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Challenges in Designing Excellence Oriented Hospital Systems -Part 3
We have highlighted in previous articles the challenges to pursuing excellence in a hospital system; namely by discussing the tensions generated by the patient journey through the phases of care and how the care teams need to achieve a high level of communication, coordination and continuity of care while managing numerous critical tasks. We also discussed patient expectations and how they are harder to manage in the age of false information and social media. In the final article of this series, we will dive into reimbursement models and how those impact decision making at the highest levels. Accordingly, we will also discuss an approach to health that goes beyond detecting and treating disease and how spending with this viewpoint can be more cost-effective in the long run.
The argument for Holistic care
Modern hospitals are designed to provide acute inpatient care. This often involves many invasive interventions for the purpose of monitoring or treatment. Elderly patients have unique needs that are often poorly served by modern hospitals. Elderly patients are more likely to develop drug reactions, receive wrong doses or experience complications during their hospital stay 1. Traditional hospital processes can quickly become poorly adept at caring for the fastest growing patient population that is likely to use inpatient facilities. Extensive involvement of family, trained nurses, and physicians is key. Specially designed inpatient units - geriatric units - that minimize noise and encourage appropriate patient stimulation or ambulation are all factors that directly impact geriatric patient outcomes 2.
Elderly patients are more likely to develop drug reactions, receive wrong doses or experience complications during their hospital stay
Interestingly, inclusive healthcare systems that aim to serve all their patient’s needs have lower costs per relative value unit (RVU) than any of the other multi- or single specialty institutions 3; suggesting that a holistic approach to patient care not only better serves patients but also cuts costs of care as well.
A holistic approach to patient care not only better serves patients but also cuts costs of care as well
These interventions which initially seem only justifiable for special patient populations will eventually become standard of care for all patients once the correlation between an environment that promotes a sense of wellbeing and hard outcomes like morbidity and mortality is better understood. As acute care becomes more expensive directing healthcare spending towards promoting wellbeing not only reduces costs but promotes a healthier population whose value is measured far beyond the beneficial economic impact.
As acute care becomes more expensive directing healthcare spending towards promoting wellbeing not only reduces costs but promotes a healthier population.
Challenges with reimbursement models
The rising cost of health care is a hot topic for governments around the world. The recent global pandemic has added an urgency to this discussion as the various models of health care globally demonstrated their resilience (or lack thereof) to catastrophe 4.
One thing single payer systems and insurance companies have in common is the realization that focusing on overall population health decreases the cost of healthcare overall.
One thing single payer systems and insurance companies have in common is the realization that focusing on overall population health decreases the cost of healthcare overall. Robust primary care systems and preventative care have demonstrated that they more than pay for themselves within 5-10 years. Value-based care models evolving out of the USA want to incentivize hospital systems to become partners in investing into community health 5. While in the long term these measures are very promising, the short-term reality is a very expensive bill upfront for systems that were not designed for population health but rather merely for urgent care. In most places hospitals are yet to demonstrate profitability without heavy subsidies by government organizations or offering concierge medicine that does not rely on value-based care models at all.
Conflict of Interest in Reimbursement Models
In the Middle East, there is no government oversight on whether clinicians have conflicts of interest in their income streams. Practices like being paid for referrals, receiving a commission for ordering diagnostic tests or being compensated by pharmaceutical companies for prescribing certain brands are all not only considered unethical but are illegal in Europe and North America 6. Providing physicians with higher salaries and compensation based on effort and complexity of care provided are strategies implemented by hospital systems abroad to ensure fair physician compensation without jeopardizing the physician-patient relationship by inserting a conflict of interest into the reimbursement model 7.
Practices like being paid for referrals, receiving a commission for ordering diagnostic tests or being compensated by pharmaceutical companies for prescribing certain brands are all not only considered unethical but are illegal in Europe and North America
Due to lower physician salaries in the Middle East and North Africa, hospital systems have relied on supplementing physician payment with commissions and referral fees that encourage use of the hospital system as a whole. While in theory this ensures that physicians are paid more when providing more complex care, the use of diagnostic tests as a surrogate measure for this clearly rewards overuse of referrals and diagnostic tests that might not serve the patient's best interests. Other practices like accepting gifts from pharmaceutical companies in the shape of all expense paid trips for conferences or sponsorship of academic conferences also compromise physician integrity while prescribing medicines. It is because of this that such practices are illegal in Europe and North America.
The use of diagnostic tests as a surrogate measure for complexity of care clearly rewards overuse of referrals and diagnostic tests that might not serve the patient's best interests.
Conclusion
This article introduced the challenges with reimbursement models in health care. We have also highlighted that shifting the focus of healthcare systems from merely detecting and treating illness to promoting wellness is the best long-term strategy for promoting healthier populations while reducing the expensive healthcare bill that is causing concern globally. This article also touched upon the ethics of reimbursement models and how the Middle East lags behind Europe and North America from a legislative perspective in this important dimension. Future articles will aim to discuss solutions to this challenge and how a step-wise approach to change can support the mutual goals of improved population health with reduced cost of care.
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