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Jan 17, 2012

Tackling health waste is about more than 'a few bad apples'

Too often we seem to forget in debates about our mythical "health system" that much healthcare is provided by private interests, whether private practitioners or companies.

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Dr Tony Webber, a GP who until recently headed the Medicare watchdog, the Professional Services Review, has kick-started a long overdue debate, about waste in health spending.

In an article in The Medical Journal of Australia, Webber estimates that $2-3 billion dollars are wasted annually through misuse of the Medicare Benefits Schedule, Pharmaceutical Benefits Scheme and the Medicare Safety Net. For this he blames poor public policy (for example, he calls the Medicare Safety Net “one of the most poorly thought-through pieces of health legislation”) and the practices of a “minority of unscrupulous and greedy practitioners”.

General practice management plans, team care arrangements, obstetricians, ophthalmologists, gastroenterologists and cardiologists receive particular mention as being involved in inappropriate use of public funds.

There is also a jab at the health bureaucracies. Webber says his efforts to tell the Department of Health and Ageing (DOHA) about cost shifting between the states and federal government fell on deaf ears, despite it being against provisions in the Council of Australian Governments National Health Care Agreement. “When this was pointed out to officers in the DoHA, I was told not to say anything,” Webber writes.

Predictably enough, the AMA and federal government have been pouring buckets of cold water on to the media fire ignited by Webber’s article.

Rather than being dampened, however, this is a conversation that deserves to be made far more wide-ranging. Some media reports have focused on concerns about a few “bad apples“. This focus is too narrow, for a few reasons.

First, what some might call “rorts”, others might call a rational business response to policy-driven incentives. As the adage goes, every system is perfectly designed to produce the results that it does.

Too often we seem to forget in debates about our mythical “health system” that much healthcare is provided by private interests, whether private practitioners or companies. Indeed, one of DoHA’s goals, as reported in its annual reports, is to support “affordable quality private health care”. It should not be at all surprising that financial imperatives influence how services are delivered as well as professional practice.

Another reason for broadening the discussion beyond “bad apples” is that waste takes many forms. One area deserving systematic attention is the use of unnecessary or inappropriate tests and treatments.

For those who doubt the extent of these problems, see this new Croakey project, Naked Doctor, which is a measure of the growing interest internationally in over-diagnosis and over-treatment. It is a project of Dr Justin Coleman, a GP who works in Aboriginal and Torres Strait Islander health in Brisbane and is president of the Australasian Medical Writers Association.

Webber highlights a lack of systematic policy efforts to tackle inappropriate spending. I have previously suggested at Crikey that a far-sighted minister or government might set up The Less is More Institute to identify and advocate for initiatives to reduce the use of health services that are unnecessary, harmful or not good value. This is not simply about the bottom line, but also is important for equity and patient safety (the Institute of Medicine in the US has identified overuse as one of three critical dimensions to patient safety, the others being underuse and misuse).

It is also about maximising population health. Indeed, a senior health service manager, Dr Patrick Bolton, a national councillor of the Australian Healthcare and Hospitals Association, recently asked whether we might get better health returns from disinvesting in healthcare in order to be able to invest more in areas such as tackling global warming or in promoting greater equity.

Then there is the waste caused by overly onerous red tape, a particular problem for indigenous health services, as highlighted by Judith Dwyer and colleagues in The Overburden Report: Contracting for Indigenous Health Services report.

There is the waste caused by inflexible work practices and resistance to workplace reforms, as is so well illustrated by our seeming incapacity to make effective use of the physician assistant role.

There is the waste of a system that too often burns out those well-intentioned professionals, managers and others trying to do the right thing in the face of complex, inflexible systems.

There is no one party or “bad apple” to blame for waste. Adelaide surgeon professor Guy Maddern has also described waste caused by no-show patients at outpatient clinics and says, “worse still, failure to attend for elective surgical procedures is a scandal which receives little publicity”.

When I see how the digital revolution is creating greater productivity, innovation and transparency in my own industry (while also damaging business models and creating uncertainty and insecurity), I wonder how much longer the health industry can avoid the crunch that surely is heading its way.

If the digital revolution can fell a dictator such as Hosni Mubarak, then surely it also has the potential to bring some much-needed changes in the health sector.

Melissa Sweet —

Melissa Sweet

Health journalist and Croakey co-ordinator

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45 thoughts on “Tackling health waste is about more than ‘a few bad apples’

  1. Joanna

    I think you have to take care with the ‘over diagnosis’ argument, which is a bit simplistic. It would be better to mount a case for improving diagnostic skills, and encouraging medical staff, especially in emergency, to proceed without prejudice.
    Last May my daughter presented at hospital emergency with what appeared to be (according to the doctor who treated her) symptoms for the onset of schizophrenia. Because we (her family) were adamant that there was no psychiatric history, nor any chance of drug use, the hospital investigated physical causes. Our concern was finally recognised as legitimate when she had a seizure in the emergency room. After days of exhaustive tests (all proving negative), and with her physical condition deteriorating, one of the specialists suggested investigating the possibility of an extremely rare and only recently identified disease – Anti-NMDA Receptor Encephalitis, which is terrible but curable. The test came back positive. She was appropriately treated and is now recovered. Maybe if we had accepted the wisdom of the first diagnosis and had not insisted on every possible test until her disease was identified, they would have eventually made the correct diagnosis. But all the available literature on this (and longitudinal studies are only now being published for the first time) indicates that the best chance of avoiding long term cognitive loss is swift diagnosis and treatment. Patients with this who are misdiagnosed and sent to psychiatric hospitals for some months don’t fare so well: some die, some have permanent brain damage, others have long term cognitive loss.

  2. William

    This discussion (particularly those of John2066) has become pretty offensive but anyway…

    Melissa, I would like to share your optimism that this article in the MJA would ultimately actually lead to a meaningful reduction in waste in the health service but I sincerely doubt that it will.

    I have read, and reread, Webber’s piece and frankly it is poorly written and lacks direction. What evidence he offers is unsubstantiated; for example, where exactly does his estimate of $2-3bn actually come from? Finally, and perhaps most disappointingly, despite all of this he offers not one grain of a suggestion as to a solution.

    I don’t think anyone really believes that the Medicare system is perfect but it is the system that we have been given to operate within. As many others have been quick to point out, sitting in the chair of the committee that investigates the worst abuses of the system is perhaps not the best vantage point to make an objective assessment of it as a whole.

    Although I am sure that Dr Webber chaired the PSR for such a long time for all the right reasons (some might question the motive though) it seems that this piece will ultimately be seen for what it is; the last twitches of a disillusioned public servant as he slides off back into the obscurity of general practice. Frankly, I’m a bit surprised that the MJA even published it.

    Conflicts of interest: Too many to mention, but fundamentally I am a cardiologist. And John2066 I’d love to respond to your equally unsubstantiated comments but I just have to go off and count all my money.

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