Reforming Health Insurance
so, too, would care that is not cost-effective, especially where treatments are used for which a cheaper and equally effective treatment is available. VSS would also want to look at how care is delivered, ensuring, for example, that relatively sophisticated care is delivered by clinical teams that are specialized, rather than having all providers deliver all possible interventions. One strategy for VSS to promote good-quality health care would be to require that providers follow clinical guidelines. The “clinical pathway” is an attractive way of operationalizing clinical guidelines. For a given clinical condition, the pathway spells out what steps need to be taken on each day for a typical case. The medical staff, having taken the appropriate step, signs the pathway document. If deviations are required, they need to be justified. A copy of the pathway can be made available to the patient, which has the merit of making the patient feel more confident that the treatment decisions are based only on medical considerations. More important from the financial perspective is that a copy can be supplied to the insurer or payer, which provides them with a tool to check the reasonableness of the provider’s bills. The MOH has already begun exploring the pathways approach, and is planning a pilot scheme. The design of case-based payments could be linked to the pathway approach. From pathways, “normal” or “benchmark” costs could be calculated that reflect the resources required to treat patients optimally—not the resources currently used, which could be too many in cases where patients receive unnecessary tests and too much care, or too few when patients are discharged too early and “undertreated.” Of course, it may be desirable to start with more generous diagnosis-related groups (DRGs), and only gradually reduce the DRG to the rate indicated by the pathway exercise. VSS has already started experimenting with DRGs, and the MOH has done some analytic work of its own.
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