Social Learning Can Help Transform Crisis Into Opportunity

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Prior to 2019, nothing was known about the SARS-CoV-2 virus, although there was general knowledge of virology. Thus, while science is “the state of knowing,” with regards to the particularities of this virus, the world’s researchers have until the past year been in a state of ignorance. Using the information at their disposal, different governments have taken differing scientific to addressing COVID-19.

Accumulating Evidence

Over time, scientific evidence , and the quality of the evidence available often improves. For instance, when the United States Preventive Services Task Force (USPSTF) makes recommendations, it notes that there can be low, moderate or high certainty regarding the net benefit. While interventions with low certainty of net benefit may be beneficial, such interventions nonetheless are only supported by a limited number of studies, studies with methodological flaws or studies that are not generalizable.

Likewise, there may be inconsistency in findings across the literature. Different professional societies may likewise review the same evidence and offer different, but equally valid, recommendations due to differences in priorities as well as their interpretations of the evidence.

Unsurprisingly, the evidence supporting COVID-19-related interventions has evolved over the course of 2020, and public policy has changed as well. While early public policy efforts included closing large outdoor spaces, such as national and state parks, as the dangers of respiratory spread became better understood, the emphasis instead became on encouraging people to spend time outdoors when possible. The US surgeon general switched from telling people not to wear masks to providing instructions on how people could make their own.

Science itself has reversed course several times during the pandemic as well. There has been a rush to develop scientific evidence, and in many cases, a reliance on findings that have yet to have undergone peer review. Preprint servers have enabled scientists to distribute their work at a rapid pace, but have also removed the safeguards offered by the traditional publication process. That said, even the integrity of peer review has been called into question, with and the both retracting studies regarding the treatment of COVID-19.

As the article retractions demonstrate, science is not about trust, but about a process of inquiry in which even published findings may be questioned. The very novelty of the SARS-CoV-2 virus should lead us to expect there to be changes in our collective knowledge of it over time. Nonetheless, diagnostic, treatment and public policy decisions must be made based upon the information available. As inaction is a decision in itself, leaders must consciously use the evidence available to provide direction.

Proceed With Uncertainty

To proceed in a time of uncertainty, it is essential to move from blindly following scientific findings of varying quality to actively weighing them. Following an approach similar to the United States Preventive Services Task Force, recommendations that are made should consider the quality of the scientific information on which they are based, with the understanding that the evidence may be of uneven quality. Cost-benefit analyses should be performed on policy interventions that are being discussed, with both direct and indirect costs considered as factors.

As we proceed with uncertainty, it is important to remember that the costs associated with errors are sometimes not symmetric. For instance, there has been some debate around the efficacy of mask-wearing. If masks are worn but later proven to be ineffective, the costs society will have borne will likely be the relatively minimal cost associated with their purchase or construction, as well as the physical and social discomfort caused by their utilization. Meanwhile, if masks are not worn, but later further evidence mounts that they are effective, the cost will be the societal losses due to the resulting illness and business closures.

The calculus regarding online versus live education for school children is hazier, as there are clear downsides to either path: Bringing children into schools may lead to increased spread of the virus, while keeping children at home may both hamper their education and their parents’ ability to work. The path that has been widely chosen, hybrid education, may be the most costly of all, as it both fails to shelter families from exposure and fails to provide parents with consistent childcare, in many cases, leading to the children spending increased time with vulnerable retired relatives or additional groups of children from alternative childcare .

One of the drivers of the decision to move toward the Solomonic judgment represented by the hybrid model has been the belief that students must be able to keep a distance of six feet, or two meters, at all times while in the classroom, a given by the United States Centers for Disease Control and Prevention but contrary to the of the World Health Organization (WHO), which recommends keeping a distance of three feet, or one meter.

The reason for the discordance between the guidance of the WHO and the United States is because there likely is no single optimum distance but, instead, a gradient of risk. Two meters is likely somewhat safer than one meter, and 20 meters is safer still. As with every decision in health care, the costs and benefits of different safety thresholds must be weighed. If maintaining a six-foot distance forces schools to not operate at full capacity (or at all), it must be weighed against the potential medical and financial harms that come from implementing such a regulation, such as increased potential exposure of the elderly.

Moreover, it must be appreciated that neither distance completely mitigates risk due to the aerosol-based spread of the virus. There may be a right answer regarding the distance that is socially optimal, but such a distance needs further exploration using the scientific process. While doing so, we must appreciate both what we know and what we currently do not know, and increase our comfort with declaring our uncertainty.

The views expressed in this article are the author’s own and do not necessarily reflect 51�Թ�’s editorial policy.

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When hospitals store health information electronically, it provides patients with a number of benefits. Digital storage enables hospitals to quickly search across a patient’s medical history, finding potential allergies, conflicting drugs, and prior procedures that��may impact care. Computers can support physician decision-making using the data found in records, enabling physicians to better practice evidence-based medicine tailored to the unique needs of each patient. Furthermore, digital records can be shared between physicians in different departments, different hospitals within a common organization or even between hospitals which are part of separate organizations.

Electronic health information systems, like any innovation, require money to implement. India is a republic of economic diversity. As a result of this, the people of India are served by a mix of hospitals, for-profit and non-profit, world-class and bare-bones. For-profit hospital chains compete for patients and, in some cases, refer patients between facilities with common ownership. of $616 is the lowest of the BRIC economies. Nonetheless, there are pockets of greater affluence. For instance, in the northern city of Chandigarh, the local is US $1,900, and the populace traverses the planned city in a combination of luxury vehicles and auto-rickshaws.

The pockets of affluence in Chandigarh appear to have facilitated some adoption of electronic health information systems. A recent study of electronic health information system utilization in Chandigarh-area hospitals found that 18 of the 24 hospitals in the metro had electronic health information systems. All the hospitals with electronic health information systems reported that it was possible to use the systems to review patient demographic information internally. Furthermore, 65% could share patient summaries internally. Nonetheless, all but one of the hospitals surveyed reported that it was not possible to share data with an outside organization.

Despite the potential benefits to clinical care, the majority of the hospitals with electronic health information systems reported that physician resistance had been a major barrier to implementation. Although it ranked as the second most common barrier, less than half of the hospitals reported that capital constraints . Thus, while lack of capital may be an issue in some organizations, it is not necessarily the dominant barrier to adopting new technologies.

India is undergoing a widespread campaign to encourage digitization. Prime Minister Narendra Modi’s initiative has deemed digital infrastructure a core utility for every citizen that can be used to provide governance and services on demand in order to citizens. Modi’s digital push materialized most dramatically when the Indian government announced the demonetization of the 500 and 1,000 rupee banknotes on November 8th, 2016. The banknotes were replaced with new 500 and 2,000 rupee bank notes, which were initially in short supply, encouraging consumers and businesses to adapt to credit cards and digital payments in a country which had previously run largely on cash. The digitization of health records is yet another example of the transformation that India is undergoing away from paper-based systems.

Although Chandigarh is not a typical Indian city due to its above-average income, its prominent use of electronic health information systems demonstrates that there are numerous exemplar organizations that Indian hospitals can follow as they seek to digitize care. The city likewise demonstrates to vendors that there is a market for electronic health information systems in India. While there are still opportunities for even the Chandigarh hospitals to make their systems more feature-rich, their existence demonstrates that the groundwork has already been laid for digital healthcare in India.

The views expressed in this article are the author’s own and do not necessarily reflect 51�Թ�’s editorial policy.

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In China, about half of healthcare spending is on pharmaceuticals, while in the United States only 10% is. Both nations are in the process of undergoing healthcare reform. While America is implementing the Affordable Care Act, aimed at decreasing healthcare utilization, China is implementing its 12th Five-Year Plan, which contains a number of healthcare provisions aimed at increasing healthcare utilization. Given the policies currently being pursued by both nations, it is likely that their pharmaceutical spending patterns will head towards convergence, with Americans spending a relatively larger share on pharmaceuticals, and Chinese spending a relatively smaller share.

Historically, the American and Chinese healthcare systems have had somewhat different strengths. The American system has relied on using highly-trained clinicians to provide expensive reactive care to a small percentage of the population, while the Chinese system has relied on using clinicians with wider variation in training to provide care that is more focused on prevention and is more affordable. This dissimilarity in provider infrastructure is one of the causes of the different use of pharmaceuticals in the two countries.

As a result of the different focuses of the two healthcare systems, healthcare spending is 17.4% of America’s GDP and 4.6% of China’s GDP. Heavy reliance on pharmaceuticals can lower healthcare system costs, as generics have almost no marginal cost, and it often costs less to administer pharmaceuticals than the physician services they sometimes replace. For instance, antidepressants are a lower cost, albeit imperfect substitute for some forms of psychiatric services. Pharmaceuticals likewise can be administered with less training and time. While often cheaper, pharmaceuticals do not always provide better outcomes than physician services, and often carry side-effects.

China’s reliance on pharmaceuticals has multiple origins. While high pharmaceutical use is in part motivated by the design of China’s healthcare delivery system, there are also other factors at play. Currently, Chinese public hospitals (the vast majority of hospitals) operate under price controls. Prices will need to be increased in order for hospitals to be able to sustain themselves solely on healthcare services. While physicians cannot officially charge more than the set prices to patients, they can derive revenue from other sources. One legal source is through the sale of pharmaceuticals. While American physicians cannot dispense the drugs they prescribe, Chinese physicians currently can. This has created a financial incentive for overprescribing which may be impacting treatment decisions.

Recognizing this issue, the Central Committee of the Communist Party of China has called for the separation of dispensing from prescribing in public hospitals in its 12th Five-Year Plan, which guides policy development from 2011 to 2016. Although the integration of dispensing and prescribing makes sense within the context of Traditional Chinese Medicine due to the personalized nature of treatment, it has become clear that it is problematic within the context of allopathic medicine. While this separation will have a substantial financial impact on Chinese hospitals, Minister of Health Chen Zhu is working to ameliorate this problem through increasing the schedule of prices that hospitals may charge.

Meanwhile, in the United States, pharmaceuticals are becoming more affordable to Americans, as the Affordable Care Act increases prescription drug coverage for both seniors and the poor through requiring insurers and drug manufacturers to provide rebates and greater cost sharing. Growing access to health insurance without commensurate growth in the number of physicians is creating a physician shortage. As a result, Americans may have to rely on a more varied set of providers, as Chinese do today. Pharmaceuticals may likewise play a greater role both due to the substantially lower cost of generics relative to physician services, and due to the shortage in physicians available to provide services. Thus, America’s use of pharmaceuticals may become more Chinese while China’s use of pharmaceuticals becomes more American. Moving forward, lessons from China’s past may increasingly become relevant to America’s future.

The views expressed in this article are the author’s own and do not necessarily reflect 51�Թ�’s editorial policy.

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China and the United States are both in the process of undergoing healthcare reform. In 2009, China announced its healthcare reform, which it elaborated upon through the 12th Five-Year Plan released by the Central Committee of the Chinese Communist Party in 2011. After considerable debate, the US launched its own series of reforms, with the HITECH Act, which was a component of the American Recovery and Reinvestment Act of 2009, and the Patient Protection and Affordable Care Act, which was a standalone entity that was enacted in 2010. While both reforms were created in part to increase access to health insurance, they were created for differing reasons and do so in different ways. After comparing the two reforms and their resulting healthcare systems, three general themes emerge; healthcare systems are influenced by national objectives, the structure of the government, and economic conditions.

Healthcare systems are influenced by national objectives

While China and the US worked on reforming their healthcare systems during the same period of time, they did so for substantially different reasons. In China, shielding people from financial shocks resulting from medical expenses was a paramount concern. In America, the focus was on improving access to health insurance to discourage the use of expensive emergency care. China was motivated to increase access to health insurance in part because people were saving a large proportion of their incomes in order to from medical losses. Insurance reduces the financial shock that people experience during illness, enabling them to devote more of their incomes to consumption. Having money saved has been essential for survival in China, as people have typically been expected to pay at the time of treatment. Meanwhile, in the US, a major factor motivating the reform was the desire to increase the number of people with health insurance in order to encourage people to seek preventive treatment and to reduce the burden on providers caused by people receiving care without paying for it. Thanks in part to the Emergency Medical Treatment and Active Labor Act, Americans can receive urgent care at hospitals . As emergency care is expensive and bad debt must be either absorbed by hospitals or tax payers, Americans have hoped that improving access to insurance would help people receive care in lower-cost settings and be less likely to face costly health catastrophes. Thus, while both China and the US sought to increase access to health insurance, they did so for somewhat different reasons.

Healthcare systems are influenced the structure of the government

China’s recent health insurance reforms have primarily focused on people living in rural areas and on people living in urban areas not working for large employers, while America’s reforms have focused on employed people, low-income people, and children. One reason that the reforms have addressed different demographics is that the two nations slice their populations differently when thinking about health insurance.

China historically has divided people by urbanicity and employment status when determining the healthcare financing program that is most appropriate, while America has historically divided people when doing so. China tends to control for urbanicity at the national level, while the US tends to do so at the state level due to differences in the nations’ legislative processes. As Chinese lawmaking has historically primarily occurred at the national level, national policies tend to have the . Meanwhile, the US has a strong tradition of creating laws at the state level, and has states create different flavors of the health insurance programs for low-income people and children, as well as for the health insurance products sold to working-age people. Thus, a difference in the structure of the Chinese and American governments causes the healthcare systems to divide their populations in different ways.

Healthcare systems are influenced by economic conditions

China and the United States have drastically different per capita GDP – approximately , and approximately in the US. As incomes are lower in China, there is a greater need for affordable care – the average health insurance premium of a family in the US costs more than the average household income of a family in China. To provide healthcare at a cost affordable to the average Chinese family, the Chinese healthcare system utilizes a combination of greater tiering of providers and a greater emphasis on prevention than is seen in the American healthcare system.

While rural Chinese are now offered health insurance with a governmental premium subsidy of about $30 per year, the first tier of the system (with the greatest rate of reimbursement) consists of without formal medical school training. As more formally trained providers do not appear until patients reach higher tiers of the system, a large number of basic problems can be handled at a lower cost. Meanwhile, in the US, licensure requirements limit the ability of less-trained people to practice medicine unsupervised. Although nursing has traditionally been the affordable front-line of the American healthcare system, the push to have nurse practitioners hold doctorates there as well. Thus, differences in incomes have driven China and the US to create different minimum standards for medical care providers, with China ensuring affordability by permitting a broader range of providers.

The general lesson that can be learned from comparing the healthcare systems and reforms of China and the US is that local conditions play a central role in determining the structure of a nation’s healthcare system. While international comparisons are frequently made on nations’ cost, quality, and level of access to healthcare, it is often not possible for healthcare systems to be transplanted from one nation to another. Healthcare systems are a product of the nations that build them, and their design must accommodate the national objectives, government structure, and economic conditions of the nation in which they exist.

The views expressed in this article are the author’s own and do not necessarily reflect 51�Թ�’s editorial policy.

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