ClinicSpeak & BrainHealth: are you a positive return on investment?

Are you considered a drain on public resources? Isn't it time to do something about it?  #ClinicSpeak #BrainHealth #MSBlog

"Just back from a week's break in the Alps with my family. Fortunately, no fractures despite a few minor falls. I am sure the French private healthcare system is upset that we didn't need to call on their services last week. In comparison, whilst I was away in the Alps one of my patients with advanced MS (EDSS = 8.0) was admitted to hospital for a week with possible septicaemia from a urinary tract infection; this was her 4th or 5th admission in the last 12-18 months."


"With this backdrop I read on the way to work this morning the Perspective below, from last week's NEJM, on how the US healthcare system classifies patients as being a good, or positive, return on investment (ROI), or a negative ROI. The latter is shorthand for a loss. This patient of mine would be classified as a negative ROI. The article goes onto debate the issue of perverse incentives in the healthcare market and focuses on non-cancer associated chronic disease vs. cancer and how the system is designed to monetise the cancer despite there being variable gain for society. The authors suggest flipping the coin and incentivising healthcare systems to keep people out of hospital. I am all for this and in some ways this is  how the NHS would like to work, but is unfortunately handcuffed by ring-fenced budgets and short time horizons. In the other words spending is typically on a 12 month cycle and managers don't give a toss about saving money down the line; their task is to make sure they don't overspend on their allocated budget this financial year. This is why there is such pressure on us not to prescribe expensive innovative drugs in case we blow this year's budget."

"It is irrelevant to the budget holders (NHS England) that the strategy of early access to effective DMTs may prevent, or at least delay, disability and keep these people out of hospital in the future with their recurrent UTIs, falls, fractures, pneumonias, etc. Reducing future healthcare expenditure is simply not on their radar. This discussion does not even mention the elephant in the room, i.e. societal costs. What about keeping these individuals in work? What about preventing the need for their spouse, or partner, to give up work to become their full-time carer? What about the disability living allowances, community care and social service expenditures to try and maintain these people's' quality of life? Surely it is time to do something about perverse incentives that underpin healthcare?"


Asch et al. Perspective: Asymmetric Thinking about Return on Investment. N Engl J Med 2016; 374:606-608.

Excerpts:

.... Lately, we’ve attended many conferences about providing health care to patients with high medical and social needs — people with chronic illnesses who are frequently readmitted to the hospital. It seems as if every presentation refers to “return on investment” (ROI), which is invariably presented as a constraint — as in “Our program kept people out of the hospital, but we just couldn’t get the ROI to work.” Heads nod understandingly, and then participants move on to other topics.....

..... At conferences about providing care for patients with cancer or other acute illnesses, by contrast, we almost never hear the term ROI. Instead, people talk about clinical gains, using understandable and patient-centered terms like “survival.” Though high drug prices are sometimes mentioned, no one ever says the ROI is prohibitive. No one mentions ROI at all.....

..... There is no obvious reason why ROI is more relevant to some clinical situations than to others. So why do we focus so heavily on ROI when the topic is chronic illness but rarely mention it when the topic is cancer? A huge amount of the cancer care we deliver provides such small personal and social gains that, were those gains monetized, the endeavor’s ROI would be deeply negative. And yet we ask, “What’s the ROI of that program that keeps chronically ill patients out of the hospital?” but not “What’s the ROI of treating advanced lung cancer?”.....

...... There are at least three reasons for this difference. One is that from the financial perspective of doctors and hospitals, the ROI of treating cancer is favorable. Reimbursements for cancer care are high in part because the political and popular value of cancer care is high, and those values are both revealed and reinforced by a history of largely cost-based fee-for-service pricing explicitly designed to at least meet providers’ costs.....


...... In contrast, the ROI of keeping chronically ill patients out of the hospital under current payment models is often unfavorable — which means you often lose money trying it. The amount of money currently devoted to keeping some patients out of the hospital and in alternative care settings is a fraction of the amount we devote to putting other patients in the hospital. Some might argue that one reason that cancer care is reimbursed so heavily is the presence of the same kind of political pressure that led to prohibiting the Centers for Medicare and Medicaid Services (CMS) from considering cost in coverage determinations. Efforts to help chronically ill patients receive the right level of care do not seem subject to the same pressures......

....... A second reason is that keeping people out of the hospital is hard — typically requiring care coordination with multiple services..... 

..... So when advocates and organizations devoted to keeping people out of the hospital lament their inability to make the ROI work, they should know that the game is thrice rigged against them.....

...... What if the financing of cancer care and of efforts to achieve population health goals traded places? Suppose doctors and hospitals were paid for cancer care by capitation or bundles or through penalties for undesired outcomes and were paid directly and adequately to keep people out of the hospital. Oncologists might begin lamenting that although new approaches to cancer care helped patients, they just couldn’t get the ROI to work. And the outlook for population health might become less financially gloomy.......

...... Rewards and penalties have the same ultimate effect on investment income, but they influence thinking in different ways. We might encourage greater effort and innovation in keeping people out of the hospital and coordinating care if we reframed its financing as positive payments for noble work rather than punitive revenue reductions. As U.S. health care financing begins again to shift risks to hospitals and physicians through bundled payments or readmission penalties, the financing of the care for our most challenging patients might be better shifted in the other direction.....

CoI: multiple

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