Financing models do not promote value

The budgets of public health systems and those of private insurers are highly pressured by the constant emergence of new drugs, such as direct-action anti-virus to cure hepatitis C, or new technologies such as transcatheter aortic valve implants (TAVI) and logically the funders expend a lot of energy in limiting the use of these innovations. The battle, needless to say, has a predictable outcome because the conjunction of investors with the beneficiaries is usually lethal to the guardians of health expenses. An article based on American healthcare, emphasizes the waste induced by the "low cost" rates (if you are interested in the subject, I leave a second related link). The issue explained in Health Affairs  would take the opposite extreme as instead of "very little but expensive activity", this analysis focuses on "a lot of very cheap activity" and, it sounds untrue, but, at least in the US, at this point there could be more waste.  

Some will think that this doesn’t happen in Spain because we have a national health system, a planned model and some program contracts that guarantee both quality and adequacy, but let's take that idea for a spin. According to the latest report, "Health at a Glance" by the OECD, of the $ 3,248 that each Spanish citizen spends annually, on average 30% is on private healthcare -an insurance environment, that, with few exceptions, is characterized by "low-low cost" rates with the corresponding result of generating a lot of activity to be able to make some cash, and if not, ask the doctors of the public health sector who go to their private practices in the afternoons. 

And now let's focus on public health that represents 70% of spending. In this sector, professionals receive a salary and as a consequence money doesn’t follow the patient. It seems then that we would not have to suffer from the excesses of unnecessary clinical activities as happens to Americans or to cooperatives in our environment. However, the problem lies within the concept that the most precious value of the healthcare system is that the care activity is so ingrained, that the autonomous parliaments, public opinion, the press and the professionals themselves do not talk about anything else therefore forgetting the effects of the waste that is induced by this misunderstanding. If you doubts it, let's give examples of some of the topics of special political sensitivity:

1. The waiting time for an appointment to a family doctor after a scheduled request, without analysing whether that care would have been instead better resolved by an administrative, by a nurse or by a social worker.
2. The percentage of prescription of generics, without having developed indicators of quality and adequacy of said prescription (except the Results Centre of Catalonia).
3. The waiting time for the consultation of the specialist, forgetting to analyse the necessity of the request of the visit.
4. The much-desired reduction of surgical waiting lists, without any reflection in relation to unnecessary  or poorly justified interventions.
5. Waiting times in hospital emergencies, with little attention to the large number of people who come with problems that should be addressed more appropriately in the continuous care or emergency devices of primary care.
6. The average stay of admitted patients, with very little interest in analysing how many admissions could have been potentially avoidable.
7. The mortality of the ICU, without taking into account the criteria of adequacy of their admissions. 

Managers and clinicians do well to pay attention to efficiency. They handle many resources so it’s reasonable that they do so, but focusing exclusively on it, hides the reality that a significant volume of production (between 25% and 33%) doesn’t contribute any value to quality or quantity of people's lives and, blinded by the activity figures, we do not even realize it.

It’s about time that insurance companies began to pay for the value of the services they purchase, while public systems should reflect on their mania by measuring the activity to concentrate on instead of on the value-based healthcare.

Jordi Varela

Editor