16 September 2019

System is not perfect … but mess with it at your peril

Patients TheHill

When someone mentions value-based healthcare, or a pay-for-performance scheme, it’s hard not to let one’s eyes not glaze over.

It certainly doesn’t capture the imagination like a measles epidemic or major changes to the MBS.

But if you’re a practising GP, it would be wise not to tune out altogether, because this is the type of health system many of our top policymakers would like to see us move toward.

I recently heard Dr Stephen Duckett, the Grattan Institute’s Health Program Director speak on the subject. He wasn’t saying anything particularly new, but he did reiterate the point that our current fee-for-service model was unsustainable financially and it made sense to move to a model where providers’ remuneration was linked, at least in part, to patient outcomes.

Such a system inherently is more efficient and would ideally reduce the risk of patients receiving unnecessary or ineffective treatments.

It is impossible to argue with the principle of such a system.

But the major sticking point with the scheme, as Dr Duckett and many other health reformists will acknowledge, is defining what are the health outcomes we are wanting to achieve.

Of course in some areas of medicine it is relatively easy. Dr Duckett gave the example of the audit of hip prostheses the Grattan Institute had undertaken to determine revision rates for the various implants. Straightforward – find the implant with the lowest revision rate and have a system that ensures this becomes the first choice of hip surgeons.

And not so long ago there was the report that showed knee-replacement patients who attended post-op rehab as an outpatient had just as good a return to function as those who underwent inpatient rehabilitation. A value-based healthcare system would see outpatient rehab become the standard.

But it gets a hell of a lot harder in primary care. How do you determine a valuable outcome? What do you measure?

Our UK colleagues have been experimenting with this idea for years. More than a decade in fact. They tried targeting chronic diseases and rewarding healthcare providers if they could achieve “quality outcomes” based on very measurable indices such as HbA1c and BP levels.

To date, no-one has been able to show this has been an effective exercise – for the patients, the doctors or the healthcare system. And the bureaucracy involved, as you can imagine, has been a nightmare.

As a 2016 report put out by The Economist Intelligence Unit stated: “Years of structural healthcare reforms have both impacted the morale of providers and left a more fragmented system, making it unclear to what extent the country can actually increase value for money, even if it can identify that value.”

And that’s the other problem. A good health outcome is more than just value for money. There is what the patient considers valuable. And, as every GP knows, patient expectations can vary enormously. 

Dr Duckett says that patient expectations and “the patient experience” need to be taken into account. All well and good, but what happens when the patient expectations are unrealistic, or at least at odds with medical expectations?

I remember many years ago working with a vascular surgeon who simply refused to do fem-pop bypasses on smokers. He was ahead of his time in terms of practising value-based medicine, but I’m not sure the patients would have ticked the box on satisfactory health outcomes.

And in reality, the current Australian primary care system is already very much orientated toward outcomes deemed as valuable by the patient. If a patient doesn’t think you deliver value they will simply go elsewhere.

Were we to move to a healthcare system fundamentally based on outcomes we would need to make sure each patient only attended one practice.

Patient registration is a key factor in being able to monitor management over time, so patients would lose the autonomy over choice of doctor they now have.

There are, of course, many advantages to patient registration, the benefit of continuity of care is well-recognised, but there are disadvantages too.

I know I sound like I’m against a value-based system, but I’m not at all. Things have to change, and building a new model of healthcare that is both effective and efficient is something we should, and do, aspire to.

But we need to be very careful before we change the current model of primary care. It is definitely not perfect, but it is a largely honest system – we deliver a service we get paid. Packages of funding based on outcomes has yet to be proven worthwhile – for the patients or the budget.

And that’s just for your very basic outcome measures, let alone the million and one other possible measures that might be considered valuable by all the key “stakeholders”.

It’s a bit of a minefield really. We can only hope the reformists focus on areas of the healthcare system where the data is more concrete and reflective of practice – readmission rates to hospital, surgical complication rates, casualty waiting times – and refine the process before experimenting with primary care.

Sometimes I don’t think these policymakers truly believe that a good health outcome for the patient is the chief motivating factor for the overwhelming majority of Australian GPs. But we are probably the most value-based, performance-driven sector of the entire health system.

Maybe one day they’ll see that.

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