Health Care Reforms That Work

Diseases like diabetes, heart disease, cancer, chronic kidney disease, and stroke are on the rise in both the developed and the developing world, and they have a few things in common.

First, they are responsible for contributing a large chunk of patients into the health care system, especially in developed countries like the US. In fact such diseases are the cause of death in more than 4 out of 5 cases in the US. Second, these diseases are non-communicable, and are caused by poor diet, lack of exercise, and unhealthy lifestyle rather than bacteria, viruses and other micro-organisms.

Third and most importantly, unlike communicable diseases where the incidence rates and overall costs are on the decline, these conditions are posing a heavier burden on health care systems every year. All of our new policies and efforts to provide affordable health care could pale in comparison to the exponentially rising costs associated with these diseases and their demographics. In light of this increasing burden, what can we do?

One area where we’ve begun to make some inroads is with chronic kidney disease (or CKD for short).  CKD is a condition that affects 1 in 10 Americans over 20 and costs the US health care system almost $100 Billion a year. In the US, a little over 1 % of Medicare patients have advanced renal impairment, and yet nearly 8 % of the total Medicare budget is spent on treating them. Today nearly 2 million people in the world are kept alive by dialysis. CKD is closely linked with other conditions such as hypertension, diabetes and heart disease. It disproportionately affects the poor, and is expected to worsen in developing countries at an alarming rate—though the incidence and prevalence of CKD is increasing at an alarming rate in every part of the world. This disease is poorly understood and very few people take measures to prevent it, though CKD is preventable and its progression can be slowed by simple strategies and lifestyle changes.

The good news is that we’ve already begun to transform costs for CKD.  Five innovative reforms have been found to help reduce costs without compromising on the quality of health care services:

Decentralization of responsibilities: Most dialysis centers today are trying to provide drug management, laboratory services, and vascular surgery management in addition to dialysis service under one roof. This bundling of care allows each center to function independently and to provide a one stop solution to all patient needs. In 2010, provision for bundled care was included both in the Patient protection and Affordable Care Act and in the Affordable Health Care for America Act. Bundling services together discourages unnecessary care, and encourages better coordination across providers which can lead to better quality of service at a lower overall cost.

Transparency: In a country like India, the incidence and prevalence of kidney disease is still unknown today. The lack of such data makes it impossible for any country to allocate resources effectively. In other words, cost containment cannot be achieved without cost estimation first. Unlike India, the UK has been devoting significant effort towards the maintenance of the UK Renal Registry which discloses all outcome measures including patient survival for kidney disease population. This approach has helped UK become one of the most cost-effective and one of the best providers of kidney care in the developed world today.

Incentives: After a decent level of transparency is established in any system, it becomes relatively easy to evaluate its performance and suggest remedies to improve it or maybe even reward good performance. In some hospitals in Europe, an incentive program is being discussed to encourage good performance. For example, a hospital in Italy has suggested a model which advocates higher use of Peritoneal Dialysis (or PD for short, a form of home dialysis which is cheaper than traditional hospital dialysis). Published literature indicates that PD is at least $ 15,000 to $ 20,000 cheaper than traditional hospital dialysis per year and also offers similar if not better quality of life. If hospitals decide to raise the percentage of patients on PD from 12% (the European average), to an easily achievable 40%, it could lead to a considerable amount of savings without any compromise in quality of care.

Patient participation: Nowadays, patients want to be in control of their own therapy and want to know more about it. They want to be given the choice of how care should be provided and what services they will receive. Taking all this into account, it is of paramount importance that the system gives patients the right to choose. A number of successful evaluations have been carried out in the US and the UK where patients were given their own personal budget to allocate, rather than a standard menu of services. These evaluations have shown that such an approach not only makes the patient feel more satisfied but also overall expenditure falls, since clinicians are less conservative than patients when it comes to spending money on health care.

Another innovation that has contributed to the improvement of patient participation is telemedicine. Today, there are home dialysis patients who are remote monitored by the doctor, and as result the patients spend less time in the hospital, less money on drugs required to treat complications, and most of all enjoy a higher quality of life. These patients are more “in control” of their lives.

A focus on prevention: Chronic kidney disease is actually divided into 5 distinct stages, and the costs associated with each stage are different. A study in 2004 revealed that costs continuously increase as we progress from stage I to stage IV. This is clear proof that a far greater sum of money can be saved by health care systems if they can reach patients at an earlier stage. Currently the US only spends less than 4 cents on preventive measures for every dollar spent on health care. It might help if more resources are allocated in educating the public on how to avoid diseases like chronic kidney disease, like emphasizing how to eat and exercise right.

If we can apply what we’ve learned here to the other big four diseases, we might be able to stem the rising costs even as the incidence of these diseases continues to rise. But we have to keep innovating. In all, the need is for innovative policy, new perspective and a more holistic approach to providing health care. The five reforms arising from CKD management can possibly be a powerful tool in achieving that goal.

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