High Tech – High Cost: The Dilemma of Health system

October 22, 2011, 6:07 pm


Dr. K. M. Wasantha Bandara

I thank Sunday Island for publishing - in its issue of October 9th - the enlightening speech delivered by Dr. Deepthi Attygalle at the inauguration of sessions of the Galle Medical Association. In the light of present day mainstream trend in the practice of medicine, the title, "From the art of health to mark of high tech" itself draws a great deal of attention. She seems to be of a different breed who is brave enough to challenge the conscience of the medical elite. I bow my head in honour.

Today in our market driven socio political system every aspect of life is being commercialized. The practice of medicine is no expectation not only in Sri Lanka but world over, So called "supply and demand driven by economists" encourage competition among providers at health care as a tool of Improving quality of medical care. Contrary to that expectation the health care providers are Indiscriminately introducing technologies that are far from being scientific interventions as tools of gaining the competitive edge. This situation world wide has lead to a vicious cycle of High Tech - High Cost and funding cuts – low outcome in the health care delivery systems.

The policy makers who promote so called competition conveniently ignore the fact that demand for medical care in induced by the suppliers themselves. Although not very much talked of, there is enough evidence that in the case of health care market undue competition escalate costs and undermines the delivery system itself.

At a time when delivery of medical care centered on the doctor or the practitioner the tools of competition were professional knowledge, competence and the ability of being responsive to the expectations of the patients. In that system although there was certain degree of supplier driven demands escalation that did not lead to high cost of care in the delivery system. Today in institutionalized and industrialized practice of medicine the tool of competition is technology where indiscriminate use is supplier’s choice.

As Dr. Deepthi points out, this trend is very much facilitated out only by the capital owners of the private hospitals and medical professionals, but by the patients or the customers themselves. In the modern consumerist word there is a convenient belief that the higher the technological inputs the higher the quality of the outcome. In reality patients randomly experience that there is no such relationship except for escalation costs. But the patients have no choice other than accepting the recommendations of the care providers.

Today this vicious practice of High Tech - High Cost is very much encouraged by various health Insurance schemes. In the USA cost of health care accounts for 13.5% of the G.D.P. yet there are so many millions of people without any subsidized health care plans. In that system about 30% of the health care cost account for insurance overhead. There, the insurance is a two-edged sword, where on one side insurance encourage the use of high cost technology and on the other, having an insurance leads high administrations over head in the health care system.

In any country there are limitations in the healthcare funding. As such, High Teach – High Cost approach invariably leads to rationing of very same services in the government sector and depriving of services in the private sectors. This type of rationing actually does not control the indiscriminate application across all the segments in the society. But it is a type of rationing that make services available to the well connected people or the higher segments in the society. Also indiscriminate allocations of the funds to acquire so called advance technology leads to shortages of funding in other vital areas of healthcare delivery system. More often the funding is deprived to public health sectors leading to deprivation of basic are to vulnerable segments. So, ultimately the technology which is considered to be a tool of improvement of individual care, undermines the quality of health care delivery systems.

Dr. Deepthi in her long speech gives us an insight as to how in the recent past the art of medical care has transformed itself into a science of high tech and high cost. She convinces us that the answer to indiscriminate industrialization of practice of medicine leads to Injustice in the system is to bring back the practice of art of medicine in to the system. No doubt any medical elite who is highly benefited by the present trend will in his or her heart agree with Dr. Deepthi. But will they simply change their economic behaviours just because the naked truth is bleeding In their eyes. Will that change the attitudes and behaviours of the hospital owners as well as the patients?

The High Tech - High Cost system is sustained and thrives on very attractive incentive scheme targeting at medical practitioners especially the specialists. They are offered as high as 20% as commissions by the laboratory and hospital owners for investigations and medical, surgical or radiological procedures they recommend or order. In some cases pharmacists also offer commissions for certain high cost medications that are prescribed. Most of all when patients demand such expensive investigations or interventions or medications, even a right minded practitioner will be helpless in the present day competition among specialist practitioners. So ultimately the high tech – high cost system is sustained on more use – more commission platform.

In my personal opinion there is no magic wand strategy that would change the spoilt minds of those stake holders overnight. Precondition for change in the status is to establish a meaningful dialog on the issue which Dr. Deepthi has already initiated. At least in fairness to her I would like to suggest fire prone strategy instigate public debate.

First is to establish General Practitioner (GP) service as the entry point to the health care delivery system. There is no need to have a single service nationwide with common funding arrangement as in the case of health care delivery system in U.K. Instead, Sri Lanka could have dual approach where government GPs provide the service in government hospitals and private GP provide the serviced in a private dispensary or hospital. Ultimate objective is for every citizen in the country to have a GP of their choice and a continuing medical record. This system should guarantee the continuity of care and systematic referral for secondary care. For this purpose the government will have to revive the Private Medical Institution Act which is now defunct.

Second strategy is to introduce compulsory protocols for use of High Tech - High Cost technologies in the government system, which would also get a voluntary and indirect guideline for the private sector. After a certain period of voluntary implementation those guide lines can be compulsory in private sector as well under the regulations of private medical institution act itself.

Third strategy is to introduce regulation of health care costs through the same act in the private sector which will apply to the government sector as well when certain services are obtained from the private sector. Then all the private institutions shall be compelled to provide detailed information of pricing to the customer before each and every part of service is delivered.

Fourth strategy is to prohibit acceptance of commission by medical professionals for investigations they order and medications or medical or surgical interventions they prescribe. This should be a serious offence under the medical ordinance as well as the private medical institution act.

Fifth strategy is the bottom line where all health care professionals should be well taught and motivated against purpose full commercialisation of medical practice for undue gains. This should be a integral part of basic medical education as well as in the internship training. Above all it is the moral standards of the individual that makes the difference.