Blog 6: The ZOO in the room

A while ago I was inspired enough to write a comment on an article in the Australian Doctor website by a Jane Hall who is professor of Health Economics at the University of Sydney –

OzDoc

Medicare review must deal with ‘elephant in the room’ incentives.

You can hopefully still access this article if you click this title.

The article discussed aspects of the Medicare Benefits review initiated in recent times. It brought up the problem that the reviewers may “fail in their task unless they deal with the incentives to over-treat created by our fee-for-service system”.

It even concluded with the following including a direct mention of relevance in pain management:

“Then there’s the issue of the threshold for investigation or treatment. Take pain, for example: how much of it is serious enough to warrant an MRI? The point we’re trying to make here is that it’s rare that an indication or symptom is clear and without room for discretion.

And that leads to the elephant in the room that the reviewers have to deal with if they’re going to be successful.

Our health system is based on a fee-for-service model, so every time a doctor provides a service, the government pays a fee via Medicare. This means the more services provided, the higher the provider’s income. Not surprisingly, this unintentionally encourages increasing volume but not necessarily appropriateness (the right treatment for the patient) or quality.

Of course, this doesn’t mean patients are not treated well or that doctors don’t provide good quality care. But the incentives in the system are not well aligned with delivering the most efficient care.

Ensuring that what’s good for the patient and good for the future of Medicare is also good for medical business is really the only long-term fix for a better health system. We’ve long talked about making healthy choices the easy choices for consumers, now it’s time to focus on making efficient choices easy choices for health service providers.

This review is an indication of a more considered and consultative approach to formulating health policy. But let’s not forget that it’s the incentives that matter.

And this was my comment:

“The elephant is certainly in the room. The room also contains a flock of ostriches (with their heads in the sand), a dinosaur Medicare schedule, and people who still prefer to think the earth is flat.

Plain and simple – in the current system it is far easier, less time consuming and exceedingly more profitable to ‘intervene’ than to ‘educate’.

This is particularly pertinent to the management of musculoskeletal pain as mentioned briefly in the article. What a curious observation it is that, based on available data, the period over past decades with expensive major advances in investigation and therapeutic options, technology, interventional and surgical expertise etc, coincides rather uncomfortably with a significant increase in chronic musculoskeletal pain outcomes in the same time period. Persistent pain is associated with tragic outcomes for patients and their families and has major health expenditure ramifications. So not only is the budget straining with the funding of these tempting technologies and interventions, but it then is forced into the red further by the expenses associated with contentiously effective and increasingly common ‘pain management’ requirements. Curiously again these are also disproportionately interventionally focussed.

Patients in pain are scanned expensively and repeatedly. There is almost always some sort of degenerative finding discovered which is speculated and then informed as causative even though these are found abundantly in asymptomatic screening. Then, an expensive pathway ensues with low level evidence for most musculoskeletal & orthopaedic interventions and surgeries. This is despite questionable real outcomes beyond placebo construct responses (NB: sham comparison research trials on knee arthroscopy). In common spine pain, the expensive negative outcome consequences of this accepted process are becoming increasingly recognised. Persistent pain patients who have undergone spinal surgery in their pathway are a well-represented number even meriting their own special named syndrome …

Explaining pain carefully and properly is crucial to facilitate recovery via neuroscience education, reassurance, proper perspective and self-management. This is usually much more appropriate ‘treatment’, yet more difficult, and does not attract the lucrative rewards associated with interventions and surgery. To explain pain, it first needs to be understood by the practitioner, who is more readily seduced by procedures and interventions than exploring quality pain education both for themselves and for their patients. The existing financial incentives, either consciously or subconsciously, influence practitioners to offer interventions to desperate patients as ‘fixes’. Furthermore, in justification, scientifically unworthy ‘flat-earth’ conclusions emanate from selected poor quality research as firm support for these methods accompanied by avid marketing techniques.

Perverse incentives encourage disempowering vulnerable patients.

Supply, rather than demand, dictates provision of services.

Paradoxically, it was Paul Keating, who in addition to committing to the servicing incentives fashioned by Medicare, apparently was also quoted as saying -”In the race of life, always back self-interest – at least you know it’s trying”.

I was dark wasn’t I !!

I must have had a particularly frustrating case to review at work that day.

No wonder I received this comment in reply from someone identified as Wow – well said – I think. It’s going to take me some time to digest all that …”

And then I found a like minded (and much easier to understand!) comment as a letter in The Age newspaper that indicates that there are at least two medicos who think alike; hopefully more:

Best to click on it to see it better-

LetterAge

It is interesting that Dr Cheng uses the examples of antibiotics and scans in back pain as I have in my first blog.

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kalfried

I attained Fellowship of the Australian College of Sports Physicians in 1995 and have gained extensive experience in this field both before and after that milestone. I worked for five years in the Victorian snowfields, before joining the Melbourne Football Club (AFL) in the mid 1990's. I was a medical officer there for a total of 15 years with Dr Andrew Daff, as well as another 2 years with the Collingwood Football Club in the VFL. I was appointed as the AFL Australian International Rules team doctor in 2011 and 2013. I have also supported other elite sporting teams including the Australian Diamonds netball team in 2012. My main current appointment is with the TAC and WorkSafe as a medical advisor on the Clinical Panel and on various projects, and I am also an Independent Medical Examiner. In addition to general sports medicine I have developed a particular interest in the neuroscience of pain, the potential to 'de-sensitise' persistent pain, the biopsychosocial management model and exercise & conditioning prescription.

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