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Aug 3, 2011

Health reform: how to get less of what may not be best for us

With so many forces driving more and more health spending, surely it’s time you 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.

Before we come to the latest COAG health reform agreement (the details of which are outlined at Croakey), it’s timely to consider two recent items from the medical press.

The July 22 edition of Australian Doctor led with a story stating that the rate of growth of GPs’ incomes is failing to keep pace with those of specialists.

It ran a table showing that average earnings (after expenses) for surgeons and anaesthetists increased by 50% between 2005/06 and 2009/10 (from $400,000 to $600,000).  Over the same period, average GP earnings rose 12.5%, from $275,000 to $310,000.

These figures were largely based upon an analysis of data from one accounting firm, so may not be representative of the whole sector.

Nonetheless, they give a sense of why treasury officials must be concerned about the coming surge in doctor numbers. According to the Medical Training Review Panel’s latest report, domestic medical graduate numbers are projected to rise from 2264 in 2010 to 3227 in 2015.

It is far from clear whether these extra doctors will end up working in areas of need (such as the bush and poorer urban areas), or where they are most likely to deliver the best bang for the health buck — primary care.

Another possibility is that they will end up driving demand in areas already relatively well serviced, or in areas that do not deliver the best return on investment for population health. As a senior medical academic said to me recently, when warning against the dangers of increasing sub-specialist numbers, “there is no knee that doesn’t need an arthroscopy”.

On similar themes, Australian Doctor also ran several letters responding to news that The Royal College of Pathologists of Australasia is now recommending that “men seeking to assess their risk of prostate cancer should be offered a PSA test and a DRE (digital rectal examination) from the age of 40 years as a baseline measure of risk”.

Dr Joe Kosterich, from Perth, wrote of the potential harms of prostate cancer screening, including “even more false positives and needless investigations and surgery”.

Dr Hugh Nelson, from Port Hedland, wrote: “What an enormous financial conflict of interest the pathologists have. Shame on them for entering the debate on public policy on this issue. They will exacerbate the problem by increasing demand as the Women’s Weekly and other magazines quote their opinion.”

(For more background on the potential harms of prostate cancer screening, see this recent article by Professor Ian Olver from Cancer Council Australia, this free e-book by Professor Simon Chapman, or these comments by ABC broadcaster Dr Norman Swan.)

It is telling that when the pathologists’ statement hit the mainstream news this week, this Sydney Morning Herald story linked to a Google ad promoting surgeon Professor Tony Costello and robotic surgery.

Meanwhile, the recent news that Qantas will promote prostate cancer testing may be good for medical business, but not so good for the population’s health. All of which is a reminder that the forces driving demand for health services are complex and powerful — and often do not result in the most sensible or fairest investment of health dollars.

In the United Sates, as I reported for Inside Story, there is a small but growing movement to get across the message that less can sometimes be more when it comes to healthcare. The National Priorities Partnership, which represents a variety of US health groups and is convened by the National Quality Forum, has nominated overuse as one of its core priorities.


It has identified a long list of overused interventions that it suggests should be targeted by health care services and providers, and published information sheets to help members of the public avoid unnecessary interventions. The interventions it suggests targeting include inappropriate antibiotic use, unnecessary laboratory tests, unwarranted maternity care interventions including caesarean sections, unwarranted diagnostic imaging procedures, inappropriate end-of-life interventions and unwarranted use of procedures such as spine surgery, hysterectomies and prostatectomies.

Meanwhile, the US journal Archives of Internal Medicine has been running a series titled “Less Is More”, which aims to help identify areas of medical care in which harm outweighs benefit. Articles in the series have examined the harm caused by overuse of diagnostic imaging, proton pump inhibitors, and medicines in the elderly.

Similarly, the Scientific American recently ran an article identifying four common heath care myths, including that “more care is better care”, while other US authors have also raised similar concerns recently around heart disease treatments. Meanwhile, Australian debate remains fixated on the notion that we need more of everything, when it comes to health care.

So while recent Croakey posts have revealed some disappointment that health reforms have ended up delivering less than what was promised, it is also important to remember the rather huge barriers to achieving change in a sector with an apparently insatiable appetite.

As we speak, for example, the Australian Private Hospitals, is mounting an advertising campaign to oppose means-testing of the private health insurance rebate (see the August 2 release here: in Andrew Wilkie’s electorate.

So here’s my suggestion for a far-sighted minister or government: with so many forces driving more and more health spending, surely it’s time you 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; after all, the Institute of Medicine in the US has identified overuse as one of three critical dimensions to patient safety (the others are underuse and misuse).

A systematic approach is needed to balance the all-powerful “give us more” lobby.

As we’ve seen recently, any number of groups are ready to jump up and down when access to expensive new medicines is threatened. There was no such kerfuffle when researchers identified how to save billions of dollars in PBS funding by switching to use of generic statin drugs. The Less is More Institute would not only aim to achieve a more sustainable system but also a fairer one.

Minimising overuse is also about improving equity, argues Rosemary Gibson, the co-author of The Treatment Trap: How the Overuse of Medical Care Is Wrecking Your Health and What You Can Do to Prevent It, which offers policy-makers and consumers suggestions for avoiding excessive healthcare.

She told me recently: “We’re providing unnecessary back surgeries on the one hand, when there are people in the US who can’t get proper dental care … It’s a complete misallocation of resources.”

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One thought on “Health reform: how to get less of what may not be best for us

  1. gracedugan@iinet.net.au

    I’m an Australian medical student and I recently did a placement at a large private hospital in the US. It was a real culture shock to see the way medicine is practised there, the amount of over-treatment, over-referral and futile treatment. Doctors made decisions which, if I suggested them in Australia, would evoke deep scorn from my supervisors for being stupidly wasteful. I’ve spoken with a senior Australian physician who spent a few years at a famous American university hospital. He described finding the medical culture–how it accepted and promoted over-treatment and futile treatment–to be so frustrating that he switched to research.
    I really agree with the points made in this article, but to be fair I think the US needs a “less is more” movement a lot, lot, lot more than we do.