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Balancing influence between actors in healthcare decision making.

Kaplan RM, Babad YM - BMC Health Serv Res (2011)

Bottom Line: In the U.S. this has resulted in large variation in healthcare availability and use, increased cost, reduced employer participation in health insurance programs, and reduced overall population health outcomes.Failure to use effective preventive interventions is perhaps the best example of the misalignment of incentives.These actions include improved transparency of all aspects of medical decision making, greater involvement of patients in shared medical decision making, greater oversight of guideline development and coverage decisions, limitations on direct to consumer advertising, and the need for an enhanced role of the government as the public advocate.

View Article: PubMed Central - HTML - PubMed

Affiliation: Departments of Health Services and Medicine, University of California-Los Angeles, CA, USA. rmkaplan@ucla.edu

ABSTRACT

Background: Healthcare costs in most developed countries are not clearly linked to better patient and public health outcomes, but are rather associated with service delivery orientation. In the U.S. this has resulted in large variation in healthcare availability and use, increased cost, reduced employer participation in health insurance programs, and reduced overall population health outcomes. Recent U.S. healthcare reform legislation addresses only some of these issues. Other countries face similar healthcare issues.

Discussion: A major goal of healthcare is to enhance patient health outcomes. This objective is not realized in many countries because incentives and structures are currently not aligned for maximizing population health. The misalignment occurs because of the competing interests between "actors" in healthcare. In a simplified model these are individuals motivated to enhance their own health; enterprises (including a mix of nonprofit, for profit and government providers, payers, and suppliers, etc.) motivated by profit, political, organizational and other forces; and government which often acts in the conflicting roles of a healthcare payer and provider in addition to its role as the representative and protector of the people. An imbalance exists between the actors, due to the resources and information control of the enterprise and government actors relative to the individual and the public. Failure to use effective preventive interventions is perhaps the best example of the misalignment of incentives. We consider the current Pareto efficient balance between the actors in relation to the Pareto frontier, and show that a significant change in the healthcare market requires major changes in the utilities of the enterprise and government actors.

Summary: A variety of actions are necessary for maximizing population health within the constraints of available resources and the current balance between the actors. These actions include improved transparency of all aspects of medical decision making, greater involvement of patients in shared medical decision making, greater oversight of guideline development and coverage decisions, limitations on direct to consumer advertising, and the need for an enhanced role of the government as the public advocate.

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Related in: MedlinePlus

Change in Use of Selected Prescription and Non-Prescription Drugs between 1995-6 and 2003-4. Data from Health, United States 2006 Data from table 92, pg. 332 (art original)
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Figure 3: Change in Use of Selected Prescription and Non-Prescription Drugs between 1995-6 and 2003-4. Data from Health, United States 2006 Data from table 92, pg. 332 (art original)

Mentions: Demands on resources continue to grow. Aging and chronic illnesses may be associated with a disproportionate share in the growth of healthcare costs. A series of papers by Thorpe illustrate this point[26,27]. For example, 75% of total healthcare spending in the US is linked to chronically ill patients. Over the last twenty years there have been substantial increases in the proportion of the population treated for chronic conditions. For example, the proportion of the population being actively treated for high cholesterol jumped from 1.4% of the population in 1987 to 10.7% in 2003 (an increase of 664%). The number of adults treated for mental disorders nearly tripled in this interval from 5.3% to 17.4%[26]. Adjusted for inflation, the U.S. spends less on hospital care than it did twenty years ago, but more than twice as much for prescription drugs[23]. Figure 3 shows the changes is the use of common drugs over a 10 year period beginning in 1995-1996 and ending in 2003-2004. The data are based on visits to physicians that are coded as drug visits. These are defined as outpatient office or hospital outpatient department visits during which at least one prescription or non-prescription medication was recorded in the patient record. They are presented in two-year blocks: 1995-1996 and 2003-2004. The raw numbers were divided by the sum of the population estimates for both years in each block, and divided by 100 to produce the number of drugs per 100 persons in the population.


Balancing influence between actors in healthcare decision making.

Kaplan RM, Babad YM - BMC Health Serv Res (2011)

Change in Use of Selected Prescription and Non-Prescription Drugs between 1995-6 and 2003-4. Data from Health, United States 2006 Data from table 92, pg. 332 (art original)
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC3108374&req=5

Figure 3: Change in Use of Selected Prescription and Non-Prescription Drugs between 1995-6 and 2003-4. Data from Health, United States 2006 Data from table 92, pg. 332 (art original)
Mentions: Demands on resources continue to grow. Aging and chronic illnesses may be associated with a disproportionate share in the growth of healthcare costs. A series of papers by Thorpe illustrate this point[26,27]. For example, 75% of total healthcare spending in the US is linked to chronically ill patients. Over the last twenty years there have been substantial increases in the proportion of the population treated for chronic conditions. For example, the proportion of the population being actively treated for high cholesterol jumped from 1.4% of the population in 1987 to 10.7% in 2003 (an increase of 664%). The number of adults treated for mental disorders nearly tripled in this interval from 5.3% to 17.4%[26]. Adjusted for inflation, the U.S. spends less on hospital care than it did twenty years ago, but more than twice as much for prescription drugs[23]. Figure 3 shows the changes is the use of common drugs over a 10 year period beginning in 1995-1996 and ending in 2003-2004. The data are based on visits to physicians that are coded as drug visits. These are defined as outpatient office or hospital outpatient department visits during which at least one prescription or non-prescription medication was recorded in the patient record. They are presented in two-year blocks: 1995-1996 and 2003-2004. The raw numbers were divided by the sum of the population estimates for both years in each block, and divided by 100 to produce the number of drugs per 100 persons in the population.

Bottom Line: In the U.S. this has resulted in large variation in healthcare availability and use, increased cost, reduced employer participation in health insurance programs, and reduced overall population health outcomes.Failure to use effective preventive interventions is perhaps the best example of the misalignment of incentives.These actions include improved transparency of all aspects of medical decision making, greater involvement of patients in shared medical decision making, greater oversight of guideline development and coverage decisions, limitations on direct to consumer advertising, and the need for an enhanced role of the government as the public advocate.

View Article: PubMed Central - HTML - PubMed

Affiliation: Departments of Health Services and Medicine, University of California-Los Angeles, CA, USA. rmkaplan@ucla.edu

ABSTRACT

Background: Healthcare costs in most developed countries are not clearly linked to better patient and public health outcomes, but are rather associated with service delivery orientation. In the U.S. this has resulted in large variation in healthcare availability and use, increased cost, reduced employer participation in health insurance programs, and reduced overall population health outcomes. Recent U.S. healthcare reform legislation addresses only some of these issues. Other countries face similar healthcare issues.

Discussion: A major goal of healthcare is to enhance patient health outcomes. This objective is not realized in many countries because incentives and structures are currently not aligned for maximizing population health. The misalignment occurs because of the competing interests between "actors" in healthcare. In a simplified model these are individuals motivated to enhance their own health; enterprises (including a mix of nonprofit, for profit and government providers, payers, and suppliers, etc.) motivated by profit, political, organizational and other forces; and government which often acts in the conflicting roles of a healthcare payer and provider in addition to its role as the representative and protector of the people. An imbalance exists between the actors, due to the resources and information control of the enterprise and government actors relative to the individual and the public. Failure to use effective preventive interventions is perhaps the best example of the misalignment of incentives. We consider the current Pareto efficient balance between the actors in relation to the Pareto frontier, and show that a significant change in the healthcare market requires major changes in the utilities of the enterprise and government actors.

Summary: A variety of actions are necessary for maximizing population health within the constraints of available resources and the current balance between the actors. These actions include improved transparency of all aspects of medical decision making, greater involvement of patients in shared medical decision making, greater oversight of guideline development and coverage decisions, limitations on direct to consumer advertising, and the need for an enhanced role of the government as the public advocate.

Show MeSH
Related in: MedlinePlus