Wednesday, 29 November 2017

Straight from the heart: Affordable ICU Health care

Straight from the heart: Affordable ICU Health care

IMA is the collective consciousness of the medical professionals practicing modern system of medicine and is represented by over 10 lakh doctors directly through its members spread over 32 State Branches and 1750 Local Branches and through FOMA (Federation of Medical Associations of India).

Through WMA, IMA is linked to 112 International Medical Associations.

The main objective of IMA is to provide affordable, available, accessible and accountable quality and safe health care to the public through its members in a stress-free environment.

The recent Fortis issue has opened a debate on finding and fighting ways to reduce the cost of intensive care.

How can affordable health care be achieved?

·         IMA is fighting with government for one price one drug one company policy so that cost of 80% of medicine can be reduced. Medicines account for 80% of the total expenditure on healthcare. The government allows the same company to sell the same quality drug at three different costs.
·         On lines of Delhi Government policy, patients should be allowed to bring medicines from outside.
·         Only NLEM (National list of essential medicines) drugs should be prescribed and patient must be explained if any non-NLEM drug is prescribed
·         IMA is for providing all emergent services to people which are not within the reach of state government.  This can be subsidized by IMA members but should be reimbursed by state governments. 
·         Medical profession is not a business and all doctors provide reasonable subsidy to their patients. To continue this subsidy they are entitled for non-commercial rates for water, electric and property.
·         IMA is for bringing preventable deaths to zero and for that IMA recommends that every preventable death should be audited to find what went wrong so that another such incident does not happen again.
·         Cost of emergent medical care in ICU is 200% on first day of admission, 100% on subsequent days and 150% in critical ill terminal patients. Most patients cannot afford terminal care in tertiary care hospitals and this care therefore should be subsidized by the government.
·         Do not resuscitate (DNR) policy should be enacted by the government so that once a patient develops brain death and/or is in a condition of no recovery, ventilator care can be stopped.
·         Hospitals should not charge for providing two new bed sheets after the death of a person.
·         At admission, weightage should be given to outside tests if done in last 24 hours. These tests need not be repeated.
·         In all corporate hospitals, DNB and nursing school should be compulsory so that PG DNB residents and Nursing students are available to serve in ICUs.
·         MCI or DNB should permit one-year training fellowship courses in intensive care in these hospitals to reduce the cost of staff. 80% of the cost of intensive care is on fixed cost with 50% on the staff salaries.
·         Better standardization of care practice though protocols and care pathways.
·         Protocolized care for sedation, analgesia, glycemic control, ventilator management, and liberation from mechanical ventilation have been shown to reduce variation and improve the outcome of critical illness.
·         Staffing the ICU with a multidisciplinary care team under the supervision of a trained intensivist. Fewer routine care decisions are in the hands of a single individual, ultimately reducing unnecessary variability. For example, pharmacists and respiratory therapists can standardize length of antibiotic courses and use of low tidal volume ventilation for patients with acute lung injury
·         The frequency of laboratory and radiological tests, the use of generic versus name-brand drugs, and the specific indications for transfusion are all opportunities for physicians to reduce variation in the process, and cost, of care.
·         Cost control is not just the task of the health policy expert or the hospital administrator, it is also the task of the individual ICU clinician. 
·         Three areas for improvement.
o   Standing orders for laboratory studies, ECGs and chest x-ray films to be eliminated.
o   Protocols to be developed for the appropriate use of sedation, analgesics, and neuromuscular blocking agents.
o   Protocol for weaning from mechanical ventilation should be developed to allow respiratory therapists to proceed through the weaning process
·         A significant method of controlling ICU costs is closely monitoring which patients are admitted and when they are discharged. Lab tests represent a source of cost reduction, and physicians must learn to order specific tests and not simply a battery of tests which includes the actual test desired. Limits should be placed on the tests that are ordered in terms of number and frequency.

·         High-dependency units (HDUs, synonymous with intermediate care units, intensive observation units, step down units) or recovery rooms (post-anesthesia care units, PACUs) can undertake many of the traditional roles of the intensive therapy unit (ITU) at a fraction of the cost, because costs per patient day are considerably lower in the HDU (PACU) than in the ITU.

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