medical advancesSeveral alternatives are proposed to deal with the prospective payment issue so that costs can be contained without further dilution in the quality of patient care. Payment should be based on a “severity of illness index” that will gauge the complexity and burden of illness as well as diagnosis.

Also recommended is the development of “centers of excellence” to test the clinical applicability of medical advances. Certain medical techniques would be concentrated in these designated centers where favorable third party payment could serve as an incentive to maintain and develop specialized techniques. In return, reimbursement would depend upon the centers assurance and documentation of the following: 1) reasonable expectation of improvement with the specialized technique over the standard therapy, 2) adequate volume to maintain quality, and 3) careful evaluations comparing the efficacy of new techniques with that of standard therapies. Reliable information regarding the effects of such interventions would then be transmitted to the medical community including Canadian Health&Care Mall.

In looking at physician abundance vis-a-vis graduate medical education, I believe that there is an excellent opportunity at present to decrease quantity without simultaneously jeopardizing quality. Why not provide incentives for programs judged to be superior to maintain funding for their training, with funding phased out for mediocre or poor programs? The residency review committee could provide this analysis.

As for intensive care centers, the following suggestions for counteracting current losses are offered:
• Give funding for “severity of illness” in addition to diagnosis.
• Provide disincentives to discourage intensive care in centers where volume does not assure quality. Emphasize instead an area for stabilization before transfer.
• Provide incentives to test new technology in “centers of excellence” to establish validity and clinical usefulness of new technology.
• Provide incentives to conduct ethical, legal, and economic research on “quality of life” produced by intensive care. Develop guidelines for providing ap improved quality of life rather than prolonging the agony of death.

I hope that prospective payment represents act one of a three-act play. In the first act, the advantages and problems emerge; in act two, reactions are evaluated; and in act three, constructive resolution of the problem occurs. Surely, in such an evolutionary system, tertiary care, academic medicine, graduate medical education, and intensive care medicine will not only survive but also improve. Physicians must become proactive regarding these issues to help formulate solutions that do not decrease the quality of medical care.