Health system reform better than the blame game

Improving the health system and cutting unnecessary expenses is better than finger pointing for rising costs, says Dr Dwayne Crombie, Bupa Australia’s Managing Director of Health Insurance.

Talking about hospital stays as part of the debate about reform

While health insurers are easy targets for criticisim, the underlying causes of what drives premium rises are seldom discussed, according to Dr Dwayne Crombie.

“If you look at all the good health systems, they would say the primary care or general practice part of the system is the bedrock, to the extent you can get the right kind of treatment in the community. That care needs to work well with a mindset where we don't do stuff in expensive hospitals when you don't need to do it. But how do you create a system that encourages people to do things for the least cost and in the safest setting?”

"In the private sector where people have a financial incentive, it’s important to check that it's balanced in the interests of the patient as well as the profession."

“There are a lot of financial incentives for those who own day stay facilities or hospitals and who want to do things where they 'clip the ticket'. We have to face up to the fact that sometimes health professionals do behave in a way to support themselves.”

“It’s actually really hard to have a serious policy debate about health care. If you step back, there is a certain irony in the new Labor policy to have a 2 per cent cap on private health insurance premium rises at the same time the Coalition Government is offering the states 6.5% in the public system. These are two systems dealing with the same kinds of issues. We have an ageing population so we want to provide more of the care to improve quality of life. We have all the technology that gives us one of the longest life expectancies in the developed world."

Let's get real

Recent comments by a prominent hospital provider, refusing to even acknowledge the existence of low value care in the health system, are a good example of this. Unnecessary surgery is one of the big contributors to rising costs in the health sector.

“If you take a couple of examples of something that can be low value, one is inpatient rehabilitation after hip or knee joint surgery. We know that you can spend two weeks in a rehab hospital which costs about $9000 or we can go home and visit an outpatient rehab, which typically, the community options costs, between $500 and $1000.”

“If you’re a hospital operator you're quite happy to have someone go through your unit for $9000, if you're an older patient you might think 'I paid my insurance, why don't I just enjoy two weeks with my feet up?’”

“The problem is you do end up paying, because that $9000 adds up – at Bupa we spend about $160 million a year on inpatient rehabilitation. If you can go home for $500 or $1000, that's a much better choice and we could spend that money on something else or lower your premium.”

Tap into Spinal Fusion ‘epidemic’

“Another definition of low value care is when you provide something that may benefit only a small number of people you're giving the procedure to. Two of the obvious examples are diagnostic knee arthroscopy, and the one that has really taken off lately, spinal fusion for lower back pain, particular chronic back pain.”

“We know from the studies that a very small proportion of people benefit from spinal fusion of the lower back - probably in the order of 10 to 15% and yet this is a very difficult, expensive operation often with complications.”

“You might ask why we have such an explosion lower spinal fusions? Well, chronic back pain is a horrible problem to have and often people feel like any choice, even if its questionable success is something they might want to contemplate. Obviously, surgeons are willing to do it because that's what they're trained to do.”

“It's only when you step back and look at how poor the outcomes are for a majority of people that you get more of a system view.”

“I would say that at the moment spinal fusions are an epidemic in the Western world. We spend probably in the order of $50-$60 million a year without any evidence at all on the good it does. In most cases it does not beat conservative treatment and the rate at which they're being performed is rocketing up.”

A better Mental Health System

“For us, mental health in the private sector is one of the areas we can collaboratively work together with community services, with psychiatrists, mental health therapists and NGOs. We need a debate about how we can create a fantastic mental health system in Australia. Everyone agrees it could be better. At the moment I spend $0.94 of every dollar on inpatient care, I know that's not right and that's one area where I hope we could come together.”

Working together for better outcomes

“A couple of research institutions in Australia are leading the way: the Menzies Centre for health policy, Prof. Adam Elshaug, as well as the Grattan Institute. The Menzies is now working with the public health sector and looking at the different procedures people do and at what proportion of those operations is there any clear indication of benefit.”

“There are a lot of people who do very well with the existing system, no one ever likes to change the system where they will lose out slightly. It's actually hard for people to act in a mature fashion.”

“Sometimes I can get a bit despondent we’re going to get there. The most pragmatic way we can is with willing organisations and people, probably at the practical level of particular areas."

“The challenge is not going to go away if we don't confront it. We need to have a really honest discussion.”

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