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Affordable healthcare only possible with value based medicine

India is a developing country and 80 per cent of the population of our country cannot afford expensive healthcare. The facilities provided by the government are miniscule in front of the giant problem. Shortage of doctors, basic infrastructure, paramedical staff and expensive medicines makes healthcare even more out of reach for a common man. That is the reason we are still struggling with the certain communicable diseases and now added to that is the burden of non-communicable diseases.

Dr Virendar Sarwal

India is going to be the world capital for heart disease in 2030 as per the WHO report. Diabetes is rampant and there is total lack of awareness about prevention, lifestyle management, hygiene levels, sanitation and the healthy living with the result that we have huge load of patients whether it is communicable or non-communicable disease. Added to it is the shortage of manpower to treat these patients.

As per one study, our country has only 20 doctors per 10,000 people as compared to 650/10,000 in US. The budgetary provisions for healthcare are so low that even the primary healthcare cannot be delivered efficiently with the result the rural population is the worst sufferers. That is how there is mushrooming of quacks and invaluable lives are at risk.

In such a dismal scenario only alternative to improve upon the services and make each step in healthcare delivery more justified and economical, if we look at an evolving healthcare delivery system all over the world and even in developed countries like US, is Valve Based Medicine. So far, we have been practicing Evidence Based Medicine where in based on the evidence of the disease, we treat it with the costliest way of treatment. It ignores the logic of benefit vs cost ratio whether it is concerned with writing costly medicines or adopting the costliest intervention.

The value based medicine concept is different from the evidence based medicine concept in the sense that we are treating human beings and not symptoms. The treatment plan has to be based on the effective control of the disease with respect to the perception of the patient and his family in terms of benefit as compared to the cost involved in it.

Let’s say in heart disease a patient having coronary artery disease in two or three vessels can be treated with bypass surgery as well as ballooning and stenting. Now, whereas stents will cost him a big money and will also not be durable so bypass surgery becomes more economical and more durable. What the patient wants here is effective quality of life improvement with an economical and durable procedure. So, of course, bypass surgery is the best answer here. Similarly, a sore throat can be effectively treated with low-end antibiotic treatment and supportive therapy instead of expensive and high-end antibiotics.

Value based medicine is a means to compare all healthcare interventions on the same scale and a measure that can be combined with the cost of an intervention to arrive at a cost utility ratio. It provides most effective assessment of the patient perceived worth of an intervention. It also measures quality of life and/or length of life. The irony of healthcare industry is that it is one of the few industries where purchasers or the patients are unable to measure the valve of what they purchase.

So, value based medicine allows highest quality care, maximization of healthcare rupee and incorporation of patient based perception of quality of life. The goal of value based medicine is to promote what is best for the most important people in healthcare i.e. patients. It provides transparency backed by scientific opinion, communication by personal attention, no scare or fear by involving empathy, economics and 24×7 availability.

Similarly, if we come to procedures, the beating heart surgery is value based medicine. Minimal invasive surgery goes a step further in that direction as it makes the patient up and about early and the patient does not lose productive days of earning and is back to work at the earliest with less stress on the body. Also, in terms of logistics there is less ICU stay, less hospital stay, less use of blood products. Value based medicine also incorporates all the forthcoming evidence which is percolated to the patient level and helps in decision making for the patients.

Now, coming to stent vs surgery, two major trials — one in 2009 Syntax trial and the other in November 2012 Freedom trail — have clearly established and concluded that in multi-vessel disease and diabetes, bypass surgery scores over drug coated stents in terms of death, second heart attack and second or repeat intervention. So, all patients with multi-vessel disease should be offered bypass surgery as the first option for durable economical treatment.

In this scenario, value based medicine (VBM) stipulates that when it come to coronary artery disease each and every patient should meet the surgeon with his angiography report to reach to a conclusion whether he needs to go for stents or surgery. The other thing, which our country needs to incorporate into VBM is the availability of cost effective medicines, disposables and equipment. Most of the equipments, disposables used in high-end surgeries is still being imported and thereby making huge loss and leading to escalation of prices of these essentials.

The government has to encourage use of generic drugs, which should be free and easily available and encourage manufacture of disposables and equipments in our own country. It will do away the huge profit margin taken by the multinational companies when the middlemen and dealers add to the cost. There are very innovative products available in India and effort should be done to produce them at mass level and promote them at all levels. In fact, all hospitals should be told to use them as the first priority.

The infrastructural resources for the primary, secondary and tertiary healthcare delivery are very less so a policy needs to be made wherein the government and the private sectors should join hands in making the total available infrastructure at the disposal of all the patient population group. There should not be any differentiation and all available beds should be utilized to the maximum by one and all. It will help in reducing the waiting list and huge queues seen in government hospitals today. All it needs is rationalization of compensation to the private sector.

Today also many government agencies are utilizing the private resources for tertiary care by reimbursing them the subsidized cost of treatment. Why can’t it be applied to the primary and secondary care? The public private partnership (PPP) is another good concept of upgrading and bringing secondary and tertiary care in all cities and rural areas.

To promote healthcare delivery in rural areas the doctor should be encouraged by arranging for them good housing and transport facility and good schooling for their children. In fact, the concept of rural dispensaries should be abandoned and what we need is a good primary/secondary healthcare centre within a radius of 20 kilometres and that area on daily basis should be covered for OPD service by mobile vans with fixed hours backed by strong ambulance service which most states have already adopted. This will help getting the medical and paramedical manpower stationed at these centres as they will get basic facility and necessities of life for themselves and their family and doctors will be able to deliver better healthcare with better facility in terms of equipment and beds in an upgraded hospital environment. It will also help in running the various preventive healthcare programmes in true earnest.

These primary/secondary healthcare centres should be backed by tertiary care centres whether in private or government sectors at treatment cost rationalized by a committee of experts consisting of knowledgeable people from the government and the private sectors.

We need to understand that health is the ultimate necessity of life and is very important for the economic growth of this country. If we get developed this concept of value based medicine, it will see us through in building a healthy and capable society which in turn will produce a workforce which will work hard to take this country forward and will make it a world leader.

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