European states once said that «healthcare is a damned thing, it is no matter if the state is politically left or politically right». Where does all this bitterness and pessimism come from?

Let’s see, let’s inquire into the requirements which we consider to be basic for high quality «medicine».

«medical services which are well chosen»

Is this requirement impossible to fulfill? Nowadays, each region has modern diagnostic centers equipped with the world’s best models of diagnostic equipment.

«which provide maximally successful results»

Authorities interetedly take healthcare management agencies under constant control; and healthcare agencies – healthcare ministries, public health departments, city health administrations – are vigilant against medical facilities, the quality of medical care, and require more and more new achievements in figures and quality annually. These figures improve year by year (though often just by «one tenth of a percent»). Any deviation from the established indices becomes an emergency, a subject of serious investigation with a follow-up dismissal of a whole management vertical up to the minister.

«for an acceptable price»

And this is where we start stumbling… Where does the «PRICE» come from? We have free healthcare, don’t we? Alas, it’s not free anymore… OK then, «paid» healthcare. But is the price acceptable?  Nobody can tell! Has anyone studied this problem!  Well, price formation of private medicine is more or less understandable (I’m not writing «for example, in dental care», because two subsystems of healthcare – dentistry and first aid significantly stand out of the field, but it’s a separate topic). The situation with so-called «paid», «self-sustaining» services is worse – they are available, but their principle of cost formation is at least non-transparent.

What makes the price for a medical service acceptable? Obviously, adherence to the following two factors – accessibility to majority of the population and certain compliance with «publicly acceptable» expenditures on the service.  This means the issue of the price «acceptability» remains open.

In this case we don’t appeal to the laws which guarantee «free healthcare». It would be good if the public healthcare offered (again, public means accessible by the majority) an «acceptable» price!

«delivered in comfortable conditions»

And here we’ve reached the part about which we have nothing to say. Because comfortable conditions in our country are provided in «elite» medicine, and by no means in public healthcare.

 

Healthcare is an industry!


So what should we do? Should we put up with the low quality of public healthcare? Or develop elite medicine by putting on it a certain «social rent»? Is it possible to find a key that would solve all the problems in a single stroke? Probably, it’s difficult to manage tackling it at one time, but it is possible to find out what «sticks».

For this purpose healthcare must be RECOGNIZED as an industry – the field in which economic laws are in force and industrial (that means comprehensible, describable and calculatable) management methods can be used.

Well then, let’s MANAGE. To manage means to take well foreseen moves in order to get well foreseen results.

Adam Smith used the term «invisible hand of the market» which can regulate everything, provide fair prices on very different goods and services, and equalize demand and supply.

Management guru Michael Porter came to a conclusion that healthcare lacks competition; competition of medical facilities will solve problems of healthcare – it will encourage high quality of medical services and make them generally accessible in terms of quantity supplied and the price.

Assuming that healthcare is an industry and we are a part of the market, it seems that all things should work well. But it doesn’t happen. Besides, there two reasons: as opposed to other industries, healthcare has distinct social nature, in other words, obligations taken by the Society to some of its members (the government takes the responsibility of fulfilling these obligations), confuse the notions of consumers, customers, vendors and producers completely.

The second reason is ambiguity of the notion «product» in healthcare. Competition in the healthcare market EXISTS, but it is not a competition for quality. There is struggle for grants, tariffs, state orders, the number of «profitable patients», «annexation of territories», and so on and so forth, but quality remains just an associated category.

The patient doesn’t know WHAT he needs, whether he NEEDs what he is offered or not, and if he has really RECEIVED what he gave his consent to, with the promised result, and, finally, if the completed procedure costs as much as he was asked to pay. In other words, the service was delivered, but there was no PRODUCT, because in order to make a service become a «product», it must be unambiguously defined (WHAT is done, with what purpose, what result is expected), the result must be alienable, which means it must belong to the part that has received the service, and the principle of price formation for the given service must be well defined. If there is no «product», then it is impossible to develop goals, receive monitoring tools, and, moreover, develop efficient management algorithms.

Nobel prize winner Joseph Stiglitz opposed Porter, surely not on purpose, when he said that the U.S. tried to solve the problem of expensive heart surgeries and trained more than sufficient number of heart surgeons, but the price for the operation DIDN’T DECLINE. «Competition» didn’t work out. Of course, it didn’t, due to the same objective reasons of the industry specifics.

 

Dispatching


That’s how the idea of implementing an absolutely industrial management technology in healthcare appeared – the technology centered around the principles of dispatching, which is based on centralization of information flows, implementation of common standards and regulations, uniting participants in different specialized systems. Such centralization has nothing to do with consolidation of administrative power and further bureaucratization of healthcare.

It is the question of receiving objective information about how the healthcare system functions, providing the system participants with full and objective information, optimization of resource management, and coordination of all participants’ work. In this case centralization is not a purpose, but a method. Centralization is a «one window principle» in accessing the system, full access to information in compliance with authority, common rules of the game, and optimized mechanisms of business processes.

Dispatching means principles, certain architecture, and certain structure


Principles of organization

Certainly, efficient dispatching is impossible without implementation of up-to-date info-communication technologies.

By using up-to-date technologies we provide:

  • Completeness and accuracy of information, as automated input doesn’t make mistakes typical for manual input
  • access to all information (in compliance with authority)
  • adherence to all included standards and regulations
  • automated performance of specific business processes
  • an opportunity to monitor behavior and condition of the system in real-time mode, receive and accumulate statistic information for immediate analysis

Architecture of the system

Architecture of a dispatching system can be quite variable. In any case the core of the dispatching system is the Central storage of medical information process block, which tackles the tasks of very different medical processes, such as, for instance, emergency aid in cases of cerebral accidents, planned hospitalization, or personal tele-monitoring.

Meanwhile, different information and reference systems, registration systems – electronic reception, portals become an add-in and provide interface with all participants of the healthcare system, which are designed for both medical services customers and those who render such services.

The technical realization of the system is a specific question. The choice must be made taking into account features of a specific environment can be realized both as a classic client-server system and as fully «cloudy» system.

Structure of the system

Certainly, a certain structure is necessary. However, as it has been mentioned already, dispatching must be provided with information and communication technologies. Proper use of these technologies, high-quality algorithms give an opportunity to realize dispatching in the automated mode, when all tasks are tackled by the same staff or with minimal number of additional workplaces, as the functional increases significantly. Moreover, as dispatching is not a management body, practice has shown that creating a new legislative structure is unnecessary. In addition, dispatching definitely makes plenty of working places more efficient, especially in the places where information is collected, input and processed.

The main feature of the dispatching system

Now we have approached defining the product and its quality.

The practice of implementing dispatching confirmed our hypothesis that when there is no certain definition of a product the  most serious quantity and quality analysis can be performed by controlling the process of how a product is received. In healthcare it is the process of rendering services.

Dispatching provides means of accomplishing a service strictly in accordance with established regulations, take into account both the fact of delivering the service and all consumed resources, and most importantly, in the end, sometimes after a certain period of time, evaluate the achieved result and its compliance with the current regulations.

In other words, we can make sure and assure the patient about practicability of the accomplished procedure and the quality of the achieved result.

I set a question in the headline of this article. But people are not interested in a «generally stated» answer to the question «is high-quality public medicine possible?» There is point only in a practical answer which is related to a specific time and specific territory.

Creating an economically valid management system, which is based on dispatching and in which industrial management tools with implementation of info-communication technologies are used, will give us such an answer, and I’m sure the answer will be POSITIVE.

 

November 2011