Tackling over-utilisation of health services
The results of over-diagnosis, over-investigation, and over-treatment in health care systems has dire consequences not only for those individuals subjected to such treatment, but to the rest of the population who look to their health care system for appropriate treatment or management. Thus, as has been said by others, instead of rational use of resources, […]
The results of over-diagnosis, over-investigation, and over-treatment in health care systems has dire consequences not only for those individuals subjected to such treatment, but to the rest of the population who look to their health care system for appropriate treatment or management.
Thus, as has been said by others, instead of rational use of resources, many are subjected to rationing because politics limits the amount of public funding available and income levels prevent many accessing private care. As one would expect, rationing predominantly affects those who are not rich enough to use the private system or travel from areas of workforce shortage to areas of over-supply.
One could look at the bright side of rationing. If you have to wait two years for a knee arthroscopy in the public system the problem may well have settled down and you have avoided the small but definite risks of an arthroscopy. If it takes three months to see the urologist about your modestly elevated PSA (a disputed screening test for prostate cancer), the repeat test may show the level is lower and you may avoid immediate consideration of potentially dangerous interventions.
The dark side however is that patients face copayments they can’t afford or they simply can’t find the health care provider they need in their location.
The Commonwealth Fund survey from 2010 found that 22% of Australians didn’t see their doctor when ill or didn’t do tests recommended or skipped drugs or didn’t fill out prescriptions because it cost too much. They also face waiting times of years to access public hospitals for elective surgery, like hip replacement.
One issue this raises is the possibility of addressing the wasteful and dangerous over-utilisation of resources and directing them appropriately to deal with these equity issues. That really depends upon how the issue of over-utilisation is addressed.
Over-utilisation takes many forms. There is the medicalisation of the normal range of human behaviour which then requires treatment. Although there are some examples of this being due to a non-profit-based genuine scientific and human interest in improving health, it is seldom the whole story and even when that is the basis for such interest it is frequently consumed by financial interest. To arrest that process requires arresting the profit motive in health servicing. A tall order in societies that are increasingly accepting that health servicing is an industry rather than a system for delivering health care as needed.
There is, however, another form that is prominent in over-utilisation. It is a belief that one must be able to act to improve the situation. It includes a belief that as a highly trained professional, the skills one has should be able to offer something to address the problem with which the patient presents. Thus, a doctor trained to prescribe a medication for most problems may expect to do just that for problems for which medication is inappropriate. A surgeon trained to do an operation for most knee problems he sees will look to do just that even in the face of suggestive evidence that it won’t help in the long term.
It includes a conscious and unconscious link to the profit motive. But such a link is often not apparent. It involves providers, doctors and others, who work long hours responding to needs, expecting to be well remunerated, but often too dedicated to doing their work to enjoy the financial rewards, believing that what they are doing is what is required for the benefit of their patients. Some may question their own practices but when surrounded by other doctors who are much more interventionist, they feel they are demonstrating restraint.
The ever present uncertainty of data and the difficulty in interpretation of data means that clinical practice cannot be determined by the science. The science is a guide only. Every day doctors who look very critically at the data are faced by patients who do not fit into the clinical trial data which guides them. Extrapolating from clinical trials is inevitable for specialists despite a wish to rely on good data. We check with colleagues. What would you do in this situation? Teenagers are not the only group in our society who are subject to peer influence.