I was told by one of the local residents that pediatric death due to septic shock is a huge problem. Children coming into the ER in Port Au Prince are carried on foot by their parents, assessed by the physician, and then the family (in the case of sepsis) is told that rehydration (a bag of saline) is needed. The family then gathers the funds to go to the pharmacy across the street, buy the saline (hopefully only one bag is needed), and return to the hospital in time for the patient to be treated. The bag costs the equivalent of 15 US dollars, think about this in light of the fact that dinner at a glamorous Haitian restaurant in Peytonville (the most affluent neighborhood) costs 5 US dollars a person. Many families can’t afford to purchase the rehydration solution necessary to save their child’s life. In other words, the payment scheme in place in this hospital leads to the death of 3-5 children a week.
None of the patients treated at this hospital have insurance. I wondered, given this blank slate, what payment scheme I would choose to put in place. Fee-for-service payment methods pays the physician based on the number of procedures or interactions had with the patient. I imagine this would be difficult to measure in a country where procedures and services are not distinct like an EKG. The down fall with this plan is that US physicians have been found to overprescribe, although I doubt that Haitian physicians would be found to recommend in excess because of the overwhelming shortness of time and resources present.
What about paying the physician based on the number of patients they have, referred to as capitation? In the US this method is appreciated because it sets up a financial incentive for the physician to keep his/her patients healthy because he/she is paid regardless if the patient is treated (and a healthy patient requires less work for the physician). Would patient outcome in Haiti benefit from their physicians having a financial incentive to keep them healthy? I don’t think this is necessary.
Currently, Haitian physicians are salaried. I found them intelligent, empathetic, realistic and hard working. I heard about a few residents pooling their money the night before I came to purchase a bag of saline for a particular patient they felt invested in. These physicians worked long hours, traveled through dangerous neighborhoods to get to work, and battled the enormous frustration of trying to practice medicine in an environment defined by lack of resources. The way in which they were paid seemed irrelevant, and my thoughts on how to improve care in Haiti were focused solely on how to improve care for the patient, not on strategies to motivate the good intentions of physicians.