Saturday, April 7, 2007

Invest in Health - Action Plan for the City of Mumbai 2007

by Dr RD Lele


The slogan for the World Health Day, 7th April 2007, is "Invest in Health: Build for the Future".
The WHO has defined health as a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity. India has a long tradition of Health Care. Ayurwveda (literally meaning. Science of Life) clearly stated 2500 years back that the aim of medicine is three-fold: Promotion of positive Health; Prevention of disease; and Treatment of disease when it arises. One new component as part of treatment is rehabilitation.

While talking of "Health Care" most people ignore the promotive and preventive components and concentrate only on the curative components. "Health Care" has therefore become "illness Care". The so-called Health Care Industry also is concerned with illness care, pushing the importance of promotive and preventive function to a poorly neglected secondary position.

Health maintenance and disease prevention need a partnership between the family and the family doctor who is a teacher and guide. Health is not a commodity that can be purchased. It is an asset to be assiduously maintained with care and effort, by following rules of conduct regarding diet, exercise and behavior, for which the doctor acts as a teacher and friend, philospher and guide. The word doctor is derived from docere (to teach). The current terms such as "consumer" AND "provider" of health care are repugnant to the concept of doctor patient partnership based on trust (fiducial relationship).

Urgent Need for paradigm shift in India

Since 2004 I have been emphasizing the urgent need for a paradigm shift in our approach to health care.
The introduction of pre-paid group praclice under an HMO (Health Maintenance Organization) necessitates a paradigm shift from the current fee-for-service pattern of medical practice in India. In the new paradigm health insurance is an integral component of an HMO and managed care. The paradigm shift encompasses:

  1. Change of emphasis from disease management to health management.

  2. Shift of focus from curative to promotive and preventive aspects of hcalthcare and create the infrastructure especially for health education of the general population. The periodic health checks and health education undertaken by the family physician (FP) are given in Table 1.

  3. Change in the mind-set of the medical profession: self-discipline and social conscience to support the concept of HMO and '''managed care", especially for the poor segments of population in urban slums and rural areas.

  4. Spread awareness among the general public including organized corporate sector as well as individuals, regarding the need to become members of HMOs to get managed care as well as insurance cover for catastrophic illness, and life insurance for the earning members in the family.

  5. Micro-financing linked to microinsurancc is actively being pursued as a strategy to enable the 70 lakh poor citizen of Murnb8.i to participate in the HMO.
HMO - Pre Paid Managed Care

Health Maintenance Organization (HMO) providing prepaid managed care linked to health insurance is the new paradigm for health care in the 21 st Century. The medical community assumes leadership and accepts responsibility & accountability in the HMO concept.

The distinguishing features of HMO-managed care are:

  1. Financing and delivery of health care through per capita pre-payment, so that the physician organization has a budget for the carc it will provide and an incentive to use the resources wisely.

  2. Maintenance of continuous healing relationship of the family physician (FP) with the voluntarily enrolled population (l FP for 500 - 1000 families), to provide promotive. preventive and curative care to 3000 to 6000 individuals for which the FP will be handsomely remunerated - 1 lakh pm.

  3. Physicians and multi-disciplinary specialist teams can design and execute best care processes, in a most cost-effective manner.

  4. Hospital facilities, complex diagnostic equipment and laboratory investigations can be deployed on a regional basis where it can be used with greatest efficiency and economy, backed by insurance cover.

  5. Electronic patient record (EPR) which provides an accurate and comprehensive picture of each patient. EPR avoids unnecessary duplication of tests, facilitales collaboration and coordination of care among specialties, and allows monitoring of compliance with the practice guidelines to ensure high quality of care.

  6. Computerized prescription in the patient's own language gives detailed instructions about how to take the drugs and alerts for adverse reactions. It eliminates medication errors and transforms the care process.

  7. Over-use and misuse of tests and procedures, so common currently, is strongly discouraged while early detection and prevention and early treatment and chronic disease management are strongly encouraged. There is great emphasis on patient education and information. Patients are encouraged to come in early and have their symptoms checked so that any potential illness can be treated sooner and at much less cost. Emphasis on prevention reduces the need for inpatient hospital care especially for Diabetes, Hypertension, Congestive Heart Failure & Asthma.

  8. The medical peer group, not an insurance company, determines the clinical policies, which technologies and procedures will be employed and covered under the pre-payment and health insurance.

  9. The medical peer group develop the drug formulary themselves. The drug selection is based on its therapeutic efficacy, safety and cost. Physicians have the freedom to over-ride the formulary to prescribe what they believe is medically necessary in a particular case. This approach is most effective in cost control. In the current fee-for service scenario of medical practice, new single source patent protected drugs are aggressively promoted by drug manufacturers with little head-to-head comparison with older, effective and often less expensive drugs. HMOs use evidence-based approach to promote drugs of choice.

  10. HMO-managed care will not only ensure the elimination of the widely prevalent gender discrimination against females, it will actually put major emphasis on the care of the mother and the female child & adolescent girl eg nutrition, menstrual hygiene, sanitary napkins, prevention of iron deficiency. sex education & prevention of STD / HIV, emergency contraception & family life education, women's reproductive health & promotion of breast-feeding. Care of the pregnant women will ensure that no baby is born with a birth weight less than 2.5 kg.
Action Plan for Mumbai

According to income groups, I visualized four categories of membership:

Card Annual income Premium
Bronze Card 40,000 – 60,000 2,500
Silver card over 100,000 5,000
Gold card over 200.000 7,500
Platinum over 500,000 10,000

The HMO will tie up with:
  1. Insurance Company for 5 yrs. for an annual premium of Rs. 11,001- per family (Bronze) and proportionately higher amount for the other categories.
  2. Family Physicians and Specialists.
  3. Labs and Diagnostic Centres.
  4. Drug and Pharmaceutical Cos., for discounted rates (bulk purchases).
  5. Life Insurance Co. for providing the (group) cover to the earning member.
  6. Service Provider for 24 hrs. assistance and other eg. Blood etc.
  7. Hospitals & nursing homes.
I am happy to note that the new president of IMA Mumbai, along with his team and many past presidents, had publicly committed full participation in implementing the Action Plan immediately. IMA Mumbai can give the lead for the rest of the country in this mission, "Invest in Health: Build for the Future".

  1. Lele RD Editorial. Health Insurance as an integral Component of Health Maintenance Organization (HMO); Urgent Need for Paradigm Shift. JAPI 2004 Dec. 52. 947-950.
  2. Dr R. D. Lele. Towards a 21st Century Health Care System : Leadership Role for API. Guest Lecture Delivered at the Diamond Jubilee API Conference 2005.

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