Healthcare Debt Really Requires Innovation

Mia Española

The math is simple yet alarming: the reprioritization of care during the pandemic, since March of last year, meant a large reduction in planned care and created large healthcare debts. To catch up, a corresponding increase in healthcare production beyond normal levels is required.

Statistical evidence of healthcare debt is very clear. A recent report from the Health and Medical Board (HSN 2020-0681) in Region Stockholm reveals that about 50% of all elective inpatient care was canceled during the period from March to June 2020. The number of newly discovered cases of cancer has decreased by about 25%. This reduction doesn't indicate a lower incidence of cancer, but rather suggests that many cases are going undetected due to reduced screenings and fewer medical visits.

There is thus a care debt due to postponed care but also an increased need for care due to the aftercare and rehabilitation of covid-19 patients, care after isolation and anxiety, increased care consumption during the time that individuals have to wait for action and a likely increased burden of care due to of later discovery of, for example, cancer diagnoses. This situation isn't unique to one area; similar patterns are also found in other regions. Basically, this means increased suffering and a poorer quality of life for individuals in need of care.

The ambition in Region Stockholm (HSF press meeting 22/9) is that all patients waiting for treatment should receive care within the next year. To achieve this, the region will need to increase its care production by approximately 20% above normal levels. The 20% increase is not just a number; it represents thousands of medical procedures, surgeries, and treatments that need to be performed in addition to the regular healthcare workload.

Suggestions for measures have been proposed:

There are numerous effective, both new and proven, measures and methodologies that can remedy this situation and increase the availability and capacity of the healthcare system. The pandemic, as in many sectors, has accelerated some digitization and also a close care with more care in the home (increase ASIH and geriatric care in the home). More daycare operations are a possible contributing solution (although the current reimbursement system may work against it). Other, more traditional, measures that are highlighted are to increase capacity by adding resources such as evening and weekend receptions and hired staff.

The crisis has shown proof of healthcare's incredible ability to gather strength and change, but also highlighted actual weaknesses in coordination, planning and cooperation within and between the regions. It is gratifying that with renewed vigor there are many voices for increased collaboration, both within the regions (e.g. the hospital directors and the director of health and medical care in Stockholm who speak jointly), at national level (such as the national delegation for increased accessibility and the work of the National Board of Health and Welfare with knowledge management) and between the regions (as an example that Västernorrland can help Jämtland with the elective surgery).

At the same time, although the problems may be universal at an aggregate level, the solutions are usually local. This means that even the most tangible measures cannot always be solved solely on an operational level.

The healthcare system faces two conflicting challenges:

The first paradox is that development requires effort and investment in advance to reach a desired future state. It is possible to solve capacity problems (care queues) by temporarily adding extra resources, but there are two obvious risks here. Firstly, in a system with finite resources, there is the risk of stealing resources from other areas (which happened clearly in the spring). Secondly, the system may find it difficult to meet the need later when the temporary interventions cease, as no sustainable improvement has been achieved. There have been various ventures over the years with queue-reduction billions that have largely demonstrated this. It becomes an almost biblical parable that it is better to invest in improving the system than to spend money on increasing capacity only with the help of resource additions.

The second paradox that needs to be addressed is due to the complexity of the healthcare system itself. Fundamentally, many of the challenges facing healthcare are highly complex, with a low level of consensus on what the problem is and low predictability of the solution. Here, co-creation is required both in problem identification and in the solution between the various care actors, other social functions, and the patients. But even "simple" solutions become complex due to the size, organization, and financing of the healthcare system. From the outside, it can be experienced as enormous inertia (such as, for example, the one experienced in the pace of digitization). A strong systems perspective is thus required to manage this complexity. Treating the system as if it were simple with linear, cause-and-effect measures will further suboptimize the system and, in the worst case, damage it.

Strategic development work is needed in the area of accessibility. This isn't easy and requires bravery to try new things, a clear plan to follow, and people working together well. At the same time, it is more tangible and urgent than ever to achieve substantial system improvements to cope with current and future care needs. We need to come up with completely new and creative ways of doing things, very different from what we do now. Unlike during the COVID-19 pandemic when we wanted to "flatten the curve" to slow down the virus, we don't want to slow down our progress in improving care. Instead, we want to speed up, with improvements happening faster and faster.