“Just back from a week’s break in the Alps with my family. Fortunately, no fractures despite a few minor falls. I am sure the French private healthcare system is upset that we didn’t need to call on their services last week. In comparison, whilst I was away in the Alps one of my patients with advanced MS (EDSS = 8.0) was admitted to hospital for a week with possible septicaemia from a urinary tract infection; this was her 4th or 5th admission in the last 12-18 months.”
Asch et al. Perspective: Asymmetric Thinking about Return on Investment. N Engl J Med 2016; 374:606-608.
…. Lately, we’ve attended many conferences about providing health care to patients with high medical and social needs — people with chronic illnesses who are frequently readmitted to the hospital. It seems as if every presentation refers to “return on investment” (ROI), which is invariably presented as a constraint — as in “Our program kept people out of the hospital, but we just couldn’t get the ROI to work.” Heads nod understandingly, and then participants move on to other topics…..
….. At conferences about providing care for patients with cancer or other acute illnesses, by contrast, we almost never hear the term ROI. Instead, people talk about clinical gains, using understandable and patient-centered terms like “survival.” Though high drug prices are sometimes mentioned, no one ever says the ROI is prohibitive. No one mentions ROI at all…..
….. There is no obvious reason why ROI is more relevant to some clinical situations than to others. So why do we focus so heavily on ROI when the topic is chronic illness but rarely mention it when the topic is cancer? A huge amount of the cancer care we deliver provides such small personal and social gains that, were those gains monetized, the endeavor’s ROI would be deeply negative. And yet we ask, “What’s the ROI of that program that keeps chronically ill patients out of the hospital?” but not “What’s the ROI of treating advanced lung cancer?”…..
…… There are at least three reasons for this difference. One is that from the financial perspective of doctors and hospitals, the ROI of treating cancer is favorable. Reimbursements for cancer care are high in part because the political and popular value of cancer care is high, and those values are both revealed and reinforced by a history of largely cost-based fee-for-service pricing explicitly designed to at least meet providers’ costs…..
……. A second reason is that keeping people out of the hospital is hard — typically requiring care coordination with multiple services…..