This fourth and last post related to the series "Right Care" from the Lancet magazine ("Definition, gray areas and reversion" was the first, "Between too much and too little", the second, and "Question of attitude", the third), talks about various proposals to reduce the waste with the understanding that the inadequacy in the provision of health services is a wicked problem for which there are no magic solutions and, for this reason, the article "Levers for addressing medical underuse and overuse: achieving high-value health care" makes an effort, which is appreciated, to provide useful ideas to incorporate into the working agendas of both clinical managers and health managers, according to the following proposals to increase the value that health systems should bring to people.
Adjustments to the provision of services
a) Hospitals are essential in able to effectively attend to people affected by certain clinical conditions, especially acute ones of moderate or severe intensity, but are instead a burden on the resources of a country, when its surplus resources are used to admit people with needs that could be more appropriately cared for in the community. b) Internal work against clinical practices objectively known to be of no value should be encouraged. c) Diagnostic criteria should be reviewed in order to reduce the increasing trend of over diagnosis. d) Electronic medical records should be widely used to send messages about value practices to doctors' computer screens during consultations. e) The practice of clinical audits should be promoted. f) Support materials (decision aids) should be developed to ensure that shared clinical decisions are increasingly used in health care units. g) It would be appropriate to ensure that when an innovation replaces an old practice; the latter should be stopped, thus breaking the cumulative tradition, so typical of the medical sector. h) Particular caution should be exercised with the “off label” treatments in order to avoid that the treatments indicated in advanced stages, are prescribed ahead of time. i) Cost-opportunity analyzes should be encouraged to avoid introducing new practices without timely evaluations.
Adjustments to financing models
a) Clinical activities that are ineffective or that have more undesirable effects than benefits should be discontinued. b) When certain actions, due to technological progress, become faster, cheaper and safer, it would be advisable to drop tariffs, as happens in non-health markets. c) When, despite the evidence, a patient chooses an action that is not recommended, systems should ask patients to pay for it out of pocket. d) In complex (tertiary) processes it would be advisable to link their funding to a minimum of treatments, in order to guarantee patient safety. e) Capitation payment, adjusted for results and risk sharing, is the model of funding to be promoted.
Adjustments to governance models
a) The systems should give voice to citizens, patients and providers, encouraging them to become involved in health system governance, with a view to banishing clinical practices of little value, but also to ensure universal access to quality health care services. b) The leaders of health systems should focus their efforts on cost-effectiveness studies and on the extension of universal coverage.
As the Lancet magazine's "Right Care" report says, ensuring access to quality health services and not squandering resources with disproportionate actions are the two most important challenges in today's healthcare systems. The solutions are complex and need to be addressed from the governance, from funding and from service provision. Failure to do so is an irresponsibility that should be judged in the arena of social and political ethics.