Hello all - been a while. I’m putting another thread - not just to rant but also to genuinely find solutions. The situation: an unfortunate side effect of bureaucratic medicine with multiple “silos”. It is best described as #NotOnMyBudget. The impact to care: no care delivered.
I must first acknowledge that this term was proposed by a colleague and friend, and just describes the problem so succinctly and perfectly that I had to ask to use it publicly. I wish this was my brain child, but alas, it is not.
So what‘s the situation?
So what‘s the situation?
In single-payer medicine administration, budgets from a central pot are allocated to different areas/services. This can be service specific (ER vs ward), regional (different cities), etc. Let us consider these "pots".
Each individual budget or “pot” typically has a manager of some description who is responsible for delivering care with the finances they have while trying to stay within their allocated budget. It is “their” pot.
These managers typically have to answer for overages, and theoretically their position could be at risk. If under however they are typically “rewarded” with the next budget being reduced by the difference. The result: only status quo flies. Budgetary protectionism.
The issue: it becomes extremely difficult to ask more of a “pot” in one area that will ultimately have overall savings to the larger “pot” and other area “pots” to deliver optimal care in certain situations. No incentive to innovate the continuum of care if it raises one budget.
Essentially, each manager is a steward of their individual pot and don’t want their budget stretched even though there is demonstrable overall savings to the system as a whole. Basically, be innovative on someone else’s budget. #NOMB
I don’t want to paint these managers as heartless; I understand they have their own pressures. Usually when I’ve come against this barrier there is usually some sympathy, but still an unwillingness to move forward.
Here is an anonymized example of how frustrating this can be by describing a situation I was made aware of. But first to “set the stage” with a little bit of background:
For many communities they require a “locum” specialist to periodically help the local MDs cover the on call requirements. These are usually smaller communities with limited numbers of specialists (often just 1) per institution.
There is often a separate “arm” of health care finances that are dog-eared for these services. These funds ultimately still come from the much larger “health care” pot that the remaining provincial finances come from.
Additionally, for remote communities there are often travel grants for those who require services not provided at home to provide finances to partially cover the expenses of travelling to receive care elsewhere – usually tertiary centres.
Finally, in most hospitals there are OR budgets which are difficult to predict and are ultimately volatile. This can include purchasing capital and disposable equipment, nursing overtime, hires, etc. These budgets tend to be watched incredibly closely.
Enter our example: There is a locum surgeon who has a sub-specialty interest and the skills to perform specialized procedures on top of their general work. There are patients locally who could benefit from their skill-set.
For clarity, the procedures we are talking about do not need tertiary centre supports (specialized anesthesia, intensive care units, etc) and the only part that is “specialized” is what the surgeon brings.
The separate arm that recruits and reimburses locum surgeons have already brought the surgeon to the community, and that cost is fixed regardless. For coverage reasons it is necessary.
Since the surgeon has identified that there are patients locally they could help, and the waits for care in the tertiary centres are in excess of 2 years, they approached the hospital to provide those services while they are there.
Would this require some additional equipment for the OR to purchase? Yes. Is it an exorbitant expense? No. Does this OR already purchase equipment regularly that is more expensive? Absolutely.
The cost to the system overall for the procedure itself is fixed whether it’s done in a tertiary centre or in a smaller community. You could argue the cost of a tertiary centre inpatient bed is probably more expensive.
The response from the managers involved? It was a procedure that had not been performed there in a long time, and did not want the additional expenses that would be required to disrupt their budget. #NOMB
Their recommendation? “Although it is inconvenient, there are travel grants and they can wait for care in <tertiary centre>.” For clarity, this travel will require flights, hotels, meals, days off work per visit – not just a drive.
So in essence, it seems to be preferable to spend the $ on travel grants, have the patient spend on travel (incomplete coverage), and have the local employer lose an employee for days per visit and OR, than to push an OR budget.
In running the numbers, the additional cost to travel for care to the system (nvm the patient) works out to roughly 2.5-3x the additional cost the OR budget would have to cover to have it done locally. An opportunity for efficiency
However, the managers involved have stood firm, and the surgeon (and the local patients) have been denied the opportunity to have their care performed locally when the expertise is literally sitting in their hospital.
Further, it would be more fiscally efficient to the system to provide the care locally. It would also have huge benefits to the patient to not need to travel, have family nearby, and not be so far from home. #patientcentred
So my question to the more experienced medical administrators out there: how can we work around the #NOMB mentality? How do we demonstrate the fiscal efficiency when everyone is focused on their “pot”?
As a further point for discussion, I wonder how many other similar “outside the pot” efficiencies we might find if we could consistently look for them? It may be a new way to manage our fixed healthcare budgets.
The timing of this tweet to line up with when most institutions are doing their fiscal year planning is of course intentional... #NOMB
