It’s important that we find out whether the Medicare schedule has kept pace with changed knowledge and practice. But the problem is, some treatments and diagnostic tests might be justified in some circumstances and not in others, writes Stephen Duckett.
No one doubts there are items on the Medicare Benefits Schedule that no longer represent good clinical practice, if they ever did.
Evidence of indication creep – where more and more people are labelled with a disease on the basis of changed diagnostic criteria – abounds. Some blame indication creep on drug manufacturers who benefit from drug sales to the newly diagnosed.
Health Minister Sussan Ley’s announcement in April of a Medicare Schedule Review was widely welcomed. The rush of criticisms following a weekend tabloid story on how the review could mean less access to scans for back pain, bone density tests and “the great Australian tradition” of getting tonsils out early shows that the Minister should be under no illusions that this will be an easy process.
The issue, though, is how much money is there to be extracted, and how this can be done.
Claims that at least 30 per cent of all care is unnecessary or represents waste in the system have been made about the United States health system. These same claims have been uncritically imported into Australia, even though our spending per head is about half that in the United States.
The current debate conflates two types of problem – whether there are procedures or tests being performed that provide no benefit, and whether there are too many tests or treatments that might benefit some patients but are being used too widely. Both are important issues but need to be tackled differently.
The review got off to a good start by indicating at its first meeting in July that it would be heavy on clinical consultation and involvement. It foreshadowed that it would not finish its reviews of the Schedule until December 2016. Whether it intends to keep to this timetable and approach after the weekend flurry is not clear (though two consultation papers have just been released).
It is rare that a particular treatment has no benefit for any patient. Clinical decision-making is about weighing up the benefits of a treatment or test in a particular patient and the downsides for this patient in terms of side effects, exposure to risk or costs. Decisions are made in the context of what treatments and diagnostic tests are publicly subsidised, and the decision about public subsidy is made on the costs and benefits to the average patient.
It is fair and reasonable that public subsidy for treatments should be based on assessment of value. So it is right that the review checks whether the schedule has kept pace with changed knowledge and practice.
A more complex issue concerns over-diagnosis and over-treatment, the subject of a Four Corners program tonight hosted by the widely respected host of the ABC’s Health Report, Dr Norman Swan. Some treatments and diagnostic tests might be justified in some circumstances but not in others. Again, the test or treatment should only be publicly supported if, on average, it is of benefit.
What should happen when there is evidence of over-use? Simply de-listing – taking the test or treatment off the schedule – is not the right approach. Instead, what is needed is to try to get the treatment or test more tightly targeted. It is argued that both first-line imaging for low back pain and tonsillectomies are over done in Australia.
A number of strategies should apply to this questionable care as a recent Grattan Institute Report suggested. Doctors should receive clear guidance from an independent body about what is appropriate and when.
Second, this guidance might be reinforced with financial incentives in the fee schedule – for example, the rebate might only be available if clear diagnostic criteria are met.
Third, doctors and hospitals that perform the procedures should be given feedback about their rates of referrals for diagnostic tests or procedures. If doctors persist with high rates, they should be required to justify their decisions through a clinical review.
We now have more data to check variation in practice patterns. We should use it to support doctors and patients to make the best choices for patient care, and to measure where things seem to be going awry.
Stephen Duckett is the director of the Health Program at Grattan Institute.