11. Measuring improvements and ROI

Many healthcare services don’t get evaluated for return on investment. But as health care expenditure inflates, there will be a need to ration investment – I argue the highest ROI services and programs should get priority funding. We do calculate cost per QALY (quality adjusted life years) for certain expenditure buckets such as pharmaceuticals, but don’t do this for many recurrent services that have significant budgets. Ironically, most medical interventions (e.g. drugs, surgical procedures medical equipment) requires a strong evidence-base against human clinical trials, but many health services appear to escape this level of scrutiny.

Evaluation needs to meet certain basic requirements, including adequate sample size (to remove chance findings), control comparisons (to mitigate regression to the mean), independence (so no one is marking their own homework) and robust methodology (to remove type 3 error of measuring the wrong intervention or the wrong outcome).

Returns need to be considered against quadruple aims – improving access, improving experience (patient and provider), improving clinical outcomes and cost effective system utilisation.

Appropriate measurements and ROI calculations are important in assessing integrated care efforts in order to justify further roll-out or commercialisation. Consideration should be given to who invests, who ‘saves’ or reaps benefits, and how a business case can stack up for multiple players in the health system to collaborate. For example, many integrated care efforts rely on upstream investment (in primary or community care) which yield results in downstream facilities (for hospitals and insurers) – determining a business case that defines the necessary partnerships and how rewards will be shared is important to getting the right incentives in place for investment.