"More provision is not automatically better provision"
"Health service research can contribute to a patient-centered medical system", says Milo Puhan, president of the Steering Committee of NRP 74 "Smarter Health Care".
The Swiss healthcare system is often referred to as one of the best in the world. Do you agree?
Milo Puhan: That's not easy to judge, it really depends on the kind of care you’re talking about. We know that patients with acute illnesses receive very good care in Switzerland. Hospital statistics show good data to support this. What we don’t really know so much is what happens after a patient is discharged from hospital, or what kind of care patients with chronic diseases get, for example.
What does that mean?
It is clear that some things do work well and that GPs play an important role. However, since we don’t have much data about outpatient care, we can’t really say exactly whether there are holes in the system or where they are. This is something we want to track and review as part of the NRP "Smarter Health Care". We definitely want to look into the transition from hospital discharge to outpatient care, since there is definitely a hole in the system there.
What kind of medical provision will Switzerland need in the future?
In Switzerland, around 80 percent of healthcare provision – and so 80 percent of the costs – is for chronic diseases, so the system needs to be geared more closely to that. To be able to provide the right levels of care to the chronically ill, it is important to improve the transition from hospital to outpatient care and visa versa, for example. The NRP will deliver a set of decision criteria to be used as a basis for making possible adjustments to care provision. The intention is for government, provider and patient to really benefit from the research results.
What would be done differently in this system?
Our system is still very doctor-centric, especially when it comes to the reimbursement of services. However, doctors don't always have to be involved in providing care for chronically ill patients. Other job profiles will also change. Efforts are being made to improve and develop the skills of employees in medical practices, and physiotherapists will give more guidance to patients on training and exercising at home.
Do they not do that already?
A lot has already been tried. Providers are keen to develop new models, but there are still many barriers to innovation, most notably the lack of reimbursement models. The NRP Smarter Health Care will look into ways to address these issues.
Can this put an end to the exploding cost of healthcare?
If medical provision were based on the best available knowledge, was innovative and involved patients, our system would be more cost-efficient. That does not necessarily mean that it is more or less expensive, but that you get the maximum health benefit per franc invested. This distinction between absolute cost and cost efficiency is very important. Expensive does not necessarily mean efficient, that it is linked to a greater health benefit.
We are now talking about oversupply.
Oversupply includes all treatments that do not necessarily yield a direct health benefit. Nationally and internationally discussed examples are operations such as spinal stenosis operations or cardiac catheter interventions. This does not mean that there is more oversupply in these areas, but it is much easier to measure care provision than in other fields of medicine.
Are there any examples of inadequate provision?
There are cases where services are not used – vaccinations, for example. Whether this can be labelled inadequate depends on your perspective. It might be possible to speak of under provision for chronic illnesses when individual treatments are provided, but not coordinated. Perhaps this is why the overall effect is not as great as it could be, compared to a system where everything is well coordinated by a GP, for example.
Are there differences between towns and rural areas?
It will be interesting to see if there are. In Switzerland, there are rural areas where care is harder to access than in urban areas. However, this also raises the question as to whether this sometimes protects people against oversupply.
You have stressed that Switzerland doesn't have a good healthcare database. Why is that?
There is a lot of data, but it’s very segmented: hospitals and doctors' practices have their own systems and there is a range of registers and healthcare databases. One of the objectives of the NRP is to examine possible links between these data sources.
Dealing with large amounts of data is politically and socially very sensitive. This was demonstrated in the debate about electronic patient files and the protection of privacy. Many people fear that the data could be misused. How do you deal with that?
We have to take these fears seriously. But first we have to know what the Swiss population wants, and, at the moment, we don’t know this for sure. It is not enough to only talk to those who are against it. The decision on which data you can and cannot pass on is one for society. When we carry out research, we find that people allow us to use sensitive data if it has been anonymised, if they know what is going to be done with it and that it won’t end up in the hands of a company they know nothing about.
How can you guarantee that the data won’t be used by insurance companies to discriminate against the chronically ill, for example?
We cannot let this happen, and we have to find ways to make sure that it doesn’t. It is interesting that the fear of data misuse is much higher when it concerns data on medical services. Yet we disclose an enormous amount of health-related data via our credit cards and mobile phones, and this is generally accepted. This raises the question of why things are handled so differently. And you can’t improve a hospital system if you don’t give it a chance to learn from the data.
Research into health services has been going on many years. Why it is starting to gain popularity now?
There are several reasons for this. It is a recent development for researchers to define themselves by healthcare research. In addition, we have an ageing population with more chronic diseases. For those people, an acute-care hospital isn’t the only solution. There is also growing recognition that more care isn’t necessarily better, but rather that it is important to optimise resource use.
This raises ethical questions: who gets treatment, and who does not?
Personally, I find the debate on this issue a little strange. It implies that more services always lead to greater health. However, the definition of efficient treatment is that a patient particularly values an effective service and can benefit from it. Conversely, this means that a service is not delivered because it isn’t appreciated or because it does more harm than good. Apart from that, people certainly don't want too many treatments that will possibly cause them harm. Patients are more satisfied if you treat them according to their preferences.