MANAGED CARE NEED NOT BE A HEALTH HAZARD

The NSW minister for health, Jillian Skinner, announced March 20^th affirmative funding of $120M over three years to Western Sydney, Central Coast and the Greater Western NSW local health districts to enable the development of integrated care models.

Concurrently, the federal minister for health, Mr Dutton, is looking for ways to spend the billions of health dollars more efficiently.  This is a worthy goal and there are examples of health systems where humane care is mixed with efficiency that deserve his attention. Many make excellent use of private enterprise.

Several large private health insurers in Australia have moved in the past twenty years beyond reimbursement to members and health care providers for clinical services into the direct provision and management of care

These services have included telephone-based coaching for insured members to assist them manage chronic health problems and assistance with healthy lifestyle behaviour.  The big users of private cover are, as expected, the people with multiple long-term problems and it is in the interest of all health care providers – public or private – to ensure that these people receive efficient care and avoid where possible unmanaged deteriorations in their health that, usually after weeks, lead to hospital admissions.

Our studies in western Sydney and the ACT of patients with chronic illness have confirmed what a crisis a hospital admission is for these people. 

Take for example a patient with chronic lung disease who panics in the middle of the night with breathlessness after a week of bronchitis for which he has not sought care. Unless there is a health service care professional who knows him and whom he can call, he will call the ambulance. So would I.

The ambos do a great job but the chances are that when he arrived in the ED, where his record will not be easy to retrieve and there is little chance of the staff knowing him well he will have been given oxygen which, while good for him in many ways, will depress his breathing and he may now well need ventilation for carbon dioxide retention. 

A couple of weeks and a few hundred thousand dollars later he may be out of hospital.  The dislocation (will his cat still be OK?), the demands of hospitalisation on an individual with few reserves, the impact on family and carers, is huge. Home care support has to re-organised. His GP has to be brought up to speed.  It is also expensive.

So pursuing alternative ways of handling such incipient disasters is to be highly prized. 

Australia has an integrated system of care for patients with such problems that deserve far greater scrutiny than it receives.  It works remarkably well.  Patients appreciate it. It has a comprehensive computer-based data system for patients.  It knows what happens to them when they use different hospitals and doctors. It has programs for managing patients with different ailments.  It does not cost the earth.  Doctors generally find it acceptable.  It is called the Veterans Health Administration.

It is a managed care system.  The allergic responses of elements of the medical profession to managed care take their origin from earlier models in the US that limited clinical freedom and reduced health care costs for several years but were hugely unpopular.  Many sank without trace or regret. Progress has overtaken these old models and contemporary managed care in the US deserves a closer look. 

Four years ago I visited Kaiser Permanente (KP), a prepaid health insurance and care provider agency in California that cares for 6 million people; it has its own hospital medical centres, primary care, preventive services, community-based practices and more. You pay your premium and you receive all necessary care, managed through KP.  The outcomes (and KP does measure them whereas in Australia we don’t) are superior to those achieved by expensive, unmanaged systems.  A formal evaluation several years ago showed that the costs per patient per year were less in KP than in the British NHS.

The essence of managed care is that the payer, in this case the KP insurance company, has a vested interest in making sure you get the best outcome and that you, as the patient, stay as well as possible and manages all aspects of your health care with you.  Not just internal medicine and surgery either. I saw effective GP-based preventive care in KP that made me weep over our paltry efforts in Australia. 

One single payer for care means that the payer is interested in prevention and not just cure and in the effectiveness of all forms of care they provide.  In Australia we preserve a system that rewards cost shifting – another name for guilt-shifting over inadequate treatment form the Commonwealth to the states and back– slosh, slosh, and slosh again. (Ages ago I met a person at a dinner party who told me brightly that his full-time job in a health bureaucracy was cost-shifting.  Happy as a clam because there was SO much to do!)

KP is one of a dozen first-class managed care organisations in the US.  They all have sophisticated IT systems that link providers and patients in a social network.  No-one is alone.  Talk to the doctors working in the system.  Talk to the people using it.  Look at its financials.  Effective, efficient, and humane. Now that’s a good start.

MEDICARE WAS NEVER A SAFETY NET

Those who wish to dilute, extinguish, diminish or otherwise do damage to Medicare used to claim in the Howard era that Medicare was a safety net.  Many of us fought that battle then on the basis of the texts of history.  Now the diluters, extinguishers and diminishers are back and so is the myth that ‘Medicare was only a safety net, a means of covering the health costs of those who could not afford to pay’. Convenient untruth.

My colleague Andrew Wilson has drawn my attention freshly to the speech by Neal Blewett, the minister for health who introduced Medicare in September 1983.  Blewett described four foundations for Medicare:

Simplicity: “…the simpler we make a health scheme the more chance it has of delivering the services to those who need them most.”

Affordability: “…everyone will contribute towards the nation's health costs according to his or her ability to pay. Under Medicare people will not have to worry about falling behind in their payments and being caught with substantial bills.”

Universality: “…Medicare will provide the same entitlement to basic medical benefits, and treatment in a public hospital to every Australian resident regardless of income. In a society as wealthy as ours there should not be people putting off treatment because they cannot afford the bills. Basic health care should be the right of every Australian.”

`Efficiency: “…one of the Government's major objectives through the Medicare program is having the maximum number of health dollars spent on delivering health services rather than administering them.”

A fifth attribute, Access, was subsequently articulated with reference to public hospital care in the Medicare Agreements Act 1992, and was explicitly applied to primary health care services in the 2008 National Healthcare Agreement.

In discussion with Dr Blewett fifteen years ago, he made the point to me (along with affirming that Medicare was NOT a safety net) that, if there is to be a sustainable demand on the public purse to pay for a social security measure, such as Medicare, the commitment of all taxpayers to it should be rewarded with universal access. 

The point about one of the goals of Medicare being efficiency is important in the current context.  Medicare fee schedules have served as checks on medical fees.  If Medicare reimbursements for service are augmented with private insurance rebates, then  fees escalate.

It is thus surprising that the current minister for health, Mr Peter Dutton, who speaks wherever he goes about the need for efficiency and sustainability of the health system, is reported as having no problem with the idea that private  insurers would cover the gap between general practitioners’ fees and the Medicare rebate.  The circumventing of this limitation on private insurance by private insurers who pay participating practices an administrative fee for preferentially treating the private insurers’ clients (as in, ‘we won’t pay for your drinks but we will pay to keep the pub open’) steals from Mr Dutton’s hand an instrument for efficient control of general practitioners’ and community-based specialists’ fees.

The case for measuring the outcomes of what we do

Published in Australian Medicine, February 2014 (https://ama.com.au/ausmed)

Feeling angry? This may be a good start for 2014

Published in Australian Medicine, January 2014 (https://ama.com.au/ausmed)

Interview with Dr Clement Loy (shortened version)

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Election website of The Royal Australian College of Physicians

Voting is currently underway for the Royal Australasian College of Physicians. Place your vote here: https://events.miraqle.com/RACP-2014/Positions-and-Candidates/

Nomination for the position of president-elect of the Royal Australasian College of Physicians

Candidate Election Statement

I nominate for the position of president-elect of the Royal Australasian College of Physicians as a public health and medical research worker, educator and clinician with extensive experience in senior health management, leadership, governance and policy, and with a strong record of contribution to the RACP. As RACP president-elect I would provide leadership that advances Australia’s community of physicians and the health of Australians.

Graduating from the University of Sydney in 1966, I commenced my career in clinical medicine, and continued my clinical involvement in public health medicine and health policy.  Currently I am editor-in-chief of the Medical Journal of Australia and chair of the Western Sydney Local Health District with an annual recurrent budget of $1.4 billion.

My research interests cover all aspects of prevention through to policies for integrated care in chronic disease. With continuous NHMRC support since 1971, I have mentored many public health research workers, supervising 18 PhD students. My subsequent international interests have involved work with the Earth Institute at Columbia University in global health, especially in India.

After moving from McMaster University to Newcastle University, its medical school then in its first decade, to pursue interests in medical education, I was dean of the Sydney Medical School from 1997-2002 during a time of fundamental change to curriculum and admissions policy. I led the development of the School’s research strategy, its rural clinical schools, and its internal reorganisation. 

Throughout my career I have continually engaged with the medical and lay community through speaking in public fora and writing in the specialist and general media. I have chaired a human research ethics committee in western Sydney for 20 years, and served on and chaired many high-level working groups and committees. Senior bureaucrats and politicians of various persuasions have negotiated with me as someone whom they and others trust.

In the 1980s and 1990s I was president of the Public Health Association for four terms. I helped establish the RACP Faculty of Public Health Medicine and served on what became its board of censors and its policy arm.

My experience has impressed upon me several important insights that I consider pertinent to taking the RACP forward. 

First, whatever else a leader does his or her most important function is to be the guardian of the organisation’s core values, the keeper of meaning, ensuring that those values are expressed first in governance, then in management, and most critically in practice. 

Second, non-profit organisations such as the RACP generally work best when diversity is nurtured and all constituent groups within the organisation are supported. To maintain trust among a diverse body of fellows, power is best decentralised, shared and bestowed, and its activities owned by the fellowship.

Third, organisational management and governance, like money, really matter. Ensuring that they align with the organisation’s values is essential. Energy from its top levels is required to maintain effective, healthy management and governance.

The RACP also needs flexibility in adapting to the changing disease profile and work practices of the digital age.  Ensuring its highly visible professional functions – of credentialing, educating, nurturing and supporting physicians – is its prime responsibility. 

I would be very pleased to play a leadership role as president-elect in ensuring that the RACP continues to do that with strength and clarity.