Erroneous priorities and overconsumption
When seen in light of objective measures of health, John E. Wennberg’s analyses of regional inequalities in health services demonstrate where there is room for cost reductions and priorities in the health services (17). Wennberg categorises health services in three groups.
The first category is referred to as efficient and necessary health services. These are health services the benefits of which nobody questions, not in the medical community, nor among politicians or the population in general. Examples of such services include emergency medicine for traumas, antibiotic treatment of serious infections and vaccination programmes. The main challenge facing such treatments consists in avoiding unfair social and geographical distribution of the provision of services (18, 19). In the public debate on health services, there appears to be a widespread misconception that all medical treatment constitutes necessary health services. In reality, this category may account for only one-fifth of all health services in Norway. I base this assumption on Wennberg’s studies in the USA, which showed that this category accounted for only 15 % of the total consumption of health services (17).
Wennberg refers to the second category as preference-sensitive health services. These are health services where there are two or more options for the interventions that can be carried out (17). Examples include prosthetic surgery for arthrosis, treatment of mild hypertension, check-ups by a specialist, numerous examinations and screening programmes. The main challenge involved in these types of services is that their use is excessively dependent on the doctors’ own experience, to a varying extent on a knowledge basis and to an insufficient extent on the patient’s preferences (17).
The problems are associated with major variations in practice and an absence of evaluation of treatment results (20). The patients are too little involved in making real choices, even though methods for patient co-determination have been developed (17). Studies indicate that if patients are able to make an informed choice, many will decline an offer of costly treatment and choose simpler solutions (17). Herein, there is most likely a potential for cost savings in Norwegian health service provision (20). Wennberg showed that this category accounted for 25 % of the total consumption of health services in the USA (17).
Wennberg refers to his third category as supply-sensitive health services. This does not refer to specific forms of treatment or services like those above, but describes services that vary in extent due to variations in availability. Examples of such services include numerous consultations with specialists (21), hospitalisations (22), treatments by physiotherapists and chiropractors, and the alternative-medicine business. The main challenge for such services is that their extent varies considerably according to available supply, without having an appreciable effect in terms of better health or lower mortality in the population (17). This often entails higher costs, more unnecessary adverse effects (20, 23), less transparent health services and less patient satisfaction (17).
We need more knowledge on what would constitute a sensible extent of health service provision, and a far higher awareness among professionals and health policy makers about the relationship between supply and demand. What we do not need is an increasing range of health service options in an open health market. This will mean higher costs and more treatment-related injuries (20). Supply-sensitive health services may account for more than half of all Norwegian health services. Herein lies a likely potential for cost reductions and thus more latitude for reconsideration of priorities.
In other words, the challenge of erroneous priorities and overconsumption in the health services consists in prioritising and distributing necessary health services in an equitable manner, raising the quality of, and reducing the scope of, preference-sensitive services and regulating supply-sensitive health services to a level which can be documented as sensible. This is a major challenge for the medical profession. If we fail to meet it ourselves, others will attempt to do so using less scientific methods (5).