Improve Health Rather Than Health Care

Dr. William H. Foege makes the case that we should be focusing on improving health rather than improving health care.

American health care might also take a lesson from the World Bank, which pioneered a tool in 1993 to measure the state of health in populations. Called "Disability Adjusted Life Years," or "DALYs," this metric incorporates rates of suffering and death into a single number, making it possible to see and compare the impact of various health problems and interventions among populations.

For example, this tool can provide analysts with a snapshot of the total disease burden of an area and the contribution of various factors, such as cancer, infections, and so on. Because it allows comparisons, it has been used by organizations such as the World Health Organization to set priorities for investment in health improvements.

DALYs still lack important ingredients such as measures of quality of care or feelings of well-being. Health is more than the absence of disease. Also, the DALYs metric doesn't reflect the relative values that various societies place on different kinds of suffering or the relative values they assign to life at different ages. Still, experience with the DALYs tells us that it's possible for economists to develop a metric called Disability Adjusted Health Outcomes as a way to measure and compare the effectiveness of the care we pay for.

With such a tool in hand, health plans could be reimbursed based on their ability to achieve those outcomes. The marketplace would then shift focus from process measures to improvement of health. Comparing how various health plans stack up in terms of millions of "person-years" of health experience would quickly reveal which plans are doing best. Thus, the marketplace would be harnessed to improve health profiles nationwide.

I like this concept. Focus on improvements in DALYs rather than treatments or access to care (although these would be dealt with indirectly) and then allow the market to determine the most efficient ways of doing this.

Health plans could be reimbursed with bonuses for the improvement of conditions that are lowering population-wide health measures. This would cause health plans to enroll sick people and provide smoke-enders programs, exercise and diet programs, as well as superb diabetes-control programs.

Imagine competing to enroll the disenfranchised, with current Med-icaid funds subsidizing their premiums! Suddenly, the marketplace would incorporate prevention into medical practice. Imagine if the marketplace succeeded where current medical care failed!

That is also an interesting concept. Have the health providers compete over the disenfranchised because they are where you could improve DALYs for the least amount of money.

The major argument against such a plan is that we can't agree on defining or measuring health outcomes. If that is actually true, it means we are in a business where we don't know how to define success.

Unfortunately, I think that is correct. Measuring DALYs and health outcomes is a very tricky business. But, I think a health care system based on these principles would do a better job at providing the right incentives than the one we have now.

via The Seattle Times