Professor Guy Maddern, RP Jepson Professor of Surgery at the University of Adelaide, has some suggestions for the Productivity Commission’s inquiry into the relative performance of public and private hospitals (further to the recent Croakey post on this matter).
“Any assessment of the public and private sector needs to look at a range of initiatives not only home grown but also being assessed internationally. One such initiative that is gaining currency within the United States is Pay for Performance (PfP).
This brings in the concept that the care provided to a patient should be a total package of care and not based on adding on costs for complications or additional management interventions that may or may not have any genuine value. For individuals, appropriate volumes of surgery on an appropriate range of patients, this system seems to offer great promise. It also will dissuade practitioners who have poor results from continuing with the procedure as it will be expensive to them and expensive to the hospital.
The problem with such initiatives, of course, is the concern that more complex cases may not receive treatment because of their potential additional cost. This, however, does not at this stage appear to be a major issue within the United States and providing the fundamental fee structure is appropriate, should average over the range of patients treated by competent hospitals and practitioners.
It certainly warrants attention, particularly in a system based on a fee for service structure. This helps mitigate against over-servicing or poor practice.
Within the teaching context, public hospitals are well known to be expensive institutions for an episode of care, primarily because of the delays and inefficiencies associated with a teaching environment. This needs to be carefully considered when comparing with private hospitals. However, it also is an opportunity for private hospitals to demonstrate that they may be a more efficient and appropriate teaching venue for particularly surgical procedures. It would be important to specifically look at private hospitals that have a significant and established teaching programme to see how these costs are being managed and whether or not lessons can be learnt from the public system in the way in which the private system delivers its undergraduate and postgraduate teaching.
For any health system to remain efficient and relevant, it needs to be relying on the evidence that is available for the procedures it performs. What is the evidence that evidence-based practice is occurring in either our public or our private hospitals? And if it is demonstrated to be occurring, are there benefits and efficiencies that flow from it? This would be an important area for the Productivity Commission to consider in its review.
Finally, the great concern that exists within the public sector is the time patients have to wait until appropriate care is given. This is made of up two components. The time from a consultation being booked and actually delivered which can, in some cases, be months or years, and the time that the patient goes onto a waiting list and waits until subsequent surgery is provided. It would be important to look at the differences that occur to patients managed in the public system and the private system and to assess whether or not there is, in fact, an important difference between the time patients wait. No doubt the private is quicker in delivering care but does this have relevant and important advantages for patients?
These are the challenges the Productivity Commission should be wrestling with, rather than the somewhat superficial terms of reference it currently has.”