By Norman Swan and Claudine Ryan
When we are sick or in pain we do not realise that what is done, or not done, in the GP’s surgery can set us on a journey to a place we may not want to be.
We might be grateful to a doctor who takes the trouble to send us off for a scan, without realising that that seemingly simple and benign decision can have implications which last for years.
A special Four Corners investigation tonight reveals many of the treatments and tests we get are unnecessary, sometimes harmful and needlessly expensive, costing the health system billions of dollars every year.
Figures from the Australian Institute of Health and Welfare show Australia spends just under $155 billion on health each year, and it is estimated that one-third of that amount — about $46 billion — is being squandered. This is total spending by federal and state governments, private health insurance and in hard cash from patients in gap fees.
Adam Elshaug, Associate Professor of Healthcare Policy at Sydney University, is an authority on what is called low-value care and has identified at least 150 unsafe, inappropriate or ineffective medical services that receive Medicare and health insurance rebates.
He says the system is wasting precious health dollars and putting patients at risk.
“We know that patients are being harmed by receiving tests and treatments that they should never have received,” he said.
“There’s a cost too, and that cost should also be counted because those are dollars that are wasted and could’ve been reallocated to other areas of medicine.”
Most of us are unaware there is often little evidence supporting many of the medical services we receive, according to Professor Robyn Ward, chair of the Medical Services Advisory Committee.
The committee is responsible for reviewing the evidence behind proposals to add new items to the Medical Benefits Schedule (MBS) — the list of more than 5,700 services, tests and procedures for which Medicare will reimburse patients and doctors.
“There is not a great understanding among the average person that potentially these treatments or tests are offering very little in the way of outcomes, and in some times actually harming people and leading to a whole lot of other events, like other interventions, surgery even, that in itself has side effects,” said Professor Ward, who is a leading cancer specialist and researcher.
To get a sense of how this much money is being wasted and how unnecessary treatments can send you on the wrong journey, take a look at what can happen when you go to your GP with a common health complaint: knee pain due to osteoarthritis.
MRI for knee pain
Knee pain is a common health complaint in middle-aged and older people.
If you go to your GP with knee pain, it is not unusual to be sent off for an MRI. In fact since GPs were given permission to order knee MRIs three years ago, the number of GP-ordered MRI scans has gone from zero to more than 150,000 in the past year.
These scans often find signs of wear and tear in the joint, or a tear in the menisci (the discs of cartilage on either side of the knee). But there is no guarantee that this damage bears any relationship to your pain.
In one study, researchers did knee MRIs in middle-aged people regardless of whether they had any symptoms. They found that most of them had age-related damage including torn menisci or cartilages.
That means all a knee scan is likely to pick up in someone over 50 is normal wear and tear, but that’s not how it is read by doctors and patients.
The cost: Over the past 10 years Australia has spent nearly $486 million for knee MRIs in the private sector, including the gap paid directly by patients. This figure is much higher when you add in public hospital imaging.
Knee arthroscopies
Once you’re on the knee journey, the next stop is the orthopaedic surgeon, who may offer you keyhole surgery to fix your cartilage and wash out the debris from your arthritis.
It is called knee arthroscopy and sounds great.
“But it doesn’t work,” said Ian Harris, Professor of Orthopaedic Surgery at the University of NSW.
Rachelle Buchbinder is a rheumatologist and clinical epidemiologist at Cabrini Hospital in Melbourne.
“There’s been very good evidence for over 10 years now that arthroscopy to treat osteoarthritis of the knee with washing out the joint or cleaning up the lining is no better than placebo,” she said.
The cost: Knee arthroscopies cost $215 million a year, including $21 million in cash from patients.
Knee replacements
For those with knee arthritis, a knee replacement is often the end of the line.
“In appropriate patients, it is a very good operation,” Dr Buchbinder said.
“But there is some evidence that at least around 20 per cent of knee replacements may be inappropriate. And by inappropriate, I mean they are not better off after the operation compared to how they were before the operation.
“Some people are getting the joint replacement when they would be better off not having the procedure done.
“If patients know that the evidence shows a treatment doesn’t work and it only has more potential for harm than benefit, I don’t think anyone in their right mind would want to have that procedure.
“The fact that what I know to be inappropriate treatments are still being performed, I think means that the patients just haven’t been told.”
The cost: Up to $23,500 per procedure. The cost to both the public and private health systems more than $1 billion — not far short of 1 per cent of the national spend on health. In 2014, knee replacements cost patients about $31 million in out-of-pocket gap fees.
What’s going wrong?
So how is it that you can walk into your GP’s office with knee pain and end up having had unnecessary and expensive surgery?
This scenario, as covered on Four Corners, repeats itself for low back pain, angina (chest pain on exertion which goes away when you rest) and testing for what is known as prostate-specific antigen (PSA) for prostate cancer.
In part it is because of the way Medicare pays doctors for their services. Doctors are paid for doing things to patients. They are not paid or given incentives to give the best care. Few of the items on the MBS were assessed for evidence before they were added to the schedule.
“Most of the MBS was created at a time when evidence was not a prerequisite for reimbursement,” Professor Ward said.
Over the years doctors have lobbied for their favourite tests and procedures, regardless of evidence. Once these items made their way onto the schedule, very few of them were reviewed, and only one or two removed.
Accepting uncertainty
Jenny Doust, a GP and academic whose research focuses on evidence-based medicine, understands all too well why this situation can arise.
“Part of the problem is where GPs feel that they need to do more tests, refer patients on, and that’s driven partly when GPs don’t feel that they are clinically certain about what’s going on and they’re not willing to rest with that uncertainty,” she said.
“Then sometimes it’s also driven by patients expecting to be referred on or expecting tests to happen”.
But “sometimes the best medicine is no medicine at all”.
“Those conversations with patients take time to explain, that the evidence simply doesn’t support doing a test or prescribing a drug [takes] long conversations … and it’s much easier in clinical practice to do things quickly and prescribe or order a test,” Professor Ward said.
The Federal Government is reviewing the evidence for MBS items, but the question remains whether the interests of Australians will prevail over pressures from doctors and the medical industry.
But what are we, as patients, supposed to do?
Ask for the evidence, says Professor Harris.
“I think patients should be asking for the evidence. They should be asking for the evidence that they will be better if they follow course A or course B,” he said.