|
Proposals to healthcare reform should be judged not on the
goodness of their intentions but rather on the basis of there results –
in other words: nobody washes a hired car
The focus on consumer choice within both major parties
seems to respond to the core weakness of the British health system, as
reported by patients (A Coulter, Picker Institute BMJ: 331, 19/11/05,
pp 1199). The deplorable heritage of the NHS - its cold war bureaucracy
and a paternalistic doctor-patient relationship – is the very opposite
of choice. And there are many doubts whether the recently introduced
patient choice between hospitals for elective surgery is the most
urgent kind of choice that people are coveting. Over 500 consultants of
Doctors for Reform have declared: “The NHS was conceived more than half
a century ago, at a time of rationing and considerable poverty. We once
believed it was the finest healthcare system in the world. Today few
healthcare professionals would make that claim.” Indeed Britain seems
to be coping worse than other Western countries with soaring health
costs and is dramatically falling behind other Western countries in
such crucial things as cancer survival rates.
The intangible revolution
Quite a different issue is to predict the future of the NHS in a
competitive global health market. As everybody knows, here are
economies of scale, particularly in purely knowledge-based goods. This
is what some experts like Roger Boothe call the intangible revolution.
They maintain that the economic potential and wealth creation of the
knowledge-based technology of the future is enormous. This is
especially true for the health sector which in the future will produce
lots of intangible products and services. But today, as a closed
market, the NHS simply cannot compete with the lower prices of the much
larger international markets. That’s the bad news. The good news is
that the globalization of healthcare services and products is the best
way to contain exploding costs everywhere. Surprisingly loss of control
over health expenditures happens in very many countries, regardless of
ideology and the way health care is organized – from central Europe to
the United States of America.
Control over health expenditure is the main challenge
Some countries have already responded to exploding costs with
incentives to save money at the origin of all health expenditures: the
patient or consumer. These ideas try to encourage more responsibility
by healthcare users. For example the Dutch introduced a no-claim bonus
for health insurance. Switzerland introduced something similar with
different choices and levels of healthcare coverage. The USA introduced
medical savings accounts. Denmark is charging an extra fee for seeing a
consultant and Germany introduced a general fee for seeing a GP. We
certainly can learn from other countries how to achieve more.
Public confidence in health reform is dwindling
Unfortunately nothing like this is happening in Britain, except in
some private insurance companies. Not surprisingly, 54% of electors
don’t believe that the billions of pounds that Labor has been pouring
into the NHS since 2000 will result in real improvements, and only 39%
agree that it will do so. In the most recent ICM poll by the Sunday
Express 35% of voters said that they think the NHS has got worse since
Labor was elected as against 24% who think it has improved. 35 % think
things have stayed the same. In a recent MORI poll 44% of people said
they expect the NHS is getting worse, only 22% held the opposite
opinion. Other surveys have suggested that the American managed care
organization Kaiser Permanente was much more cost effective than the
NHS run programs (BMJ 24 August 2004). The crucial difference between
both was that Kaiser employed many more consultants per patient than
the NHS.
The politics of choice and the Web
Although countries differ considerably, choice seems not to be as
overwhelmingly important to patients as politicians often suggest.
According to surveys of patient preferences, the heaviest users of
primary care the elderly and the chronically ill value continuity of
care higher than choice of providers. However younger patients value
fast access higher than continuity. But both groups want greater
personal involvement in their treatment. Ever more people are turning
to the internet to get information on their condition, because it is
not provided sufficiently by their doctors, surgeries and hospitals.
Even among people aged 45 and over about 30% have searched the web for
information about their condition. Finally choices between competing
providers or hospitals seem less important to patients than fast access
to specialists.
Social and medical Progress
The NHS was founded in times when political and social collectivism
prevailed – as were the dominant concepts of epidemic and contagious
diseases. And this is reflected not only in the health bureaucracies
created by Aneurin Bevan but even today in the top-down centralism of
the NHS. But social and medical progress renders those collectivist
concepts obsolete. Biotechnology has deconstructed the fiction of “one
size fits all” medicine. The new consumerism has created a huge
increase in demand for quality and choice in health services and the
pharmacotherapy of the future will be much more individualized - no
longer the same tablets and average dose for everybody. People are
becoming even more different as we approach the genetic level of
understanding diseases. And this means that, increasingly, any kind of
socialized health insurance will be deeply flawed. Risks in the future
will be centered in the individual and family rather than in the group
or collective.
Dramatic change of disease burden
Past social progress and ongoing medical innovation have led to a
fundamental transformation in the disease burden, due to changes in two
major areas.
Firstly the affluent Western societies created a lifestyle which is
outright unhealthy. It is to blame for the leading causes of death
these days: coronary heart diseases, stroke, many different cancers,
sexually transmitted diseases, asthma, diabetes and fatalities of
poly-pharmacy. This lifestyle encompasses smoking, overeating,
promiscuity with unprotected sex, abuse of illicit drugs like cocaine
and alcohol and lack of exercise. In response, we consume vast amounts
of medicines in the attempt to postpone or avoid any deterioration of
health. Prudent disease prevention and health improvement through
healthy lifestyles are the exception.
Secondly, globalization with mass tourism and mass immigration has
introduced or brought back a host of infectious and tropical diseases
to the Western societies. These include the reemergence of tuberculosis
as a corollary of the HIV epidemic, diphtheria and other infectious
diseases. International sex tourism also has given a booster to
sexually transmitted diseases. All these factors and the masses of new
immigrants with no or poor English language skills have put our Western
health systems, not at least the free-for-all English NHS, under
considerable pressure.
Not surprisingly, according to a survey by the think tank Reform, the
productivity of the NHS has constantly declined over the last decades
despite a huge increase of the NHS budget.
Since
unhealthy lifestyles are to blame for much of the Western disease
burden, this is where we need to look first in terms of keeping
healthcare costs under control. Simple exhortation is not enough, as we
have seen on the obesity epidemic for example.
So how can we achieve sustainable ways of behavior or lifestyle changes?
Setting the right incentives for consumer choice
The most promising solution would be to give patients/consumers
back responsibility for their own health, and control over their own
health care expenditures. Only thus we can contain the progress of
chronic diseases driven by lifestyles in which peoples damage their own
health. The clue is self-reliance and incentives for people to look
after their own health, supported by full access to health information
via the web and a viable health insurance system. Previous attempts to
get people to live healthier have failed because they lacked any
economic underpinning or incentives to do the right thing. But at least
they may have raised awareness of the problem.
Patients value self-care high
According to surveys (Picker Institute, Oxford) most patients value
preventive advice and support for self-care high. But our healthcare
system does not offer any reward or incentive for combined efforts of
doctors and patients to achieve this. There needs to be benefits for
patients who really care about health improvement and disease
prevention. Only rewards for patients who protect their health plus
rewards for doctors, who are committed to health promotion with their
patients, will accomplish anything. This should be the meaning of a
patient-centered health care.
Health care funding needs to be linked to personal risks and lifestyle
Abandoning third-party payment systems is the truly global solution
to the health care crisis. It is the way to make health care systems
sustainable over the generations. It clearly implies a turn to
individualized methods of raising health care funds: only this allows
different patterns of individual health risks to be taken into account.
It implies a competitive insurance system of staggered premiums
according to different risks. Only then we might accomplish a fully
patient/consumer-driven health care.
Provision of health care by private companies is not enough
The tax-funded system of health care in this country has become
counterproductive. It does not give any incentive to prevent or avoid
diseases. As a result not only should the provision of health care be
decentralized, but also opened up to market forces, as initiated by the
Tories and continued by New Labor.
However, if only the delivery of health care is privatized there
remains the problem of collective or state purchasing of health
services. Any kind of third party commissioning as a proxy for patients
is prone to bureaucratic failures and complexity. Probably the most
advanced concept, although not implemented yet, has been developed by
Newt Gingrich at the Washington based Center for Health Transformation
(CHT). He is attempting to abolish third-party payments in all US
public healthcare provision under Medicaid and Medicare.
This means that the patient acquires full consumer power since he
is put in control of all health expenditures on his behalf. The crucial
point of a consumer-driven healthcare system will be the direct link
between personal lifestyle and individual control of health expenditure
with fully informed consumers.
The information point is important and the internet as well as new
virtual or real health coaches hopefully can reduce the knowledge gap
between health professionals and the consumers. The bridging of this
gap is crucial in order to provide us with a true consumer driven
health care system. My impression is that this problem of bridging the
information gap is underestimated in the CHT approach which is focuses
on IT implementation in the US health care system.
Markets can best address inequalities in health
Contrary to the prevailing prejudice, healthcare is not much
different than other sectors where the market prevails. True, the bulk
of our healthcare resources are taken up only in the last couple of
years before we die. But the way to deal with this is that every
consumer/patient should contribute to the necessary pool of resources
to cover for these expenditures with a monthly basic contribution let
us say of about Pounds 150. Upon entry into the workforce this payment
should be mandatory by law.
People with healthy lifestyles will not need to spend more than
this – they may spend even less. But people with risky lifestyles, like
skiing or horse riding etc, will have to pay extra fees. The same of
course applies to couch potatoes and people who keep smoking, boozing
or overeating. However, for people with inherited diseases, permanent
disabilities or for the ten percent of people who cannot afford the
contribution, the government would have to step in.
Such ideas do not have to be developed from scratch, because others have already tried market-style solutions for health care.
Good
examples are Denmark, Switzerland, the Netherlands and the United
States, although mostly in the private sector. What they have in common
is the implementation of meaningful consumer choice - with impact
before any disease hits. People in some countries are encouraged to
take responsibility for their future health earlier in life - all of
which can be monitored by them selves or their doctors - and are
rewarded with lower monthly health insurance contributions.
Evidence that the new concept will work
Evidence that a combination of activity, attitude, and good
nutrition, can actually achieve a significant improvement in health and
can prevent or at least postpone chronic diseases was provided by
scientists at Nestlé - most of all in the area of obesity and diabetes.
They have also proven that the improvement of physical health will make
a huge difference in figures of mental health - showing that there is a
strong connection between both. It is not at all surprising that
lifestyle changes like increased physical activity and weight loss will
also decrease depression and anxiety. Without treatment depression and
anxiety can result in unemployment, unnecessary disability, substance
abuse, inappropriate incarceration, suicide and homelessness.
The challenges for self care
The self monitoring of health parameters and introduction of
personal risk management will be big challenges, but well worth it.
Special bespoke software programs for consumer health control solutions
need to be developed in the near future. If instead of just one third
of the British population being able to maintain a normal body weight,
two-thirds could do so, then the disease burden or work load for the
health service could be nearly halved.
Contrary to the common belief free access to the health service
without payment does not serve the patient because it is an invitation
to neglect your health and leads to a general waste of resources. One
example for this is that, according to a recent survey
(Picker-Institute, Oxford) British patients, used to the NHS, are less
inclined to get involved in health improvement than patients almost all
other European countries. Another example is the millions of missed
appointments with consultants, GPs and nurses in the NHS.
Public health is to be reconsidered
Fifty years of Public Health in the NHS have witnessed a complete
failure to improve the health of the population at large. Apart from
vaccinations in childhood and cancer screening, which are more or less
established in all Western countries and not a merit of NHS-style
public health, most other public health interventions to target things
like cholesterol, weight and blood pressure have failed. There is poor
evidence that this kind of public health interventions achieve any
long-term health improvements. Admittedly, in other Western countries
the results are not any better. It is therefore as true for state
health interventions as for other things: market forces tend to be the
stronger.
To be fair, in spite of the huge controversy over cancer screening
two years ago, some benefits of the centrally planned NHS are still
outstanding. Those are programs for the prevention of breast and
cervical cancer in women, which should probably be maintained and
developed further to other areas of prevention. But the bulk of the NHS
workload is curative care for acute and chronic conditions. And for
this business the future consumer and patient must have a completely
different and more central role, which will impy more choices and more
responsibility as well.
Doctors for Reform
Recently Doctors for Reform rejected the current tax-based
healthcare system in Britain. As Dr Christopher Lees, one of the
founders admitted the group was disappointed by the Wanless Report’s
conclusion that taxation was the best way to fund healthcare. Doctors
for Reform are looking increasingly to health care systems in
continental Europe, one of the favorite candidates being Switzerland
which has implemented the most advanced market based health-reform - it
combines mandatory social insurance with individual discounts for
people who stick to a healthy lifestyle and take up less health care
resources. In the Swiss system employers no longer contribute to health
insurance for their employees.
According to Doctors for Reform taxation-funded healthcare can never
meet demand and compulsory insurance in Europe works much better. “The
NHS as we know it has had its day”, said the founder of the group, the
oncologist Professor Karol Sikora. He added, tax finance is simply no
longer fair because people with a healthy lifestyle have to subsidize
people, who knowingly damage their health in a variety of ways. Indeed
the NHS provides incentives not to bother about one’s health and even
to remain ill in order to get the most out of the NHS. It is another
example of the welfare state that actually encourages people to the
opposite of what it seeks to achieve. James Bartholomew has looked into
this in his book “The Welfare State we are in”.
Getting away from centrally planned and politically driven NHS,
Doctors for Reform maintain, would provide more flexibility, freedom of
choice and more competition for excellent health care. Putting power
into patient’s hands would mean more choices. And the patients in the
UK seem to agree. In the already quoted ICM poll 52 % of respondents
agreed that Britain should move towards a European style system “where
everyone takes out health insurance and the Government tops up payments
for people who can’t afford the premiums”.
Implementation
How can we implement this new concept of consumer driven health care?
Inevitably, any reform of NHS financing must be gradual. But once
it is under way, it could serve as a template for other countries and
give Britain an advantage for the export of ideas and services to
bigger markets in Europe and abroad with the possibility to employing
millions of people. This means the huge present workforce of the NHS
1.3 million do not have to expect redundancy.
Many pundits expect the healthcare sector in the developed countries to
grow faster than others and an increasing part of this expansion of the
health market will come from private, out of the pocket payments. Even
in the UK, with hero behemoth NHS, a growing part of the electorate is
willing to spend more for their health out of their pocket. In the ICM
poll 41 % were open to charging patients for some NHS services. These
people will purchase Top-Up fees for primary care and medication.
And that’s what the market should offer them in the areas of self
management of disease prevention and chronic conditions. The
introduction of electronic health records, given interoperability, will
foster the use of personal software modules for disease prevention and
for the control of chronic ailments. There are many other new
developments such as the digital directories, online services for
directing consumers to the right health provider and so on.
Ten guiding principles for a patient driven health care:
1) Devolution of decisions
2) Create full price transparency for consumers
3) Develop individual health risk management tools
4) Create a genuine health insurance market
5) Create comprehensive IT support
6) Give every patient his own electronic health care record
7) Abandon third-party payments
8) Enable early access to orphan drugs
9) Manage heath care market as national asset
10) Pay for outcome instead of performance
Self care and individual risk management tools
In order to prepare for this change we need to establish a
think-tank exclusively dedicated to market based health reform with a
focus on individual health risk management. The main purpose would be
to develop concepts for self care and risk management for every major
preventable disease and also for the management of chronic conditions.
These modern software modules will include modern technologies for the
monitoring of body functions taking patients beyond mere good
intentions. If the patient can see on his or her laptop what difference
they can make in terms of health and disease, this is much more
rewarding and motivating. However the most sustainable incentive will
be financial. Healthy people will be able to save in their health care
accounts for their future (already many millions of Americans save into
Medical Savings Accounts).
How to build the SelfCare think tank
Sponsors for a self care think tank could come from in the existing
health care industry, e.g. pharmaceutical, NHS and insurance companies,
HMOs or PFI consortia. The main remit would be to develop and design
multiple software modules for coaching and personal health management
including health promotion, disease prevention and disease management.
Most of those software modules would be protected by intellectual
property rights and form the basis for software products destined to be
marketed for private purchase and consumption. This means the sponsors
of SelfCare could benefit in the form of ownership of certain
disease-specific modules or software products which would grant them a
return on their investment.
|
