Monday, September 28, 2015

Medicare services review, and mixed feelings

On Sunday, the Australian Health Minister, Sussan Ley, announced a review of the 5800 services currently available for either full or partial funding under Medicare.

Ley says the review is targeted at weeding out procedures or practices that are unsafe, outdated, inefficient or unnecessary. The ALP says it's about cutting Australia's social healthcare system to ribbons by a stealthier method than the disastrous copay idea. The Greens, led by the increasingly centrist / right Richard DiNatale (himself a doctor), support the idea of the review, but not an outcome that leads to cutting any actual money out of the health budget. The Australian Medical Association has very hurt feelings over the apparently insulting idea that some doctors or specialists may be over-servicing or ordering unnecessary tests (even though Ley has been careful to not suggest that this is being done cynically, but rather through lack of awareness or habit).

It's unusual for me to feel so conflicted about a Liberal policy idea as I do about this one. Perhaps it's the Turnbull effect, but, on the face of it, the idea of reviewing health interventions and diagnostic tests to see if they are actually effective and helpful doesn't sound like such a dumb one. I do believe there are areas in which we are over-treated and certainly over-tested, and I don't think this ends well for patients, never mind the health system.

To cite one example - Australia currently has a Pap smear regime of 2-yearly Paps for people with cervixes, with colposcopies ordered following two abnormal smears in a row. This is a very expensive program, and one, I was surprised to learn after my own colposcopy experience in 2014, that gynaecologists generally don't think is a good use of public money.

Why? Well, let's put it this way: If you have a cervix, your lifetime risk of cervical cancer in Australia is 0.65%, but your lifetime risk of being referred for colposcopy / biopsy is a whopping 77%. Cervical abnormalities, as my gynae cheerfully informed me, are common. Everyone with a cervix gets them sometimes, and only very rarely are they cancer. Any way you cut it, biopsying 77% of people across their lifetime to catch less than 1% who actually have a cancer is a massive sledgehammer swatting a fly ... a fly, moreover, that is better and more accurately identified by the (much less expensive) testing for the presence of HPV and concentrating diagnostic regimes on people with active forms of the virus.

Indeed, so true is this that Australia will very soon be moving to a regime mirroring that of the Nordic countries, where HPV swab testing to done on a 5-yearly basis, and only cervix-havers with positive HPV AND relevant symptoms will be sent for Paps and colposcopies. Countries where this is the norm have equivalent or better catch-and-cure rates for cervical cancer -  and it costs a shitload less to run.

It's not only about the money, either. Unnecessary or medically inadvisable tests, especially invasive ones, are stressful, costly, sometimes frightening, and in some cases even traumatic for patients. (I certainly wasn't keen on my colposcopy!) I myself will resist ever being sent for another MRI (one of the big tests under question, given just how over-referred it is based on results, especially for backs and knees) unless it is completely and convincingly medically necessary. MRI is a classic example of a test that is at the very least psychologically uncomfortable for most people, and close to impossible for severe claustrophobes with anxiety issues; the cost of referring for it unnecessarily is not just financial by any means.

There are other areas where I can't see it as a bad thing that the overall menu of procedures and options might be capable of improvement. The utter stupidity of the "medical certificate for work sick leave" thing, for instance - if I had my way, such consultations would not be bulk billed, they would be billed at full whack to the EMPLOYER for requiring people with gastro, colds and flu to drag themselves to the local GP for a pointless certificate.

All of that said, however, the reality is that I *don't* trust the motives of the government in all this. I think the goal IS to reduce health spending, but more craftily, under the guise of efficiency and modernity. (Tellingly, the review has no scope to suggest new or improved procedures to be added to Medicare, only ones to be removed). I am sure Ley and Turnbull wouldn't object to better patient outrcomes if that is a consequence of knocking out ineffective tests, but I doubt very much that that's the core objective.

So, as I say ... conflicted. Is it a good idea to review all the tests, procedures and services covered under Medicare to see if they work properly and produce good outcomes for real people? Well yes, I think so. But not if any money saved is ripped out of healthcare for other, less socially useful, ends.

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