Capitalist free markets have been touted as the best solution to organize resources to address problems. Some extreme proponents contend that free markets can address all problems all of the time. Others acknowledge that sometimes free markets produce unintended consequences (market failure) that need to be addressed through government regulation or incentives.
In US health care, the free market has given us a situation where we spend twice as much as other developed countries but end up at the low end of health status. Some would call this market failure. On the other hand, the market has been a success for some people. Profits for all sectors of the health care industry (insurance, doctors, hospitals, pharma, device makers, etc.) are spectacularly high. Cynically, one could say that the market is a success and doing what it is intended (producing profits) and that we shouldn't expect better health as an outcome from this market. Any health benefit (or adverse health impact) is merely an unintended consequence of the market.
And this brings us to the primary dilemma of the free market and health. The primary goal for the free market is profit. Any diversion from this goal is inefficient and against the interests of the holders of capital. However, the primary goal of the population is better health. It might seem that you could organize a market to reward 'better health' but all that we have been successful in organizing is markets that deliver health products and services. Some of these improve health, others are just a waste of time and money, some can be detrimental to health.
In health, free market advocates say that personal gain is sufficient to ensure that everyone receives appropriate goods and services. Most people concede that we do need to have regulation to make sure that people don't sell goods and services that are dangerous or not effective. The problem is that when the primary motive is personal gain, there are a host of incentives to sell unneeded goods and services and to hide defects. Regulation is not adequate in many cases and some would argue that it cannot be adequate in some cases. The result is that health care market suffers from a plethora of abuses.
The bottom line is that the free market is not appropriate for health care. The U.S. needs a single payer government financed health system that covers everyone. This payer needs the authority to determine which health services and goods are useful and to determine when they will be provided. It also needs the authority to set the prices it pays.
There is plenty of money being spent on health care in the U.S. It is just not being spent on the right services for the right people.
Wednesday, November 19, 2008
Thursday, November 6, 2008
Health Care is a Right
The U.S. is suffering from a dysfunctional health care system that does not provide basic health services to many but still manages to consume more money than anyplace else on earth.
How do we decide how much to spend and how do we spend it?
I think that this is the core issue when people propose 'universal health care' or 'health care as a right'. People worry about public funding of cosmetic surgery, genomic based treatments, lifestyle diseases, etc.
The answer is simple; and it is complex.
First, the simple answer... 'as much health care as we can afford'.
Q: How much is that? A: X dollars
Q: But that's rationing! A: Yes
Q: That's communistic, socialistic, immoral, etc.!
A: Our current system is rationing based on ability to pay, not individual need and not on the value of the treatment. Our country currently spends 2x to 3x as much per person as other developed countries, all of whom provide better care and as a result have better basic health indicators. Even Cuba has equal or better health indicators than the U.S.
The 'free market' for health care in the U.S. is very successful at producing spectacular profits for everyone involved and a dismal failure at providing goods and services that improve health. This is a profound market failure.
Q: How do we ration?
A: We need adult supervision. We need regulation. We need the government deciding which services are useful and beneficial and cost efficient.
I know this is an extremely unpopular message and I expect that everyone who is making money in the current system will attack it and patients will also attack it because they will (wrongly) perceive that they won't get needed services. They will get needed services. They won't get every unproven test and treatment. If they want to spend their discretionary income on unnecessary tests and unproven treatments and concierge medical care, that's fine. Just don't expect the taxpayer to fund it.
Welcome to the real world. This is the way the rest of the world works. The party on Wall street is over. It is time to end the party that we call 'U.S. Health Care'. It too is a house of cards that is generating obscene profits while providing services of dubious value.
Friday, October 31, 2008
A Health Informatics Strategy
Health Informatics
Health informatics is the art and science of collecting, analyzing, communicating, and using health information. A commonly accepted definition states:
The Problems
Creating useful health data has always been problematic due to its complexity and the necessity of collection at the point of contact under often difficult conditions. In many resource poor areas, especially Africa, health data is notorious for being of low quality and out of date, therefore lacking usefulness. Health information systems have been historically based on paper forms which are prone to error during data collection, difficult to analyse, and cumbersome to communicate. They have been difficult to convert to electronic systems due to the lack of informatics expertise of health professionals. An additional complication is that health information systems have generally been designed and 'pushed down' from the top level to meet specific reporting needs that are not necessarily useful to those collecting the data. The difficulty in implementing these in the field and the lack of relevance at lower levels has contributed to poor data quality and an increasing burden of data collection. The result is that the data that is collected is rarely used at lower levels where it could improve the management and quality of health services and is lacking quality at higher levels where it could inform policy and strategy development.
A great deal of effort goes into collecting health data in developing countries. However, often data is not used because it is not available when and where it could make a difference. Health systems have many decision points including direct patient care, management of health services, planning, program monitoring, and evaluation of services.
The key to improving access to data is to have clear definitions and communication protocols.
The Mission
A health informatics group will strive to develop information systems that ensure timely, accurate, actionable information at all levels of the health system. Each group of potential information users from the individual clinician through communities, facilities, districts, national, and international levels have unique needs for health information. Patient care, health services management, planning, strategy, policy and monitoring and evaluation each have unique information requirements. All require appropriate, timely, relevant information at a decision point.
The art and science of health informatics has made steady progress along with improvements in information and communication technology (ICT). Capturing, analyzing, and presenting health information is a complex process and resources for training and implementation in developing countries are limited. The result has been slow adoption of electronic health information systems with a resulting lack of vital information at all levels. However, we now have enough experience and technology has improved to the point where we understand how to design and implement useful health information systems in resource poor environments. An important part of our understanding is built around the complex interactions of information system, user interface, work flow, training, and management.
There is a science to designing health information systems to facilitate the collection of useful information and to ensure that the information can be used over time and distance.
The Benefits
The immediate goal is to improve the use of information to make decisions. Improved health information systems increase the efficiency and quality of health systems performance and this leads to better health.
Data standards improve the communication of information. Information can move quickly and clearly to the decision point. This can be the clinician at the point of care with a patient having current test results and patient history; it can be a manager at the district level deciding where to send immunization teams today; or it can be donors making decisions on grants. The person making the decision has better information to make a timely decision and this improves health.
A health informatics group should work to develop collaborative communities which can customize health information systems from the bottom up as well as provide training and support. Open source software and data standards are a powerful enabling environment that take advantage of state of the art communication networks to improve the development, implementation, and deployment of health information systems. Collaborative communities are more responsive, relevant, and sustainable than the often short term vertical program focus of top down initiatives. Open source software can leverage scarce human and financial resources through re-use and collaborative development. The result here also is better information, better decisions, and better health in a more sustainable environment.
1 Wikipedia www.wikipedia.org/wiki/Health_informatics
Health informatics is the art and science of collecting, analyzing, communicating, and using health information. A commonly accepted definition states:
"It is the intersection of information science, computer science, and health care. It deals with the resources, devices and methods required to optimize the acquisition, storage, retrieval and use of information in health and biomedicine. Health informatics tools include not only computers but also clinical guidelines, formal medical terminologies, and information and communication systems."1Health informatics is based on information science which is a discipline independent of the implementing technology. Health informatics may use paper or electronic technology to implement information systems. To further clarify, it should be stressed that information systems are not necessarily technology based and conversely that there are many applications of technology to health that do not involve information systems.
The Problems
Creating useful health data has always been problematic due to its complexity and the necessity of collection at the point of contact under often difficult conditions. In many resource poor areas, especially Africa, health data is notorious for being of low quality and out of date, therefore lacking usefulness. Health information systems have been historically based on paper forms which are prone to error during data collection, difficult to analyse, and cumbersome to communicate. They have been difficult to convert to electronic systems due to the lack of informatics expertise of health professionals. An additional complication is that health information systems have generally been designed and 'pushed down' from the top level to meet specific reporting needs that are not necessarily useful to those collecting the data. The difficulty in implementing these in the field and the lack of relevance at lower levels has contributed to poor data quality and an increasing burden of data collection. The result is that the data that is collected is rarely used at lower levels where it could improve the management and quality of health services and is lacking quality at higher levels where it could inform policy and strategy development.
A great deal of effort goes into collecting health data in developing countries. However, often data is not used because it is not available when and where it could make a difference. Health systems have many decision points including direct patient care, management of health services, planning, program monitoring, and evaluation of services.
The key to improving access to data is to have clear definitions and communication protocols.
The Mission
A health informatics group will strive to develop information systems that ensure timely, accurate, actionable information at all levels of the health system. Each group of potential information users from the individual clinician through communities, facilities, districts, national, and international levels have unique needs for health information. Patient care, health services management, planning, strategy, policy and monitoring and evaluation each have unique information requirements. All require appropriate, timely, relevant information at a decision point.
The art and science of health informatics has made steady progress along with improvements in information and communication technology (ICT). Capturing, analyzing, and presenting health information is a complex process and resources for training and implementation in developing countries are limited. The result has been slow adoption of electronic health information systems with a resulting lack of vital information at all levels. However, we now have enough experience and technology has improved to the point where we understand how to design and implement useful health information systems in resource poor environments. An important part of our understanding is built around the complex interactions of information system, user interface, work flow, training, and management.
There is a science to designing health information systems to facilitate the collection of useful information and to ensure that the information can be used over time and distance.
The Benefits
The immediate goal is to improve the use of information to make decisions. Improved health information systems increase the efficiency and quality of health systems performance and this leads to better health.
Data standards improve the communication of information. Information can move quickly and clearly to the decision point. This can be the clinician at the point of care with a patient having current test results and patient history; it can be a manager at the district level deciding where to send immunization teams today; or it can be donors making decisions on grants. The person making the decision has better information to make a timely decision and this improves health.
A health informatics group should work to develop collaborative communities which can customize health information systems from the bottom up as well as provide training and support. Open source software and data standards are a powerful enabling environment that take advantage of state of the art communication networks to improve the development, implementation, and deployment of health information systems. Collaborative communities are more responsive, relevant, and sustainable than the often short term vertical program focus of top down initiatives. Open source software can leverage scarce human and financial resources through re-use and collaborative development. The result here also is better information, better decisions, and better health in a more sustainable environment.
1 Wikipedia www.wikipedia.org/wiki/Health_informatics
Thursday, October 30, 2008
Welcome
I have worked in health and development primarily from an informatics viewpoint since 1993. Prior to that, I worked in health informatics in the U.S.
There are many issues in health and development where I would like to post my experience and ideas. This will include both developed country and developing country posts since it is often useful to compare and contrast approaches and take the best from each.
There are many issues in health and development where I would like to post my experience and ideas. This will include both developed country and developing country posts since it is often useful to compare and contrast approaches and take the best from each.
Subscribe to:
Posts (Atom)
Posts
