Health Care Financing :)

Have you ever heard of the word Managed Care? The first time i heard the phrase i thought it was some part of a sentence. I did not know it was a concept of its own. However, as usual i did some side reading, and found out what it actually is. This is what i would like to share with you today. The concept of Managed Care.

Managed care is when an organization is formed to manage the financing and delivery of health care. It is mainly to avoid redundant services, improve quality of care while reducing costs. Managed care works by ammending the services provided so that it is cost effective. It can be provided by an insurance company or even in a government setting.


As usual now lets look at the system both in Indonesia and Malaysia. I will be mentioning more about the Malaysian system because we have studied the Indonesian system extensively during lectures and tutorials. In Indonesia, Ministry of Health (government) pays only 30 to 40% of the health care costs. The health financing in Indonesia is divided into a few aspects :


1) National Health Service - this is a tax based payment of health care by the government. It is only for the poor people where everything is free. It is called Jamkesmas - Jaminan Kesehatan Masyarakat.


2) Social

• PT Askes - Asuransi Kesehatan (An obligatory social health insurance for civil servants. The civil servants just have to pay a minimum amount of premium.)
• PT Jamsostek - Jaminan Sosial Tenaga Kerja (Also a social health insurance for private sectors where they have to pay a premium also
• Commercial Health Insurance - (An option for everyone to sign up for it. It is also premium based.

Whereas in Malaysia the financing is more to a dichotomous public-private system :

1) Goverment - led and funded public sector

2) Thriving private sector

The Malaysian goverment spends about 6.9% of its total expenditure yearly on health care. The public hospitals are subsidised up to 98% of their entire budgets by the government. The patients regardless of their financial status only pays 2% of the costs in a public hospital. For instance, a person who goes to the public hospital in Malaysia only pays RM 1 (Rp 2800) for an outpatient clinic services. However, because of this, there is a problem of health care financing when it comes to tertiary services. Therefore, the government has set up the Malaysian Assistanc Fund (MAF). The MAF caters for tertiary specialist care and it can be utilised only by public or quasi government healthcare facilities. There is also an emergency fund known as D'tik - Dana Talian Insan Kritikal Yayasan Kebajikan Negara. The huge or nearly full subsidy is a very difficult concept to be maintained. It still leaves holes that cannot be covered by the government. These holes has to be filled by some extra mechanism such as donations and funds as mentioned earlier. 

Now lets look at managed care and its stages. 

Stage 1 ( The Push)

- the fee for service is dominant

- the payers are still focused on volume

- there are no incentives to control hospital use, the hospitals tend to overcharge.

Stage 2 (The Squeeze)

- integrated system begins to develop, there are more groupings of medical officers.

- payers are purchasing volume by negotiation of deals.

- the service is concentrated more on the specialists rather than the general practitioners.

Stage 3 (The Purge)

- quality measures will be reported

Stage 4 (The Promise)

- health care providers are coordinated in larger groups and capitation contract prevails.

Managed care is perfect when it reaches stage 4 successfully covering ALL the citizens of that particular country. When this happens, everyone is happy with good quality of service and low costs. :) However, there are no managed care system that is perfect without loophole. We have to keep improving ourselves to reach the goal on reaching out to everyone's health rights.

References
1. Lecture Note - Managed Care, Gatot Subroto, PT Askes
2. Dictionary - http://medical-dictionary.thefreedictionary.com
3. The Malaysian Health Care System : A Review, Quek David KL
4. Stages of Managed Care Evolution, Knowlton D, Group MH, NA NA.
5. Managed Care, Market Stages and Integrated Delivery Systems : Is There A Relationship?, Lawton R. Burns, Gloria J. Bazzoli, Linda Dynan, and Douglas R. Wholey

Being a Medical Doctor.

After all medical students graduate medical school and finish their clerkship, before becoming doctors, they are sworn in by the Hippocratic Oath. Now, what is the Hippocratic oath and what does it say? 

The Hippocratic Oath is an ethical code. There are a few versions of it, in the older versions, the doctors-to-be swore upon the Greek Gods - Apollo,  Asclepius, Hygieia, and Panacea. But now, we use the modern version of the Hippocratic Oath which is very long, so if you want to read it fully you can visit http://en.wikipedia.org/wiki/Hippocratic_Oath. The oath mentions about the obligations of a practitioner to provide only beneficial treatment according to his/her judgement and abilities. He/ She also swears to not cause harm or hurt. These points are what medical ethics are made of. 


Okay after swearing in, we have our internship and then this hassle of getting our license. And the license has to be maintained over the years to ensure of the quality of the service provided. I have mentioned this in my previous post. Anyway, this maintainence is called continous professional development(CPD). In Indonesia, The Indonesia Medical Association says that every medical practitioner has to have 250 credit points within 5 years if the practitioners wants to prolong their license. The credits can be obtained from attending seminars, number of patients treated and et cetera. Whereas, in Malaysia, CPD is also practiced by obtaining credits, but its not compulsory as it is in Indonesia. The MMC (Malaysian Medical Council) are planning on making it compulsory in the near future. 

As long as we have a valid license, we are free to practice. However, the battle doesnt end there. We have medical law to be scared of. Okay first lets see the outline of a doctor's job scope. :)

Built a relationship with patients ---> Patient's data (Health history, Physical examination, Supporting examination) ----> Analyze the date ---> Planning medical treatment and informing patient about the condition they are in ---> Treating patients ---> Follow up. 

It looks simple, but its pretty complicated. Besides the fact that the doctor has to be very skillful and knowledgeable to be able to complete his/her tasks successfully. He or she has to be cautious about the medical law which if not followed, a very high price has to be paid. So now, lets look at medical law.


In Indonesia, the legal aspect of medicine is based upon Health Act 1992, Medical Practice Act 2004, Role of Minister of Health on Informed Consent, 1989 and the penal code. These laws makes malpractice as a criminal matter especially if it involves bodily injury. Bodily injury may be caused by medical negligence. Whereas in Malaysia, malpractice is treated as a civil matter. Even medical negligence are treated as a civil matter and not a criminal matter where the accused medical practitioner who has caused bodily injury is not charged as a criminal. (Susila, 2005). 


So now lets look at what are the doctor's and patients' right and obligations.

Doctor's rights :
1. To have certainty when performing medical procedures and throughout the practice.
2. To have propers Standards and Guidelines from the medical association in giving medical service to patients.
3. To get a complete patient health data.
4. To obtain salaries for the job done.


Doctor's obligations :
1. To give service based on Standard Operating Procedures and guidelines.

2. To refer a patient to a more competent doctor or to a better well equipped hospital if necessary.

3. To protect patient's confidentiality

4. To give emergency aids if needed

5. To have medical records on each patient.

6. To update knowledge and skills (life long learning)

Patients' rights :

1. To get a good, understandable and clear explanation about the problem (disease) they are having and also on the medical procedures done.

2. To get a second opinion from other medical practitioner.

3. To refuse any medical procedure or interventions.

4. To get their medical record anytime they want it.

5. Not being made to wait for an excessive period of time.

Patients' obligations :

1. To provide a full truthful health data

2. To abide by medical service and rules.

3.  To take care of medical service costs. 

However, the patients' obligations are up to the patients to follow. Whereas there are laws to make sure of doctor's fulfill their obligations. This is because being a doctor is a very risky career. In the past, medical practitioners are not answerable to law where the doctors had a high position in the society. During that era, the patients think of doctors as "Gods" and listen to every word they say. But in this modern times, this doesnt apply anymore. Doctors can be questioned both by the patient and the law. Medical malpractice has affected the doctor-patient relationship significantly. The Washington Times has reported that 70% of Maryland's Obstetrics and Gynecology specialist have been at least sued once for medical malpractice. Looks like it is getting harder and harder to be a good practicing doctor as the years goes on. 

References :

1. Lecture Note - Legal Aspect of Medicine, dr. Hendro Widagdo

2. Wikipedia - http://en.wikipedia.org/wiki/Hippocratic_Oath

3. Encyclopedia Brittanica- http://www.britannica.com/EBchecked/topic/266652/Hippocratic-oath

4. Malaysian Medical Council - http://mmc.gov.my/v1/index.php?option=com_content&task=view&id=10&Itemid=96#Q2

5. Law relating to medical malpractice : A comparative study between Indonesia and Malaysia, Muh Endriyo Susila, 2005

6. Legal Aspect of Medicine, Jonathan Montgomery.

Quality of Care

Hello everyone. First of all i would like to apologize for the delayed update, however i will try to make it up in these few weeks. 


Okay. In the previous post i mentioned about health system, its definition, function and et cetera. Today i am going to write on quality of care and how the best care possible is ensured. :) I am sure we are all concerned on the quality of materials or even services that we get no matter what we buy or where we go. Thus, i am sure we wonder about the quality of health care. So, lets look at the aspect of quality from the health system point of view. 


First lets look at the word Quality. It is defined as degree or grade of excellence. There are 3 types of quality in this context which are :-
a) management quality
b) professional quality
c) service quality.
All these 3 components are important to ensure a high quality of health care. So now, lets look at how do we maintain this quality. 

Clinical Governance


This was the first time i heard the word myself. Anyway after lectures and some side reading by myself i was able to understand the meaning of this word. Lets look at some definition of this phrase.

 " Clinical governance is about ensuring 
   that patients are safe and risks are managed.
   Janet Seaton, Clinical governance facilitator, NHS 24


" Clinical governance is the framework through 
   which all the components of quality, including 
   patient and public involvement, are brought 
   together and placed high on the agenda of 
   each organisation. 
   David Steel, Chief Exec NHS QIS

From my understanding, clinical governance is an association who are responsible for improving the standard of clinical practice. It is also mentioned in the law (UU 29, 2004) that the health care providers namely physicians have to follow the standard to ensure the quality of care. Now lets look at the governance itself.


Firstly, the AIM :

• for appropriate access and also high quality of care
• to reduce risk

The aim of clinical governance will be clearer as we look at the components of the governance. The COMPONENTS are :

1. Education - Where the physicians have to go through con tinuous education which means they constantly upgrade themselves with the new updates of interventions, drugs and etc. For example, the concept of continuous professional development. This is learning activities through which health care professionals maintain and develop their skills and knowledge. This helps in improving quality of care. However, this has been focused more on individuals rather than groups of physicians or other health care providers who work together.

2. Clinical Audit - This is where the clinical performance is reviewed. Its a cyclical process performance against standards.

• The objectives of a specific clinical audit may be developed specifically based on characteristics such as appropriateness, timeliness, and effectiveness of a treatment procedure. 
• The criteria of the clinical audit are developed from national guidelines and it has to be agreed upon before use. From the criteria we develop its standard and what are the exceptions to justify when these standards are not performed. 
• Next we perform data collection which can be performed prospectively or retrospectively. The data may be obtained from medical records with the help of Clinical Audit (CA) assistants. 
• After obtaining the data we analyze them by the level of compliance, pattern of deficiency and with the help of some diagrams. 
• The next step will be to implement changes. However to do this, first we have to determine the problem, plan of action, responsible team, timeline and also cost. 
• After the specific time mentioned, we have to re-audit to determine if the changes are effective. 

3. Clinical Effectiveness - This is a measure of the extent to which an intervention works. It can be measured on its own or together with the appropriateness of the intervention and also the financial aspect of it. It may be assessed using randomized controlled trials or meta analyses. The term that is closely related to clinical effectiveness is Number Needed to Treat.

4. Risk Management 

• Patient risk - it can be reduced by compliance to statutory regulators and also constant review of the service and intervention given.
• Practitioners risk - we have to reduce the risk of practitioners to infections and ensure they are in a safe environment.
• Organization risk - it can be decreased by high quality employment practice and constant review of individual and team.

5. Research and Development - It is done to ensure professional practice. It may be done in ways of clinical appraisal of literature and also by developing guidelines, protocols and etc.

6. Openness - It is important for the governing team to be open to public scrutiny but at the same time respecting patients' and also practitioners' confidentiality. 

With all these ways, quality of health care can be improved and IS being improved. It's a huge relief that even as i type this, there are people thinking on improving quality of health care. :)

Thats all for now, 

Adios, Tc and looking forward to learning together again. :)

References :
1) Lecture Note - Briefing for Clinical Audit Practical Sessions, Prof. dr. Adi Utarini
2) Lecture Note - Quality Framework, Clinical Governance and Patient safety, Prof. dr. Adi Utarini 
3) Clnical Governance - Nigel Starey Bsc MBBS, MRCGP, Director, Centre of Primary Care, Univeristy of Derby
4) Health Professions Council - http://www.hpc-uk.org/registrants/cpd/
5) Dictionary - http://www.thefreedictionary.com/free

Health System Introduction

Hello again :)

Here we are in a more serious note to learn something about health system. Lets try and understand what health system actually is. I was wondering what it really meant,

And then after some help from lectures and Mr. Google, i found a few definition related to health system. All right, so first lets look on what a system means. 

System is a group of interacting, interrelated, or interdependent elements forming a complex organized structure. 

Now a simple view on health system. Health system is actually defined as a system that consists of all the organizations, institutions, resources and people whose primary purpose is to improve health. A good health care system will be able to provide quality services to ALL people when and where they need them with at an optimum or affordable cost. A well functioning system would respond in a balanced way by 4 main factors which are :-

1. Improving health status of individuals, family and communities. When this point is achieved, people are healthier, this leads to a happy good quality life. :)

2. Defending population against what threatens its health. When this point is achieved with an efficient system, the people are protected from these threats. :)

3. Protecting people against financial consequences of ill-health. It is common knowledge that health care can be VERY expensive at times (the financial part of the system will be discussed in the later posts). A good system will be able to guard the people against the financial risks of health care.  

4. Providing equitable access to people centered care. Where EVERYONE who needs the care should have access to the care regardless of their financial status, geographical distribution and et cetera. 

Of course every system has its setbacks and problems of its own. It's never perfect ain't it? Anyway that is what we'll see over the next postings. All right lets come back to the issue at hand here. 

Now we shall see how we measure the outcome of the system. The outcome can be measured in 3 ways. 

1. Health status - as mentioned earlier the health status plays an important role indicating the efficiency of the system. It can be measured using indicators such as mortality, morbidity, life expectancy and so on.

2. Citizen satisfaction - this refers more to non clinical quality care. I was a little confused on what this meant. So again i headed for Mr.Google. According to WHO, there are 8 criterias for non clinical quality care :-

• Interpersonal :
• Dignity
• Autonomy
• Communication
• Confidentiality
• Structures
• Quality of basic amenities
• Choice
• Access to social support network
• Prompt attention

Thus, now we understand what it means by it. All these 8 criterias indicate the patient's satisfaction during the care giving process.

3. Financial risk protection - With this the concept of equity is acknowledged. The citizens must be protected from financial risk because as mentioned earlier, the health care cost can be high and unpredictable at the same time. The equity here depends on the household income and wealth. A way of measuring this outcome is by calculating the percentage of people having health insurance.

I hope with this post you will have a slight understanding on what health system really is. My main purpose is for the basic understanding of the subject. I wish to simplify things for a better understanding. I hope reading this post has helped you. :)

p/s : Since many did not understand the cartoon in my previous post, I will explain it a little. Please look at it again and notice that the patient is dead (his ECG is flat, no electrical activity) and the dr is still prescribing him Aspirins. Hope you see it now. ;)

Adios. Tc and Keep reading folks :)

References :

1) Lecture Note Block 4.2 - Introduction to Block 4.2 and Health System and Its Outcome (Prof. Laksono)

2) World Health Organization -  http://www.who.int/en/ 

3) Estonian Health System (pdf)

4) Dictionary - http://www.thefreedictionary.com/

A tiny Glimpse

Hello :D


Welcome! For the next few weeks, I will try my best to unleash issues related to the health system. Don't worry, i will introduce the concepts related to the system first so that you may have some basic understanding about it. :) (Not like i am extremely familiar with it, lets learn about it together). I will update soon with a new post regarding the system. 


Just for the fun of it : -

Adios. Tc and keep reading ;)