Meaningful Family Medicine as the Foundation of a Health System
The goals of all healthcare systems boil down to providing quality care and saving lives. Dedicated doctors, who are familiar with their patients, are central in this mission and are the heartbeat of family medicine.
Prof. Ernesto Kahan has been working internationally with health systems for almost forty years. He shared with us why meaningful family medicine should be the foundation of a health system.
Meaningful Family Medicine
The most important aspects of family medicine are the continuity of care for the patients and their relationship with the family doctor. The doctor is able to guide tough decisions, like which physician or specialist to see. “The patient doesn’t feel alone,” says Kahan, “and the system does not feel far from the patient.”
In many countries, Kahan explains, doctors have no choice but to jump from one job to another in order to earn the same amount of money that they could receive in one place in a full time position. For doctors to be fully dedicated to their patients, however, they must work in one family clinic. There cannot be continuity when the doctor is different at every visit.
Such a dedicated relationship is the best way to ensure primary prevention (early detection and care). Investing in primary prevention saves more lives and, for health insurance systems, it saves money.
Health Insurance Systems Based on Family Medicine
When family medicine is not the basis of health insurance systems, coordination between the components (doctors, clinics, etc.) in the system is quite low, and so is patient satisfaction. Kahan recommends that the family practitioner and clinic act as the organising body on behalf of the patient.
Case Study: The Revolution of Healthcare in Israel
In Israel before 1995, four major HMOs provided healthcare. 5% of the members’ salaries went to the HMO they belonged to. As the population was quite poor at the time, only a small minority could afford private medicine.
According to Kahan, at the time about 80% of the population belonged to the HMO Kupat Holim, which suddenly filed bankruptcy. The government had to intervene.
Dr. Kahan was involved in the many discussions that took place in the Knesset (the Israeli Parliament) and in the creation of the model that followed. It aims to provide equal quality care for every citizen.
1. Obligation - It is obligatory for every citizen to choose a health provider among the four HMOs.
2. Capitation - 5% of salaries are paid to the national insurance organisation, which in turn pays each HMO according to the number of members. The HMO receives an equal amount for every person regardless of salary, so that no one receives preference over another.
3. Freedom to Elect the Provider - Members may change their provider without charge once a year, which increases quality and satisfaction.
4. Freedom to Elect the Family Doctor - Members can change their doctor every six months if they are not satisfied. The doctors pay close attention to this, as they receive extra money for the number of patients they have, an amount that may be more than their salary.
5. Doctors are limited to treat only a maximum number of families - “No matter how dedicated the doctors are,” explains Kahan, “they cannot provide quality care if they treat too many patients.”
6. The budget for primary care (family medicine) is about half of the health budget - In many other countries, around 70% of the budget is allocated to hospitals. Investing more in primary care prevents pricey secondary prevention (when a disease is known) and tertiary prevention (of complication and death) – saving lives and money!
Improving Coordination and Equality in the System
There is a system in place for the annual transfer of money to medical institutions. The HMO transfers payment annually to hospitals and clinics that serve the patient. The HMOs themselves receive a budget per capita, so every person is equally important.
Dr. Kahan explains that while it seems complicated, it is actually quite simple. How to establish such an arrangement is among the methods he teaches in his Health Systems Management programme.
“As in all countries, there is never enough money for healthcare,” says Kahan, “But if we can find a cheaper way to provide better care for everyone, we must.”
