The current healthcare reform debate and the healthcare system it seeks to change are full of bittersweet ironies.
The race to reform the system follows on the heels of spiraling healthcare costs. Almost two decades of investment and reliance on advanced biomedical technology have fueled explosive growth in healthcare costs.
One of the ironies is that the bulk of expenditures occur at the end stages of life and thus do little to enhance primary and preventive healthcare. As a result, it can be argued that our much-envied "state of the art" health system doesn't meet the basic healthcare needs of many Americans.
In fact, it's truer than not that the lack of access to basic healthcare services-checkups, immunizations, well-baby care, health screening services and the like-has created the healthcare crisis in America.
But we're proud of our country's system, and there can be a tendency to view it as superior to other countries' efforts. For example, the healthcare system of Ukraine is undercapitalized and low cost when it's compared to ours. Those factors have forced that system to focus on home visits and emphasize primary and preventive care-all its citizens receive free care from a primary-care physician, including gynecological services for women.
The irony, of course, is that Ukraine's system, with all its constraints, is in the general vicinity of where we're attempting to bring the advanced American healthcare system.
Maybe Ukraine has something to teach us about how to build a system that's based on the premises of a family doctor for all and regular, preventive and primary care for all citizens.
The healthcare system in Ukraine historically has been hierarchical, with health budgets for regional and local governments allocated from the national level. In 1992, the system was reformed to decentralize the healthcare budget and bring allocations down to the county-or Oblast-level.
In principle, it's a highly integrated single system of publicly owned polyclinics (which provide a wide variety of services), hospitals, pharmacies and sanitariums. All Ukrainian citizens receive free healthcare, and all healthcare workers, including physicians, are salaried public employees. Hallmarks of the American healthcare system-physicians in private practice and private health insurance-are in their infancy there.
Compensation for Ukrainian physicians is tied to the district population, the number of home visits they do and the volume of services they perform in polyclinics. Because health services has been categorized as a "non-productive" sector of the economy, physician compensation is relatively low, compared with the pay for other types of jobs.
In an effort to reform the Ukrainian system, one of its physicians developed a pilot project that features a prepaid healthcare plan modeled on Western managed-care plans.
The employer-based plan, Family Medicine Insurance Ltd., serves one city and features a benefit package that includes 24-hour coverage for ambulatory and inpatient care, prescriptions, home care and other services. It's organized around primary-care physicians who serve as gatekeepers to manage access to services. Employers contribute 20% of the monthly payment to the plan, while the Oblast provides the remainder to cover employee and dependent coverage. Some services require copayments.
It's interesting to compare the Ukrainian plan with New York state's Medicaid managed-care program. Both are based on access to comprehensive coverage 24 hours a day, and both are organized around primary-care gatekeepers. However, the Ukrainian plan is much less structured. In addition, the low cost of acute-care services in the Oblast doesn't make it necessary to try to control costs by limiting utilization.
Other significant differences exist. The Family Medicine Insurance plan doesn't have a well-defined structure, as does the New York plan. Also, it lacks guidelines, which New York has, that ensure comprehensive, high-quality and timely care. New York's plan places more emphasis on supervising and coordinating the full range of healthcare provided to the enrollee, which aids in preventing inappropriate use of services.
But the most striking differences in the plans are financial and budgetary. The Family Medical Insurance plan's budget isn't tied to the cost of treating patients. Ukraine doesn't have an information system to track costs, while New York's plan can draw on the state's Medicaid data base to get the historical costs on which to make projections.
Also, the Ukrainian plan isn't able to address quality assurance issues, license and accredit physicians or establish practice standards.
Much of this is to be expected as Ukraine moves out of the past. The Oblast's model doesn't offer a panacea for America's healthcare ills.
However, Ukraine's plan does provide a reform model that's based on the promise of universal access to comprehensive, primary and preventive care.
Perhaps the highly integrated single healthcare system in Ukraine provides a framework for a more rational approach to the delivery of care and allocation of resources in this country.
Terry West, assistant vice president for HHC's office of strategic planning, also contributed to this article.