Thursday, October 15, 2009

Is it possible that Thailand is ahead of the US when it comes to health care? - Part 2

Last time we outlined the inner-workings of Thailand's health care system. Today, we will explore problems within the system and finally examine where we stand compared to the US. Hopefully with all this information you can decide who will emerge on top, maybe 20 years from now.

What are the problems within Thailand's health care system?

1. Lack of oversight - many parts of the system operate haphazardly because the government lacks power/money to impose appropriate control. It does not have enough money to compete for young doctors for underserved areas with rich private hospitals in big cities. The residency process is largely unregulated - with more spots than the number of applicants, graduates flock to high-paying specialties, leaving primary care unattended. Because supply is higher than demand, no one could be forced into primary care spots, and the gov't can't incentivize young graduates with the money it doesn't have. There are no regulations on quality control within health care facilities, but that does not say much considering most hospitals in the US or any other country let doctors practice haphazardly without quality control either.

2. Lack of human resources - there are not enough nurses or doctors to go around. It doesn't help that most of them concentrate in city private hospitals with higher pay, but even if we were to spread them all out, the ratio of doctor/pt is still a whopping 1 per several thousands, which explains long lines at governmental 30-Baht hospitals. The bottleneck is with the limited capacity of major medical schools and also the lack of incentives to persuade doctors to serve understaffed rural areas. It is also precarious that new, inexperienced medical school graduates are sent to rural areas where they are left to their own devices without much supervision to treat patients - great clinical experience should not come at the price of patient safety.

3. Money problem - the current reimbursement system has some good qualities built in, but it is far from perfect. Here we return to age old debate on the pros and cons of various types of payment schedule: fee-for-service, capitation rate/salary, DRG, etc. The capitation rates paid to starting point hospitals is a good thing - it encourages consolidation of medical records, reduced transfer of care, a focus on primary care to keep people healthy and reduce cost/utilization. However, the capitation rates are too low, forcing major hospitals into the red as their popularity draws in 30-Baht customers. Doctors consider giving less care to prevent their hospitals from going bankrupt thereby losing their jobs in the process, since there are no quality control or incentives to consider quality other than their self esteem. Lack of facility fluidity in emergency situations is another problem - starting point hospitals and "emergency" hospitals engage in turf wars trying to rid cases of catastrophic accidents, since the costs usually exceed that paid by DRG rates.

4. Lagging medical curriculum - medical schools focus on multiple-choice test scores instead of knowledge application/acquisition and quality attributes that make you a good doctor, such as professionalism, communication skills, etc. They are aware that good test scores do not translate into good doctors, but they claim that without fair and effective measures for these attributes they must rely on numerical outcomes (which is true - what we use in the US is mostly arbitrary, US medical students just have no rights/say in the matter like Thai medical students). There is not enough focus on patient interaction or a comprehensive approach to health care (not that US doctors do), and the lack of role models like their professors or attendings on the floor does not help the matter. Evidence-based medicine is constricted by lack of adequate access to journals, lack of English proficiency, and lack of statistical knowledge to critically digest and understand journal articles, both in teachers and students. Students are overwhelmed by lectures focusing on memorizing knowledge that will become obsolete by the time they graduate, leaving no time for extracurricular activities that cultivate maturity, self-empowerment and leadership. With test scores as the only carrot on the stick, students become walking, obsolete textbooks who barely talk to patients and lack the ability to acquire new knowledge.

5. Low quality of care - doctors are usually only as good as their medical schools. The aforementioned problems in medical curriculum, combined with lack of money/oversight/human resources, result in low quality of care. The system is overwhelmed with new patients who with a snap after 2001 become eligible for care. Doctors never learned how to talk to patients, and now they also do not have the time. Lack of quality control/quality incentives does not help doctors synthesize and come to a realization that counseling their patients is more important than getting rid of them from the clinic to finish a day's work, for they will come right back with more problems, increasing costs for the whole hospital.

So where does that put us?
At the beginning of part 1 I mentioned that I had the opportunity to speak with a few local authorities in Thailand's health care system, one of them being the CEO of one of the three major hospitals in Thailand. We spoke at length comparing the pros and cons of our systems - I told him about incorporating lean manufacturing in hospital management and he was intrigued. A few days later as I was walking around the hospital, I in turn was even more intrigued to find that there was already a lecture on using lean manufacturing in hospital management taking place that week - most US hospital CEOs wouldn't know what lean manufacturing is.
I mentioned the above example to illustrate a point - Thailand has been aware of the right ideas for a long time, sometimes before the US, but they never materialized due to faulty implementation. We know lean manufacturing can be used in health care management, but if the hospital CEO never heard of it, the implementation is doomed. We know test scores measure nothing, but we haven't tried to find better outcome measures that encourage students to focus on becoming a good doctor and not a textbook. We know capitation-based payment is creating problems, but we have not learned to devise a scheme that draws from advantages of various payment schedule to achieve high quality (but neither has the US). We realize the importance of community integration, but our well-planned community-based health care system lacks doctors who recognize the importance of primary care with enough conscience to stay in rural areas and refuse to waste their talents in overstaffed private hospitals. We know primary care residency needs to be boosted, but no organization has stepped in to make that happen.
That's where Thailand stands, and I think that's where the US and most everyone else stand. Providing quality care is not rocket science - we know exactly how to do it and we've known it for years, but we have not achieved it for various reasons. In Thailand I think it is due to inexperience and lack of good management, but in the US I think it is mostly due to incumbent parties who fight inhumanely to keep the status quo and the money that comes with it. I personally think inexperience is easier to get rid of than big pharmaceutical companies, but we might find out in a few months if I'm right.


  1. Hmm. may be, may be not - let's wait and see.

    Good one ja.

  2. Interesting thoughts krab :) Healthcare is one of the most complex systems the world, where many stakeholders take part and that is where the problems start.

    The way we see the problems depend on where we stand and with your background I'm not wonder why you can come up with such viewpoints.

    I mostly agree and would encourage everyone not just let it go, we need a healthcare reform too!

    Looking forward to seeing your next articles ja :)

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