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The Health Wrap – on the election, high-value care, healthy (and tasty) prescriptions, and some good news

Lesley Russell writes:

If you are new to The Health Wrap, I offer this round-up every two weeks. It reflects my idiosyncratic interests and biases – and I try to focus on interesting things that you might otherwise have missed. I’m always interested in your feedback.

Health and the election

My colleagues at Croakey are doing a marvellous job of keeping us up-to-date with analyses of election commitments.  Make sure you read the following:

The Greens have released their health policy – which makes some of us wish this approach was more accepted by the major parties. As the Consumes Health Forum said in a media release, “The Greens’ call for emphatic health reforms in prevention, funding, chronic care and dental care, presents rational options to improve a health system that is currently captive to old ways.”

Of course, we all know that writing fine policy words on paper is the easy part of health and healthcare reform; it’s much harder to implement these proposals, especially when work must be done simultaneously on a number of fronts.

A landmark health review recently prepared for the Western Australian Government makes sweeping recommendations for transforming the State’s health spending and services, to refocus from acute hospital care to public health and community-based care.

It offers much useful advice for other jurisdictions, especially around the need to move action on health beyond the healthcare system and the health portfolio, and could easily serve as a roadmap for the next federal government. You can read a summary of the report here.

And when you have a spare thirty minutes, you might be interested in listening to this podcast prepared by Peter Clarke for Inside Story, where Jennifer Doggett and I discuss where we think the healthcare system is most in need of reform, and what values we should use to guide change. (Sorry about the length, but we had a lot to say!)


Doing less low-value care and more high-value care

As the looming election brings into focus the need to both improve health outcomes and ensure better value for the healthcare spend, it’s appropriate to look at the need to do less low-value and more high-value care.

These two quotes from the report of a meeting of the Queensland Clinical Senate held 17-18 March 2016 on Value-based healthcare – shifting from volume to value sum up the issues:

We can no longer continue to use the ‘we have always done it this way’ argument. We need to adopt a new way of thinking – to challenge ourselves continuously around the value of the service being provided to the community for the investment of resources used.”

To ensure a sustainable healthcare system, it is acknowledged that clinicians and consumers must question existing models of care to ensure there is real benefit to the patient for the investment of resources.”

Strategies such as Choosing Wisely have emerged across the globe and are gaining increasing momentum in Australia. However, success around reducing investment in low-value care has been mixed, both in Australia and internationally.

Value-based care involves considering the outcomes – but the outcomes that matter differ for clinicians and patients. Clinicians tend to look at mortality, prevention of adverse events, complications, and readmission, while outcome measures important to patients include health-related quality of life, symptoms and measures of functional ability. Focusing on mortality alone may obscure large differences in outcomes that matter most to patients.

In some instances, the healthcare provided may actually be delivering worse outcomes than no treatment, but we can’t know this if outcomes are not measured in ways that are meaningful. Measuring and feeding back outcome data is, in itself, a good intervention.

But more needs to be done to narrow the research-into-practice gap (currently assessed at around 17 years) more quickly. The 2012 Care Track study highlighted this gap; it found that 43 percent of Australian adult patients did not get healthcare that was appropriate or based on evidence.

Education is one element to effect behaviour change and changes in practice but social and behavioural science, human factors engineering, design and technology are more critical in driving behaviour change.

In 2012 the “Choosing Wisely: Things we do for no reason” concept was started with hospitalists in the United States. (You can read about all of the issues tackled via the Journal of Hospital Medicine here.)

In the same year, Professor Adam Elshaug and colleagues reviewed the scientific literature and identified 156 potentially ineffective or unsafe medical practices being utilised in Australia’s Medicare Benefits Schedule (not including pharmaceuticals). This work now forms the basis for that being undertaken by the MBS Review, of which Elshaug is a member.

A 2018 report from Deloitte, The right healthcare the right way: Global case studies in reducing low-value care, looked at ten case studies – from the US, UK, Brazil, Israel and Singapore – and distilled a number of lessons from successful programs and initiatives to reduce low-value care.  It found:

  • There is no magic bullet/one-size-fits-all solution to reduce low-value care . Multi-component and tailored solutions are needed, involving a range of issues including systems design, clinical workflows, multidisciplinary clinical teams, and community education.
  • Although technology isn’t a solution in and of itself, it can enable the implementation, functioning, and monitoring of successful strategies to reduce low-value care.
  • It is critical to ensure that cultural changes accompany technological changes. For doctors and other healthcare providers, this is a shift from a culture of thoroughness to a culture of appropriateness.
  • Patients must be front and centre in these initiatives. For patients, the culture shift is from a more-is-better mind-set to an understanding that too much can be not only costly, but even harmful. Healthcare providers should understand that patient questions about services don’t normally constitute demands or expectations.

There’s an argument that the primary cause of low-value care lies in an unchecked fee-for-service payment system which creates a pervasive culture that rewards providers for delivering more care, not necessarily the right care.

However, a Canadian study published last year in the British Medical Journal found that while global budgets might bluntly reduce the overall volume of some services, they are by themselves insufficient in changing a broader culture of medical practice that results in the delivery of low-value care.

An accompanying editorial stated, “Low-value care is more complex than a simple financial incentive problem alone—and it remains globally pervasive and stubbornly intractable. Very few interventions have been shown to durably reduce it—and clearly as the authors argue, it is time to transition into a new era of experimentation and discovery of scalable interventions that reduce low-value care.”

A second paper in this BMJ edition found that clinician pre-commitment to follow Choosing Wisely recommendations was associated with a small, unsustained decrease in potentially low-value tests and treatments for only one of three targeted conditions and may have increased alternate tests and treatment. Again, the argument is made that medical practice culture matters.

Why do doctors overtreat? Probably because currently, that’s what they are trained to do.

How do we address this? As outlined above, a multi-factorial approach is needed, but this paper Limit, lean or listen? A typology of low-value care that gives direction in de-implementation provides some useful guidance by classifying low value care as ineffective, inefficient or unwanted and then offering strategies (limit, lean or listen) for disinvestment.


Food as medicine

Healthcare spending is intrinsically linked to diet-related conditions like cardiovascular diseases, cancer, and type 2 diabetes. But in many countries (including the United States and Australia) nutritional health – at least for some segments of the population – remains suboptimal, while healthcare expenditures continue to rise.

A microsimulation study from Tufts University published last month in PLOS Medicine looks at the cost-effectiveness of financial incentives for improving diet and health through the Medicare and Medicaid programs (these two health insurance programs together cover one in three Americans). The researchers used computer models to calculate that prescribing healthy food to patients could help prevent medical conditions such as heart attacks and strokes and save billions of dollars in healthcare costs.

Two policy scenarios were evaluated: (1) a 30 percent subsidy on fruits and vegetables (F&V incentive) and (2) a 30 percent subsidy on several healthful foods including fruits and vegetables, whole grains, nuts/seeds, seafood, and plant oils (healthy food incentive). It should be noted that this modelling approach does not factor in the extent and appropriateness of food preparation and consumption.

Over a lifetime, the F&V incentive would prevent 1.93 million cardiovascular disease (CVD) events and 0.35 million CVD deaths and save US$40 billion in healthcare costs, with net costs of US$83.5 billion.

The healthy food incentive would prevent 3.28 million CVD cases, 0.62 million CVD deaths, and 0.12 million diabetes cases and save US$100 billion in healthcare costs, with net costs of US$111 billion.

The model of implementing food as medicine has already garnered some traction. In 2016, doctors in Flint, Michigan, began to offer children prescriptions for fruits and vegetables that could be redeemed at the city’s farmers’ market or a YMCA Veggie Van. (Read more about Michigan’s approach, some of which has been evaluated, here.)

Last May, in an effort to keep chronically-ill patients at home and out of hospitals and nursing homes, California launched a three-year US$6 million pilot program to give Medi-Cal recipients with Type 2 diabetes or heart failure free, nutritious meals. On the basis of the Michigan work, the 2018 Farm Bill included US$25 million in funding for pilot programs that prescribe produce.

The flipside of the coin is that, while good nutrition can keep people out of hospital, it is also essential for the recovery of people in hospital.

A paper from Swiss authors in the most recent edition of The Lancet highlights that, for medical inpatients at nutritional risk, the use of individualised nutritional support during the hospital stay improves important clinical outcomes, including survival, compared with standard hospital food.


Update on healthcare merger in the United States

Do you remember back in January 2018 when Amazon, Berkshire Hathaway, and JP Morgan Chase announced they were teaming up to form a not-for-profit company to cut health costs for their employees, effectively setting up a major challenge to what they described as ‘an inefficient healthcare system’? (At the time I talked with Geraldine Doogue on RN radio about it.)

Here are some updates on what has since happened.

  • The venture currently has no name and fewer than 20 employees. There are plans to tackle several areas, including how benefits are provided through traditional health insurance plans and the costs of prescription medicines.
  • In June 2018, surgeon, author and checklist-evangelist Atul Gawande was named as CEO of the healthcare venture. Gawande has said that the solution for many of the problems in healthcare — from quality to cost — is a team-oriented, systems approach.
  • In February this year a federal judge in Boston denied a request by UnitedHealth (a major US health insurance company) to have an executive who previously worked for them stop working for the new venture. The suit was filed on the grounds that the employee was privy to sensitive information; it was seen as a sign of the anxiety established insurance companies and pharmacy benefit managers have about newcomers to their territory. Amazon, which has made tentative forays into the pharmacy business, has emerged as a particularly worrisome competitor.

Ostensibly nothing to see (or fear) here – but it’s a potent indication of how business territories are safeguarded.


Some good news

Regular readers know I like to conclude each edition of The Health Wrap with a good news story.

In this vein, last week The Guardian had a great story about an Indigenous rooftop garden in Sydney’s Eveleigh industrial park. It’s a project by the Indigenous start-up Yerrabingin.

The garden has 2,000 native plants – mostly bush foods that thrive in harsh conditions, in high sun and wind, given their elevated position. Much of the farm produce will go to local chefs and restaurateurs. The market for bush food is growing rapidly but currently only three percent of this is supplied by Indigenous companies. The rooftop also has space for cultural events and workshops.

In conclusion, in case you missed it, please read this article by Dr Katie Thurber, Indigenous health and ‘the gap’ would be better served by focusing on positives, not negatives. She argues that a constant “deficit discourse” (the act of continually talking about gaps and problems) can become a self-fulfilling prophecy. Refocusing the conversation on strengths and successes means that protective factors can be identified and built upon.

I totally concur with her on this: “I’ve explored these ideas in the context of Aboriginal and Torres Strait Islander health, but this is something we can do for all populations, all the time.”

• Meanwhile, I will be back in touch soon, for my latest #CroakeyEXPLORE – reporting from a recent walk in France.


Croakey thanks and acknowledges Dr Lesley Russell for providing this column as a probono service to our readers. You can follow her on Twitter at @LRussellWolpe.

Previous editions of The Health Wrap can be read here.

 

 

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