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Nikolina Dukić Samaržija, PhD
Assistant professor
University of Rijeka
Faculty of Economics and Business
E-mail: nikolina.dukic.samarzija@efri.hr
Andrea Arbula Blecich, PhD
Assistant professor
University of Rijeka
Faculty of Economics and Business
E-mail: andrea.arbula.blecich@efri.hr
Luka Samaržija, PhD
Assistant professor
University of Rijeka
Faculty of Economics and Business
E-mail: luka.samarzija@efri.hr
THE PARADIGM OF PATIENT-CENTERED CARE IN
THE PUBLIC HEALTH DECISION-MAKING*
UDC / UDK: 614
JEL classification / JEL klasifikacija: D01, I12, I18
Review / Pregledni rad
Received / Primljeno: June 29, 2018 / 29. lipnja 2018.
Accepted for publishing / Prihvaćeno za tisak: December 10, 2018 / 10. prosinca 2018.
Abstract
Equitable provision of health care has been a longstanding goal in many
European countries. Provision of such universal coverage comes with the
problem of growing health expenditures that is recognized globally. This article
argues that patient-centered care (PCC), which has become a new promising
paradigm for cost-effective provision of health care, should also become the new
paradigm in the public health decision-making. PCC relates to the notion that
patients’ preferences, objectives and values should be considered in the process
of decision-making and delivery of health care. If we apply the PCC paradigm to
the public health issue, it can be argued that any public health program or health
policy should be created and evaluated considering patients’ preferences.
* This study was founded by the Croatian Science Foundation under the project 6558 Business and
Personal Insolvency – the Ways to Overcome Excessive Indebtedness, and by the University of Rijeka
under the project: Approaches and Methods of Cost and Management Accounting in Croatian Public
Sector (No. 13.02.1.2.09).
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504
Therefore, the aim of this paper is to elaborate the importance of preference
elicitation in health care decision-making as a part of PCC.
Keywords: health care; health decision-making; patient-centered care; stated
preference
1. INTRODUCTION
In Europe health care systems are struggling with ever-growing health
care costs that are largely accelerated by unfavorable trends. Most important are
aging population and increase in chronic diseases. Currently, Europe has the
highest proportion of elderly population and by 2050 it is expected that more than
37% of the European population will be older than 60. On the other hand, it is
estimated that only 10% of African population will be older than 60 (Deloitte,
2014). Due to the growing need to meet all desired goals with limited resources,
the health care decision-making has become increasingly complex. Additionally,
due to a gap in knowledge and information, especially between physicians and
patients, the agency problem is pronounced in health care systems. Consequently,
integrated care has become the new promising model for redesigning health care
(Busse, Blümel, Scheller-Kreinsen & Zentner, 2010; McKee & Nolte, 2004). The
goal of integrated care is to enhance consumer satisfaction and system efficiency
by cutting across multiple services, providers and settings (World Health
Organization [WHO], 2016). Therefore, a high degree of collaboration and
communication among health professionals is needed. Hence, the importance of
evidence-based medicine and patient-centered care (PCC) is rightly emphasized
(Barratt, 2008; Barry & Edgman-Levitan, 2012).
When evidence-based medicine, which is based on conducted empirical
research and the efficiency of medical interventions, was at its beginnings
(Barratt, 2008), the involvement of patients in the decision-making was neglected
(Evidence-Based Medicine Working Group, 1992). However, the importance of
shared decision-making in health-care, as well as the integration of medical
evidence with patients’ preferences (Sackett, Rosenberg, Gray, Haynes &
Richardson, 1996) has soon been recognized. In fact, the study of preferences is
in the focus of PCC that is no longer aimed on diseases, but rather on patients and
their families (Barry & Edgman-Levitan, 2012).
Hence, the aim of this paper is to elaborate the importance of preference
elicitation in health-care decision-making as a part of PCC. This paper consists of
five parts. After the Introduction, in Section 2 we discuss the role of preference
elicitation in patient-centered care, followed by Section 3 in which preference
elicitation in creating the optimal health-care programs is elaborated. Section 4
explains the role of preferences in economic evaluations in health. Finally,
Section 5 is the paper conclusion.
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2. THE ROLE OF PREFERENCE ELICITATION IN
THE PATIENT-CENTERED CARE
The concept of PCC was accepted as a fundamental approach in
improving the quality of health-care in the United States (National Research
Council, 2001), emphasizing the importance of collaboration between physicians
and patients. Respectively, evidence-based medicine and shared decision-making
should lead to better health outcomes and result in cost-effective utilization of
health resources. This approach is in accordance with medical ethics indicating
that patients’ autonomy should be respected (Sheridan, Harris & Woolf, 2004).
The most important characteristic of PCC is patients’ active involvement
in the decision-making process (Barry & Edgman-Levitan, 2012). Gerteis,
Edgman-Levitan, Daley & Delbanco (1993) argue that consideration of patients’
values, preferences and needs is significant indicator of health-care quality.
Consequently, implications of preference valuation are comprehensive as they
give important insights into factors influencing health-care utilization (Merino-
Castelló, 2003). This has important role in health-care rationalization. For the
purpose of studying patients’ preferences, different stated preferences methods
are used and improvements of health-care services are made accordingly.
Economist Intelligence Unit (2011) proposed a scenario for the
development of health-care systems by the year 2030 that is based on the primacy
of preventive medicine and healthy life promotion over curative health-care.
Namely, according to the WHO (2005), at least 80% of all forms of heart diseases
and diabetes are preventable. However, their prevention requires a change in
lifestyle, which is attainable through combination of various policies of
education, prices and taxation, as well as by encouraging healthy habits of
population. Such changes require at least alignments at the state level, since they
involve various government sectors (from education to tax policies).
3. PREFERENCE ELICITATION IN CREATING
OPTIMAL HEALTH PROGRAMS
Since in the future the main health activity will be changing unhealthy
habits and early detection of disease, successful implementation of promotion and
prevention health programs will be of great importance. Aimed at providing
useful services to end users, preventive health programs should be oriented
towards their preferences. While the study of consumer preferences is very
important in the real sector, its importance is not recognized in the public sector.
This has negative influence on public health-care spending. This is evident in low
response rate to preventive programs in Croatia.
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Considering the results of many international studies (such as Brown,
Lipscomb & Snyder, 2001; Mandelblatt, Lawrence, Mizell Womack, Jacobson,
Yi, Hwang, Gold, Barter & Shah, 2002; Eichler, Kong, Gerth, Mavros & Jonsson,
2004), the importance of cost-effective preventive programs was recognized in
Croatia and three screening programs had been introduced at the national level:
National Breast Cancer Screening Program, National Colon Cancer Screening
Program and National Cervical Cancer Screening Program. However, Croatia did
not benefit from positive economic and other effects of these programs due to low
response rate. Reason for this can be found in poor compatibility with population
preferences. Under these circumstances cost-efficiency cannot be achieved, since
its achievement depends on the high response of the target population (target
response rate for breast cancer screening is 70%, for colon cancer screening is
45% and for cervical cancer screening is 85% (Croatian Health Insurance Fund
[HZZO], n.d.). Screening response rates differ between different counties but
overall response to breast cancer screening program is around 60% (Šiško &
Šiško, 2017), for colon cancer screening is around 18% (Bergman Marković,
2015) and for the cervical cancer screening data are inconclusive.
According to the Australian Population Based Screening Framework
(Community Care and Population Health Principal Committee of Australian
Health Ministers’ Advisory Council, 2016), the implementation of screening
programs primarily depends on the need for organizing screening. The program
success depends on appropriate implementation and program management since
it is an integrated process where all activities should be carefully planned,
coordinated, monitored and evaluated in order to assure quality. In order to obtain
maximum benefits from the program all activities must be adequately supported
and financed. The screening process consists of four basic activities outlined in
the following scheme.
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Scheme 1 Population based screening process
Source: Community Care and Population Health Principal Committee of Australian
Health Ministers’ Advisory Council (2016). Population Based Screening Framework.
http://www.cancerscreening.gov.au/internet/screening/publishing.nsf/Content/16AE0B052
4753EE9CA257CEE0000B5D7/$File/Final%20Population%20Based%20Screening%20F
ramework%202016.pdf
From the Scheme 1, it is evident that the most comprehensive process of
screening is target population recruitment. If the initial screening phase is not
conducted successfully, there will be no positive outcomes from early disease
prevention. Even though there are many screening guidelines, they are not
sufficiently emphasizing the importance of the target population preferences
evaluation. It is because countries involved in the development of the guidelines
do not have target population response problem. Additionally, these countries
have sufficient resources to change unfavorable behavior and promote preventive
activities.
Among EU countries that have introduced cervical cancer screening,
Finland, Iceland, the Netherlands, Norway, the United Kingdom and Sweden
have a screening response rate of 100% (Anttila, 2004), whereas Croatia is at a
very low level of 10%, which led to a termination of the program. Therefore,
Croatia must improve the activities related to the initial screening phase –
recruitment of the target population. Also, the remaining national preventive
programs in Croatia failed to achieve a satisfactory level of response.
Phillips (2002) has shown that patients’ preferences may influence their
willingness to utilize health services as well as their health outcomes. Also,
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understanding preferences is important due to a growing interest in patient
involvement in the health-care decision-making (Coulter & Collins, 2011;
Epstein & Street, 2011; Barry & Edgman-Levitan, 2012). There are surveys
specifically designed for this purpose (utility-based preference surveys), which
give insight into the way how individuals “weigh” harms and benefits of health
interventions (Phillips, 2006). Thus, when designing and improving preventive
programs and health-care policies, target population preferences should be
evaluated. Although the terms “attitudes” and “preferences” are sometimes used
as synonyms, here the meaning of “preferences” is taken from the economic
theory: patients have preferences concerning health-care and seek to maximize
them within their budget.
As public health cannot rely on revealed preference (price and quantity
signals), the methods of stated preferences are a reliable way for determining
benefits of public health-care programs. Consequently, it can be concluded that
there is a need for the implementation of stated preference methods in the design
of preventive public health-care programs to ensure their greater efficiency.
Dukić (2014) proved the correlation between the level of respondents’
preferences with the screening program and the decision concerning the
participation in the screening. Therefore, planning and implementation of national
preventive programs in accordance with the preferences and needs of the target
population is a way to go against a trend of poor response to preventive programs
in Croatia.
4. PREFERENCE ELICITATION IN ECONOMIC
EVALUATION OF HEALTH-CARE
If limited resources are used to meet a specific need, the opportunity to
meet another need is lost. Therefore, the economic evaluation of different
resource allocation with the purpose of informed decision-making is required.
Economic evaluation includes cost-benefit analysis (CBA), cost-effectiveness
analysis (CEA), cost-utility analysis (CUA) and cost-minimization analysis that is
based on the concept of opportunity costs (Drummond, Sculpher, Torrance,
O'Brien & Stoddart, 2005). Any economic analysis has to be done differently,
depending on the subject who makes the decision (government, health insurance,
hospital, etc.). Namely, every decision is made for a specific purpose and within a
specific social and political context (Tsuchiya & Williams, 2010).
CBA explicitly expresses all benefits and costs in health-care program
evaluation in monetary units. For this purpose, the human capital (Grossman,
1999) and willingness to pay (WTP) approach are the most commonly used.
Within CBA it is possible to compare different health goals with each other and
with other society goals. Furthermore, the possibility of expressing costs and
benefits in the same unit (monetary) for different health-care users can address
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the question of distribution (fairness) in the health-care system (Detels, McEwen,
Beaglehole & Tanaka, 2002).
Since WTP for public health services cannot be determined on the basis
of revealed preferences (market prices), the use of contingent valuation method
(CV) is most commonly used. However, Ryan (2004) argues that discrete choice
methods (DC) is more appropriate for determining WTP because they have
multiple advantages over CV methods. They are more flexible in estimating
marginal values of health services and policies. Furthermore, the use of WTP
could lead to a potential problem in the health resource distribution in favor of the
rich. Potentially successful approach in addressing the distribution problem is the
use of DC methods (Scotland, 2011). By analyzing individual choices between
different health-care scenarios which differ in terms of costs, benefits and
beneficiaries, the efficiency-equity tradeoff can be determined. This possibility of
DC method represents the future course of research, since the question of equity
in health-care is of global importance. Due to the constant pressure on the
sustainability of national health-care systems and ongoing reforms, which are
mostly based on the rationalization of health spending, the question of fairness, as
one of the explicit allocation criteria, requires health-care decision-makers
attention. Although, evaluation of the stated preferences allows the quantification
of WTP, it proved to be extremely demanding in practice, which is why CBA are
less frequently used than CEA. Despite that, CUA method is more appropriate
because it uses a generic health outcome measure comparable at the level of
different programs, procedures and policies. The most commonly used outcome
measure within CUA analysis is quality adjusted life years (QALY), which is a
combination of years of life and health-related quality of life. QALY indicator
allows preferences evaluation of the general public regarding health outcomes of
the alternative health-care (Ali & Ronaldson, 2012).
Even though QALY has its advantages, primarily due to its generic
nature, it is not applicable in all evaluation studies. Namely, QALY-based
approach only evaluates outcomes that directly affect the health-related quality of
life and/or years of life. At the same time, this is also a disadvantage of the
QALY approach because process characteristics and non-health outcomes may be
crucial information for decision-makers when evaluating different health-care
programs. Accordingly, when making resource allocation decisions, process
attributes, such as, patients’ autonomy in the decision-making process, should be
considered (Moony, 1994). It is difficult to capture this within the QALY
concept. Another criticism against the QALY concept (Nord, 1995) relates to
neglecting of social preferences towards a fair distribution of health. Namely, an
increasing number of studies emphasize that the society differently values the
improvement of health status between different social groups. For example,
higher weights are assigned for the improvement of health status of children,
chronically ill and the poorest in society (Petrou, 2010; Baltussen, Stolk,
Chisholm & Aikins, 2006; Jelsma, Shumba, Hansen, De Weerdt & De Cock,
2002; Cookson, Drummond & Weatherly, 2009). Most studies are focused on the
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potential use of DC methods in determining weights for health outcomes of
different social groups (Baltussen et al., 2006; Norman & Gallego, 2008; Lancsar,
Wildman, Donaldson, Ryane & Bakerc, 2011). Hence, it is possible to
incorporate the component of fairness into the CUA analysis (Scotland, 2011).
5. DISCUSSION AND CONCLUSION
Many developed countries have accepted the concept of PCC as a
fundamental approach for improving the quality of health-care. A key feature of
the PCC–based health system is the active involvement of patients in the
decision-making process. Its benefit are reflected at the macro level by creating
the public health policies that are focused and specially tailored for sensitive
groups in the society, like elderly people. Whereas, at the micro level the benefits
are reflected in creating the optimal health programs and policies (e.g. preventive
programs, health and health literacy promotion) that would generate savings in
the overall health-care system and contribute to resolving the health issues of
aging population.
Although it is not possible to fully incorporate market principals into the
public sector, in order to change unhealthy behavior, it is imperative to
acknowledge the preferences of the population. This does not mean that decisions
will be made solely on the basis of the population preference analysis, but will
primarily depend on population epidemiology, scientific progress of medical
diagnosis and cost-efficiency of the programs themselves. The evaluation of
patients’ preferences aims at better adaptation and implementation of public
health policies, which leads to savings due to reduced public health expenditures
(the cost of hospitalization, medicines, sick leaves, and disability pensions or
similar). Additionally, the elicitation of stated preferences is applicable in
economic evaluations in health-care, especially for determining willingness to
pay in cost-benefit analysis.
Although there are numerous methods of stated preferences evaluation,
DC methods, eliciting preferences of respondents based on their choice, are
theoretically and methodologically most acceptable. Namely, most judgments in
everyday life consist of the choice between comparable alternatives. The
compromises that consumers make by choosing smaller quantities of one good
for larger quantities of other good reveal the essence of the marginal value they
assign to that good. This allows for a wide application of DC methods in planning
health-care policies.
Preference elicitation by DC methods has a growing importance in the
field of economic evaluation. It has the possibility of improving QALY concept
by accounting for the equity issues, which is of great importance regarding health
policy concerns. Although economic evaluations are very useful and have
multiple advantages, health-care decision-making process (especially when it
comes to public health policies and health reforms) cannot solely be based on
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their results. Namely, there are factors that require equal attention from decision-
makers. These often include (Sorenson, Drummond & Kanavos, 2008): need for
health intervention, health policy implications, availability of alternative
interventions, fairness, impact on the budget, expected use of the product or
service, product innovations and cost-effectiveness. Finally, the success of any
health policy or reform will largely depend on stakeholders’ acceptance, which
will largely be affected by their preferences.
The main contribution of this paper is emphasizing the role of PCC in
public health decision-making. This is especially important for national health
preventive programs in Croatia as target population did not recognize their
benefits, which is reflected in low response rate. We argue that in order to
improve cost-effectiveness of national screening programs (or any other) it is
inevitable to turn to PCC. Also, the principles of integrated health-care are of
grate use in the process of creating, adopting and enforcing health programs of
public interest as they imply coordinated actions by numerous stakeholders and
focus on life-long care.
In Croatia the first step towards integrated health-care was the
introduction of integrated information system (Government of the Republic of
Croatia, 2007) that connects different health-care services. Most recently the
Ministry of Health (2018) introduced a National plan for the development of
clinical hospital centers, clinical hospitals and general hospitals for the period
2018 – 2020, which is based on the principle of functional integration between
different hospitals. It also proposes the establishment of the National University
Hospital as the umbrella institution for the hospital sector.
Therefore, we can conclude that the importance of integrated health-care
has already been recognized in Croatia but in order to fully apply integrated
health-care model, on any level, the PCC will have to be emphasized and applied
by health decision makers. One part of the solution could be in eliciting patients’
preferences by using DC methods in order to better understand health related
behavior and alter the undesirable one. The other part of the solution must be
faced towards the elevation of population’s health literacy as shared-decision
making holds responsibility for both health-care providers and patients. Having
that said, the future research should address these issues and provide empirical
research on benefits of patient-centered care and integrated health-care on
different levels of health-care in Croatia.
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Dr. sc. Nikolina Dukić Samaržija
Docentica
Sveučilište u Rijeci
Ekonomski fakultet
E-mail: nikolina.dukic.samarzija@efri.hr
Dr. sc. Andrea Arbula Blecich
Docentica
Sveučilište u Rijeci
Ekonomski fakultet
E-mail: andrea.arbula.blecich@efri.hr
Dr. sc. Luka Samaržija
Docent
Sveučilište u Rijeci
Ekonomski fakultet
E-mail: luka.samarzija@efri.hr
PARADIGMA PRISTUPA USMJERENOG NA
PACIJENTA PRILIKOM DONOŠENJA ODLUKA U
JAVNOM ZDRAVSTVU*
Sažetak
Jedan je od dugoročnih ciljeva europskih zemalja kvalitetna i pravedna
raspodjela zdravstvene zaštite. Pružanje takve zdravstvene usluge dovodi do
problema rastuće potrošnje u zdravstvu. Ovaj rad ističe da pristup usmjeren na
pacijente (PCC), koji je postao nova paradigma za troškovno-efikasno pružanje
zdravstvenih usluga, treba postati i nova paradigma u stvaranju zdravstvenih
politika i programa. PCC ističe da preferencije, ciljeve i vrijednosti pacijenata
treba uvažavati prilikom donošenja odluka u vezi sa zdravljem. Ako se PPC
primjeni na problematiku javnog zdravstva, može se reći kako se bilo koji
zdravstveni program ili politika trebaju stvarati i evaluirati na temelju
preferencija pacijenata. Sukladno s time, cilj je ovog rada elaborirati važnost
vrednovanja izrečenih preferencija, kao djela PCC, u procesu donošenja odluka
u javnom zdravstvu.
Ključne riječi: donošenje odluka u zdravstvu, izrečene preferencije, usluge
usmjerene na pacijenta, zdravstvena zaštita.
JEL klasifikacija: D01, I12, I18
* Ovaj rad nastao je uz potporu Hrvatske zaklade za znanost u okviru projekta „6558 Business and
Personal Insolvency – the Ways to Overcome Excessive Indebtedness“ i uz potporu Sveučilišta u
Rijeci u okviru projekta „Koncepti i metode troškovnog i upravljačkog računovodstva u javnom
sektoru Republike Hrvatske“ (br. 13.02.1.2.09.).