Friday, June 13, 2014

Cost Containment in Healthcare: Is it What Matters?

Increasingly, it is apparent that the health care system in Canada (and many other countries) is focussed on cost containment. Don’t get me wrong, cost containment is an important thing – the costs associated with duplicate tests, the costs associated with preventable ill health, the costs associated with inefficiencies and the costs of waiting – are all things an efficient and effective health system should seek to eliminate.

But, I have a confession to make: cost containment as a goal, in and of itself, is as about as sensible as using caesarean rates to measure the quality of maternity care. It is at best misguided – and at worse will pave the road to a health system that fails to meet the needs of patients and results in avoidable death and disability.

I have another confession to make: we don’t do a very good job of measuring costs in healthcare in the first place – nor do we do a good job of measuring outcomes. We are particularly lousy at measuring things from the patient perspective.

Admittedly we have a lot of excellent data (the Discharge Abstract Database, the Medical Service Plan Database, the Pharmacare and Pharmanet Database, the Home and Community Care Database, the Health Authority Management Information Database. There is also a lot of work being done to aggregate the information in those databases to look at use and cost of use “across the system” – but there are also a lot of limitations to that data. If something in the health system was done, and publically paid for we have (at least some) information on that.

However, here’s what we don’t have very good information on. Anything that was privately paid for we have next to no information on. If you went to the states (or elsewhere – India, Mexico, or a number of other countries with burgeoning medical tourism industries) to access care and paid out of pocket, we have no information on what was done or what it cost. If you had a private MRI or CT we have no information on that. If you went to a psychologist and paid out of pocket, again no information. Wait times – our information on wait times in Canada is severely lacking. The wait times that are measured, are generally measured (in BC) from the time the surgeon submits the booking form until the time the treatment is provided. I have heard rumours that some surgeons are not even submitting the booking form until they know the procedure can be completed within a specified period of time. We also have no information on the private cost of waiting – we have very little information on the level of disability or suffering experienced by those who are waiting, nor do we know much about their lost incomes. Further, once a procedure is completed – we do not know a lot about the impact on health that was experienced by the patient who received the treatment. We also don’t have good information on services that were provided under an alternative payment scheme – with some seemingly large gaps in information resulting. We have no information on services that were needed but never delivered.

Further, there are those who are very firm in their opinion that we have enough data and do not need to invest in more data or better data.

And maybe we don’t need more data or better data if cost containment is the only thing that matters in the health care system. Maybe all we need to do is set the budget – and let the pieces fall where they may. Care will be rationed – but it is unclear, if anyone really cares that that is the obvious outcome of a system focussed on cost-containment.

But if the focus is on a health care system that provides quality care – we most definitely do need better data and a better handle on the costs of the system – and just as importantly the outcomes and experiences of patients.

I would argue that, that is what needs to be the focus (quality care delivered efficiently and effectively) if we are to make progress to a high-performing system that delivers value for the resources used. There’s a good chance that it would need to be a hybrid and allow for private health insurance. It’ll probably cost some money – but there’s a very good chance that it’ll pay dividends.

Or we can continue down the path we’re on – the one where the system is very likely and chronically under-resourced. The one where patients are not having their needs met, but their voices go unheard. The one where providers are frustrated because they are not trusted and are hamstrung from delivering the care that they know is wanted and needed. It is wholly unsustainable to have a system that is focussed on “cost-containment” – but by the time we get around to focussing on what really matters (and measuring it), it might be too late.

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