Noble goals and outcomes, decision trees and healthcare finance
Part 1: Noble Goals and Outcomes
Consider…
Dr Saad Aswad, a senior consultant gynaecologist and oncologist – the only specialist of his kind in the UAE, says….
“We need to do something to protect the women,” Dr Aswad said. “Cervical cancer is a cancer we can prevent. Why are we not doing this across the country? If the Ministry of Health introduced it, I think everyone would follow.”
While schoolgirls in Abu Dhabi are offered the Gardasil vaccination for up to Dh50 (US$13.60) for the required three doses, it can cost up to Dh1,900 in Dubai and is not as widely available in other emirates.
Dr Aswad said the preventive vaccine should be available across the whole country. “We must push for this to be nationwide. It is much easier to implement prevention than cure.
or
OK…maybe not all. How bout just the young ones? Consider Ireland….
Girls as young as 12 could be vaccinated against the sexually transmitted virus which causes cervical cancer from next year following a strong recommendation to Health Minister Mary Harney yesterday.
The report of an analysis by the Health Information and Quality Authority (HIQA) also recommended a once-off catch-up programme for 13- to 15-year olds in the first year.
It estimated the annual cost of the vaccinations, which would be free to around 30,000 children, would be €9.7m and the the once-off catch-up for around 60,000 girls would be €29.2m.
It conceded the vaccination was a “long-term investment” and the improved health outcomes would not be seen for another 15 to 30 years as the girls age.
or
just those who can afford?
Noble goals: As prominent physicians, altruistic in the call of duty, faithfully adhering to the Oath sworn upon graduation, promote mass treatment or screening programs in an effort to improve humanity’s health at all costs, increasingly frugal payers will decide what ultimately will be rationed out based on economic factors relating to a set of potential outcomes.
Outcomes: The critical first question is who will determine what the appropriate outcomes are and how to assign relative values to them? Remember of course, that this discussion is only relevant for a society or company that chooses to pay for the health needs of its citizens out of a fixed resource pool. If, after understanding the risks and benefits, individual consumers wish to pay for services themselves, then power to these people. There are potentially four different agents representing different points of view on outcome priority which will demand a seat at the table. How important is each and will all opinions be weighted equally?
1) Patients:
Outcome priority:
The patient’s priority will be I want to be protected as best possible against all, and treated/cured against any. As life is precious, it is my right as a human being to have equal, immediate and full access to the best the healthcare profession can offer. And preferably the cost is minimal.
The ultimate healthcare consumer will have an opinion for sure though my view is this opinion should be weighted the least UNLESS the patient is willing to bear responsibility for his health and not try to persistently outsource it to medical communities and governments. Attending to wellness, appropriate diet and regular exercise, abstinence from smoking and other evil mind altering substances, age appropriate periodic physical exams, compliance with treatment protocols, attendance to screening and vaccination programs…
Hmm whose responsibility is this???
Governments and physicians can educate but as the saying goes, “even if you lead the horse to water you can’t make him drink”.If you choose to smoke and subsequently develop COPD, lung cancer, hypertension, coronary artery disease, congestive heart failure then why in the world should anyone else pay for your fully educated but clearly foolish choice? If your parent unwisely decided to forego vaccination against polio or MMR for religious reasons or otherwise, who should pay for your disease management once you have contracted the easily preventable infectious disease? If you didn’t wear a seat belt while driving, drunk or otherwise, who will cover your surgeries and rehab for your broken spine and quadreplegia? Ok. Maybe a little extreme. My point is that patients must share in the cost at ever escalating levels based on the types and levels of risks they choose to take. Sound familiar….thats because it’s a methodology insurance companies have relied on forever to minimize moral hazard. Insurance companies should be able to charge much higher premiums and co-pays for individuals refusing preventive or precautionary measures or neglecting their health or for undertaking higher risk activities. I believe, for the most part, todays actuaries for health care insurance primarily consider age tables.
2) Healthcare Providers
Outcome priority:
The physician’s priority will be to do everything possible to improve the health and well being of patients with minimal consideration to cost, conflicts of interests notwithstanding (See Trust me, I’m a doctor). So far, agents 1 and 2 seem to be in complete alignment. The physician SHOULD always advocate on what is best for the patient and it is not the profession’s job to ration healthcare based on costs or any other factor. Physicians should lay out the potential options and their probabilities of success and society/consumer/insurance company will decide what they can afford.
Physicians have the extensive domain knowledge as well as years of invaluable experience understanding the subtle nuances involved in caring for patients and in rehabilitating the mind and body from illness. Unfortunately, they are human. The forever rapidly expanding body of knowledge with respect to diseases, the number and variety of investigation options and treatments are potentially overwhelming the ability of any individual to effectively keep perspective. Yes, there are evolving treatment protocols, and other enforced continuing medical education programs such as journal clubs and conferences, but it is far more likely that patients are investigated or treated by the particular protocol that a physician has been comfortable with through his years of personal clinical experience. Typically these won’t deviate from a range of what is considered the acceptable standard of care but, in the future, physician governing societies and specialist groups should create bodies which systematically survey the most recent research and create and adjust treatment protocols as the literature supports, and physicians should be compelled to follow these protocols unless a clear reason exists to otherwise. These groups must be independent of governments, insurance companies, and medtech/pharm manufacturers who should be prohibited from lobbying or marketing to these groups. This doesn’t mean there can be only one protocol per illness. In fact several options should be provided and then data should be mined to truly assess the efficacy of treatment especially with respect to cost.
3) Payers: Insurance companies, Employers, and Governments
Outcome priority:
To maximize shareholder value. Not much more to say except there will be occasions (understatement) when the interests of the payers will conflict with the interest of patients. This battlefield can be navigated by the physician guided treatment protocols I have discussed. For the former two, the emphasis is on earnings and usually the less spent on the delivery of care or any other potential cash outflow, the better, outcomes notwithstanding. However, asymmetric information is dangerous to the health of these entities (pun intended). One type of asymmetric information is patients withholding important health information. Unhealthy individuals (pre-existing conditions) need not apply. The second is a HUGE information/data gap on the health benefit/ cost analysis of various treatment protocols. The infrastructure is just not there until ALL data, clinical research as well as actual practice, positive outcomes, adverse outcomes, side effects, drug interactions, compliance issues and associated costs, is digitalized and can be mined for actionable information (See Leapfrog: The (hopefully) rapid adoption of HIS in Asia).
For governments, maximizing tax payer utility (getting re-elected) is the issue. This means there is an optimal trade off between forever increasing taxes to finance unlimited access to healthcare (See Healthcare finance: The Ultimate moral hazard), and the aggregate health/productivity benefit to society. It appears that this will also critically rely on the digitalization of medical records and all other health information. For society to decide who gets what at what price, we need to know the health benefit/cost analysis of the various treatment protocols.
4) Medtech, Big Pharma, Biotech and the Innovators
Outcome Priority:
Here comes the hard part. How do we do all of the above without stifling one of humanity’s most promising and innovative industries. Again, this group like #3 has a clear and overwhelming priority to maximize shareholder value. However in this case I believe that this is fully aligned with patient’s and society’s best interest, fraud notwithstanding. A pharma, medtech, or biotech company will make megaprofits ONLY when their products have been shown to be superior in some way and demand is increasing by rising acceptance from the provider and patient community. This should occur within the context of non-partisan, immune from lobbying or marketing efforts, structured physician groups entrusted with determining the various tiers of treatment protocols. The controversial discussion will center around patent protection which delays the commoditization required to lower costs for consumers. How long is appropriate etc.
Conclusion: It appears that agents 1, 2, and 4 have interests that are relatively aligned. Only “he who pays the pied piper” agent 3 has issues. Current trends in innovation in healthcare and the ever escalating cost of increasingly sophisticated diagnostic and therapeutic modalities suggests that private insurance payers and governments will be compelled to assume more of the costs in a system which will ration the most effective care to the most “deserving” individuals at the time. Physicians MUST take a leadership role for they have the domain knowledge and are able to evaluate the clinical efficacy (NOT cost) of existing and new diagnostic and treatment modalities. Specialist groups and Physician governing societies should be structurally organized to assist in determining the optimal clinical treatment protocols to maximize positive patient outcomes. Once a multi-tiered system of treatment protocols are established, costs can be ascertained for each protocol. The primary protocol (the one which currently maximized positive outcome for minimal cost) can be covered then and various co-pays can be instituted to pay for more expensive or higher risk choices by patients in consultation with their physicians. Benefits and risks for the higher cost choices must be spelled out for consumers to be informed. The feedback loop then should be instituted by the data mining of electronic health records to assess the appropriateness of the protocol choices and to adjust these protocols as data suggesting other alternate options becomes available.
stay tuned for Part 2: Decision Trees and Finance
Tej Deol, M.D.
Will the United States health care system ever be a single payer system? will we follow the examples in Canada or the UK?
I am concerned that leaders in the reform movement are making assumptions that the US will become a single payer system.
also, not so much talk about how universal coverage gets paid, we know the high tax bracket folks will be effected , but what about the small and medium sized businesses. the economic engine of the United States – I worry that too much of the burden will be placed on the small business owner.
-jeff
Jeff,
My visceral reaction to your question would be a resounding “NO” from my experiences living and practicing in the U.S. However, the past few years have been a complete shocker in terms of far the government is willing to do some very un-American things such as the financial firm bailouts. It is also been a shocker to see the relative lack of real anger of the people towards Congress and the Federal Reserve for allowing the country to get into this mess to begin with. However, that is a different story. But desperate times call for desperate measures and I think the Government has little choice but to ration healthcare (price fix and control distribution) unless the PEOPLE are politically willing to carry more of the economic burden individually (as opposed to collectively) especially for Medicare and Medicaid. My view is that this will be a process. Even if there is no intention to have single payor system, the law of unintended consequences may prevail. As Obama says “If you like your health insurance, you’ll be able to keep it”. Unfortunately, the distortion caused by having the large elephant in the room (Government health plans) will probably make it uneconomic for these private insurers to stay in business and eventually the Government system will creep into becoming the only game in town. And how to pay? There will be no real accurate estimate because no one can predict the effect on utilization (demand) unless we have more information about how much, if any, patients will be required to copay or deductibles etc. The greatest danger here is moral hazard and if that becomes the case costs skyrocket and not only affect the wealthy but everyone.
My latest post which is a link to another article is an excellent view in my opinion of what may transpire. See “Socialized Healthcare vs. The Laws of economics”
Thanks for your comments.
Tej
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