Tuesday, April 14, 2020
Tuesday, January 7, 2020
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.
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.”
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
Tuesday, November 26, 2019
The difficult challenge of medical indemnity
Published in Australian Medicine 18 November 2019 https://bit.ly/2Dg9ZeL
Tuesday, November 5, 2019
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
Saturday, October 26, 2019
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.
Tuesday, October 22, 2019
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