Richard Smith: “Flat of the curve” healthcare

richard_smith_2014Alain Enthoven, an economist and inventor of the internal market, described “flat of the curve” healthcare where increased expenditure on healthcare produces no further benefit. Are we at that point in many health systems in high income countries, including Britain?

Enthoven’s graph is best thought of as theoretical insofar as it’s not easy to measure the total benefit from a health system, although economists have tried to do so. But we do know that plotting expenditure on healthcare against life expectancy for each country shows that once a country spends about US$600 per person on healthcare there is little improvement in life expectancy. Indeed, Cuba, which spends US$558 per person, has the same life expectancy (79) as the United States, which spends US$8895.

We know, however, that healthcare has only a small effect on length of life and that its benefit is on quality of life. But attempts at aggregating health benefit show a similar graph to that for life expectancy—at a fairly low point further expenditure produces little benefit. What is sure is that the extra value produced by further expenditure becomes smaller and smaller, meaning that hard-hearted economists (and even rational soft-hearted ones) would spend the money on something else—housing, environment, education, the arts—where extra spending would produce unquestionable and easily measured benefit.

In fact, in many places increased spending on health is “crowding out” expenditure on other areas. Don Berwick, a paediatrician who recently ran for governor in Massachusetts, shared a graph at the World Innovation Summit for Health in Doha that showed that state expenditure on health had increased considerably while expenditure on everything else had gone down.

Worse than flat of the curve healthcare is the point where more spending means worse outcomes. Enthoven thought that he saw this in areas like coronary bypass surgery where people may be given operations that they don’t need with some of them being harmed by the surgery. This is the phenomenon of “supply led demand:” once you have many (indeed, too many) cardiac surgeons they will not be idle, they will operate on people where the benefit of the operation does not outweigh the inherent risk.

We won’t hear anything about this in May’s general election in Britain because we live in a horribly oversimplified world where more doctors, more operations, more hospitals means more health. It seems to be beyond the wit of any politician to get across the uncomfortable message that more expenditure may mean worse outcomes, and, of course, voters don’t think much about populations but more about themselves.

And people seem to be willing to pay a great deal to fend off death for a few more weeks or months. Offered a one in a hundred chance that an expensive operation will give them six months more life many people will take it. (Told that they have a 99% chance of the operation failing they might make a different decision, especially if they are also told that there’s a 5% chance that it will shorten their life and a 30% chance that the quality of any extra life will be very poor.) Surgeons might also encourage patients to have the operation to “offer hope” or because they enjoy cutting, are paid handsomely for the operation regardless of the outcome, or the hospital might decide it doesn’t need so many surgeons if such operations become unusual.

I suggest that it’s because such operations (or medical procedures) are not unusual that flat of the curve healthcare and worse is where we arrive with increased expenditure. It also explains the counterintuitive but well established fact that death rates go down when doctors go on strike. It is the fear of death that leads to valueless increases in healthcare expenditure and falling expenditure on other areas where increased expenditure would produce undoubted benefits, including warm houses, a cleaner environment, a more literate population, and joy.

Competing interest: RS is chair of and has equity in Patients Knows Best, which sells to health systems including the NHS, a way to bring all health and social care records into one place under the control of patients, and he was employed by and has shares in United Health Group. The views expressed in the blog are entirely his own.

Richard Smith was the editor of The BMJ until 2004. He is now chair of the board of trustees of icddr,b [formerly International Centre for Diarrhoeal Disease Research, Bangladesh], and chair of the board of Patients Know Best. He is also a trustee of C3 Collaborating for Health.