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This page created April 2000 by Michael Wynne
This page examines the idea of providing
health care to remote communities and the culturally underpriveleged
using a competitive market system and corporate providers. The ideas
are unrealistic and take no account of the context in which the local
communities live.
Access:- In promoting his market model of health care to the World Bank one of Graeme Samuel's objectives is "access" - getting the services to people. One of the main problems in Australia has been the difficulty in providing health service to remote communities and to Aboriginal communities. Developing nations have an even greater problem. The problems in both communities are not only distance, sparce populations and local wealth, but cutural.
The market follows money:- Current contracts have all been awarded in populated areas. The idea that the market will provide services in remote areas and in less affluent communities is an illusion. Those who tender will ask for large government subsidies and/or contracts which offer sufficiently large inducements to get the companies there. They will look to providing extra services to increase profits, rather like aged care nursing homes in the USA did with therapies. Government will be beholden to them so they will effectively have a monopoly. Government and the local population are likely to be milked.
Contracts:- In a system based on
contracts companies reduce their tenders to a minimum to secure the
contracts. Without them they have no business. Companies are forced
to lodge low tenders in order to survive. This is how government
costs are controlled. Companies respond to profit pressures and when
the company, as so often happens in this situation fails to make the
expected profit there are very strong pressures to compromise on
care. The US experience shows how readily this happens - note
particularly Tenet/NME, Sun Healthcare, Vencor, IHS, Aetna and
Kaiser. We already have problems of access in the bush and Samuel's
solution can only make them worse. Providing access under contracts
does not ensure that the sort of care required will be provided.
There will be endless cost cutting. I suggest that we will end with
something which depends on continuous intense policing of a health
system intent on outwitting the policemen - what a wonderful society
to live in!
Policing Access:- Experience with health care corporations and oversight processes reveals that even when intensive oversight processes have been set up they have not been maintained as the glare of public scrutiny wanes. Oversight procedures in a health care marketplace have not and will not work effectively to protect citizens, although they will often claim that they have done so. To provide and maintain the required level of oversight across the whole of Australia is simply not practicable.
To suggest that governments will fund and maintain such intense oversight procedures across the developing world is stretching credulity beyond reasonable limits. When set beside this a not for profit community based system which is built on genuine human emotion and commitment glows with appeal.
The contracting of care in underpriveleged or remote communities to private shareholder owned groups is reminiscent of the wishful logic of Andrew Turner's unrealistic advice that government should "butt out". It should contract services for non-paying patients to corporations and then leave the market and competition to sort out quality of care. His words have come back to haunt him. Economists in Australia do not advise government to butt out but see government as regulating and controlling the adverse consequences of market pressures. The idea of groups like Columbia/HCA, Tenet/NME or Sun Healthcare contracted to provide services in the bush and in developing countries which have limited infrastructure and no experience in oversight is mind boggling.
That the rhetoric about regulation and
control is equally unrealistic in Australia is revealed in the debate
about regulating what
food nursing homes buy for the aged.
How can we regulate effectively across the whole of Australia - each
remote aboriginal community? The success of Samuel's model,
particularly regulation and surveillance depends on people
distrusting one another. We simply cannot build a society in this
way. We do have to be able to trust one another. The reliance on
market mechanisms is fueling distrust.
Competition in the Bush:- I do not believe that there can be any real health care competition in the bush. People simply do not think that way and it is not appropriate for that environment. They live as an interdependent community. It has been and is likely to continue to be a case of enticing services to the bush and those who provide services will bend to the practices and beliefs of the local communities. The problems in cancelling or changing contracts when their conditions are not met will be akin to those in closing nursing homes. Such a policy will create a legal minefield of disputes. The unfortunate patients and the community in the bush will be the meat in the sandwich.
Alternative Solutions:- Wouldn't it be better to have a motivated and integrated community service based on the local community and their involvement. Local care would be supported by service subdivisions, each motivated to provide an equitable service across the community using modern technology to stretch human resources. It is so much simpler and there would be no pressures to encourage bizarre practices for the benefit of shareholders rather than patients.