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Thursday, June 27, 2013

UHC 15: On DOH Plan to Recentralize Healthcare

The quest for government-initiated and centralized universal health care (UHC) can be dizzying for all sectors -- patients/public, private healthcare professionals and providers, government health agencies, the legislature and everyone else. This is because when government centralizes or almost  monopolize healthcare, competition, price differentiation, market segmentation and service innovation is often sacrificed or killed.


A famous physician, expert and consultant on UHC and NCDs, also a friend, Dr. Tony Leachon, posted this story from GMA News the other day, in his fb wall,

PNoy to push for less controversial health programs in last half of his term

In a speech during the Department of Health's (DOH) 115th anniversary celebration, Aquino said his administration is determined to attain its goal of universal healthcare for all Filipinos by 2016….
"Last year mayroon tayong Sin Tax, mayroon tayong Responsible Parenthood, ngayon naman ho ay pakikiugnayan ng mas hindi masalimuot ang ating pakay," he added. Aquino, in his speech, said his government was able to enroll some 20 million more Filipinos to the national health insurance program during his first three years in office.
He also boasted of his administration's efforts to expand benefit packages for Filipinos suffering from heart diseases, aside from those with "catastrophic diseases" such as breast cancer, prostate cancer and acute leukemia.
The president likewise pledged to build more new health facilities in far-flung regions of the country, and the rehabilitate old hospitals.
"Hindi tayo titigil hangga’t may mga kababayan pa rin tayong ni hindi nakakakita ng espesyalista sa tanang-buhay nila. Kaya naman sa huling dalawang taon ng ating administrasyon—binawasan ho ako ng isang taon, siguro ‘yong writer ko po ay gusto na ring lumipat ng trabaho—target nating i-upgrade at gawing mas moderno ang 7,325 na mga ospital, klinika, at pagamutan," he said. DOH Secretary Enrique Ona, meanwhile, said his department will propose a law that will facilitate the efficient delivery of health services to distant towns in the country. 
"Kami ay nahirapan nang husto na ipaabot sa ating local health units 'yung tulong ng DOH kasi devolved ang ating health system down to the towns. Sabi namin, pag-aralan on how we can improve the devolution of healthcare," he said in an interview after the event. 
He likewise said he wants a legislation that will "improve the governance" of public hospitals under the DOH.

Among the comments raised by Doc Tony's friends were the following:

(a) Do not neglect the human resource aspect of modernizing health facilities, otherwise we willl have ghosts running our hospitals.
(b) Maldistribution and unemployment of healthcare professionals are serious issues.
(c) There is an over-supply of nurses and there is maldistribution of doctors, maybe even an under-supply of physicians.
(d) Start an Advanced Practice Nursing/ Nurse Practitioner program. Can be piloted with a very good nursing program. It will provide job security and provide additional primary care providers especially in underserved areas.
(e) "Hindi tayo titigil hangga’t may mga kababayan pa rin tayong ni hindi nakakakita ng espesyalista sa tanang-buhay nila." -- Why do the people need to see a specialist? Specialist in what? Why can't they be seen by primary care physicians or nurses? If nurses are trained to render primary care... agree ako jan.

I commented that the move now by the DOH is towards more nationalization and recentralization of public healthcare. But centralized programs often result in centralized expectations and centralized disappointment. Then I asked Doc Tony since he has worked in both private and public hospitals and other healthcare facilities, what are the efficient incentive systems that encourage HC professionals to provide really caring service to patients, so they get well and become economically productive.

Doc Tony replied that HC professionals should be compensated well to stay with a well planned career plan.

That is precisely my point. Very often in government hospitals and HC facilities, the doctors are paid flat rate, whether they see 20 or 200 patients a day, the pay is the same. So the tendency is to provide quickie prescription, little or no patient counselling, then call the next patients after 3 or 5 minutes. When government centralizes, nationalizes and monopolizes healthcare, service differentiation, market segmentation and service innovation is often sacrificed or killed. Government service is meant to uniformize, harmonize and monotonize the public, and sub-optimal health outcome is the result.

In the food sector, there is zero government carinderia or restaurant, zero government supermarket or talipapa, zero or little government farms, and yet people are eating. There are various products for various people with various budget and needs. Service innovation, price differentiation and market segmentation allows the various food producers/sellers to meet with certain food consumers.

In contrast in the health sector, (1) there are tens of thousands of government rural and barangay health centers, (2) tens of thousands of government-sponsored botika, (3)hundreds of government hospitals (DOH, LGUs, PGH, AFPMC, etc.), (4) there are free medicines and entitlement programs for the poor, (5) drug price control policy, (6) mandatory price discounts to senior citizens and persons with disabilities (PWDs), (7) government health insurance monopoly, and health problems are not declining but rising. Expectations rise, disappointment and discontent rise. Centralization and monopolization is wrong.

In another thread, there are good experiences in private-provided healthcare like the case of Dr. Meo Santos-Cao. She said, 
when I had my practice here in Laguna (up to 2006). I did not even register as provider with PhilHealth. I always made sure that this fact was clear to my patients. They paid me directly, usually before discharge from the hospital, but sometimes upon post-hospitalization check-up in my clinic if they had difficulty raising money. And since I didn't have to wait for 3-6 months for PhilHealth to pay me, I always charged much lower than other MDs here.  
I practiced general med. I did minor surgeries, checked on pregnant women and assisted normal deliveries. While it's customary for those services to be provided by specialists (surgeons and OB-Gyne), I had no qualms doing those because I was capable, had training and licensed to practice. In so doing, I gave patients an alternative to expensive services of specialists. In 2005, OBs charged 15k for a normal vaginal delivery, part was paid for by PhilHealth and the bulk out-of-pocket. Whereas, I charged only 6k for the same service, all out of patient's pocket. Malaki pa rin ang natipid ng pasyente. The important point here is that patients must know that they have options and that they cannot be held hostage by the prevailing system. Bottom line pa rin, as Marco pointed out, patient and provider must agree on the service and its cost.

I like the stories that Doc Meo shared, it's about private contract between a service provider (her as a physician) and service consumer (the patients) with no tertiary or external intervention (the state like PhilHealth, especially). The result is fine. If the patients are not happy, no need to rally or demonstrate in the streets to demand that the state should regulate Dr. Meo Cao or whoever. They simply refuse to come back, tell their friends that Dr. Cao is a lousy doctor. But this did not happen, they keep coming back, meaning they are happy with the services provided by Dr. Meo Cao.

Another physician friend also shared that "...with unjust compensation, doctors would opt not to operate lalo na kung difficult cases, the new Philhealth scheme doesnt take into account case difficulty. Di ka na properly compensated, mas malaki pa risk sa license mo, pagod ka pa. I dont think this is in the best interest of the patient. It takes forever for Philhealth to pay the MD and hospital, and only an instant to disqualify patients na may minor delinquencies sa continuity ng payment."
http://funwithgovernment.blogspot.com/2011/10/philhealth-watch-9-physicians-talk.html


On another note, I changed the subject of this thread from "Socailized Healthcare" to simply UHC. See also:
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