The writer is a consultant pharmacist at Medicine Shoppe International and has worked as a senior pharmacist with the University of Pittsburgh Medical Centre, US. She has also worked as a civil servant with the Government of Pakistan
The issuance of Sehat Insaf Card is a great initiative towards progress in the health sector which has been neglected over the decades as is evident by the persistently low allocation of budget to the sector under every past government without fail.
The fact that the Constitution of Pakistan, unlike in 115 countries in the world, does not explicitly recognise the right to health might be a contributing factor towards undermining the importance of this sector. It is the constitutional provision that morally binds the state to uphold social justice and promote equality and wellbeing of its people.
At this experimental stage it is very important that the funds are utilised wisely and in a planned manner. Insurance companies should negotiate rates on behalf of government with hospitals, diagnostic facilities and pharmacies.
The new insurance card covers surgical procedure and one’s stay in government and private hospitals. However, the rates on behalf of the government with the private hospitals are yet to be negotiated by the insurance companies.
The US is a developed country with a lot of emphasis on health sector. It has been trying to reinvent its health system over the past few decades and has learned a lot in the process.
Medicaid is administered through states. Every state negotiates its own rates with the service providers as per the requirements set by the federal unit.
A study published in The Journal of Texas medicine - June 2016, titled ‘Private Carriers’ Physician Payment Rates compared with Medicare and Medicaid’. In this study, a detailed comparison has been given on how Medicaid negotiates its rates compared to Medicare and how private insurance companies get reimbursed.
The Kaiser Commission in 2012 conducted a survey and compared the state Medicaid physician fee with the Medicare fee and found out that the Texas Medicaid to Medicare ratio was 0.65. A similar kind of study was conducted for diagnostics tests by Miller et al in 1993 for Medicare vs private insurances and the ratio was 0.4577 for diagnostic tests.
Medicare has a different system of payment, it pays the hospitals for particular diagnosis which is called the Diagnosis-Related Groups (DRG). The DRG system was developed to identify discrete conditions or products that hospitals provided such as hip replacement or treatment for acute heart attack, and then provide a uniform price for providing a package of service, the objective is to encourage hospitals to be more efficient and to bear the financial risk for slow delivery of care or negligence in the provision of treatment.
A similar system can be followed in Pakistan, especially in the wake of the 18th amendment, with autonomous provinces there is a clear road towards making this scheme successful by negotiating rates at the district level with hospitals, doctors and medical laboratories. Regulators should be appointed to monitor the process and a system of prior authorisation should be established.
Before going for any procedure, a physician should be required to explain why it is necessary to do a certain medical procedure or why they want to keep the patient in the hospital for two extra days or why the patient needs the most expensive medicine when the cheaper alternatives are available.
For medication, physicians should only be allowed to prescribe the formulary medications and patients should be given a list of pharmacies under the contract to get lowest priced medicines at discounted rates.
In a country like Pakistan where corruption trickles down within hierarchical structures, the introduction of insurance cards, with no prior authorisation requirement for the doctor to get approval before starting the procedure, no special rates for private hospital rooms, where will we end up? We are well aware of the fact that how many doctors unethically do surgeries and conduct medical treatments every day just to make money.
A very strict accountability system is required at every step, standard operating procedures need to be followed otherwise poor governance, and mismanagement and inefficiency will crumble the system before we even know it and the only beneficiaries will be the healthcare providers like private hospitals and doctors.
Published in The Express Tribune, March 7th, 2019.
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