Transforming our health system requires continuity and coherence

Nacho Vallejo
Atenció integral 

Photo of Alexas. Photos in Pexels

“Transforming health care requires continuity and consistency.” This is the title of a Harvard Business Review article written by Mark Britnell. Dr. Britnell is an executive of KPMG International and a global health systems expert. He dedicated his professional life to this field and has worked in more than 80 countries, a circumstance that has allowed him to gain first-hand unique experience of healthcare models. In 2000 he was appointed chief executive of University Hospitals Birmingham NHS Foundation Trust where he was responsible for the design of the largest NHS hospital. He is also the author of the book In Search of the Perfect Health System.

Why is the integration of services not encouraged?

Jordi Varela
Editor

 

@varelalaf

Health and social services are fragmented between various institutions, levels of care and a lot of specialities and each one of the fractions of the system provides a service that makes sense in itself, such as a three-hour weekly service of a family worker for lending a hand at the home of an elderly person who lives alone, or angioplasty intervention for a woman who has just suffered a myocardial infarction and, according to this system, funders pay differently for each activity.

Three axes for primary care reforms (with Decalogue included)

Jordi Varela
Editor

 

From the Alma-Ata declaration of 1978 to the Astana declaration of 2018

In 1978, through the Alma-Ata declaration, the WHO recommended that all countries should deploy universal access to primary health care, appropriate to the needs of each territory. The health of the communities should be attended to with a proactive attitude as it was the gateway to a healthy system. Countries that followed these recommendations, including the United Kingdom and Spain, have achieved more equitable and orderly services than those that have not, such as Germany and the United States. At the same time the waste was reduced, given that their services are more tailored to the characteristics of each person and each family.

Clinical competences hidden in the curriculum and in coding

Gustavo Tolchinsky
 

José, 85, has a fever again. His wife is no longer worried; she knows that what has always worked is taking her husband to the emergency room. On the way she writes in the family chat that they are on their way to the hospital, but no one should move until she’s told if he gets admitted or remains under observation. Her children live in the suburbs and they always volunteer so that she doesn’t have to spend the night with José. Dementia has taken its toll on José and everything is more complicated; his urine infections, which previously warned with recognizable symptoms, have now become something abstract, but the fever is what always alerts the family. In the last year, José has been admitted several times for processes similar to this one, that started with urinary infections due to the underlying urological pathology. This time, on arrival at the emergency room, his wife thinks he is worse than ever, although his vital signs are OK and the Labs are quite anodyne, except for a slight worsening of kidney function. Again, as always, José is prescribed antibiotic treatment (guided by the latest available antibiogram) and fluid therapy, fever control and nursing care. But on this occasion, despite the fever disappearing, he is exhausted, probably due to delirium, he doesn’t cooperate with the care, the peripheral line is removed several times, he refuses to eat and the fever reappears. The family doesn’t cope well with this situation, José either. Family members are informed that imaging test could be performed, to asses  again with the urologist, and even to perform a procedure such as placing a urostomy could be considered if they suspect that there is an obstructive process. However, Jose's deterioration is not solved by treating only the current episode. The family and the healthcare team agree to make one more attempt with some changes in the treatment and, if he doesn’t improve, assume that only palliative treatment will be carried out.

The excesses of image diagnostics

The practice of modern medicine is subject to much pressure from the use of diagnostic imaging technologies, many of which are truly dazzling for the eyes of clinicians and patients and, as a result, health budgets are constantly increasing. This being the case, everyone agrees that more professional debate should be generated to put the matter in its place and avoid the excesses that damage resources, irradiate people and don’t add value to clinical reasoning.

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.  

The problem is the persistence in fragmentation

The model of health services provision is a combination of professional bureaucracy and political-administrative bureaucracy, passed through the filter of organizational rationalization. The fact is that a third (approximately) of clinical processes adapts well and logically, show good results. Let's say: programmed surgical interventions, acute medical pathologies of low-medium complexity, stroke code or heart attack code. So far so good, but it’s inescapable that there are two thirds of the case-mix that don’t fit with the rigidities of what’s offered; we speak, logically, of chronic disease and geriatric frailty, but also of degenerative diseases when they begin to be limiting in the clinically complex processes of difficult labelling. Additionally, in society there are a lot of people in delicate situations, maybe they live alone, maybe they are poor or immigrants or maybe because they live in unstructured environments, to give four examples; people who either don’t access the services or, if they do, they don’t know what to make of them.

Medical Practice: an honest wage for an honest job

"outcomes-based reimbursement works only in a limited sector of healthcare" http://t.co/XFFymLHA8i

— Dr. Luis Ramos Neira (@lramosneira) April 29, 2014

Dr. Luis Ramos is a very professional dedicated to networking. He defines himself as a quali -  epidemiologist. Well, his tweet brings us to a post in The Health Care Blog, signed by a Swedish family physician, Dr. Hans Duvefelt, who works in a town in Maine, on the east coast of the United States. It’s a short clear post, from which I have extracted the main ideas.

We're hearing now that doctors should be paid in accordance with the clinical results of their work and of course we’re not talking about parameters such as controlling blood pressure or glycaemia, but about death, strokes, heart attacks, amputations, hospital infections, etc. But the question is: How can we measure the patients degree of involvement now that there’s so much talk about them? Should the doctor charge less if his diabetes patient is not doing well despite his good work? Wouldn’t this model lead us to the selection of patients?

Complex Chronic Patients: UK progress in funding

good article by Sam Everington on general practice http://t.co/Qk0iIs2ZZQ

— Chris Ham (@profchrisham) marzo 13, 2014

Director of King'sFund, Chris Ham’s tweet, takes us to Sam Everington’s article in The Guardian, about new experiences of financing (commissioning) towards community services deployed to address chronic complex patients in their own homes, even in episodes of clinical exacerbations, and thus avoiding likely unwise hospitalizations.

Closing hospitals with a community spirit: is it possible?

Any idiot can close a hospital but it takes talent, time, and money to improve services in the community. http://t.co/90XFbpW14d
— Richard Smith (@Richard56) January 14, 2014

This week we have a couple of tweets from Richard Smith, former Editor of the British Medical Journal. The first one which is quite persuasive; sends us to one of his articles published in The Guardian where he raises a controversy, since against all appearances, hospital beds have become, in political terms, prevention goods against the spending cuts. But the reality persists, says Mr. Smith, and however you may look at it, the number of hospital beds must be reduced, not to preserve health system resources but to strengthen community services. Closing hospital beds with a community spirit he says, takes talent, investment and time and doing things right. But if this is not done correctly the price can be very high, as treating people in hospitals when they could have been treated at home, is uncomfortable, dangerous and expensive.

Adding value to doctor's remuneration

Perspective article: “Adding Value to Relative-Value Units.” See it on our #HealthPolicy page: http://t.co/2JG09NVWKW
— NEJM (@NEJM) noviembre 28, 2013

NEJM devotes an editorial and a couple of articles (they can be downloaded for free) to the new model for doctor’s remuneration by Medicare. This is a matter specific to the Americans, you’ll say. Therefore, it wasn’t necessary to choose it as this tweet to discuss. Although I have to admit that in these aspects of innovations in cataloguing and financing models, sometimes the Americans are right, as was in the case of DRG, then we all rush to import them into our systems.

Adjusting contracts to the value provided by services

'Commissioning for value'bona iniciativa del NHS per identificar els millors programes d millora de la salut http://t.co/7whaXuF2d4
— Dr J Vidal-Alaball (@jvalaball) noviembre 22, 2013

Dr. Josep Vidal-Alaball is a family doctor trained in England and passionate about public and community health. He’s a keen Twitterer, very active in innovation.

The link in Dr. Vidal Alaball’s tweet, directs us to the English National Health Service’ website, named "Right Care", where it is stated that the purpose of the health system is to deliver more value to people’s health and, according to this statement, proposes that service contracts should be adjusted in-line with this value (Commissioning for value) and clarifies that the NHS adopts Michael Porter’s definition of value: clinical outcomes in relation to costs.

Back to Sutton’s Law

Last week we saw the status quo bias starting from the article "Assessing Value in Health Care Programs". Remember that this bias is due to the human tendency to keep doing things as usual, without questioning too much the meaning of what is being done.

But in this post I want to talk about exactly the opposite innovative attitude and the difficulties inherent to the changes in an environment as segmented and as regulated as the health system. For this reason I have chosen three examples that illustrate the obstacles that many professionals must overcome when they are eager to change routines or adopt a new drug they know is supported by scientific evidence. But the problem is that to adopt the novelty, investments are required, or simply more budget because the new drug is more expensive. So the question is: who pays for the novelty when we were told that we can not spend more?

Example 1 - Adherence to treatment

Let’s consider a program that may improve adherence to treatment, which barely reaches 45%, after myocardial infarction (Volpp 2012). Let’s imagine that a new program foresees increasing this adherence to up to 70% and as a result there would be a 10% reduction in readmissions both for new myocardial infarction and for stroke or revascularization, with a cost reduction that could collect savings for the association of $2,000 per case per year. Does this mean that the program should not be approved if its cost would be $3,000 per case and year?