Less is more

I was asked to address the Committee for Economic Development of Australia (CEDA) about how to place health consumers at the centre of future healthcare reform and the delivery of health services. ‘Less is more’ is the presentation I gave on 2 November in Brisbane.

I would like to take you with me this morning to my practice in the Sunshine Coast hinterlands and introduce two of my patients. For privacy reasons their names and details have been altered.

To refer or not to refer?

My first patient is Susan, age 24. Susan requests a referral letter to a plastic surgeon. When asked she explains that she thinks her breasts are too small, and that she wants a breast enlargement.

What would you do if you were in my shoes? Can I please see a show of hands: who would refer Susan? Who wouldn’t?

This is of course about shared decision-making. I noticed Susan was slightly uneasy, she clearly felt uncomfortable about something, so I decided to explore her request a bit further. During our conversation Susan broke down in tears and told me that it was actually her boyfriend who thought her breasts weren’t the right size.

Our conversation about relationships and body image went on for over 20 minutes. Susan decided she needed some time to think things over and talk to good friends, and that she would come back if she needed further assistance.

Susan could also have gone online to an automated referral website.

Issues with online referral services

This is a screenshot from a real Australian online referral service. Here, Susan would have had to fill out a brief online questionnaire, pay with her credit card and she would have received a referral instantly via email.

But Susan decided to make an appointment with me instead and left without a referral. She could have ended up with implants she didn’t really want or need – and a large bill.

Never just about a script

My next patient this morning is John. He comes for a repeat prescription for blood pressure pills. When he sits down the first thing he says is: “Doc, I can do my banking online, why can’t I just send an email to request my scripts?”

John has a blood pressure machine but hasn’t been able to use it recently as he has been overseas.

I take his blood pressure which is very high. I notice John has gained weight since his last visit. He tells me he has a new job and works overseas as a plant operator for a mining project– and hasn’t had much physical exercise. He suddenly also remembers that he needs boosters for his travel vaccinations. As I check the records I notice his blood tests are overdue.

Although John came in for a script it looks like there are several health issues he may want some help with. Email contact would have been more convenient for John – but some problems would have gone unnoticed if he hadn’t come in.

In my job it’s never just about a script or a referral. Opportunistic screening and preventive care are key elements that make general practice effective.

At the same time we must ofcourse find ways to increase the uptake of digital health solutions. Telehealth, video consultations and asynchronous consultations with the usual GP practice have many advantages including potentially reducing travel and waiting times for our patients.

Unfortunately, one of the main reasons for the low uptake is that Medicare currently subsidises face-to-face GP care only.

High value care

Good doctors know when not to ask for a test, when not to prescribe antibiotics or opiates, when not to refer and when not to operate.

There are some great initiatives appearing that promote ‘less is more’ healthcare such as ‘Choosing Wisely Australia’. This initiative brings consumers and health providers together to improve the quality of healthcare through reducing tests, treatments and procedures that provide no benefit or, in some cases, lead to harm.

On the other hand we are seeing more disruptive, commercial, mainly profit-driven healthcare: Competitive markets built around growth, turnover and profits, and as we all know corporate medicine can drive resources away from patient care to meet market priorities.

After Hours presentations
Source: Department of Health and Australian Institute of Health and Welfare

This chart shows what happened after the rapid expansion of after hours home visiting services operating outside the more traditional medical deputising approach.

The two bottom lines show the explosion of visits by after hours home visiting doctors, funded by Medicare, with no meaningful reduction of emergency department visits – the top line.

Although the service is convenient for patients, the question has rightly been asked: does it represent high value care?

Health Care Homes

A solution suggested a few years ago by the Royal Australian College of General Practitioners (RACGP) was the patient-centred medical home, which concentrates care and funding for a patient in one preferred general practice.

The model was meant to enhance patient-centered, holistic care. It included for example:

  • Support for coordination of care, to improve the patient-journey through the various parts of the healthcare system;
  • Support for practices providing a comprehensive range of services locally;
  • A complexity loading which would support practices to respond to socioeconomic and Aboriginal and Torres Strait Islander status, rural status and the age profile of their local community, and reduce health inequalities.

This concept was reviewed, adjusted, modified, tweaked and tuned but what the Department of Health eventually came up with was a very different model; a model that simply pays practices a capitated lump sum for patients with chronic health conditions, and removes the fee-for-service system for chronic care – without significant extra investment to keep Australians well and in the community.

The department’s version of the ‘healthcare home model,’ which doesn’t necessarily solve our main problems such as poorly integrated care, is being trialled but the profession is lukewarm at most.

Pay-for-performance

What about performance indicators, targets and pay-for-performance? This seems to be a hot topic in Australia. It is tempting to pay doctors when their patient loses weight, has a lower blood pressure or improves sugar levels.

Pay-for-performance schemes have been tried elsewhere in the world but the results are disappointing.

For example, performance management has gone wrong in the British Quality and Outcome Framework pay-for-performance system and has resulted in:

  • only modest improvements in quality, often not long-lasting
  • decreased quality of care for conditions not prioritised by the pay-for-performance system
  • no reduction of premature mortality
  • loss of the patient-centeredness of care
  • reduced trust in the doctor-patient relationship
  • reduced access to GPs
  • decreased doctor morale, and
  • billions of pounds implementation costs

As Goodhart’s law says: “When a measure becomes a target, it ceases to be a good measure.”

Primary care is a complex system. Quality improvement processes that are traditionally applied to linear mechanical systems like isolated single-disease care, are not very useful for complex systems.

Slow down

We know that countries with a strong primary care system have better health outcomes and more efficient health systems. An important ingredient is continuity of care by the same general practice team.

It involves empowering patients to drive their own care as well as improvements in the healthcare system. We need to listen to our patients. This may also mean that we need to slow down. Less is more.

The RACGP believes that when GPs can spend more time with their patients, this enhances continuity and quality of care and will result in less prescribing, less pathology tests, less referrals and, importantly, less hospital presentations.

Government health spending
Source: AIHW

This chart, based on data from the Australian Institute of Health and Welfare, shows that General Practice services represent less than 9% of total government recurrent expenditure on health. Less than 9%…

In comparison, expenditure for hospitals represent 46%. Are we really doing everything we can to keep people well, in the community and out of hospital?

4 take-home messages

I have four take-home messages for you today:

#1: Take the good, leave the bad

We need to test new models of care in the Australian context, but we must avoid making the mistakes others have made before us, such as the UK performance payment schemes.

#2: Slow down

Let’s slow down. Allow patients & doctors to spend time together when needed. High turnover or profit-driven healthcare is not healthy for patients, doctors and our health budget.

#3: Convenience ≠ high value

We have to find a balance between convenience and value. Convenience is important, but it is never just about getting a referral letter or a script.

#4: Keep people well in the community

If we want to make a difference we must strengthen healthcare in the community, when people are relatively well, not just in hospitals when they’re terribly unwell. Rechanneling funding from hospital to primary care would achieve this.

Take home messages

Disruption by the after-hours industry and why you should care

Disruption by the after hours industry and why you should care

After-hours medical home visiting services are important for patients and their doctors but we need an ethical and sustainable model that integrates with day-time services.

Doctors and professional medical bodies including the RACGP and AMA regularly express concerns about healthcare models that compromise on quality, fragment and duplicate care or fail to use scarce health dollars efficiently.

The Medicare Benefits Schedule (MBS) Review Taskforce has voiced similar concerns in relation to some of the home visiting services. In its recently published interim report the taskforce notes that the growth in claiming of urgent attendances by after-hours medical services is showing an increase far in excess of population growth.

The taskforce believes the services often interfere with continuity of care by the patient’s regular GP and represent low value care. It is not convinced that the rise of urgent after-hours home visits has had a significant impact on hospital emergency department services.

Inappropriate use of funding?

Indeed, there are indications that funding for after-hours medical services in the community may be used inappropriately. For example, I have received reports from some of these services delivering repeat prescriptions after-hours to patients’ homes. The care is often not provided by GPs but by less qualified practitioners.

An after-hours visit classified as ‘urgent’ attracts a Medicare rebate which can be $100 more compared with the same service provided at a GP practice. This has created a lucrative standalone after-hours industry which doesn’t always represent value for money for the taxpayer.

No reduction of emergency department presentations
The assumption that increased provision of urgent, after-hours consultations (MBS item 597) would reduce demand for emergency departments has not been confirmed. Source: AFP

Let’s look at the ACT: since the arrival of the bulk-billing National Home Doctor Service in the capital, home visits rose from 1588 in 2013–14 to 20,556 in the previous financial year.

According to the Medicare Benefits Schedule Review Taskforce, Medicare benefits paid for urgent after-hours services have increased by 170 per cent, from $90.8m in 2010–11 to $245.9m in 2015–16, whilst benefits paid for normal GP services increased by 27 per cent.

There is no reasonable explanation for the exponential growth. The taskforce is of the opinion that MBS funding should continue to be available for home visits in the after-hours period but has made some sensible recommendations to improve the model.

After-hours lobby 

The response from the after-hours lobby speaks for itself: The National Association for Medical Deputising Services started an aggressive lobbying campaign to ‘protect home visits’.

Although several after-hours services left the corporate lobby group – including the Canberra After-Hours Locum Medical Service, the Melbourne-based DoctorDoctor service and the Western Australian Deputising Medical Service – the campaign continues to target consumers and politicians.

The actions of the lobby group and some after-hours services have raised eyebrows. Mass media advertising and marketing campaigns via television, newspapers, and billboards will drive unnecessary use and should be avoided. Similarly bookings for after-hours deputising services during daytime hours should stop.

A sensible solution

It’s not rocket science: As after-hours home deputising services do not offer comprehensive GP care, they should only be used when a patient’s usual GP or general practice is not available and the patient has a health concern that cannot wait until the following day.

It is time to use these Medicare-funded services wisely – when genuinely needed, not wanted or promoted.

Doctors vs corporates: who’s winning?

When trying to inform government policy, the medical profession is often up against lobbyists representing large corporate commercial interests. This usually does not improve patient care. It is also difficult for patients to distinguish between groups that advocate for the public good versus those that are after increased profits, power or influence. Below are some examples.

There are strong indications that funding for after-hours medical services in the community is used inappropriately. For example, I have received reports from some of these services (who mostly employ non-GPs) delivering repeat prescriptions after-hours to patients’ homes. After-hours visits classified as “urgent” attract a Medicare rebate of $130–$150 compared to non-urgent visits of $55 and $36 for standard GP surgery consultations.

The after-hours industry is booming.

Let’s look at the ACT: since the arrival of the bulk-billing National Home Doctor Service in the capital, home visits rose from 1588 in 2013–14 to 20,556 in the last financial year. This trend is seen at a national scale and there is no reasonable explanation for the steep rise in home visits.

What we need is ethical and efficient after-hours deputising services that work seamlessly with day-time medical services.

After a pushback by the profession and the launch of a Medicare Benefits Schedule (MBS) Review Taskforce, the National Association for Medical Deputising Services started an aggressive lobbying campaign to “protect home visits”.

Although several after-hours services recently quit the lobbying group – including the Canberra After-Hours Locum Medical Service, the Melbourne-based DoctorDoctor service and the Western Australian Deputising Medical Service – the campaign is still ongoing.

Big pathology

Another example of an influential lobbying group is Pathology Australia, representing several big corporations, which converted their public “Don’t Kill Bulk Bill” campaign to a backdoor deal with the government to reduce the rent they pay to GP practices for co-locating their pathology collection rooms.

The response from the Royal Australian College of General Practitioners (RACGP) was that the proposed changes will create an anticompetitive environment, propping up multinational corporations that make hundreds of millions of profit each year, while GPs running small businesses lose funding on top of the ongoing MBS freeze.

The Australian Medical Association also made it clear that this proposal went too far, interfered with legitimate commercial arrangements that have been entered into by willing parties, and that it would damage medical practices.

Pathology Australia made five donations to political parties in the last financial year alone, totaling $69,600.

Big vitamins and pharmacies

A recent episode of Four Corners once again revealed the influence of the Big Vitamins industry, selling their unproven complementary products via community pharmacies.

Complementary Medicines Australia, a lobbying group representing the complementary medicines industry, argued on the program that, despite lack of evidence, there was a role for homeopathy and that “some consumers do find that it works”.

The Pharmacy Guild of Australia does not oppose the sale of unproven products, such as homeopathic ones, via community pharmacies.

The medical profession has been calling for more transparency about efficacy for years. RACGP president Dr Bastian Seidel said that the current retail business model of pharmacies, which allows products like vitamins and supplements to be sold to Australians, is inappropriate within the health care environment, and that these products must not be sold as complementary or alternatives to evidence-based medicines prescribed by a doctor.

Health consumers also have concerns: the Consumers Health Forum of Australia reiterated in a media release, following the broadcasting of the Four Corners episode, that the Therapeutic Goods Administration (TGA) does not include a check of the efficacy of most complementary products, and that a clear signal from the TGA about the therapeutic worth of these products is required.

The Pharmacy Guild made 37 donations to political parties in the last financial year alone, totaling $236,530.

There are other examples, such as the private health industry lobby and of course Medicines Australia, the pharmaceutical manufacturer lobby group. The Grattan Institute estimated that if the Department of Health kept vested interests out of the Pharmaceutical Benefits Scheme policymaking, taxpayers would save $320 million a year. As the Grattan Institute put it: “Seeking the advice of drug company lobbyists gave the foxes a big say in the design of the hen house”.

Medicines Australia made 17 donations to political parties in the last financial year, totaling $82,212.

Pressure

It appears that there is increasing pressure from a broad range of big corporations and lobby groups on the health care sector. I believe this usually does not improve patient care and, in some cases, will adversely influence health outcomes.

It is clear that politicians and decision makers are being heavily lobbied by these organisations, and the questions arise: will they be able to withstand these forces, and are they able to make decisions in the best interest of Australians – even though this may not always be popular?

This article was originally posted in MJA Insight

Follow me on Twitter: @EdwinKruysDisclaimer and disclosure notice.

The rise and fall of the medical expert

Has the election of Donald Trump signalled a new era? Expert advice and scientific evidence seem to be taking a backseat while populism and an anti-elite ethos are gaining momentum. In Australia this may further fuel non-scientific opinions and scepticism towards medical expertise and science in general. Trumpism is, of course, not new. Australia has had its fair share of health policy based on little or no evidence.

Throughout history experts and scientific evidence have often been viewed with suspicion. The election of Donald Trump is a case in point. “Donald Trump’s lack of respect for science is alarming,” said the Scientific American.

Indeed, Trump is doing nobody a favour by, for example, spreading the incorrect and unproven message that vaccines cause autism. Apparently seventy percent of Trump voters believe this is true, despite the existence of extensive scientific safety data demystifying the dangerous misperception.

In Australia there are also signs that medical expertise is undervalued. The funding withdrawal for several primary care research initiatives are illustrative of the common perception about objective sources of information.

A classic case of dismissing medical expertise is the My Health Record (formerly PCEHR). The first big cracks in this government project started to appear in 2013, when the medical leads decided to resign en masse. More recently we have seen similar issues with the Medical Home project, which had full support from the profession until it was radically changed.

Then there are the changes to legislation around medical cannabis, which have created a perception of easy access for patients. Although there are plenty of anecdotal reports from people who have experienced symptomatic relief with cannabis for a range of conditions, doctors are still waiting for the research to provide information on indications, efficacy, safety and quality of cannabis products.

Science vs everything else

Vested interests

“Most people are happier with experts whose conclusions fit their own ideas,” write Clarke & Lawler in The Conversation. “But the Australian suspicion of authority extends to experts, and this public cynicism can be manipulated to shift the tone and direction of debates.”

When trying to inform government policy, experts are up against lobbyists who often represent large corporate commercial interests. An example is the campaign by some of the large corporate after hours home visit services which seem to be mainly concerned about their profitability.

I’ve received reports from these services (who mostly employ non-GPs) delivering repeat prescriptions after hours – which is of course inappropriate use of tax-funded health services and is concerning, especially as Medicare funds are scarce at the moment.

The facts are clear: since the bulk-billing National Home Doctor Service in the ACT arrived, home visits rose from 1588 in 2013-14 to 20,556 in the last financial year. This trend is happening at a national scale and there is no reasonable explanation for the explosion in urgent home visits.

What we need is an ethical and efficient after hours service that works seamlessly with day-time medical services.

Another example where profit comes first is Pathology Australia, representing several big corporates, who transformed their public ‘don’t kill bulk bill’ to a backdoor deal with the government to reduce the rent they pay to family practices for co-locating profitable pathology collection rooms.

Vested interest campaigns have eroded confidence in experts and scientific evidence for a long time – and not just in the health industry (see video below).

Replacing experts

Other trends seem to indicate that experts are regarded as expendable and should be replaced by others – because it is deemed cheaper or more efficient. Examples are physiotherapists prescribing opiates in emergency departments, radiographers reporting on scans and non-medical staff performing gastroscopies.

Who thinks I should fly this plane?

There are situations where tasks can be safely delegated within a supervised team environment. However, the evidence that task substitution leads to better health outcomes or lower costs is minimal. The reality is, as always, more complex – think about the Canberra nurse-led clinic that did not ease pressure on the hospital but instead increased emergency department presentations.

The retail pharmacy sector is lobbying intensively to get their non-scientific business proposals approved by governments across Australia. Their justification for taking over parts of general practice is to ‘relieve pressure on busy GPs’. Again, this is misleading, incorrect and not supported by medical organisations.

Research suggests that it’s all about the business of pharmacy and that the sector shows little interest in working cooperatively with GP teams: only one-fifth of pharmacies participating in a Victorian experiment had contacted the GPs of the patients involved.

This is disappointing as we’re desperately trying to reduce fragmentation and work better together in the interest of our patients. At the same time there are many ways in which pharmacists could add value.

Having more options as health consumer sounds appealing but doesn’t necessarily make us healthier or happier. Sometimes less is more. For example, the Royal Australian College of General Practitioners (RACGP) recommends against a range of popular screening tests because of lack of evidence and the potential of harm for patients, not to mention the added costs to the health system.

The RACGP has also published a list of tests, treatments and procedures doctors and consumers should question. This is not always easy to explain to patients, but at the end of the day it’s the right thing to do for all parties involved.

Expertise: a subjective thing?

Annabel Crabb said in the Sydney Morning Herald: “Expertise is now a subjective thing. You can discover much about people’s deep ideological beliefs or prejudices simply by observing what advice they accept without question, and what they take with a grain of salt. Sometimes there is little logic to the position.”

The best defence is a good offence and when medical experts object to proposals or policy based on opinion instead of science, they are usually accused of defending their territory or ‘turf’ – which distracts from the real message of course.

Expert opinions and scientific evidence are not a fix for all our problems. There are other factors that need to be taken into account. However, as populist movements like trumpism are gaining momentum, the anti-elite ethos may further fuel non-scientific opinions and scepticism towards medical expertise and science in general. This is a real health risk and we should look at why this is happening and what we can do to improve things.

Follow me on Twitter: @EdwinKruysDisclaimer and disclosure notice.

Video: Why aren’t people listening to science?

Medicare Local action will disenfranchise many general practices

Medicare Local action will disenfranchise many general practices

Some Medicare Locals still don’t get it. Australian Doctor Magazine reported last week in an article titled Medicare Local threatens AMA that yet another Medicare Local is trying to add ‘search and seize’ clauses to after hours service contracts with GPs. These clauses give Medicare Locals the power to attend the practice and conduct an audit…

Meanwhile our own Medicare Local has issued another hefty document: a 22 page long Request for Tender for after hours care. As mentioned before our practice has been providing after hours care for many years, yet we now have to go through an onerous tender process to receive funding for this community service.

In the latest AMA GP Network News, AMA GP chair Dr Brian Morton wrote:

This Request for Tender (RFT) is a stunning example of how well intentioned policy has been completely bureaucratised. Practices have gone from a relatively simple application form under the old PIP system to a burdensome process that will disenfranchise many general practices and see GPs walking away from after hours services. Once they are gone, it will be hard to get them back.

Perhaps even more stunning is the appointment of one of the country’s most high profile consultancy firms, PricewaterhouseCoopers (PwC), to assist in the assessment of tenders from local practices. I am not sure how in touch with local conditions PwC is and I am sure local GPs would like to know how much this is costing.

It seems to me that one of the biggest winners from the Government reforms to GP after hours funding has been consultants. While the Government has provided additional funding, one has to ask how much of this has been diverted away from supporting front line GP services for patients. Hopefully, the current review commissioned by the Government will give some answers. Certainly, if the Coalition is elected we expect that it will undertake a root and branch review of these types of issues.

Couldn’t agree more.