An Undisciplined Economist: Robert G. Evans on Health Economics, Health Care Policy and Population Health

Citation

MacVane Phipps, F. (2017), "An Undisciplined Economist: Robert G. Evans on Health Economics, Health Care Policy and Population Health", International Journal of Health Governance, Vol. 22 No. 2, pp. 118-120. https://doi.org/10.1108/IJHG-02-2017-0005

I took up the challenge of reviewing this collection of Canadian Health Policy Analyst, Robert Evans’ essays, thinking I might learn something. I am a Lecturer in a health care subject and not an economist. As someone concerned about the complex interactions between health, population demographics, political systems and how health care provision is funded and accessed, I had heard Evans alluded to; shamefaced I admit I had never read any of his vast output. With these handicaps, I did not find the book an easy read, particularly the essays in the initial section dealing with economics and economists. However, I discovered it was a necessary read and well worth the effort of reading and re-reading to digest what is a very rich and varied menu. What I learned by far exceeded my expectations and I will heartily recommend this text to any of my graduate students considering a future career in health management, health care policy or health care regulation. In fact, I would say it should be on the recommended reading list for all health care students who wish to develop a deep understanding of how health care provision works in the modern world.

The book consists of 16 essays, divided into four separate sections. The first section focusses on economics and economists. In this section Evans shatters the myth that economics is a precise science that can be explained by mathematical formulas or make predictions based on models. Such formulas and models ignore the messiness of real life; they neglect the psychology of human behaviour and how this influences the choices people make. A recurring theme is that economic analysis most closely resembles religious belief when it lacks intellectual rigour but enjoys strong political appeal. The opening chapter in this section, “Slouching toward Chicago”, first published in 1982, is surprisingly prescient in its relevance to today’s complex world. The final chapter in this section, which was presented at the World Congress on Health Economics in 2011, examines the patterns of health care provision and distribution. Evans identifies three frameworks or paradigms through which both health and economic professionals and lay people or service users interpret the interactions inherent in all health systems. Evans labels these as: the naïve clinical; the mainstream economic; the eclectic structuralist. Each of these is made up of three elements, the normative view of how patterns of health care provision and distribution could, or should be determined; a positive view of how they are determined and third, a set of narratives that explain why one section of the flow of health care provision is the most important, therefore directing research, analysis and policy towards that sector. This harks back to the point made in the first chapter and developed through the section, and indeed all Evans’ essays that culturally conditioned assumptions and values inform economics. There are always gaps in the process of analysis caused by missing or ambiguous evidence. Economists paper over these gaps with assumptions, guesswork or judgements based on previous experience. The way is which they do this is coloured by the individual philosophical, theoretical and political assumptions leading to divergent results.

The second section of the book is concerned with health care financing and opens with an essay from 1985 which asks the question of whether a universal health care system can meet the needs of an ageing population. Again this seems a very prescient discussion and one, which is becoming crucial in Western economies with falling birth rates and increasing lifespans. Evans argues against a private/public funding mix for health care and demonstrates how a universal public health care system reduces costs by enabling national price negotiation between health care providers and health care funders. He points to the spiralling cost of US health care that has shot even higher in the 30 years or so since this was written. Evans also questions the assumption that older citizens use a disproportionate amount of health care services, asking whether the health choices offered could be reconsidered. This is a pressing question for today when increasing use of technology is often seen as the solution to health problems, despite evidence that more conservative measures are just as, if not more, effective. These themes are developed throughout the more recent essays in this section, which ends with a chapter exploring the complex business of health insurance. While some forms of private health insurance are available in most countries, health care consumers in the USA are largely dependent upon private insurance companies. Evans proposes that there are no valid arguments that competitive private insurers offer the most efficient allocation of health care. He points out that services provided through private insurance schemes are always more expensive than publicly funded health care and questions why this is so, when theoretically, competition is meant to reduce the costs of goods or services.

The third section of the book deals with the health care policy. The first chapter grapples with the problem of physician-induced demand for healthcare. Evans warns that particularly in a for-profit system, there is an ethical issue concerning the conflicting role of doctor as patient advocate and doctor as marketer who has a vested interest in selling higher priced goods and services from which the physician directly benefits. As in earlier chapters, Evans seems to be writing ahead of his time as this brings to mind recent discussions asking why cardiac surgeons often advocate placing a cardiac shunt in patients with angina when research demonstrates that conservative measures such as diet, gentle exercise and aspirin are just as, if not more, effective (Rezende et al., 2015). Another chapter in this section returns to the topic of the effect of an ageing population on healthcare resources and patterns of care. Evans argues that the “received wisdom” that older people are disproportionate users of health care, thereby driving up the price of such care for all users, cannot be supported by the evidence. He proposes that healthcare interactions between providers and service users, and the relationship between health utilisation and morbidity in older people are just too complex. A linear tool predicting health care utilisation is doomed to inaccuracy. Although patient visits to a general practitioner or hospital do increase with age, data cited by Evans demonstrates that many of these visits were physician initiated rather than patient initiated which may reflect points raised in the first chapter of this section. The final chapter is the wonderfully titled “Political wolves and economic sheep: the sustainability of public health insurance in Canada” and is Co-authored with Marko Vujicic, previously a Health Economist with the World Health Organisation (WHO) in Geneva and more recently a Senior Economist at the World Bank in Washington, DC. Evans and Vujicic discuss the concept of sustainability as it relates to health care, concluding that publicly funded healthcare is able to contain the costs of services and goods more effectively than for-profit systems. They point to the fact that the cost of prescription drugs, which are outside of medicare and reimbursed through insurance, or paid for out of pocket, is rising much more rapidly than other elements of Canadian healthcare. New, more expensive drugs are often introduced to replace existing medicines and then aggressively marketed as superior, even though their chemical composition may be the same as, or very similar to the existing formula. However public funding relies on an egalitarian view of society as the wealthy pay more of their income yet receive the same services as anyone else accessing health care. If private funding were increased, the wealthy could end up paying less, but getting more for their health care dollar. On the other hand, private insurance schemes mean that the poor would pay more but receive less, therefore making such a system non-sustainable in a society seeking equity for all citizens.

The final section of the book deals with population health. In the first chapter, “Producing health, consuming health care”, Evans examines the disparity between the concepts of health and health care. The provision of care is a reaction to what has caused an imbalance in a person’s equilibrium, leading people to view health as the absence of disease. However, this interpretation of health was challenged almost seventy years ago by the WHO, who defined health as the complete state of physical, mental and social well-being, and not merely the absence of disease or infirmity (Huber, 2011). Despite this widely quoted definition that values the social and mental, as well as the physical aspects of health, these are largely ignored by providers of increasingly scientific and technical treatments which may not be warranted, or even all that “scientific”. The section ends with an essay that was originally a memorial lecture, which returns the reader to the concept of sustainability in a discussion of environmental threats including population growth.

In a postscript, the editors state how difficult it was to select 16 articles for inclusion when they had originally identified 30 that they felt warranted inclusion. The articles that were culled are included in recommended reading lists at the end of each section.

Finally, as a reviewer, what were my overall impressions of this book? It was sometimes difficult, but always interesting. The author is erudite, and constructs and defends his arguments extremely well. The key concepts that I took away from this book are the fact that economics should not be viewed as a pure science or used, in isolation to make predictions about health trends, outcomes or policies. These are best considered within a multidisciplinary team consisting of economists, health professionals, social scientists and health care users. In addition, health economists as well as health professionals and managers need to be aware of the cultural, theoretical and political beliefs and assumptions which underpin analysis of health economics. Evans’ own assumptions and beliefs were clear, although perhaps unacknowledged as potentially influencing his own analysis. As a health professional who has argued for universal single payer healthcare funding since my teenage years, the fact that Evans provided clear evidence to support this was reassuring. However if my own political views were right wing and my economic philosophy favoured the free market then I imagine I would be trying to pick apart Evans’ conclusions. Evans also provided a strong critique of “received wisdom” both in economics and health care and asked hard questions about why, with sufficient good evidence, are health care providers still supporting practices that are unnecessary, inefficient or harmful?

Overall, this is an excellent collection of essays and now that I have been introduced to Evans through reviewing this book, I shall certainly seek out more of his work. My only recommendation is “Highly Recommended”.