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What ineffective treatments should we stop funding?

Monday, 14 April 2008

By Professor Peter Brooks, Executive Dean of Health Sciences at University of Queensland

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At the 2020 Summit, I will be arguing that Australian taxpayers should stop paying for medical treatments that don’t work or are of only marginal benefit.

The Medical Benefits Schedule should be reviewed, so that ineffective interventions can be removed from the list of treatments receiving government subsidy.

Treatments whose public funding should be reviewed include:

Hospitalisation for back pain
Arthroscopies for knee pain
Surgery for chronic back pain
Vertebraplasty (operations in which cement is injected into fractured vertebra).

What are some other ineffective treatments, devices and procedures whose public funding should be reviewed?

Should we also review the level of funding for operations which become easier and quicker to perform such as cataract surgery?

Should we be paying more to primary care providers such as GPs, and less to proceduralists?

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Gavin Mooney Monday, 14 April 2008 2:17:02 PM: I agree Peter. Beyond that we need a 'health care ethical code' which would mean that ineffective treatments were deemed unethical as they use resources that could otherwise be used for effective treatments and thereby do more good. The code might then go on to say that inefficient treatments (they cost more than the benefits they produce) are unethical on similar grounds i.e. the resources could be used to pursue more efficient treatments thereby doing more good. Such a health care ethical code - it would need to embrace equity as well - is well overdue. That would give us the values framwork that John Manadue was on about in Crikey last week. But will 2020 go up that road? I hope so Peter. Will Roxon's health commission get the values message? We must live in hope! But you are right Peter to write of the issue of power in Australian health care. We need the powerful voice of the people to set the values and not the voice of the powerful people silencing these issues.
Darren Holmes Monday, 14 April 2008 2:54:16 PM: There are many others, particularly for very old people. We all get old and we should be allowed to. We perform complicated surgeries and treatments on people of very advanced years and very poor healing ability. We don't provide proper advice and guidance to a generation that was brought up to believe that Doctor is always right. Does a 90 year old want agressive cancer treatment that might extend their life by a few months, or would they prefer better pain control and assistance at home to allow them to pass with dignity? But most of all, fix the nursing homes - provide better funding to allow minor treatments in the homes. If nursing homes could afford RN's to administer many of the minor treatments that residents are shipped off to hospital for, we would have a significant impact on costs. 90 year old Mr Citizen gets sent off to hospital to investigate why he is falling, could it be because he is old and tottery? I only hope I have the wherewithal at the same age to say no.
Adam Elshaug Monday, 14 April 2008 3:41:08 PM: Dear Professor Brooks, I commend your call to advance this work. In December 2007 I was awarded a PhD that focussed in this specific area - that has been coined ‘disinvestment’ (from ineffective/inappropriate health care practices). You (and others) may be interested to read the following papers that I have published in the area along with my colleagues A/Prof John Moss and Prof Janet Hiller: Elshaug AG, Hiller JE and Moss JR. Exploring Policymakers’ Perspectives on Disinvestment from Ineffective Health Care Practices. International Journal of Technology Assessment in Health Care, 2008; 24(1): 1-9. Please contact me if you are unable to access this paper online. Elshaug AG, Hiller JE, Tunis SR and Moss JR. Challenges in Australian policy processes for disinvestment from existing, ineffective health care practices. Australia and New Zealand Health Policy, 2007; 4: 23 (31 October 2007). FREE ONLINE AT: http://www.anzhealthpolicy.com/content/4/1/23 I have also completed an
Adam Elshaug Monday, 14 April 2008 3:46:48 PM: continued from preceding message below... I have also completed an interview with Norman Swan on the ABC Radio National Health Report, available on the ABC web site and at (The second half is more explicitly about disinvestment): http://www.adelaide.edu.au/podcasts/interviews/health/ In the last two years I have received over 30 invitations to present on this work to various groups (including Government Health departments in Europe and Canada) but despite this I believe there is scope for additional traction at a policy level. My current Fellowship is based in this work and so I would be delighted to communicate with you further (and others) in a joint effort to advance this priority area. Regards, Adam Elshaug adam.elshaug@adelaide.edu.au
Jennifer Doggett Monday, 14 April 2008 3:49:17 PM: I think Peter makes a very important point for the future of our health system. Funding for medical/health services should be allocated on the basis of the benefits they provide. If primary care/GP services provide a greater benefit than some specialist services then they should be funded at a higher rate. Ineffective services should not be funded publicly - if consumers want these servies they can pay for them directly out of their own pockets. Consumers should be given access to information which gives them greater ability to assess the efficacy of medical/health services and have more power over the allocation of health resources. It should not just be left to the Government as governments will always be more vulnerable to influence by lobby groups and vested interests wanting funding for their sector than will individual consumers. This issue should be high on the agenda at 2020.
Lilian Ashman Monday, 14 April 2008 5:24:39 PM: A few unnecessary services ,personally encountered lately. 1: A scan needed to diagnose a cracked hip bone [in a P.H].one look by an orthopod, said NO #..this after four days of indecision. 2:A govt. funded Private Rehab..noted for no hard cases,would have allowed me to have heavy pain killers ,2 hrly [hence quicker through-put= more income 3: A friend overheard talk by 2 Drs, considering stem-cell treatment,for her 93 YEAR OLD DEMENTED FATHER. {of course not 1 person had read his filed advance directive.] A lot of these tests are being done on older persons, with no one, to say...STOP NOW. Regards,..Ex nurse, Ex patient.
Brett Forge Monday, 14 April 2008 6:31:32 PM: Thanks for the article Peter, The health system has been disfigured by money motivated decisions constantly favouring intervention and procedures. These invariably are far more expensive and frequently not evidence based. A recent letter by myself and others highlights the fact that there is NO evidence that coronary stenting or cardiac surgery reduces heart attacks or death rates in stable angina. In spite of this the number of patients receiving this expensive treatment continues to mount at a spectacular rate. A similar case can be made in unstable angina as well and will be the subject of an upcoming letter to the journal. How should stable coronary artery disease be managed in the modern era? Richard W Harper, Esther M Briganti and Brett H R Forge || Keith V Woollard and Mark A J Newman — Med J Aust 2008; 188 (2): 122-123. http://www.mja.com.au/public/issues/188_02_210108/letters_210108_fm-3.html
james rose Monday, 14 April 2008 8:22:56 PM: Add breast screen and prostate screening, for which considerable doubt exists as to any saving of lives. One major obstacle to this sensible type of policy, is that we aren't collecting enough outcome data. Notable exceptions are mostly regarding pharmaceuticals, and there head to head comparisons of different active treatments are a rarity.We need government funding for management versus outcome research, broad coverage of treatment modalities and a climate of acceptance of the need to use effective treatments. The general community needs to decide on priorities, as every doctor is likely to want the best treatment for each patient.
Les Irwig Monday, 14 April 2008 8:59:50 PM: Bravo Peter Archie Cochrane in his book 'Effectiveness and Efficiency' bemoaned the disparity between expenditure and effect in health services - that 'so much went in and so little came out''. With spiralling costs, so much more could be achieved with scarce resources if $$ were redirected to interventions shown to work. I expect the community would support the idea if people had the opprotunity to gain a better understanding of what constitutes good evidence in health. Towards that end, the 2nd edition of our book for consumers on understanding evidence and decision-making in health care [Smart Health Choices] has just been published, and I hope will help....
Glenn Salkeld Monday, 14 April 2008 10:43:40 PM: Well said Peter. In the 1980s Regan lead Congress down a path of pouring huge amounts of money (though tax breaks) into the development of new drugs. It was a golden time for pharmaceutical companies and their shareholders. Who knows that the return was for the poor taxpayer. Australia could have just gone along for the ride but we didn't. Our government showed leadership. With political will, good timing and a bit of science, legislation ensured that we didn't sink public money into drugs that were ineffective. But it did provide a reward (a higher price) for those drugs that could prove their effectiveness (and cost effectiveness). Can this government show some leadership and demand that the MBS is subject to the same level of scrutiny? It took a couple of major scares in the 1960s (eg thalidimide) to change the culture in the pharmaceutical sector to one of rigour and scientific evaluation. We've had major scares in our public health system - isn't it time for a culture change?
Stephen Leeder, University of Sydney Tuesday, 15 April 2008 9:10:43 AM: Few would dispute the good sense in ceasing to pay for therapies that are unequivocally ineffective. However, much hinges on what we take 'effective' to mean. Where randomized trials can be carried out that compare one therapy with another or with none, we are presented with evidence that can be used sensibly in changing practice. But the proportion of therapies that are supported by such evidence is very small. What are we then to do about those procedures - which is most of the human interactive side of medical care - where we have no such metrics? Therapy given at the end of life with small chances of success could be similarly held to questionable, but who will ask the questions and who will answer? Tackling procedures that are proved to be useless makes good sense - but as a strategy to reduce or contain medical costs I fear that it will address only a tiny percentage of current expenditure. More to come...
Stephen Leeder, University of Sydney Tuesday, 15 April 2008 9:13:21 AM: More importantly, it will reduce only a fraction of the total burden of human suffering that the health service seeks to relieve. On the other hand there are lots of proven effective things that we could do but don't. Most people prescribed corticosteroid inhalers for asthma don't take them beyond the first inhaler. About half of people with hypertension take their medications. Only a fraction of people with diabetes are treated to a point of optimal control. One in eight patients discharged from hospital with a chronic chest or heart condition receive effective rehabilitation. What are we to say and do about these things? Before we strain for the gnat, I suggest that we deal with two camels - first, how to mange the provision of care for which there is not, and never will be, evidence from randomised trials but which expresses the essence of humane medical care, and second, how to do all the things that we do poorly which, if done properly, would benefit millions of Australians.
Guy Maddern, professor of surgery Tuesday, 15 April 2008 10:59:46 AM: Surgical procedures are constantly undergoing change and refinement. Unlike a drug which requires a clear formulation, surgical techniques often undergo slight modifications over time that lead to significant benefits for some patients. Surgeons have no incentive to continue with less effective surgery when a more effective one emerges. Just like drugs, some procedures are more effective than others. So, too, some devices work better than others. The Australian Joint Registry monitors the performance of joint implants and poorer performing devices are clearly highlighted by this process, which is fully supported by the Australian orthopaedic surgeons. Publishing the evidence for surgical performance has been the task of the Australian Safety and Efficacy Register of New Interventional Procedures - Surgical (ASERNIP-S), an initiative funded by the Fed Govt and run by the Royal Australasian College of Surgeons.... more to come
Guy Maddern, professor of surgery Tuesday, 15 April 2008 11:01:44 AM: (part 2) Over a 10 year period, this project has evaluated new surgical procedures such as laparoscopic donor kidney surgery, lap band weight reduction surgery and laparoscopic colon surgery, to name but a few. Its reports are published in peer-reviewed journals and through consumer networks. More needs to be done by Government to help not only assess new procedures before and during their introduction, but also funding for registries of new devices and interventions needs to be found so that Australian population-based outcomes can be determined in a timely fashion. The task is neither easy nor cheap, but it needs to be done if patients are to have the best quality surgical care into the future.
JamesK Tuesday, 15 April 2008 11:18:17 AM: With repect to the treatments that Peter Brooks says should be reviewed: 1. Nobody(or perhaps almost nobody!) is admitted to an acute hospital for back pain. 2. Arthoscopies can be therapeutic but are often helpful diagnostically and in treatment planning. They are day day only procedures. Ask the relevant specialist doctors of their efficacy. 3.Spinal surgery is not for chronic back pain 4.Crush fractures of vertebra is a common cause of pain & disability Vertebraplasty (minimally invasive procedure performed in an XRay Department under local anaesthetic.) often works for severe pain and may have a role in preventing some of the dire consequences of crush fracture. Its use is still being actively assessed. I do hope Dr. Brooks does not influence public health policy!
Robert Wells, Menzies Centre for Health Policy, ANU Tuesday, 15 April 2008 11:36:58 AM: Peter Brooks raises a very important point. Not only do these ineffective treatments potentially cause harm, they also waste considerable health resources in terms of direct costs and also indirect costs,eg the time taken by health professionals to perform procedures and hospital beds tied up unecessarily. Peter's proposed solution of a thorough review of the schedule makes a lot of sense and should be undertaken asap. The cost of a thorough review would be easily offset by savings in a very short time. Presumably the only barrier to such a review and delisting would be opposition from the medical profession on behalf of those doctors whose livelihood might be affected. However given that the AMA keeps highlighting a doctor shortage there should be no lack of opportunity for these doctors to do work which is known to be effective. Indeed one might expect the AMA to support the proposal enthusiastically. More to come...
Robert Wells, Menzies Centre for Health Policy, ANU Tuesday, 15 April 2008 11:38:22 AM: The question of relativities between proceduralists and 'cognitive' doctors is much harder to sort out. The Relative Value Study undertaken about a decade ago was intended to sort these matters but was spectacularly unscuccessful because it tried to change everything in one big hit. Perhaps a more gradual approach (eg tackling the most obvious anomalies first) is called for.
ian Hickie Wednesday, 16 April 2008 2:36:47 PM: Rather than a focus on "ineffective' vs 'effective' treatments, perhaps the greater problem is the distortion in rewards for procedural vs non-procedural medicine. As long as this persists, hospitals, day surgeries, clinics and individual providers will continue to design health services to maximise financial rewards (ie. sustainability of the business). I have often made the comment that the best way for my colleagues and I to sustain our psychological medicine (i.e. time and people intensive practice with low financial reward unless we transfer the cost to the consumer) would be to run a skin clinic one day per week alongside our other practices. In the absence of specific incentives for collaborative care, co-located practice, multi-disciplinary care or tracking of outcomes from episodes of psychological illness, we are likely to see a further movement away from this relatively poorly rewarded area of medical practice.
ian Hickie Thursday, 17 April 2008 2:39:27 PM: for a fuller description of my comments see home page of www.usyd.edu.au

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What ineffective treatments should we stop funding?

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