CCTOS: Healthcare Economics

• Economics of healthcare service workload:
  • Issues:
    • Healthcare economics:
      • In every society healthcare is a necessary service from a social point of view, but healthcare depend always on other sectors of the economy which produce directly goods.
      • The priorities may depend on the context:
        • In developing countries:
          • Healthcare should be made available to everybody, as stated in the 2015 goals.  At least good basic healthcare is essential for many children and young adults. The needs in developing regions are very large since the populations are vary large.
            
          • Lack of adequate care of chronic diseases prevent adults to work.
        • In developed countries:
          • High quality care requirements are increasing faster than the resources. Even in countries with higher economic level, improvment of healthcare efficiency becomes a must.
            
          • As a mean the number of healthy years and the life span are increasing. Many retired people do not participate anymore in the work force and consume a high percentage of the care services.  In some countries the legal retirement age is at 60 years. In consequence an increasing group of mostly still valid people, are to be economically supported by younger groups.
          • As long as possible elderly people should stay at home, for the quality of life and also in order to avoid huge expenses in institutions.  There is a large group of elderly people at an intermediary level, wel needing assistance but relatively limited assitance as maybe 1/2 hour a day and the possibility to call occasionally at any time. 
            Remark: of course patients needing attention every few hours should be grouped in institutions.
            
          • In general elderly patients have multiple deficiencies related to aging.  An overview of the global  "Problem List" is particularly necessary.
    • Telemedicine acceptation issues:
      • In general the tradition is that doctors are paid when they encounter patients, face to face. Historically Social Security systems have been build on that principle.
        
    • Familial factors:
      • The trend is that adult children live far away and are less available to help their elderly parents.
        
    • Doctor's demographic issues:
      • Obvious in developing regions with an order of magnitude of less than one doctor per 30.000 inhabitants.  (In developed countries > 1 per 500).
        
      • "Brain Drain" issue in developing regions.  Even in regions where national doctors could be available:
        • Attraction to migrate to countries where incomes are much higher.
        • Isolation from continued learning opportunities.
      • Also an increasing shortage in rural regions of Europe.  GP going in retirement cannot enough be replaced.  Most medical student are attracted by specializations.
        
    • Healthcare organization:
      
      • Hospital and health centers have difficult to cover the costs.  Here 2 factors, at one side the increasing costs of personnel and at the other side the the cost of new medical technologies and pharmaceutical products, which everybody want of course to have, hoping to get a little better results.
      • The issue is to improve the efficiency, remaining in the limits of the available resources.
    • Health insurances:
      • Budgets are increasing out of available limits in both developing and developed societies and for both public and private insurances.  The first urgent target is to limit the number and the duration of admissions. 
        In such crisis situations, insurance organizations could be willing to provide resources, as far as the benefits of telemedicine networks would be demonstrated.
        
      • Public authorities are trying to promote prevention and life style issues.
        
    • Human factors:
      • As far as possible patients prefer to remain in their usual environment, in their usual neigboughood and at home if possible.
         
        
  • Approaches:
    • Take advantage that telecommunications which make collaborations much easier than before. 
      • Telecommunications and access to knowledge can alleviate the isolation in remote areas.
        
    • Support of collaborations between the levels of experience:
      
      • Efficient use of the time of available care resources:
        • Since time and qualifications are limited resources, try to make optimal use of resources at every level of competence.
        • At every level of competence it is important to learn own limits, i.e. to learn to recognize the critical situations requiring a call at a higher level of expertise.  For example a nurse should recognize early symptoms suspected of meningitis and other critical conditions.  A GP should well know his limits when a problem should be referred to a specialist. 
          Important at every level, patients, nurse, primary care doctor, specialists.  For example the UK NHS had usually too long waiting list, but at any time a citizen can dial a call center with specially trained nurses, filtering what looks urgent or not.
      • Wel defined roles:
        
        • Lower level of expertise side:
          • Taking account of the available level of know-how require every care providers to go as far as he can.  Before asking questions at the next higher level, th e requirement is to prepare a report of what has been observed, of current concerns and of considered treaments.  Moreover multimedia can sometimes be useful with a few images and short audio records.
            
        • Higher level of expertise side:
          • Manage the information in such a way that not too much time will be necessary to provide meaningful advices. 
            Typical answers may look like: 
            
            • "OK I agree with your report", 
              
            • "recommendations to think about ...., look at ....., ask lab tests ... ",
              
            • or "call immediately an ambulance".
              
    • Context and typical scenarios:
      • In developing countries:
        • A shared electronic patient record on a regional server made accessible for the nurse of a nearby village, the regional hospital maybe up to one travel day away, and for some questions to remote international experts.
      • In developed countries with aging populations:
        • A shared electronic patient record on a regional server made accessible for a call center, for nurses seeing the patient at home 1/2 hour a day, for the GP, and to some extend for the patient himself or children of elderly patients.
        • Monitoring devices (pulse rate, oxymetrie, mouvements, ...) should be connected in an integrated way to a medical call center, manned 24 hours a day.
    • Funding:
      • Seek agreements about fees, based on services and responsibilities through internet, making the face to face contact no more mandatory.
      • To a limited extend experts are available and agreeing to give advices as volunteers, but:
        • Take care that the questions should be well prepared and documented.
        • Volunteers should have no out of pocket expenses about equipment and internet access.
          
      • In developed regions:
        • In one way or an other, as a mean the experts working through telemedicine should normally get incomes according to responsibilities and time spend for teleconsultations.
      • Sustainability in developing regions:
        • Volunteers:
          • Fortunately there are experts accepting to spend time free of charges to provide advice and education for developing countries.  Telecommunications make remote assistance possible, because otherwise these experts would not be willing to travel on site in developing countries, where life is much more difficult. 
          • At the moment the main limiting factor is telecommunication.  At a later stage the availability of affordable medical experts will become the major limiting factor, in relatively poor regions.  Therefore efficient use of the expert time is anyhow critical.
            
        • Support for individual patients is urgent, but on longer term education and training of local human resources is even more important.
      • In both contexts telecommunition should remain affordable, i.e. sharing know-how in open source, affordable support services and affordable equipement.
    • Beside pure medical applications, provide software tools helping to manage the related administrative issues including invoices.