ClinicSpeak & BrainHealth: are you a positive return on investment?

Are you considered a drain on public resources? Isn’t it time to do something about it?  #ClinicSpeak #BrainHealth #MSBlog

“Just back from a week’s break in the Alps with my family. Fortunately, no fractures despite a few minor falls. I am sure the French private healthcare system is upset that we didn’t need to call on their services last week. In comparison, whilst I was away in the Alps one of my patients with advanced MS (EDSS = 8.0) was admitted to hospital for a week with possible septicaemia from a urinary tract infection; this was her 4th or 5th admission in the last 12-18 months.”

“With this backdrop I read on the way to work this morning the Perspective below, from last week’s NEJM, on how the US healthcare system classifies patients as being a good, or positive, return on investment (ROI), or a negative ROI. The latter is shorthand for a loss. This patient of mine would be classified as a negative ROI. The article goes onto debate the issue of perverse incentives in the healthcare market and focuses on non-cancer associated chronic disease vs. cancer and how the system is designed to monetise the cancer despite there being variable gain for society. The authors suggest flipping the coin and incentivising healthcare systems to keep people out of hospital. I am all for this and in some ways this is  how the NHS would like to work, but is unfortunately handcuffed by ring-fenced budgets and short time horizons. In the other words spending is typically on a 12 month cycle and managers don’t give a toss about saving money down the line; their task is to make sure they don’t overspend on their allocated budget this financial year. This is why there is such pressure on us not to prescribe expensive innovative drugs in case we blow this year’s budget.”

“It is irrelevant to the budget holders (NHS England) that the strategy of early access to effective DMTs may prevent, or at least delay, disability and keep these people out of hospital in the future with their recurrent UTIs, falls, fractures, pneumonias, etc. Reducing future healthcare expenditure is simply not on their radar. This discussion does not even mention the elephant in the room, i.e. societal costs. What about keeping these individuals in work? What about preventing the need for their spouse, or partner, to give up work to become their full-time carer? What about the disability living allowances, community care and social service expenditures to try and maintain these people’s’ quality of life? Surely it is time to do something about perverse incentives that underpin healthcare?”

Asch et al. Perspective: Asymmetric Thinking about Return on Investment. N Engl J Med 2016; 374:606-608.


…. Lately, we’ve attended many conferences about providing health care to patients with high medical and social needs — people with chronic illnesses who are frequently readmitted to the hospital. It seems as if every presentation refers to “return on investment” (ROI), which is invariably presented as a constraint — as in “Our program kept people out of the hospital, but we just couldn’t get the ROI to work.” Heads nod understandingly, and then participants move on to other topics…..

….. At conferences about providing care for patients with cancer or other acute illnesses, by contrast, we almost never hear the term ROI. Instead, people talk about clinical gains, using understandable and patient-centered terms like “survival.” Though high drug prices are sometimes mentioned, no one ever says the ROI is prohibitive. No one mentions ROI at all…..

….. There is no obvious reason why ROI is more relevant to some clinical situations than to others. So why do we focus so heavily on ROI when the topic is chronic illness but rarely mention it when the topic is cancer? A huge amount of the cancer care we deliver provides such small personal and social gains that, were those gains monetized, the endeavor’s ROI would be deeply negative. And yet we ask, “What’s the ROI of that program that keeps chronically ill patients out of the hospital?” but not “What’s the ROI of treating advanced lung cancer?”…..

…… There are at least three reasons for this difference. One is that from the financial perspective of doctors and hospitals, the ROI of treating cancer is favorable. Reimbursements for cancer care are high in part because the political and popular value of cancer care is high, and those values are both revealed and reinforced by a history of largely cost-based fee-for-service pricing explicitly designed to at least meet providers’ costs…..

…… In contrast, the ROI of keeping chronically ill patients out of the hospital under current payment models is often unfavorable — which means you often lose money trying it. The amount of money currently devoted to keeping some patients out of the hospital and in alternative care settings is a fraction of the amount we devote to putting other patients in the hospital. Some might argue that one reason that cancer care is reimbursed so heavily is the presence of the same kind of political pressure that led to prohibiting the Centers for Medicare and Medicaid Services (CMS) from considering cost in coverage determinations. Efforts to help chronically ill patients receive the right level of care do not seem subject to the same pressures……

……. A second reason is that keeping people out of the hospital is hard — typically requiring care coordination with multiple services….. 

….. So when advocates and organizations devoted to keeping people out of the hospital lament their inability to make the ROI work, they should know that the game is thrice rigged against them…..

…… What if the financing of cancer care and of efforts to achieve population health goals traded places? Suppose doctors and hospitals were paid for cancer care by capitation or bundles or through penalties for undesired outcomes and were paid directly and adequately to keep people out of the hospital. Oncologists might begin lamenting that although new approaches to cancer care helped patients, they just couldn’t get the ROI to work. And the outlook for population health might become less financially gloomy…….

…… Rewards and penalties have the same ultimate effect on investment income, but they influence thinking in different ways. We might encourage greater effort and innovation in keeping people out of the hospital and coordinating care if we reframed its financing as positive payments for noble work rather than punitive revenue reductions. As U.S. health care financing begins again to shift risks to hospitals and physicians through bundled payments or readmission penalties, the financing of the care for our most challenging patients might be better shifted in the other direction…..

CoI: multiple

11 thoughts on “ClinicSpeak & BrainHealth: are you a positive return on investment?”

    1. Cartel…so what's new here?We (MDs) have said this for many years. Mention (drug) cartel and the US government may get interested…it is clear there is no real competition on price. Copaxones price was hiked as its patent came towards an end wringing more profit. Roche could undercut them all and sweep the floor with the rest…will this happen? No, it will be pricied between natalizumab and Alemtuzumab, but you give ocreluzimab 6 times less than naalizumab but it will not be six times cheaper no way…

    2. Join this entire cartel situation sponsored by Big Pharma and add corruption pervaded the state, then you have the "perfect storm" … That's what happens here in Brazil …

  1. Glad you are bringing this to everyone's attention. However it is very dispiriting that such short term views are taken by administrators/managers/budget holders in the NHS… dare I say it's a no brainer that horizons should be longer term to maximise benefit financially and societally (is that a word?). Not to forget, benefit to individuals, their families and to simply benefit fellow men/women. Thanks again… also for the photo!

  2. Your patient with EDSS 8 – how demoralising is this for a doctor. When you qualified in neurology, could you ever imagine that 20-25 years later there would be patients like this ie beyond help? As much as we are on awe of MS reseachers / teams, the case you cite is a stark reminder that we are a long way from having a world free of MS and tragic cases such as these.

    1. I don't view it as demoralising. It doesn't matter how advanced someone's MS is it is our job to help them make their lives liveable and to give them some quality of life. You will be surprised how your worldview changes with time and your expectations with them. I have many patients with advanced MS who have a good quality of life and many family members and friends who care for them and love them. If we view the world from their new perspective it is very different to ours. My role as a doctor is to understand and appreciate this and not to judge. This particular patient has the most loving and caring husband in the world; he would literally move heaven and earth for his wife. It is our role to help make sure his task a little easier. If I could vote for the 2016 most caring husband award he would get my 1st, 2nd and 3rd vote.

  3. I have RRMS, and last year I was diagnosed with tonsil cancer.The difference in approach, in attitude, was, and is, extraordinary. I am immensely grateful for the all-out stance taken by my oncology team – I also happen to be lucky enough to be in the catchment area for a beacon cancer centre, so pretty much at the top of their game – but the contrast between the overall ideology towards something that is increasingly curable (so far, so good for me after surgery, chemo and radiotherapy), and the chronic, the MS world, I still haven't quite got my head around.One of the ironies, because of the cancer (which was HPV positive), I had to drop the DMTs. Subsequently, trying to get advice on what MS treatment options are open to me in the future has taken a great deal of work, because this is all unknown territory, particularly with the newest DMTS. So I also risk dropping off the list of the MS specialists – so far they have agreed to keep seeing me, until we make a decision on if/what DMTs – and falling further down the treatment ladder, and further away from quality MS-related care.

    1. I don't see a difference in my care from neurologists following cancer. They just don't take risks with treatments that could be harmful to a cancer survivor. Wider society treats us with much more compassion if we survive cancer, than we get from the chronic illness MS.

  4. The USA system is quite different than national care systems such as Canada/UK. Ours is hybrid with Federal insure, State insurer and/or private insurer. While there have been some entities that have taken advantage of the new care situation and often taken to task on it in meds, MS and other chronic disorders have a different landscape. A rather complicated rebate system exists. This is why you do not see private insurers loosing their minds on cost as its "paper". MS meds who's "visual costing" has skyrocketed is not for reasons people suspect. Instead, its so patients have "choice". Insurers do not thus dictate, "Here do Avonex its cheapest". Instead, neurologists and patients can make informed decisions based on their individual MS and issues. Costing IS more expensive in the USA and there are real reasons for it including that of market economics. The rebate (for lack of a better term) system affords both pharma and insurers tax incentives. In the USA Pharma will try very hard to get someone on a therapy even if they cant afford pay a red cent and insurance is not an option. Again, its a system that has been established to actually get meds into people hands. Its a complex system with some holes need be plugged. While people scream when they see raw gross cost they are not paying it and much of it is paper asset against taxable revenues.

  5. That said,one of the "fears" on the "inside" are long term outcomes. Aka: Will insurers end up looking towards lifestyle and compliance matters as risk. For example. The next step in USA RRMS is towards lifestyle alterations towards best long term outcomes. Questions such as dietary compliance are a real "Yahoo" moment. But for example prescribed physical therapy and non-compliance of it may result in altering insurer curves. Since many chronic disorders are now shown to be impacted due to lifestyle it may end up as a rated or graded chronic care environment down the road. Similar to risk pool auto insurance. Aka: "If one does not want do the work / efforts towards best outcomes (prescribed) then one will have incentive to do so, caps and/or rising insurance costing as risks.Now that effective DMT's really exist and choice, lifestyle is becoming the new discussion and not only in MS.

  6. Towards this end… Some here (who have some brains) consider Mr. Trump a seed. A person who can "sell" populous into significant changes while both mainstream parties throw hands up and say, "Wasnt us, you all voted him in". From a stand back view the show going on appears as though this may well be the case. A man of his wealth knows boardroom decorum and politik. This is not what is being displayed. Instead its more reality show which may well result in "Be careful what you ask for, here it is".

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