STEPHEN LEEDER. Over-servicing in health.

Abuse of Medicare or other reimbursement schemes is much easier if the regulations surrounding it are lax. That is what makes the current review of Medicare so important so that the rules are clear and make the best match possible between cost and benefit. This will result in less temptation to overuse useless procedures that might make the clinician rich but do nothing – and perhaps even harm – the patient. 

Medicine and surgery remain incomplete responses to disease and suffering. Of course, miraculous advances have led to many previously fatal disorders now being treatable and symptom relief has progressed mightily. Pathology and imaging are far less invasive and immensely more accurate than even a decade ago.

But any suggestion that we have neat, boxed and wrapped solutions to many – or even most – of life’s ills is nonsense. Consequently, the proposition that our woes with health care financing would disappear if only we followed ‘evidence-based guidelines’ fails to match up against the reality that most doctors try to do their very best for each patient and often this will include a good serving of trial and error in the absence of evidence from clinical trials.

And patients who are told – as some undoubtedly are – that western medicine cannot do anything more for them often then in desperation spend billions of dollars a year in Australia chasing alternate medicine therapies that come with generous helpings of warm hope from their practitioners.

That said, we know from studies of medical care worldwide that many useless drugs and operations could be foregone without compromising the chances of success of patient benefit.

A recent study in California showed that patients having surgery for cataracts do not need expensive work-ups prior to surgery unless they have an established medical problem. By cutting out the work-up, waiting lists were shortened and patients were happier. Measurements of their health showed no disadvantage after surgery among those without a work-up.

The electronic transformation of data systems is making it easier to find out what different medical and surgical treatments achieve, especially when electronic medical records work properly and contain dependable information – which is by no means as often as you might expect. So progress is occurring

But then there is the urgent need for the development and support of expertise among clinicians to take patients fully into their confidence when examining the benefits or otherwise of treatment on offer. This takes time and repetition: it follows the principles of high-quality education. When time is at a premium and the communication is incomplete bad things happen and patients feel deserted.

So the realities of clinical care can be overlooked by those of us advocating an evidence-based approach in which the value of proposed treatments is discussed openly and at length with patients. It requires resources, good managers, motivated clinical staff and willing patients to occur. Lining all those players up into one team is far from easy.

A further barrier to this approach arises from time to time in what we might call the moral or ethical dimension – the exploitation, conscious or unconscious, by otherwise principled and reasonable practitioners of opportunities to grow rich through over-servicing. Such behaviour, although ultimately an individual responsibility, is similar to weight loss: it is very difficult to do if the social structures are not on the right setting.

Abuse of Medicare or other reimbursement schemes is much easier if the regulations surrounding it are lax. That is what makes the current review of Medicare so important so that the rules are clear and make the best match possible between cost and benefit. This will result in less temptation to overuse useless procedures that might make the clinician rich but do nothing – and perhaps even harm – the patient.

Assuring that what clinical services we offer, as far as is possible, are based on solid evidence of benefit is an excellent goal. We are a long way from having the structures in place to ensure it and simultaneously to support patients for whom we can currently do little.

In the midst of the debate about the best use of money to provide clinical care we need to remember that our overarching goal is to improve the population’s health. We need to take prevention far more seriously – way beyond the single figure percentage of investment we make in it at present.

There is a global push for universal health care arrangements. It seeks to provide access to appropriate medical care to all. But ethicist Larry Gostin from Georgetown University in Washington DC has questioned whether universal care, which costs a lot of money even if restricted to evidence-based care, is the way to go when there is a massive agenda of prevention virtually untouched because all the money is going into clinical care. We have serious choices to make.

Stephen Leeder is Emeritus Professor of Public Health and Community Medicine, Menzies Centre for Health Policy and School of Public Health, University of Sydney.

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One Response to STEPHEN LEEDER. Over-servicing in health.

  1. Ian Webster says:

    Dear Steve,

    You are absolutely right to say we are far from having nicely boxed answers to the health predicaments especially as many people have complex multiple health problems.

    The problem with some guidelines is that they are constructed using the best randomised control data they can access. But in many circumstances the RCTs have been so conducted that most patients seen in practice would not have beeen selected into the treatment studies.

    In the alcohol and drug field, most published treatment outcome trials would exclude from treatment research the patients most commonly seeking treatment – the mentaly ill, those who have failed earlier treatments, those who are poor and marginalised, those in unstable housing, the poorly educated …

    In chronic pain there are very few studies which go beyond the short-term. Only a few reach six months!

    In the face of these ambiguities we should value the skills of the physician who is prepared to listen carefully to the story and carefully assess the patient, take into account the patient’s values and preferences, and above all, be prepared to follow-through in patient care and evaluate how well they are travelling. Also, accepting that cure may be an unrealisable goal for this patient.

    So much better to be able to prevent the development of these problems in the first place, as you say. But that requires medicine to to lift its eyes to social world.

    Thanks for your thoughtful piece.

    Ian

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