Prescription apps – can we afford not to?

The Norwegian health service is in a paradox. Never before has the desire for digitalization been clearer in the authorities' plans and strategies. At the same time, the incentives for effective digital health tools to be used are almost non-existent. The result is that we are developing digital solutions that can help patients and relieve healthcare personnel - without a system for putting the solutions into use. Chronicle in Dagens Medisin by Anne Therese Tveter, Nina Østerås, Lise Solberg Nes.

Caption: Digital health tools with documented effects are being developed – but Norway lacks a system to put them into use. From left, Anne Therese Tveter, Lise Solberg Nes and Nina Østerås. 

Digital health tools – such as apps and web-based programs – have increasingly shown documented effectiveness. They are used for osteoarthritis, diabetes, long-term pain, mental health disorders, cancer, and cardiovascular disease, among other things.

Research shows that several patient-focused digital health tools can be as effective, and sometimes better, than traditional treatment options. This is especially true for interventions that improve functioning, quality of life, and coping. At the same time, the solutions can make good support more accessible, reach patients regardless of where they are or live, and also reduce the need for health services.

Yet, such tools are rarely introduced and used on a large scale.

Why? Yes, because it's not worth it for those who have to pay.

When effective treatment becomes a financial loss project

Digitalization challenges established boundaries and divisions of responsibility. The benefits often end up in one place, while the costs come from another. Municipalities can save on reduced need for home services, while specialist health services may lose income-generating activity. Society can save large amounts on digitalization in the long term, but no one wants to foot the bill here and now.

Hospitals are partly financed through activity-based schemes. When patients are doing better at home, the need for outpatient consultations, admissions and testing may decrease. This may also reduce the hospitals' income. Is it reasonable for hospitals to pay for apps that precisely aim to reduce the use of hospital services?

In the municipal health service, responsibility is also not clear. Municipalities have many statutory tasks and limited resources. Digital tools that support patients in managing more themselves can relieve a pressured municipal health service. But where does the funding belong? With the GP? The health and care centre? The health and care service? Or in the IT budget?

Health Norway is often highlighted as a natural platform, since digital solutions can increasingly be incorporated there. But here too we encounter the same fundamental questions: Who is responsible for long-term operation and development? Who pays for maintenance? And who ensures that the content is kept professionally updated? Without clear responsibility and funding, good solutions risk fading before the population has time to use them.

When responsibility is unclear, what often happens in Norwegian healthcare happens: nothing.

When the winnings end up in one place and the bill in another

A recent column in Finansavisen described how today's financing models can make it "cheaper to cut off the leg than to save it." The pointed formulation points to a well-known problem: The health service often rewards measurable activity and physical attendance, not prevention, self-treatment and long-term societal benefits. 

The same problem applies to patient-oriented digital health tools. The system rewards physical attendance over measures that can reduce the need for health care. This makes it difficult to implement solutions that actually work.

This is classic silo thinking – between service levels, between budgets and between professions.

As long as the health economy does not reward reduced disease burden, reduced need for health services, and increased patient coping, digital patient-oriented tools will remain scattered initiatives. They will not become an integrated part of health services.

The patient who pays last

When neither governments, hospitals nor municipalities have a clear responsibility to finance effective digital support and treatment tools, the patient is often left as the payer. But the willingness to pay for healthcare services is low among Norwegians, and for good reason: we have built a healthcare system on principles of solidarity.

A lot of time and resources are spent developing good digital tools for patients, yet many of them end up in a drawer.

It is difficult to defend, both professionally, ethically and from a health policy perspective.

Digital treatments on prescription

If digital tools are to become a real part of the health service, funding must change. Digital treatment and follow-up must be valued in line with physical consultations. But that is not enough. We also need schemes that make it possible to implement solutions that actually reduce the need for health services. One such measure stands out:

Patient apps and other digital tools with documented clinical efficacy should be included in the blue prescription system – on a par with drug treatment. The logic behind the blue prescription system is simple: when treatment is necessary and effective, the patient's ability to pay should not determine whether it is used.

Based on clear indications, GPs and other authorized healthcare personnel should be able to prescribe digital tools such as:

• has documented efficacy through clinical studies
• is approved according to clear quality and safety requirements
• has a responsible actor who ensures operation, maintenance and professional updating

When digital treatment can provide better function, fewer side effects and lower overall cost to society, why don't we better facilitate its use? Why should a patient be covered for a drug with moderate efficacy, but not a documented digital treatment?

A quality-assured scheme with an app on prescription will be able to:

• provide clear incentives for the use of effective digital solutions
• ensure fair access regardless of ability to pay and place of residence
• shift focus from income-generating activity to impact
• make prevention through self-treatment more attractive

Digital treatments on prescription are not a radical experiment. It is already an established practice in several European countries. Norwegian health authorities must now choose whether to keep up with the development or be left behind on the platform.

Digitalization requires more than good intentions

Norway does not lack plans, innovation and initiatives. We lack structures that make it possible to implement them. As long as it is more profitable to call in than to prevent by supporting self-treatment at home, digitalization will remain an ideal, not a reality.

Prescription apps are not a technological project. They are a health policy choice.

The question is not whether we can afford to do this.
The question is whether we can afford not to.

-----------

About the columnists:

Anne Therese Tveter, senior researcher at the Unit for Health Services Research and Innovation, Diakonhjemmet Hospital and professor at OsloMet

Nina Østerås, senior researcher at the Unit for Health Services Research and Innovation, Diakonhjemmet Hospital and professor at the University of Oslo

Lise Solberg Nes, clinical psychologist and head of department at the Department of Digital Health Research at Oslo University Hospital and Professor at the University of Oslo.