Re: A Reform of Rewarding Systems of the Providers and Other Players in Health Care Arena: a Structural Way to Prevent Overdiagnosis and Disease Mongering
5 July 2012
This paramount essay (1) proposes some actions that we can take about overdiagnosis:
a) to build on existing knowledge with the 2013 Conference on overdiagnosis, to provide a forum for learning more, increasing awareness, and developing research on ways to prevent the problem.
Moreover, at a policy level:
b) to start a reform of the process of defining disease, narrowing the disease definitions and raising many disease thresholds, and furthermore recognizing the wider social and environmental determinants of health
c) to review the permanency of some diagnostic labels
d) to increase independence in the design and running of scientific studies
e) to adjust the legal and structural incentives driving overdiagnosis.
We think that the latter is the real root of the problem, which lies on the main current rewarding systems in the health market, and on their logical consequences on the behaviour of nearly all providers.
If the health systems follow models that actually “pay for the disease”, no wonder that the market adapts its behaviour and “sells the disease” as much as possible, diagnosing/anticipating it even if the prognosis does not change, dramatizing it and even “creating” it.
Paying for the disease puts Health Boards and Systems, and Hospitals, GP practices, doctors, pharmacists, and nearly all players in the health market arena in structural conflict of interests with health and wellbeing.
It is time for the public health systems, in alliance with WONCA and EURACT and UEMO (2, 3, 4), to undertake two main actions.
First, they should react more boldly and give clear-cut answers, highlighting the possible health and economic risks of many diagnostic and therapeutic technologies, for both the individual and the community (starting from the involvement of the middle classes, who bear the greatest burden of taxation to support NHS where too many resources are unnecessarely wasted, and whose own safety is also threatened by the increasing diagnostic “epidemic” and overtreatment). This strategy can be more effective, rather than simply claiming that “there is not sufficient evidence” to recommend/pay for these technologies.
More important, the NHSs should reform the health organizations’ financing systems and the professionals’ remuneration schemes, so that their interests become aligned to the patients’ and community health (expressed as an unequivocal outcome, that is longevity) rather than to their diseases.
Examples of ways to pay for diseases are:
• Fee-for-service, reimbursement systems, price for drugs
• D(iagnosis of disease)RGs
• Disease management
• Private practice (fee-for-service rewarded)
• Payment for inputs, processes, outputs not related to outcomes.
Different ways to pay for health (by a tax funded National or Regional Health Fund, or possibly by a Health Manteinance Organization with a territorially defined catchment area) are (5-6):
1) Capitation weighted for the patient’s age (to reward GPs, pharmacists, health Districts, local Health Units …), in a yearly continuous progression, i.e. a centenarian yearly capitation should weights ten times an adolescent capitation.
This would be an equitable way to pay for the additional work of caring for patients getting older; but, above all, it would give a strong signal of a health policy targeted to the main objective of a Health System: a healthy longevity for all. It would give a virtuous incentive - not related to the quantity/complexity (both easily induced by providers) of performed services – to help one’s own patients’ cohort to age more and better, thus aligning ethics and better income for GPs, Health Local Units and so on (5). This virtuous rewarding model should include even Hospitals, whose core business should come from a fraction of the capitation of the Local Health Unit in which they are placed and that pays them, in relation to the age structure of population that corresponds to their catchment area (5, 7).
2) A complementary way to pay for Health may be: further incentives, based on health (or economic) outcomes (or levels of outcome), that may be added for special objectives, not rewarded enough by the age-weighted capitation (5) (for example:
- babies cared for by a GP practice, who are breastfed for one year or more over challenging thresholds (based on local epidemiological data)
- having a percentage of obese babies and adolescents followed by a GP practice under challenging thresholds (based on local epidemiological data), making it convenient not to have many obese patients and to treat them, but rather to have few obese patients, due to the fact of having effectively prevented their overweight during their life
- hypertensive subjects treated with first line low-dose thiazide-type diuretics over high and very high thresholds, instead of being treated with more expensive but not more effective drugs).
In any case, fee-for-service incentives should be carefully avoided, because they increase technological abuse, services that are profitable, irrespective of their effectiveness, and disease mongering.
1. Moynihan R, Doust J, and Henry D. Preventing overdiagnosis: how to stop harming the healthy. BMJ 2012; 344:19-23
2. van Weel C, Carelli F, Gerada C. Reforming primary care: innovation or destruction? BJGP
2012 Jan; 62:43-4.
3. Public statement of EURACT Council Meeting, University of The Algarve November 10-12, 2011. http://www.euract.eu/euract-news/116-general-practice-family-medicine-can-delive\
4. UEMO Position on Disease Mongering and Quaternary Prevention. http://www.uemo.eu/uemo-policy/123.html
5. Donzelli A. Allineare a etica e salute della comunità dei cittadini le convenienze dei diversi attori in Sanità. Mecosan – Management and Economia Sanitaria 2004; 50:131-47
6. Donzelli A. Elementi di un sistema di remunerazione virtuoso per le farmacie. ASI 2006; 37:12-3
7. Donzelli A. Un pagamento prospettico più evoluto e “virtuoso” per gli erogatori, alternativo al pagamento a prestazione. ASI 1999; 21:18-24
• Francesco Carelli, General Practice MD, Prof. of Family Doctors University of Milan, Italy
• Claudia Lattes, MD - Service of Education for Appropriateness and EBM of ASL di Milano, Italy
• Luigina Ronchi, Dr - Service of Education for Appropriateness and EBM of ASL di Milano, and Member of Board of Movimento Consumatori Milano – Italy
• Silvia Sacchi, Dr - Service of Education for Appropriateness and EBM of ASL di Milano, Italy
• Donatella Sghedoni, MD - Unit for Clinical Support in General Practice - ASL di Milano, Italy
Competing interests: None declared
ASL of Milan, via Ricordi 1 - 20131 Milano (Italy)
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