Wednesday, July 23, 2014

The Shift to Appropriateness in the Hunt for Healthcare Savings

The pressure to conserve healthcare resources is intense, for years the government has declared growth in health spending to be unsustainable and has clearly articulated a need to "bend the cost curve". In recent years, there has been some evidence that indeed, the cost curve has been bent, as the rate of growth in healthcare spending has slowed. However, this somewhat ignores the impact of a whopper of a recession - one that resulted in higher levels of unemployment (and therefore, lower levels of insurance for extended health benefits), and also governments that have been exceedingly budget constrained. In a system where all "medically neccessary" care is publicly funded, bending the cost curve can be as easy as the stroke of a pen. Care that is not provided, is not funded - and when only the things that are done are measured, it is easy to be blind to the consequences of rationing care.

It is entirely possible that constrained budgets resulted in greater care efficiency (providing the same care with fewer resources) - if there was a simple efficiency to be found, it was likely implemented. Further, there are likely other efficiencies to be found - but it should be expected that those efficiencies are likely to be the result of upfront investments that pay dividends over time. In short - efficiencies are not all free (and those that were may have come at some expense of quality), and some efficiencies require substantial sums of money to implement in order to realize savings over the long run. Money that is scarce in provincial budgets and governments who do not have the courage to take the long-view on healthcare savings (after all, the benefits might accrue to a different government) - mean those efficiencies might well be foregone.

So, there is a new buzzword on the health policy front. Appropriateness. It is a politically correct way to call into question care that, in retrospect, appears to have been "unneccessary". But what is the test of appropriateness? How are policy makers identifying what is or is not appropriate care? Is there cause for concern and skepticism about the new quest to save health care dollars by applying the lens of appropriateness?

One of the ways policy makers are identifying "inappropriate" care is by examining variations in utilization patterns. It seems reasonable enough, if one area (area A) of care has higher rates of a procedure than another (area b) and outcomes are similar, it seems obvious that some of the procedures provided in area A were "unneccessary". After all, no additional people died when comparing area A and area B. Further, if area A could get their rates down to the rates observed in area B, a significant amount of money could be saved. It is not a very far stretch for a policy maker to then assume that setting a target, and perhaps even attaching a reward for progress towards that target appears to be a good thing.

Alternatively, determining what is "appropriate" care might be done by looking at the costs and benefits at a population level of specific procedures and deciding to support care (by developing guidelines and perhaps paying for adherance to those guidelines or penalizing for failure to adhere to the guideline) that, on the evidence, the benefits exceed the costs of providing the care.

It seems, on its face, to be good policy. After all, the resources that are not used to provide "inappropriate" care can be redirected to other uses in the health system (or the education system, or the transportation system).

It is policy with good intentions.

Unfortunately, like many well intended things, it is policy that could drive the system further away from delivering the best outcomes possible because it provides strong incentives towards guideline driven care, guidelines that might be based on incomplete information and neglects the very individual reality of medical decisions.

Variations in utilization can reflect so many things (differences in availability of services, education or income levels, cultural preferences, etc.). There is so much more to healthcare, and the decisions that are made with respect to undergoing or refusing to undergo a procedure are very much so individual decisions. What is beneficial care for one person, can be detrimental to another - even if they are "statistically the same" with respect to age and health status. There is so much in the way of "quality" that goes unmeasured - and the broad measures of outcomes are simply crude at this time.

Which is why, I am both skeptical and concerned about the buzz around apropriateness in health care. Ultimately, I believe the most efficient healthcare decisions are the result of empowering those with the best information to make the best decision in the circumstance. In healthcare, I do not believe that policy makers and administrators are the ones with the best information to make medical decisions - because those decisions are so intimate and personal. There is an art to medicine - and that art is applying expert knowledge to an individual circumstance and enabling and empowering patients to make the choices that are best for themselves in their own individual circumstance.

There is a certain audacity to then labelling those decisions, inappropriate. There is a certain violation that occurs when the right of an individual is arbitrarily denied. Make no mistake, guideline centred care in the guise of appropriateness, will be very costly indeed.

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