Tessa Richards: Patients as cost savers?

Tessa RichardsMight patients hold the key to putting the brake on spiralling healthcare costs?  If you had asked me that question a few days ago I’d have said no. We all know about the problem of spiralling demand for healthcare and rising patients’ expectations. But after participating in the Salzburg  Global Seminar,  where the  thesis that” better decision making by patients will result in better and cheaper healthcare” was debated,  my views have shifted.
All participants agreed that health professionals  have an ethical duty to support patients to make informed  “shared”  decisions, and  that they should explore patients’ values and preferences for treatment, although  choice is not a luxury that all countries enjoy,  as Biao Xu, an epidemiologist from Shanghai underlined in her blog.

But in well resourced countries, patients do have options, and evidence presented at the meeting, including the work on choice of treatment for  prostate cancer  suggests that when they are fully and accurately informed about the benefits and harms of interventions, they opt for fewer treatments. Hence  the  potential for cost savings.

Several  participants  dissected the choices and decisions made about their own medical care, and  half way I found myself silently interrogating one of mine.  Five years ago I opted to have postoperative abdominal  radiotherapy, despite the absence  of evidence it would reduce  recurrence of a rare cancer. The consultant was clear about this but suggested that it made empirical sense.  Towards the end of treatment ,  when I had boned up on all the risks of undergoing  high dose radiotherapy I became alarmed about the trade-off and skipped the last sessions. A good example of a bad and expensive decision?

Many factors influence patients’ choice about treatment, foremost among which is the ability and readiness  of doctors to offer it.  But this varies from region to region and unit to unit and needs to be confronted and unpicked (read BMJ article by Jack Wennberg).  “Supplier induced demand” is a reality,  that doctors and patients need to be much more aware of.  One way to counter this is to ensure that decisions on management are fully shared and informed, the  “nothing about me without me ”agenda. Patients need  comprehensive accurate and up to date information about the benefits and harms of treatment (and  high quality decision aids help) and their preferences and values taken into account  (read BMJ article by Albert G Mulley), not least on decisions about end of life care. These messages came over loud and clear from the  authors of these two seminal BMJ papers , Jack Wennberg and Al Mulley, who cofounded the Foundation for Informed Medical Decision Making, which supported the symposium.

Doctors’ enthusiasm to offer treatment to patients is  fuelled by the publication of papers that are optimistic about its value.  Medical journals clearly have a pivotal role here. I shrank in my seat as I listened to a  barrage of criticism about the  way journals propagate misinformation, and fan the daily tsunami  of hype ridden  health stories in the media.  Editors need to get much better at tackling publication bias (towards studies with positive results),  misleading communication of risk (read BMJ article by Gerd Gigerenzer et al), letting authors get away with spin, and reproducing this in press releases.

This was my main take home message, and in the linked blogs below you can read what other  participants took away from Salzburg, where snow doesn’t  disrupt  services and the Sound of Music is everywhere,  and  the vision of realising best practice can be seen.

Tessa Richards is analysis editor, BMJ.

  • Thank you for this excellent commentary which spans the most relevant issues in medicine (and economics) today as health care surpasses other markets in its growth rate. This is not a good economic indicator because increased illness represents a decline in productivity and disability among the population. As you note:

    1. Supplier-induced demand is the result of a ‘misconception’ that health care treatments (whether drugs or CAT scans), are mere commodities to be bought and sold like so many jars of caviar to those who can afford such gourmet delights. The drug ads on TV spend more audio time listing the adverse health effects than they do describing the benefits, demonstrating that even the epicureans are suffering from high rates of ill health. . The visuals are the selling points of happy, drugged people. There is no reason to insist that health care is not one of the rights (to life, liberty and the pursuit of happiness), and lower costs by offering care through distribution by non-profits. Good salaries can still go to the deserving, dedicated providers and researchers while keeping services equal to costs. Premium tiers of care will always exist, regardless. Furthermore, salaried physicians may be more likely to find those extra minutes needed to actually consult with their patients.

    2. Realizing that patients should be partners in their health care will go a long way to keeping physicians (versus researchers) in touch with the fact that a great deal of treatment is really experimentation. Patient satisfaction with outcomes would be far greater if they made a conscious choice to accept it, even if that outcome is unsuccessful. Frequently ignored procedures such as lab cultures and sensitivity testing would be chosen so patients don’t take unnecessary antibiotics, or be forced to take multiple drugs until they hit the right one—to the detriment of their immune systems. “End of life” counseling would be easier if “Health in Life” counseling were ongoing.

    The point about ‘spin’ by editors and health journalists is valid but also generated by the informational sources. Researchers want that next grant and sponsoring companies need to sell to consumers, a better target for advertising than physicians themselves. An editorial board of individuals lacking vested interests in such matters would be an excellent resource for writers on technological issues pertaining to our increasingly complex society. The health impacts of any new advances in product R&D need to be discussed from a risk perspective as American children show us how we are declining (one in four with some chronic condition and one in six showing a learning problem). The data on children demonstrates that ‘life style choices’ aren’t the only keys to declining health.

    Barbara Rubin

  • whether or not patients save costs the approach promoted at Salzburg will certainly increase value , and that has to be the priority for the next decade, or century ; Michael Porter has given a clear definition of value

    “Value in any field must be defined around the customer, not the supplier. Value must also be measured by outputs, not inputs. Hence it is patient health results that matter, not the volume of services delivered. But results are achieved at some cost. Therefore, the proper objective is the value of health care delivery, or the patient health outcomes relative to the total cost (inputs) of attaining those outcomes. Efficiency, then, is subsumed in the concept of value. So are other objectives like safety, which is one aspect of outcomes.”
    Source: Porter ME. (2008) What is Value in Health Care? Harvard Business School. Institute for Strategy and Competititveness. White Paper.

    even if steps to increase value do not release cash they should be taken

    muir gray @ muirgray.net