Care Redesign 2016

Practical Strategies for Efficient Care: Lessons from India

Article · January 21, 2016

Health care systems in high-income countries, particularly the United States, are plagued by high and rising health care costs. To achieve efficiency, low- and middle-income countries, such as India, have implemented strategies that high-income countries might be able to adopt. Here we describe four problems in health care delivery that India routinely faces and how it sometimes addresses those dilemmas. For each one, we offer ideas about how the U.S. might use India’s example to think differently about efficiency, even if some of the situations do not directly apply to high-income countries.

Problem 1: High Patient Volumes

In large, middle-income countries, long queues in busy outpatient departments are common, particularly at government health centers. Some of our colleagues in India describe scenarios in which only two cardiologists face as many as 200 patients in one afternoon. Imagine what happens when one of the two cardiologists needs time off — 200 patients still show up! What is one very small — but concrete — way these dedicated physicians save time in a clinical context where every second counts?

Strategy: Limit blood-pressure measurement to only systolic blood pressure (BP).

This approach is probably tough for many U.S. physicians to imagine. But the vast majority of clinicians base BP-related treatment decisions only on systolic BP, and the additional 5 or 10 seconds to measure diastolic BP means 20 to 30 extra minutes each afternoon. Doctors in India have made a utilitarian trade-off to help them see as many patients as they can, given their extremely high patient volumes.

Lesson: Utilitarian considerations can help put a focus on the key diagnostic data that guide clinical decision making. It seems unlikely that U.S. clinicians will stop recording diastolic BP with other vital signs, but it is important to note that many clinical data points that are captured do not change treatment. Take, for example, imaging for uncomplicated headaches, simple syncope, or nonspecific low back pain. The American Board of Internal Medicine has explicitly identified these and other diagnostic tests and treatments as targets of efficiency in its Choosing Wisely campaign.

Problem 2: Unaffordable Services

Patients in low- and middle-income countries often forgo or delay necessary health care services because they can’t afford them. Many people in those countries pay out of pocket for services right when they are rendered, instead of having the benefit of prepayment through private, social, or government insurance. Lack of prepayment through some form of health insurance can lead to catastrophic health spending or distress financing in low- and middle-income countries, particularly when a patient has an acute cardiovascular event, such as a heart attack or stroke.

However, private or not-for-profit hospitals can compete for patients by offering services similar to their competitors’ at lower costs. But for hospitals to potentially gain an advantage, pricing information must be available to consumers. How do patients in India come to know the costs of medical services?

Strategy: Post pricing information.

Hospitals in India routinely and clearly post pricing information related to diagnostic and treatment services, including time-based pricing for office consultations. Prices may be posted in the waiting room of a physician’s office or in the emergency department, or provided through brochures available in the office or hospital. The effect of posting (as a stand-alone factor) on competition, access to care, and catastrophic health spending is uncertain, but transparency in pricing in the U.S. appears to have inherent benefits.

Lesson: It is possible for patients to see pricing information up front, even though that may seem hard to imagine in the U.S. Many hospitals in India bundle costs associated either with services (e.g., cardiac catheterization) or disease states (e.g., acute myocardial infarction), a strategy increasingly used in the U.S. While the Centers for Medicare and Medicaid Services and private companies have improved access to price data, the current system for exploring and comparing pricing information is unwieldy.

Problem 3: Limited Supply of Clinicians

Most low- and middle-income countries have low physician-to-population ratios and major burdens of disease. Large efforts are underway to improve medical education in regions such as India and sub-Saharan Africa, but what can be done to alleviate this imbalance while these clinicians are being trained?

Strategy: Use more nonphysician health workers.

The HIV/AIDS epidemic and subsequent response led to a major expansion of the use of nonphysician and community health workers in at least 25 countries in sub-Saharan Africa for routine diagnosis, evaluation, and treatment of a disease that had previously been treated only by specialists. Similar efforts have improved BP control, adherence to medications, and depression in 11 countries. In India, accredited social health activists (ASHAs) serve under the auspices of India’s National Health Mission not only to provide clinical care but, occasionally, to participate in epidemiologic data collection. However, as of 2011, only 22 countries had laws allowing nonphysician health workers to prescribe medications. As of 2012, only 15 U.S. states and the District of Columbia had laws regulating community health workers, only 8 with language related to scope of practice.

Lesson: When access to care is limited or uneven, nonphysician health workers can help fill this gap, but they need prescribing power to be most effective. The U.S., a country with a legal framework to allow nonphysician prescribing in all states, has no uniformity across states in law, language, or regulations specifically for prescribing by nurses. As the elderly U.S. population grows, nonphysician and community health workers could play an increasingly important, adjunctive role in routine clinical care (beyond their current roles) and, perhaps, even in research.

Problem 4: Low Treatment Rates

Most patients in low- and middle-income countries take no medications at all after a heart attack or stroke. These high-risk patients would benefit from the simultaneous use of multiple, low-cost generic medications: aspirin, statin, and BP-lowering drugs. Although more than half (55%) of all statin products available in India are part of a combination pill that includes other cardiovascular drugs, many fixed-dose combinations are not approved in India, raising questions about their quality. Nevertheless, stock-outs, nonadherence, and cost all are barriers to treatment, but they also were barriers for patients with HIV/AIDS. Can lessons from HIV/AIDS care improve medication adherence more broadly?

Strategy: Explore fixed-dose, combination-therapy options.

Lesson: Combination therapy improves adherence by 40% to 50%. Only 1 of every 4 patients with a prior heart attack in the U.S. takes a combination of aspirin, statin, and BP-lowering drugs. Strategies to improve secondary prevention of cardiovascular diseases in the U.S. and India typically involve a cadre of clinicians, such as nurses or pharmacists, and can be difficult to scale. Strategies to reduce drug costs improve adherence yet depend on payers. Fixed-dose combination therapy is used for a variety of disease states (e.g., HIV/AIDS, malaria, tuberculosis, and hypertension) and can be scaled for other common diseases, such as heart attacks and strokes, to improve adherence. To date, secondary-prevention trials of fixed-dose, combination therapies have not been powered to assess outcomes, but outcome trials of combination therapies for other disease states, such as HIV/AIDS, were not conducted before those therapies were widely adopted.

***

Strategies for efficient health care exist in many low- and middle-income countries, often driven by necessity. Some of these strategies can be applied, to varying degrees, in high-income countries such as the United States, thereby driving improvements in efficiency without compromising quality of care. Much in medicine is done as a reflexive habit, but new ideas from other parts of the world can challenge the status quo with the goal of improving care.  What’s happening in India might give us some ideas for how to act differently.

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