Around the world, clinicians are part of efforts seeking to address “the costs and harms associated with systemic overdiagnosis and overtreatment” and to reduce the use of ineffective and low-value care.
When a review of the Medicare Benefits Schedule was announced in April, it was welcomed by the AMA and consumer groups. Indeed, a case could be made that the review was long overdue; researchers have been laying out the case for some years now.
So what to make of the AMA’s announcement that it is withdrawing support for the review, following recent headlines that may have left some of its members worried about their “practice incomes” and a focus on over-servicing? Perhaps they are also anxious about the repercussions of the forthcoming 4 Corners report investigating waste in the health system.
And what to make of the Shadow Minister for Health Catherine King’s statement suggesting the review is all about “cuts to health”?
While scepticism about the Government’s motivation is understandable, given its destructive efforts in health policy to date, these attacks on the review smell more like self-interested political plays than efforts to support evidence-informed policy.
The terms of reference for the Medicare Review Taskforce make no mention of costs, with the stated aim being “to align MBS funded services with contemporary clinical evidence and improve health outcomes for patients”. Similarly, the Department explainer states: “there are no targets for savings attached to the Review.” More information is in the consultation papers released today.
It is also worth noting that the Consumers’ Health Forum is calling for the Review to be supported (see statement at the bottom of this post).
In the article below, Professor Peter Brooks, from the Centre for Health Policy at the University of Melbourne, urges colleagues in the health sector to get behind the Review, arguing that it is important for the safety and quality of care, as well as for best use of health dollars.
There is also an important message for the Government here: any efforts to turn the review into a cost-cutting exercise risks blowing an important opportunity for meaningful reform to improve the safety and quality of healthcare.
Peter Brooks writes:
The Review of the Medicare Benefits Schedule commissioned by the Federal Government and chaired by Professor Bruce Robinson from the University of Sydney has the potential to make a major difference to the way we practise medicine in Australia.
It is exactly the type of reform that could be a real game changer in an area, where change is desperately needed but has been very hard to achieve.
As such, it needs the support of all health professionals and the community, as the review team work through over 5000 items and look at the evidence for whether they actually benefit patients or not.
Surely no one would suggest that we do ‘things ‘ to patients that have little or no evidence of benefit, charge them for that procedure or treatment and subject them to the possibility of risk of an adverse event.
It is unfortunate to see some of the reporting of this issue in the Australian over the last week which might suggest that the newspaper is starting a ’scare’ campaign (Little benefit in one-third of treatments: health chief and Heart care attacked for $267m wasted).
In these articles it is suggested that perhaps a third of “treatments” might be what we refer to as low value care – things that do NOT make a significant difference to a patient in terms of their health status.
These data are not new by any means, and should not be seen as “explosive” revelations as suggested in The Australian.
Adam Elshaug (now at the Menzies Institute in Sydney) and colleagues identified some 150 potentially low value health care practices in 2013 in the Medical Journal of Australia, and these figures are mirrored by similar studies in the USA and in Europe.
These low value procedures include blood tests (particularly for screening a variety of conditions), X-rays for conditions such as low back pain, and arthroscopy for osteoarthritis of the knee. And there are many others likely to be identified in the Medicare review.
It was sad to see (The Australian, 21 Sept) that the Australian Medical Association was ‘increasingly alarmed by the commentary on the review and that the “explosive” revelations in the The Australian served to justify the AMA’s decision to withhold its support for the review.
Is the AMA really going to condone treatments that don’t do anything for patients, place them at risk and yet support doctors who charge those same patients for these low/no value treatments?
What an extraordinary attitude for the ‘caring profession’. I cannot believe they will not support this review when they have thought this through, though the Association’s rhetoric is disturbing and perhaps designed to try to soften the review process – which in itself would be unfortunate.
The AMA was supportive of the last review of Medicare payments some years ago – the so-called Relative Values Study – that was directed at addressing the significant disparities between procedures (such as endoscopies and surgeries) and consultations – the bread and butter of general practitioners and physicians.
Unfortunately, that review failed to be implemented for other reasons, including lack of political leadership at the time, and leaves Australia with one of the biggest “gaps” in the world between what a GP/non proceduralist physician and proceduralist/surgeons can earn (OECD Health 2013. No wonder we have a problem recruiting to general practice.
But back to low value care: the AMA needs to step up to the plate on this one, as do all health professionals. We have great health system BUT we cannot sustain it with our current practices.
The review needs all of us to be engaged as it works through the difficult business of looking at evidence that what we do does in fact help our patients. This surely is what medicine has to be about.
In fact, with the move to patient participation in decision-making, there is an obvious opportunity for the Medicare Review to engage patients and particularly in the final stages when recommendations are being refined and also in the implementation phase.
This is often where a review becomes unstuck, with the fear tactics of the self-interest lobby groups who will not want “their” procedure (or their income) to be removed from the MBS.
Patients could be powerful advocates for change and to support the Minister – who will hopefully consider the implementation of the review findings in the light of what is best for patients, rather than what is best for the health professionals.
An additional option for the Review would be to encourage Medicare itself to be engaged in research as to what works and what does not.
Imagine, for example, that there are a number of MBS items where evidence is not all that strong – we suspect that the item number involved adds no value to patient care but the trials have been poorly carried out, insufficient number of patients etc.
What if that procedure/treatment was given a special item number and doctors/patients could only access Medicare funding if the patient was enrolled in a proper research study? These funds could even be administered by the NHMRC, and could be seen as part of the new funds flowing through the Medical Research Future Fund, giving it a much-needed boost.
This would also be seen to be promoting clinical/translational research – the type of research identified as in particular need of funding by the McKeon Review some years ago.
In this way all of us can gain – health professionals, researchers, patients/community and even politicians. We can also contribute to the international database providing health professionals and patients with more robust data on which to base treatment decisions.
What we must all accept is that everything we do to a patient has the potential for harm. It is one thing to carry out an unnecessary procedure (test or surgery); it is something different to charge Medicare and patients. And there is always the risk of a patient having an adverse event from an unnecessary procedure.
So I really hope the AMA reconsiders its engagement with this important review. Professor Robinson and his team need all our help on this one – and so do the Minister and the community.
ABC Four Corners – 8.30 on Monday evening 28th September is reviewing Low Value Care – watch it; you may be surprised at what we do to patients!
• Peter Brooks AM MD FRACP has Professorial appointments in the Centre for Health Policy, School of Population and Global Health and the School of Medicine University of Melbourne. He established the Australian Health Workforce Institute at the University of Melbourne in 2008. He was Executive Dean of Health Sciences at the University of Queensland from 1998 to 2009 and has held professorial positions at the UNSW, University of Sydney, Flinders University and the University of Tasmania.
Statement from Consumers Health Forum: Strengthening Medicare
The current review of the Medicare Benefit Schedule is critical to the long term sustainability of a universal Medicare system, says Leanne Wells the CEO of Consumers Health Forum.
CHF welcomed Minister Ley’s announcement of the Medicare Benefits Schedule Review back in July and now welcomes the release of the review’s discussion paper for public consultation.
“The emphasis of the review is to look at which treatments, test and procedures offer good value for money, to both the consumers and the tax payers. Many have never been robustly evaluated and so we simply do not know if they are effective or efficient.
“We know there are tens if not hundreds of items on the Schedule that need revising. We can stop wasting money on items that are not effective and that money can be reinvested into new items. This should ensure Australians in the future have access to the best treatment options that are available.”
“It is important that the revised items are designed to around the needs of consumers and we are glad to see the Review is looking for consumer input and asking consumers to give their own examples of where the MBS is problematic and how it can be improved.”
“We hope the process maintains its momentum and is given enough time to complete the task. It is in all our interests to ensure that all health expenditure, both government and personal, is well directed.”
• COI declaration from Melissa Sweet: I have an honorary appointment at the University of Sydney. Two key figures for the review and related issues – Professor Bruce Robinson and Associate Professor Adam Elshaug – are based at the University of Sydney.
Links to the AMA statements today will be added.
Of course the AMA should participate in this review. Prof Brian Owler sounded like a member of the CFMEU on the television news today: all rhetoric and extremes. The more the AMA takes that stance, the more it sounds like a hip pocket response. Collaborate for the sake of patient care, all of you!
This is a stimulating and provoking commentary. It focusses on the delivery of care from a financial reimbursment point of view and highlights the failure to adequately address the issues of the “quality of care”.
There is now abundant evidence for the roles of clinicians (as we see them as doctors and not all in the community including patients) and their unsupported clinical decision making being major factors in the overuse, underuse and inappropriate use of health care resources. Also unsupported clinical decsion making is a major factor in the inappropriate variation in health care (Dr J Wennberg, Dartmouth Institute) that adversely affects patients outcomes and the costs and quality of care.
As a nation we need to stop addressing these health cost issues from a “reimbursement model” (medicine is not a business our business is clinical medicine) and focus on the core drivers of health care ineffiiencies and outcomes.
As Lucien Leape of To Err Is Human report (2000) stated in a publication five years later that we have learnt very little from that reports findings. [Five Years After To Err IS Human. What have we Learned?]
The problem that the Government faces is that has created a perception that it primarily driven by a desire to cut expenditure on all aspects of social services. Scott Morrison’s pronouncement that there is a spending problem, with no acknowledgement of a revenue problem consolidates that view. The public rightly has no trust that the review will not be utilised by the Government as an excuse to cut health expenditure, rather than optimise the health delivery system.
I am also disappointed in Labor’s position on this issue. A review of MBS funding is well over-due and the Government has appointed a group of very well respected and non-partisan health experts to the review committee (I would have liked to have seen more women and more consumer representation but this takes nothing away from the expertise of the other members). There is no justification for using public money to subsidise low value or unnecessary services – regardless of whether the saved funds from the Review go back into the health system or are used for other purposes.