The difficulty of putting a price on quality care

In our market economy, we can buy what we want, as long as it’s available, and we have the money. And we normally expect the more expensive the product, the better the quality.

However, this is not the case in healthcare, simply because we just don’t know if a better-skilled doctor or surgeon, or hospital amenities, always means better care.

As a recent Grattan Institute report on private health insurance states, in this context it would be fair for “specialists with demonstrably better skills than their colleagues in the same specialty” to charge more.

But the Grattan report goes on to spell out the quandary over financing healthcare, saying: “Since the public has no access to information about relative skill, such as complication rates after taking account of the complexity of the patient, it is hard to justify the higher fees that are charged. Higher fees are ... about what these doctors think the market can bear.”

The underlying problem is that the Australian healthcare system doesn’t have the systems and processes in place to collect and analyse data to determine the true price of quality healthcare.

We’re operating in the dark.

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Read more: Doctors’ fees are under scrutiny, and so they should be

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Technology can help to fix the problem. But defining the desired result — beyond avoiding death or major complications — varies according to age, general health, patient preference, the severity of the particular problem, and what’s possible.

However, some moves are afoot to rectify the lack of data on quality care and what it costs to deliver. One initiative GPs will be well aware of is the new Quality Improvement Practice Incentive Program (QI PIP) that aims to measure the quality of care in general practice.

The scheme, rolled out earlier this year, sees Primary Health Networks gathering data from participating practices, which they analyse and feed back as advice on how they can improve by identifying priority areas and quality improvement activities. Practices receive a lump sum for taking part in the program.

A similar scheme in the UK that has been running since 2004 goes a whole step further and pays GPs to meet specific quality activities or outcomes that have been benchmarked using practice data in what’s known as a ‘pay for performance’ scheme.

Writing in the BMJ last month, advocate Dr Joanna Bircher, clinical director of Greater Manchester GP Excellence Program, explains why GPs need to be at the forefront of determining what amounts to quality care.

“Primary care doctors have an important role in quality improvement. They need to be aware of practice performance data and find ways to present it to the practice team and patients in a meaningful way — for example, by considering variations in practice demographics and list turnover.

“Feedback from participants of the program indicates that it has improved job satisfaction and teamwork and embedded basic quality improvement methods that practices can apply to other aspects of care such as patient outcomes and access.”

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Read more: Practice owners demand year-long QI PIP amnesty

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There’s no hint at present of QI PIP evolving into this kind of pay-for-performance scheme. But the UK program highlights how far some jurisdictions have gone — especially when taxpayers’ money is at stake — to link the delivery of quality care to healthcare financing.

As one can imagine, the UK scheme is far from perfect, with mixed reports about its success.

One of the latest studies highlights the complexity. The research, published in the New England Journal of Medicine last year, looked at the impact of removing incentive payments from a range of services in around 3000 general practices. It examined changes in documentation of service provision after withdrawal of incentive financing.

The results were mixed.

It found that documentation fell with regard to lifestyle counselling in hypertension, cholesterol testing stroke and TIA patients, and testing of glycated haemoglobin in those with serious mental illness when the incentives were withdrawn.

However, the simultaneous removal of pop-up reminders in the e-health record systems to document care may have contributed to the decline, the authors say.\

They also point out that for any quality improvement scheme based on pay-for-performance to be sustainable in the long-term, incentives must, from time to time, be removed from ineffective areas of care, so they can be targeted at effective services.

It’s clear that the relationship between financial incentives and the delivery of quality care isn’t simple, and those wishing to use payments to encourage all doctors to improve outcomes should test their ideas first.

It is too early to say how the QI PIP will unfold. But hats off to those GPs who have stepped up to the plate for this experiment.

Published in the Medical Observer 12 December 2019 https://bit.ly/2T4uXp

Peace and Happiness

Published in Australian Medicine, 9 December 2019 https://bit.ly/2sVQ1V0

The difficult challenge of medical indemnity

Published in Australian Medicine 18 November 2019 https://bit.ly/2Dg9ZeL

Healthcare is in danger of becoming humanless

Two communication challenges that have hit the media recently should act as a warning for the increasing automation of communication for GPs.

First, there’s the mandatory new rules for referring patients to public hospital clinics in Victoria; and second, the ineffective management of patients supported by the National Disability Insurance Scheme (NDIS), which sees GPs’ involvement relegated to a form-filling exercise.

Australian Doctor reported last month that Victoria Health had introduced more formality in GPs’ referrals to specialist clinics, including vascular surgery, urology and adult ENT. Patients referred without ‘complete’ information — and the information required is extensive — will no longer be accepted, nor will patients whose referrals do not satisfy specific criteria.

For example, a patient referred for an aortic aneurysm requires radiological evidence that it is at least 4cm in diameter or is growing more than 1cm a year. And a patient for prostate cancer assessment must have a PSA level according to certain age criteria, a palpable prostatic abnormality or bone pain.

These stipulations for referral aim to make the best use of expensive medical care facilities. Sloppy referrals of patients probably not needing specialist attention should be reduced. But care is needed, as with any guideline, to allow clinical judgement to be the final arbiter. No guideline based on statistically grouped data can fit each case.

While guidelines for referral concentrate the mind, they should allow for exceptions based on clinical assessment that need human communication and interaction.

Do we really want to get to a situation where healthcare is as humanless as the likes of border control and modern retail?

Recently in the US, I was impressed (and greatly relieved) to discover that the previous immigration procedures on entry were now paperless, depending instead on facial recognition and fingerprints. But the humans, generally friendly, who had staffed the stalls were also gone.

Arriving at Atlanta, one of the biggest terminals in the country, we also found the coffee shop ominously quiet: orders were placed via an iPad at one’s seat and customers silently consumed refreshments while watching television.

Communications were once based on people speaking to one another rather than completing forms. In US medical circles, there is currently lively controversy and debate about what has been lost with the almost universal move to electronic medical records.

There is evidence of benefit in reducing medication errors, but it is sparse beyond that. Experienced clinicians complain about the opportunity cost of the time spent entering data and the subsequent loss of time for direct patient interaction.

Author John Banville recently reviewed the wide-ranging book The Unnamable Present by Roberto Calosso, an Italian polymath. Writing in the New York Review of Books, Banville quotes Calosso’s concern that, in the brave new world of the web, “information tends to replace not only knowledge, but thought in general”.

The internet leads to “disintermediation” — a loss of connection with others who can help and guide us — and becomes instead a place where “a man can entangle himself in a series of algorithms and imagine he is thinking”. Calosso hopes our preoccupation with digital data “may come to be regarded one day as an instance of mass delirium”.

Why not build into the stylised referral a two-minute (or maybe five-minute) phone conversation between the GP and the clinic to ensure everyone is in sync? This suggestion may provoke mirth because it is naive, but it could be done.

In the case of the NDIS, as with any new system, there will be discomfort. Management of the program in its early years has been unimpressive.

Although GPs fill out a bundle of forms to ensure patients can access the scheme, they’re not deeply involved in the planning of services and have no direct communication with the NDIS when they should have. The issue is now concerning both the AMA and the RACGP.

The tendency of communication based on templates, and information technology, is to reduce the human element and human interaction. This may be vital to the mechanised production of goods, but in the provision of collaborative medical services, it utterly misses the point.

More information: The Unnamable Present by Roberto Calasso, reviewed by John Banville

Published in the Medical Observer 4 November 2019 https://bit.ly/33oXkS4

Healthcare costs increasingly shifting to patients, study shows

13 September 2019

Out-of-pocket spending on health by households in Australia is rising faster than overall household spending on goods and services—and taking an increasingly bigger slice of the household budget, according to a research study published today in Australian Health Review, the journal of the Australian Healthcare and Hospitals Association (AHHA).

The study, by Sydney University researchers Professor Farhat Yusuf and Professor Stephen Leeder, uses consumer-reported data gathered by the Australian Bureau of Statistics Household Expenditure Survey.

Household out-of-pocket (OOP) spending on healthcare rose by more than 25% over a recent 6-year period while overall household spending on goods and services rose by 15%.

In 2015–16, the mean amount spent by households on healthcare out of their own pockets was $4,290, or 5.8% of total household expenditure.

The most expensive OOP item was private health insurance ($1,744), followed by non-PBS medicines ($585), specialists ($438) and dentists ($396). Spending on GPs was $96.

The biggest percentage rises in out-of-pocket healthcare costs between 2009–10 and 2015–16 were for health insurance (51% rise), co-payments to ‘other health professionals’ (42% rise), and co-payments to specialists (35% rise).

‘Out-of-pocket expenses on healthcare as a proportion of the total household budget has been rising in real terms since 1984’, said AHHA Chief Executive Alison Verhoeven.

‘This study notes that the progressive movement of healthcare costs “from public to person” has occurred “without policy debate, slowly and steadily, with small steps such as freezing Medicare rebates”.

‘Other more recent data suggest that OOP costs have continued rising right to the present day.’ The situation was brought to a head earlier this year with media reports of huge five-figure co-payments for some types of medical and surgical care, particularly cancer care, with dire financial consequences for individuals as a result.

‘Yet, there is no evidence that higher OOP costs are related to better quality of care or increased access to care.

‘This creeping burden on individuals challenges our notions of universal healthcare, a fair go, and care based on medical need rather than the depth of your pockets’, Ms Verhoeven said.

The study found that OOP costs were highest among affluent households, especially those holding private health insurance.

Correspondingly, OOP costs were lowest in low-income households, but no data were available on to what extent care was skipped because of the cost. Other studies show, however, that OOP costs weigh most heavily on individuals with low incomes and multiple health problems.

‘This individual upward drift in out-of-pocket health expenses deserves very serious policy attention before our nation’s health starts to drift downwards’, Ms Verhoeven said.

Recent estimates of out-of-pocket expenditure on health care in Australia is available at http://www.publish.csiro.au/ah/Fulltext/AH18191. This release is also available online.

The Australian Healthcare and Hospitals Association is the national peak body for public and not-for-profit hospitals, Primary Health Networks, and community and primary healthcare services.

A child shall lead them

Published in Australian Medicine 21 October 2019 https://bit.ly/2NhDL7B

Confronting the problem of suicide

Published in Australian Medicine 16 September 2019 http://bit.ly/2kGGqNR