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Germany: Easing the burden of chronic disease; strengthening peer review
Sudden illness may be what scares most people, but chronic conditions place the greatest strain on health care. Around 75% of the U.S.'s $2 trillion annual health-care expenditure goes toward ailments such as heart disease, asthma, diabetes and certain cancers, and the vast majority of that is spent when these conditions require hospitalization and emergency care. The problem is particularly acute in the U.S. public sector: over 20% of U.S. Medicare patients have five or more chronic illnesses.
Preventing these conditions from developing in the first place is helped by a holistic approach to preventive medicine that encourages changes in what people eat or how much exercise they get. But for those patients already battling a chronic illness, there are steps health-care providers can take to keep them stable and out of hospital as Germany's experience shows. The solutions can be as simple as educating patients about their condition, having nurses call patients to make sure they are staying on top of their medication and allowing doctors to compare their success rate with other physicians. (See pictures of the dangers of printing money in Germany.)
Germany's "disease-management programs" began in 2002 and cover some 3 million chronic patients. The results are promising. One survey by the University of Heidelberg of some 11,000 patients in the Saxony Anhalt and Rhineland-Palatinate regions found that the death rate in older diabetics in the program was about 8% lower than among diabetics who received regular care. And when one of Germany's largest insurers tracked 20,000 coronary heart disease and diabetes patients enrolled in disease-management programs for 15 months, it found the percentage of patients requiring hospitalization dropped from 4.3 to 2.9 and 25% of the patients also gave up smoking.
The challenge is finding the funding to implement such schemes. In America's health system, there are few financial incentives for providers to take proactive measures to keep people healthy: the longer and more extensively a doctor or hospital treats a patient, the more income they recoup. That's why the American College of Physicians and others are calling for reform in health-care reimbursement, with the Federal Government and large insurance companies setting up "Patient Centered Medical Homes" in which a portion of doctors' pay will be linked to performance targets. As in Germany, these homes will target chronic diseases by allowing doctors, nurses, dietitians and therapists to educate all patients especially chronic ones on how to stay healthy. In 2007, Geisinger Health System began a pilot program in Pennsylvania, hiring nurses to check on patients with diabetes, heart disease and other chronic ailments, as well as linking 20% of physician income to targets in areas such as patient weight loss, smoking cessation and cholesterol levels. After the first year of the study, hospitals reported a 20% fall in admissions in the area and health-care expenditure dropped 7%.
The Germans have also shown how effective it can be to allow physicians to compare their performance against their colleagues. The country has the largest database on hospital performance in the world, which helps spread best practice. Such ideas would prove equally effective in the U.S., according to Karen Davis of the nonprofit Commonwealth Fund, but change needs to come at the policy level. "Right now we can see how successful these programs are in places like Germany and Pennsylvania but then doctors and hospitals come back and ask, 'Who's going to pay for it?'," she says. "It's a fair question."
Britain: How much is a year of life worth?
Placing a cap on drug costs could save U.S. health care billions. But it's not without controversy. England and Wales have set up a body called the National Institute for Health and Clinical Excellence (NICE) which reviews treatments to decide which are the most cost-effective and which the National Health Service (NHS) should pay for. A new drug has to offer value for money and if it doesn't, whether it is life-saving or not, NICE won't approve it.
NICE uses a metric called "quality-adjusted life year," or Qaly, which grades a person's health-related quality of life from 0 to 1. Say a new drug for a previously untreatable condition comes on the market and the drug is proven to improve a patient's quality of life from .5 to .7 on the scale. A patient on the drug can expect to live an average of 15 years following the treatment. Taking the new drug thus earns patients the equivalent of three quality-adjusted life years (15 years multiplied by the .2 gain in quality of life). If the treatments costs $15,000, then the cost per quality-adjusted life year is $5,000.
Taking its lead from Britain's Department of Transport which has a cost- per-life-saved threshold for new road schemes of about $2.2 million per life, or around $45,000 per life year gained NICE rarely approves a drug that costs more than $45,000 per Qaly (the fictitious drug would easily pass).