The demand for health care is limitless but funding for it is not. And any scheme has to balance essential needs with what is desired. In the last of a series of articles this week Dr Robin Roberts highlights the critical issues in the formulation of a National Health Insurance scheme for The Bahamas.

Health care cost is spiralling; it has outpaced inflation and it has done so at the budgetary expense of the other essential goods and services.

In 2010-11, the Canadian province of Ontario spent $44.77 billion on health, 40.3 per cent of its total spending on programmes. Based on current trends, this share is likely to expand to more than 44 per cent by 2017-18. Canada’s ten provinces and three territories currently combine to spend an average 36 per cent of their budgets on health care.

Health care spending in the United Kingdom in the past 20 years has more than doubled in real terms and is outstripping all other major public spending, £57.6 billion ($87.7 billion) in 1993-94 and by 2013-14 it had reached £129.4 billion ($199.1 billion). Note how quickly the government of The Bahamas’ spending has doubled, $166.9m in 2001 to $314m in 2012.

How much we should spend, who should spend it and where the money should come from is one of the great debates of the 21st century. The financial discourse is at the forefront of every political and national agenda and for many, it’s a personal economic reality too – people can’t afford to pay health insurance premiums, even more so upon retirement.

In countries where private health insurance plans are predominant, the uninsured numbers are increasing; individuals and families are unable to afford health insurance premiums. Companies providing employer-based health insurance benefits are challenged to maintain their profits and competitive advantage as health care costs spiral; fewer employees are being covered and the extent of the coverage is decreasing.

In public sector-funded health care services, budgetary constraints due to increasing health care costs have resulted in health care rationing; there are long waiting times for physician and clinic appointments and for diagnostic and therapeutic procedure. It’s a recipe for unfavourable outcomes in health care delivery. People die waiting to receive care.

There is a crisis in health care and the central issue is containing rising health care costs.

It is not for want of solutions. The managed care model introduced in both private and public sector care had its moments of success. There was improved efficiency and quality of services and health care costs showed decreasing trends. Once this was optimised, however, the substitution of managing cost through limiting care was unravelled and health care costs resumed their exponential path. The promising public-private partnership models have eased the financial constraints on public sector budgets but not necessarily decreased national health care spending as a percentage of Gross Domestic Product. The ethical and political issues regarding privatisation of health care services remain a topic of hot debate.

Another recent trend is the shift to prevention and wellness programmes in light of the onslaught of the lifestyle-related, non-communicable diseases. These programmes, however, are not inexpensive and one cannot ignore the argument that we are merely shifting costs to end-of-life care.

The debate on solutions to providing affordable health care will only intensify. The population is aging. Our senior citizens utilise more health care services – and the costlier ones at that. Of even greater concern is the shrinking working force. This is more paramount in the developed countries, where fertility has plummeted through better reproductive health and family planning, the dependent non-working population and, in particular, the aging group has outstripped the taxpaying working force.

There are dire predictions for lack of available health care dollars for the post-World War Two “baby boomer” populations because of the explosive need and cost for health care services. In Ontario, the Institute for Clinical Evaluative Services estimated that one per cent of patients, 80 per cent of whom are over 65, account for 34 per cent of total health care costs. Five per cent of the population accounts for 84 per cent of combined hospital and home care costs.

Defining medical consumerism

The success of any solutions to resolve this health care crisis must refocus on the issues underlying the increasing costs of health care and how to control them. So what have been the major factors contributing to rising health care costs?

The technological and pharmaceutical advances take centre stage. These two budgetary items are vital to our longer life spans and improved quality of life. Managed care and private-public partnership have made major inroads to improving efficiency, utilisation and curtailing costs. The malpractice issue is being addressed through advancing risk management programmes and limiting settlement amounts through legislation.

Medical consumerism, the desire to want and consume more health services, especially if a third party payer foots the bill – yielding the perception that health care is free – is the primary engine fuelling today’s costs in the health care industry. Someone else is paying the bill; so let’s get it all and only the (perceived) best will do.

The attention on curbing health care cost must focus on what could be proposed as the most significant paradigm shift in health care in the past 50 years – the transformation of health care from an essential service model to a consumer product and manifesting all the classical features of the product life cycle experience in the field of marketing. The analogy is likened to a shift in Maslow’s hierarchal structure from a level one basic physiological need to a level four – and ultimately a level five – self actualisation. In the words of Sir Thomas More “health is the greatest of bodily pleasures”.

Is newer better?

We have become consumers of health care services, with little regard for the effectiveness of the product, particularly in regard to its utility compared to other available products. The medical literature is inundated with examples of our products in the human market, each proclaiming to be the latest and the best. This is exemplified readily in the treatment of prostate cancer; the options are numerous and so are the varied costs.

The progress and benefits to treating prostate cancer are testimonials to the medical advances of the last century. In the surgical arena, there are the benefits of the minimally invasive techniques – pinhole surgery or no scars, less pain, shorter hospital stays, earlier return to regular activity and longer lifespans. In radiation, there is External Beam Conformal Therapy (radiation from the outside), Brachytherapy (radiation from the inside), IMRT (Intensity Modulated Radiation Therapy) and now Proton Beam Therapy. The non-radiation treatment programmes are flourishing too: Cryosurgery and High Intensity Focused Ultrasound. The newer modalities are all at prices exceeding the costs of the traditional open surgery. But are the marginal benefits cost effective? Are we getting value for money spent?

The new toy on the market is the robot. Within two years of its introduction, the robotic technique accounts for over 60 per cent of the radical prostatectomy procedures performed in the United States. Proponents of the robot laud its numerous advantages over the open procedure: a shorter hospital stay (one day on average) and the need for less analgesia (one day too) and less bleeding (but not leading necessarily to less blood transfusions). But for the two major complications of the paramount concern, however, control of urination and return of sexual function, there is no advantage.

In the era of health care cost restraint, can one justify purchasing a $1.5m machine with a $100,000 per annum maintenance costs when no new capital outlay is required for the traditional standard open surgical procedure? But to remain competitive, the hospital must have a robot and the surgeon must be able to market to the public that he/she does the robotic procedure.

The patient wants the latest and the best treatment and expects that the outcomes are superior.

Far from it. The technology and marketing is driving consumer choice. A Google search of “Da Vinci Robot” yields over 35 million hits; the public is being inundated. The marketeers are in full swing. The robot is rapidly being deployed for new diseases to conquer: in gynaecological surgery for hysterectomy, general surgery for bowel resections and now open-heart surgery too. The other treatment options for early prostate cancer that yield marginal better outcomes, at best, are being marketed heavily too.

Now a new debate has surfaced that prostate cancer is over treated; the use of PSA (prostate-specific antigen) for early detection is diagnosing an early cancer that is not harmful, and need not be detected or treated. The facts are that the patient is overwhelmed with a shopping list of expensive products to treat the prostate cancer that may not need to be treated in the first place.

Doctors peddling new products

Let’s not neglect the other side of the health care equation – the doctors. The sacred trust that is embodied in our profession, the social contract – to place the patients’ interest above that of the doctor’s – leaves much to be questioned. The conflict of interest issue is huge and pervasive. The potential to make more income with higher reimbursements for new technologies – and particularly as the first kid on the block with the newest and latest toys – is overwhelming.

Physicians are driven by higher charges and collections. To enter into the market place before reimbursement codes are regulated is most tempting. The “big centres” have the competitive edge and are setting and defining the goalposts – how many procedures need to be observed and proctored before one has the “right” to be practising independently?

This amounts to the practice of medicine being dominated and driven by all the forces of consumerisms: the industry to market and sell the new technology – the latest and the best; the physician to earn more through selling the service and doing as many as possible; and the patient who has been enticed through marketing and advertising to have the latest and the best. Health care cost for the surgical treatment of early prostate cancer has spiraled through the roof. This scenario is replicated for many diseases diagnosed today.

The case against fee-for-service medicine

From a financial perspective, the consumerism issue is underscored by one dominant fact: the more the service is used, the more monies are spent. The vicious cycle of fee-for-service on the impact of health care, more utilisation, more fees, more monies spent, has to be broken. Paying for performance and value-based payments have become the new solution being peddled.

The new frontier of reimbursing for patient outcomes to a group of health care providers, who are co-ordinating and integrating health care services, has to be the way to go. It breaks the cycle of fee-for-service medicine and meets all the suggested recommendations of the Institute of Medicine, to curtail the costs of health care.

Of equal importance is the new approach to the incorporation of new technologies as the diagnostic or therapeutic standard of care. They must be evaluated first within the context of the real value that they bring to the health care market. This is particularly true for the developing countries with limited health care resources.

Returning to our original debate, how do we provide quality care at an affordable price?

Paying for consumerism

The solution at its core must re-establish and itemise an essential core of health care services. These core essential services must reflect the standard of care underscored to be the most cost effective and proportional to the capital investment and human resource demands. The investment of a traditional nerve-sparing radical prostatectomy with a capital cost for equipment of less than $10,000 cannot be measured simply by a one day shorter stay in hospital, one less unit of blood and one day less of analgesia when trying to justify a capital investment of $1.5m for a robot, especially considering the need to create a new physical site, training and maintenance.

The selection criteria for a diagnostic or treatment plan should mimic the initial principles of the Oregon plan; those who are paying for health care must be informed of the relative costs of the procedures and through public consensus determine the standard of care to be adopted. The health care providers’ role must be minimised due to the conflicting interest; we are only to provide the scientific facts of the pros and cons and the evidence to the effectiveness, efficiency and value.

In these core services, reimbursement is predicated on population outcome measures; a group or network of core health care providers contracting with the payers to provide the services and producing the evidence that the care is efficient, effective and betters the health of the defined population for which care is being delivered. There cannot be fee-for-service delivery: simply do more and earn more. Incentive reimbursement is agreed to on the basis of patient results. In fact, there may be penalties depending on failure to achieve the desired results.

Patient choice and options for services cannot be denied; there must exist a parallel health care service in which patients can choose whatever they desire – the tenant of consumerism and the right to choose must be available, but at the patients’ expense, not that of the payer for the core group of services. This ensures a stabilising of prices for the core group of services.

The treatment of advanced prostate cancer exemplifies the issue of essential versus desired care and the impact of consumerism on costs.

Let’s review treatment of advanced prostate cancer in which the standard of care is hormonal ablation – the elimination of testosterone produced by the testes. This can be done medically using drugs or surgically by removing both testicles. The drug treatment plan is required indefinitely until the cancer recurs or the patient dies; the surgical plan is a one-time expense, a minor outpatient procedure. Computed over a five-year course of treatment, the medical route is 30 times more expensive. If the more recently advocated “total” hormonal depletion programme is applied to the pharmaceutical route, (shown to be of minimal or debatable advantage) the cost increases by 40 fold over the surgical route.

There is no difference in outcomes in the use of drugs versus surgical treatment with regards to living longer or failure of treatment. The cited reason for medical option over the surgical one is deemed to be psychological – the mental anguish of having one’s testicles removed. Both have the same outcomes, vis-à-vis loss of sex drive and impotence, both produce the side effects of testosterone withdrawal syndromes.

Moreover, the research for the advantage of the additional drugs for the total hormonal castration remains a topic of much debate, as to whether there is a significant increase in longevity. It is interesting to note, also that, over time with the drug treatment, the testicles will atrophy, virtually disappear as if surgery were performed.

Why spend millions of dollars simply to pacify the (perceived) psychological needs of the patient, for the same outcome several years later. Is it that the medical plan is more profitable? Major cases in Medicare fraud for doctors using medical therapy are well documented. Or is this just another consumer product driven by aggressive marketing by the pharmaceutical industry? What is it that we are actually paying for?

The budget can only be expected to spiral as the aging population rises and prostate cancer remains the most common cancer and the most common cause of cancer-specific deaths in our male senior citizens. Drug treatment for advanced prostate cancer is a consumer choice. Shouldn’t this cost be paid directly by the patient and not the group?

The principles of two parallel systems, a product line of basic care services and a consumer driven one, is underscored by the culture and economic norms of a country and the community. The British National Health Service (NHS) has adopted these principles in a rudimentary form. You can opt to receive care at the NHS facilities, funded by the government taxes, or one can receive the convenience and upscale product of the Harley Street private concierge health care.

The NHS provides equal access to the appropriate; individuals receive the medical care as needed care. Alternatively, they can opt to pay for the Harley Street concierge services.

The core of essential services, however, are patriarchal based; citizens have minimal direct input into the services to be provided. The recent spiral increase in the costs of services from the Pay-for-Performance programme in the NHS is unfortunate and shows the weakness in reimbursement in a fee-for-service programme; the outcomes that defined the benchmarks for the GPs should have been the standard of care from the onset.

In the Canadian one-payer system, the Supreme Court has already set the stage for consumer-driven private care programmes. Public-private partnerships should do well to reduce the demand on the provincial health care budgets. A universal one-payer system is entrenched via Medicare and Medicaid in the traditional American private insurance-based health care. But the American universal one-payer system has not reflected the cost containment administrative effects of the Canadian system.

The implementation of the DRG (diagnosis-related group) system of care had a major effect on containing and decreasing health care costs in the Medicare and Medicaid services. The DRG initiative incorporates the hospital and physician charges as a package deal, thus removing the fee-for-service incentive for all the providers. What needs to occur is the marriage of the DRG to population outcome measures.

Developing countries can undertake a leadership role in providing quality care at an affordable price. Without the capital funds for expensive new technological advances, the traditional standard of care services must measure, firstly, the value and merits of implementing and incorporating these new services. In most instances, the government is the major payer and provider of health care services. Health care providers are employed directly by government; health care physician services are prepaid.

Public-private health care partnerships are fodder for developing shared health care services: the private sector provides the capital, maintenance and human resources; the government becomes a purchaser of services required, without the burden, complexities and potential inefficiencies of ownership. The merits and issue of national drug programmes in developing countries has long preceded the current interest and thrust for national drug programmes noted in the developed countries.

In summary, the developing countries of the English-speaking Caribbean are laboratories for evaluating health care systems and cost containment. Through social and educational programmes, our literacy rates and health care profiles have approached those of the developed programmes and at a fraction of the cost. To establish a core package of affordable health services with universal access is essential to our survival. The ability to control the costs of consumerism in health care is the new frontier in health care.

One is reminded of the principle of taking a trans-Atlantic plane ride. One can choose to fly first class with all its amenities – early boarding and disembarcation, a choice of meals, unlimited drinks, silverware, big comfortable reclining seats and personalised service, compared to the smaller seats and limited amenities in economy class. What is important, however, is the safety of the ride. Both economy and first class passengers will experience turbulence but both classes will get there safely and at the same time. So, too, we need to distinguish that the principal factor in the delivery of the health care service is the safety and quality of the care and not be charmed by the service amenities.

What are we getting when we seek health care services – perceived unrealistic expectations, unsubstantiated outcomes and the sales pitch of manufacturers and vendors? What is a “medically necessary” health service? In a USA Today feature on cosmetic surgery in children, Dr David Staffenberg remarked that to one person the term may refer to a life-threatening condition, while another may consider it something that interferes with daily activities or a health self image. Separating the consumerism in health care – distinguishing between our wants and our needs – is essential in controlling the rising cost of health care; the provider and product must be held accountable. Let the buyer beware.

What now?

This series was intended to be informative, enlightening and to spark public interest to be involved in this national debate. As The Bahamas moves forward on this journey to a national health care coverage, it seeks to provide for each resident the right to health care and for those who need care, get the care they need and those who need more, get more, in a timely manner while minimising the risk of financial impairment.

This does not come without significant costs, and even greater efforts are required to maintain the costs of care at affordable levels. But like religion, how best to restore and advance our wellbeing defines our philosophy of life.

At one end of the spectrum, your health is your personal responsibility, your choices and thus, your expense. At the other end, the philosophy maintains that your health affects us all, we don’t live in isolation – health is a community effort, a common good; we must share the cost and the risk.

In the modern era of health care, the delivery of health services and the economics of health care are inseparable and intertwined. The demand for health care is infinite, but the funding is finite. As The Bahamas moves aggressively to be the first sovereign country in the English-speaking Caribbean to implement a national insurance programme - NHI is projected to be introduced in January 2016 - it is imperative that we acknowledge and understand the complexities of a national initiative in delivering health care.

What are we getting? Who is providing it? Who is accountable and for what? Who is paying, for what and to whom? What is this really costing us? What happens if the money runs out?

Inform yourself and let your voice be heard. Your life depends on it.

Dr Robin Roberts is a consultant urologist and Director and Senior Lecturer at the University of West Indies School of Clinical Medicine and Research in The Bahamas.