For medical control of the health cost developments!
Progress in medicine, increasing life expectancy, aspiration of each individual for living in good health as long as possible are the principal factors of the increase in the health expenses in most countries of the planet.
Proposing a high-quality health system to the population is first of all a way of providing for more efficient global economy: 1% of the social welfare system makes more than 2% of the GDP of the country!
Nevertheless, it is not viable for a country to let increase the health costs without any mechanism of regulation both at the macroeconomic level and in respect of any medical documents presented for payment.
Control of medical costs: first of all, medical control of the developments and not control of accounts!
It is difficult to assess the intrinsic quality of a health professional, yet at the same time it is possible to assess his medical practice on the basis of a large number of quality references existing in the world, and especially in Europe.
So, in any country, it is possible to define price reference scales reflecting the average level of salaries, the real estate prices and the general services.
These elements enable to assess the value of treatment in a country as compared with other countries.
The established difference in the health costs often results from other factors, such as:
–multiplication of documents (blood analysis is done many times as a result of lack of coordination);
– treatment prescriptions (inappropriate treatment is prescribed but with more considerable margins)
– poorly calculated treatment unit prices (the medicines pricing policy applied in the country playing the key role in the control)
– absence of controlled successive stages of treatment or gaps in the successive stages (which may result in absence of control upon discharge from the hospital and grave consequences such as recurrence and entailed expenses)
– fraud committed both by the patients and the health professionals (often resulting from insufficiency of means for rights verification)
– inadequate treatment pricing (for example, very high prices for dentures and inadequately low prices for conservation treatment, which results in an avoidable explosive increase in very expensive prostheses)
Who must contribute to the control of treatment cost developments?
All players are directly concerned.
First of all, the public authorities who often finance the major part of the costs (particularly, paying the costs of treatment of the most grave diseases).
Also private insurers; they often cover the expenses under collective agreements guaranteeing good coverage, also they are often very exposed to abuses or fraud.
The patients themselves! Very often, people think that paying much for their health means having access to medicine of higher quality, which evidently is not the case as the pricing policy may be “adapted” to the solvency of the patient (they make pay more those who have more financial means)!
Different solutions, important points
There are many answers to be obtained, surely they are complex, but obtainable, and many instances of international experience, particularly in Europe, have to be considered.
Limitation of expenses by regulatory provisions
The tasks and objectives are at the national level, as well as the solutions. Political dimension connected with decision-taking on distribution of financial resources (often depleted) is important (and, if possible, coherent with the decisions of the parliamentary representation).
Limitation of expenses by agreements concluded simultaneously with offering the treatment
Partnership and negotiations with the health professionals are the cornerstones of the system. Therefore, discussion of the quality of treatment and the prices must be included in the more global approach to remuneration in each profession and transparency of the revenues of the health professionals.
Limitation of consumption by systematic payments of a certain amount of money by the patient, even a modest one (not including grave or lingering diseases)
Even if it is not evident that payment by a third party (the patient pays nothing or little, and the health professional gets compensation directly from the public or private insurer) is inflationary for the expenses, there are strong presumptions that the “not expensive” notion understood as gratuitousness causes a bias in the expenses. Awareness by each individual of his responsibility is a key lever of intelligent control of expenses.
Mechanisms of anti-fraud control
It is evident that deviations are many and they are catastrophic for the general confidence. Anyway, there are no infallible systems, and risk management must be constantly performed in respect of new types of fraud…
Use of a medical approach to financial commitments
Paying differently for an image obtained using an old medical imaging device and an image obtained using a more modern and efficient device (for example, a device making it possible to identify a tumor 10 times better) is an obvious fact… which is not always evident for the health protection management systems.
Systems of protection of the personal data of the citizens relating to their health, without which it is not possible to realize the medical control of the health costs.
Medicalization of the conditions of reimbursement also requires use of the health data of each individual. Management by trusted external specialized bodies is indispensable for providing for the fundamental rights of the individuals.
Management mechanisms and efficient information systems at the service of the players
Information is at the heart of this issue. An integral and comprehensive approach shared by the largest number of players is indispensable.
Most integrated systems of management of reimbursements possible together with a system of tracking the medical processes relating to payment must be provided for. They make it possible for each individual to have easy access to different health professionals, and for the latter – to get payment for their services in a more simplified manner in administrative and financial respects to the benefit of the medical practice.
In conclusion, Protection of persons who face health problems must be considered as an investment the return on which is sufficiently prompt and important.
Risk management by medical control of the health expenses is imperative for the health protection system in Georgia as well as for the health protection systems complex of the world.
Control of the unit prices (medicines, medical equipments, images), struggle against fraud and any abuses as well as an integral approach to the treatment processes are indispensable.
This process must be developed in collaboration with the health professionals within the framework of agreements concluded with public authorities and private insurers.
One of the cornerstones of the system is creation of solid mechanisms of management trusted by the citizens, financiers and health professionals.