Health care cost and patient outcomesSunday, October 24, 2021
DR ERNEST MADU & DR PAUL EDWARDS
THIS week's column will address several critical and intersecting health-care indices that closely correlate with patient outcomes but are poorly understood by the public. Efficient and high-quality health-care delivery requires a robust and resilient infrastructure that is expensive to create and costly to sustain. Unlike other sectors of the economy, health care is perhaps one of the few areas where there is universal need but no universal access, and when access is possible, efficacy and quality are often lacking. When access, efficacy, and quality all co-exist in a health-care system, the cost may be out of reach for many. Understanding how these factors interplay in health-care delivery and their impact on patient outcomes is a starting point for the appreciation of value.
A friend, Robert Polet, the former chairman of Gucci, once gave me a long-standing Gucci mantra that he thought applied to the work we do at HIC. Gucci's approach is that they have created something of high value that comes with the perception of high cost and so they use the slogan “Quality will be remembered long after price is forgotten.” Every human being deserves access to the best-quality health care, delivered in a timely and effective manner. Efficacious, quality care is the way lives are saved and major disabilities averted. But we live in an unequal society where large segments of the population do not have access to quality care, and when they do, the speed and efficacy of care are less than desirable. The reasons are apparent. Many facilities that are accessible to ordinary Jamaicans are seriously underfunded and often lack the resources to develop the infrastructure or procure the equipment and human capital needed to deliver high-quality, effective care promptly. The affluent segments of the population have always had access to care in overseas territories, most often Florida, and are willing to pay significant amounts for even the most basic care there though they are often unwilling to spend even a fraction for comparable quality, access, and efficacy in Jamaica. This is partly because the society has been socialised, over many years of lack, to wrongly believe that high-quality, effective, timely, and easily accessible care developed locally somehow magically does not attract any value.
This line of thinking creates friction in the pathway to quality care in Jamaica. In most advanced countries, access to quality health care is regarded as a fundamental right of citizenship. It is likely the same logic that led to the abolition of user fees in public hospitals in Jamaica many years ago on the premise that the erasure of fees would ensure that citizens have access to care. Unfortunately, because of the dire economic challenges unique to Jamaica, the infrastructure in the public health-care sector is entirely inadequate to meet the demands of certain levels and complexity of care. It, thus, cannot deliver effective, timely, or quality care in many areas. Patients with cardiovascular disease, for example, routinely do not get timely intervention and, by implication, are denied effective and quality care. Several private facilities have sprung up to fill the void created by the inadequacies in the public system and should be supported and encouraged. In the United States, the Government has mechanisms to compensate private hospitals and facilities that take care of cardiac emergencies (and other health-care emergencies, for that matter). A law is established to protect private facilities from financial ruin resulting from providing emergency care to patients who either may be unable to pay for care or are subsequently unwilling to pay for such care, once provided. No such protection exists in Jamaica, and this deficit complicates access to care for many patients in emergencies.
What is the cost of providing access to emergency treatment?
Have you considered what would happen to you if you or your loved one developed crushing chest pain at 2 am on New Year's Eve and were fearful for your life? What would you do if you got that dreaded call on Christmas Day that your mother or father is having a heart attack, and you fear they will die? What will you do if your uncle or auntie collapses in church during Sunday morning service and is found to have a complete heart block? In any of these scenarios, would you want to have access to a place where timely and effective intervention could take place to save lives? Have you ever considered what it costs to put such an infrastructure in place in Jamaica?
Let us try to explore the scenario. In all the cases highlighted above, death or significant complication is highly likely without timely intervention in a well-equipped and well-resourced facility with around the clock availability of highly skilled personnel to respond to such life-threatening emergencies immediately. Such a facility ensures that utilities are always on and that highly qualified personnel are always available on site and are paid at a premium — whether any emergency patients come to the facility or not. Those things exist so that speed, quality, and efficacy will complement access in order to achieve the desired patient outcomes: prevention of death, major complication, or disability. The variable inputs for such high-quality and efficient care must be sourced overseas at high costs since Jamaica does not manufacture needed devices and supplies.
Additionally, the facility must keep a significant pre-paid inventory to ensure timely care delivery is available in emergencies. Suppose your father or mother is having that heart attack at 2 am on Christmas Day. In that case, an emergency angiogram and stent placement may need to be done. The sheath, wires, balloon, stents, and other required supplies must be readily available in the facility. Skilled interventional cardiologists trained in safe, emergency stent placement, and highly trained cath lab technicians and nursing staff must all be available to have this service performed, in addition to administrative personnel. That staff is compensated at a higher rate for holiday and after-hour work. The same applies to your uncle or auntie who collapsed in church during Sunday morning worship and needs a pacemaker for a complete heart block. In the absence of facilities willing to provide such a resilient health-care ecosystem to translate access to quality and efficacy, such patients are at the risk of untimely death or major complications.
Unfortunately, unlike luxury purses, health care is an intangible asset. Many patients and family members who, at the time of impending doom, make commitments to pay for services, suddenly devalue the services once treatment is given and the danger seems to have abated. With clothing or accessories the product on their body is a constant reminder of the quality they have paid for, but for some reason the life restored is often not enough of a reminder regarding quality. We have seen the contrary where some individuals feel that since they “lived to tell the tale” perhaps they would have been okay without any intervention, becoming unwilling thereafter to pay following emergency treatment. This friction makes it difficult for some private facilities to provide consistent quality care, which is impossible without appropriate compensation for such care.
How do we resolve cost concerns to ensure universal access and quality?
This remains a vexing question and underscores the need for continuing public education and dialogue between all stakeholders. Whether health care is a fundamental right or a privilege is a debate that has endured for decades. What, however, is a universally accepted doctrine is that all lives are sacred and should be preserved at all costs. Who pays that cost is the unresolved question. Current health-care financing mechanisms in Jamaica offer inadequate protection for patients and private healthcare facilities, especially in emergencies. There is an urgent need for an alternative financing mechanism in order for health care to preserve the lives of citizens and encourage further investments in health-care development locally. Society must assume responsibility in ensuring that facilities that take risks to make timely, effective, and quality care accessible to all Jamaicans are preserved. Florida will always be welcoming to those who are happy to spend their dollars for health care in Miami. For the rest of us, Jamaica may be our only option and we must make such care sustainable not just for us, but for generations yet unborn.
Dr Ernest Madu, MD, FACC and Dr Paul Edwards, MD, FACC are consultant cardiologists for Heart Institute of the Caribbean (HIC) and HIC Heart Hospital. HIC is the regional centre of excellence for cardiovascular care in the English-speaking Caribbean and has pioneered a transformation in the way cardiovascular care is delivered in the region. HIC Heart Hospital is registered by the Ministry of Health and Wellness and is the only heart hospital in Jamaica. Correspondence to firstname.lastname@example.org or call 876-906-2107