Unhealthy Industry

From The Australian newspapers’ health section

AT THE COAL FACE: Gabriel James

January 09, 2010

SINCE the introduction of Medicare in 1985 we’ve had more than 20 state and federal health system reviews.

Each identifies lack of money, poor planning and weak primary care as big issues. Each proposes blue-sky goals such as better rewarding of prevention, creating interdisciplinary teams and training more doctors. But what has changed?

If Australian healthcare were a business its stock price would be tumbling. It’s time we recognised that to be sustainable, health must be like any other industry. Instead, our inflexible workforce, burdensome regulation and consumer segregation makes health a nationalised fiasco, with a small proportion of private entities taking the cream.

To continue reading click here.

Does Australia’s health system need to get worse before it can get better?

In 2010, governments across the world will redouble their efforts to reform healthcare. 

Indeed, in most countries, they have been trying for decades. But a recent economic jolt reminded us just how tenuous our prosperity is and has given us a new sense of urgency.

Click here to continue reading my article on Open Forum.

Health Care Reform begins with the Individual

It’s great to hear a voice of reason amidst all this mudslinging, particularly in the USA where the possibility of any major reform is dimming by the day. And it comes in the form of an MD who reminds us that ultimately it is individuals that are responsible for their care and that much illness is preventable by better behaviour.

While we focus on the cost of drugs, procedures and insurance, it is easy to forget that we are treating people that are sick for a reason. In Australia, as in much of the USA, our current system is basically like going shopping with someone else’s credit card — no limit, no penalty, no shame. People have very little to discourage them from getting overweight, for example.

Now before you suspect me of promoting draconian fat-taxes and like measures – hear me out. The best guarantee of health in any society are norms and customs that strongly encourage healthy living. These take time, however, to develop, and can easily be lost. Then there will always be those that ignore them anyway. As it stands we have a long way to go before people are fully empowered to aim for better health.

For this reason there is increasing focus on health education. But more can be done. One great suggestion is the idea of an ‘individual health road map‘. This is a plan given to you by your health care provider that outlines all the critical steps required for an individual to maintain, insofar is is humanly possible, their health. For example, a diabetic could be given the standard of care plan for diabetics, and if he/she actually showed up, without fail, to the doctor, the podiatrist, the nutritionist and followed their subsequent recommendations, he would be less likely to require hospitalisation and expensive treatment and society would not shoulder his cost. If he misses these critical steps in his care, he pays, not us.

Obviously, any similar system must be implemented with great concern for people’s well-being – and no-one should ever be refused health care. But as it stands, we have low expectations of individuals and place very little pressure on people to truly live healthy lifestyles. Such a form of insurance may be the best reform yet.

I’m also encouraged to read that another web-based patient support tool is being developed. It’s part electronic medical record, part drug encyclopedia, and part patient chart known as the Pediatric Knowledgebase (PKB).

The PKB integrates the hospital’s medical records with drug-specific decision support generated by clinical pharmacology experts and clinical caregivers and predictive models generated by a hospital’s pharmacometric and informatics team. Forecasting tools evaluate dosing scenarios to be explored via a user friendly interface that front-ends a pediatric population-based PK/PD model. The result is therapeutic drug monitoring for children that uses patient data to help predict outcomes and inform clinical decisions in individual patients.

NHHRC: Medicare Select – What is it?

Our Parliamentary library has a good analysis of Medicare Select for those of you wondering what Option C means in the NHHRC report.

I would like to see this option compared with a ‘healthcare credit card’ system. From the analysis and debates I’ve heard on Medicare select it seems a real sticking point is the lack of flexibility it actually brings. While it would add increased competition to the market, people are ultimately still quite limited in their options of care. In some respects they are more limited. For example, now people can go to virtually any public hospital for treatment. Under Medicare select my superficial understanding is that they would be limited to a chain of hospitals, much like the HMO system in the USA. For this reason many doctors don’t like the concept either.

A credit card system would give every individual a base level of money to spend on health and allow them to spend it wherever they chose. I believe that one reason health literacy is relatively low in Australia is that we don’t need to take responsibility for our health and how we spend on health. Giving people purchasing power would allow them to learn what relative costs are in healthcare.

Clearly though, this system needs a full analysis of its own.

Innovation and Change

Words on everyone’s mind in the health arena. Here are some interesting tips from the experts.

Change (from MindTools)

Richard Beckhard and Rubin Harris first published a change equation in 1977 in “Organizational Transitions: Managing Complex Change”, and it’s still useful today. It states that for change to happen successfully, the following statement must be true:

Dissatisfaction x Desirability x Practicality > Resistance to Change

This seems to be a simple statement, but it’s surprisingly powerful when used to structure a case for change. Let’s define each element, and look at why you need it:

* Dissatisfaction: Your team has to feel dissatisfied with the current situation before a successful change can take place. Without dissatisfaction, no one will likely feel very motivated to change.

Dissatisfaction could include competition pressures (“We’re losing market share”) or workplace pressures (“Our sales processing software is crashing at least once a week”). Dissatisfaction can be any factor that makes people uncomfortable with the current situation.

* Desirability: The proposed solution must be attractive, and people need to understand what it is. If your team doesn’t have a clear vision of what things will be like after the change, and why things will be better, then they probably won’t be willing to work to deliver it. The clearer and more detailed you make this vision, the more likely it is that your team will want to agree with the change and move forward.

* Practicality: Your team must be convinced that the change is realistic and executable.

* Resistance to change: Resistance to change includes people’s beliefs in the limits of the change (“A new system won’t fit with our unusual business process”), stubbornness toward any change (“I don’t want to have to learn how to use a new system”), and general inertia or lack of interest at the beginning.

Innovation (BNET lessons from Apple)

It may take several years to cultivate new skills and rebuild your industry. You’ll need funding to create a dedicated innovation team and sufficient capital to rethink your systems and products.

Strategic clarity: Innovating effectively means creating your own opportunities in a crowded marketplace to avoid both mediocrity and commoditization.

Patience: Creativity is a fickle thing, and it doesn’t always follow the clock. False starts and the occasional flop are part of the process and must be accommodated.

Strong leadership: Innovation doesn’t happen by committee. Visionaries with effective management skills are hard to find, but they’re a critical ingredient for success.

Recruiting Stars

Most managers would consider the purpose of HR is to hire the best and brightest, from other good firms is possible. But the story is not so simple.

This great article from Jeffrey Pfeffer suggests talent should not be over-rated as your workplace probably has as much impact on your measured performance as your talent. It cites some interesting studies to back it up.

Want to Reform Healthcare? Start with the Workplaces

According to the World Health Organization, the U.S. spends by far the most per capita on health care but by most measures ranks not even in the top 30 countries in terms of health-care outcomes. If we want to improve Americans’ health and reduce our health-care expenditures, we need to understand why. There are many causes, of course, but I’m convinced one of the most important — and most overlooked — is our work culture. Working in America is literally hazardous to your health.

Read the rest of this interesting opinion piece by Jeffrey Pfeffer of BNET.

NHHRC Report Dissection

The National Health and Hospitals Reform Commission’s report is being gradually dissected by various stakeholders. Here’s a few quotes from the big fish (courtesy of the AHHA).

Australian Medical Association Federal President, Dr Andrew Pesce: “(It) is clear that (the report) properly focuses on some critical areas in health. The AMA’s objective now is to ensure the emphasis on the needs of patients is reflected in the final policy. In particular we want to make sure any extra funding goes to the bedside, the clinic and the surgery – not into more bureaucracy.”

Australian Dental Association, federal president Neil Hewson told ABC News Online: “The long awaited final report of the National Health and Hospitals Reform Commission released by Prime Minister Kevin Rudd demonstrates the same lack of appreciation of dentistry and the problems with dental care delivery as the earlier Interim Report. Those people who already have access gain more access and disadvantaged people are still disadvantaged so therefore we believe targeted programs of funding is the best way to ensure that disadvantaged actually do get their dental health improved dramatically.”

Australian Nursing Federation Federal Secretary Ged Kearney: “Community access to good quality primary health care is pivotal to easing pressure on the public hospital system. The widespread establishment of these centres and services, run by teams of health professionals is a positive initiative. Aged care is in desperate need for good reform, the population is ageing, people’s care needs are increasing and nurses and assistants in nursing are under intense pressure. But putting the burden of funding on older Australians, perhaps forcing them out of their homes, because they are in need of high level care is not an answer.”

Mental Health Foundation of Australia: “What (Medicare Select) would enable people to do is actually cash out all the services they might normally get through the health service system and use them in ways that will benefit them,” chief executive David Crosbie told ABC News Online. “That might mean improving their access to housing, improving their access to employment, improving their access to other supports that are actually going to make a difference in how well they cope. What we need to do is put in place a whole range of better access points and ways for people to access mental health services, and better quality services. That means not just more money, it means re-orientating the current health service system so it is actually responsive to people’s needs, and that means a lot more than simply putting money in.”

Public Health Association of Australia President Professor Mike Daube: “We welcome especially the emphasis on prevention and on other important issues such as mental health, Indigenous health, dental health and palliative care. PHAA is particularly pleased to see strong support for the establishment of a new National Preventive Health Agency.”

The Rural Doctors Association of Australia: The association’s president, Dr Nola Maxfield, says the commission has forgotten to include recommendations on how to encourage health workers to remote areas. She says recommendations such as locum relief and reducing HECS have already been tried, and only higher wages and improved working conditions will encourage doctors to go bush. Dr Maxfield says if something is not done now, things are only going to get worse. “The doctors are getting older and more tired and the young ones are not coming up,” she said.

John Della Bosca: argues that the election of the Rudd government and the commitment of the states and territories to work collaboratively on public health presents a once-in-a-generation opportunity. Yet the debate about how we turn this opportunity to our collective benefit needs to be much more than a turf war about which hospital department is funded by which tier of government.

Fiona Armstrong, Centre for Policy Development: argued that the National Health and Hospitals Reform Commission’s report puts forward a weak and flawed approach that will further entrench the blame game and cost-shifting. She also said that the proposal to hand control of primary health care to the Federal Government but for the states to continue to be responsible for hospitals will do nothing to deal with the issue of inequitable access.

Dr Jeremy Sammut, of the Centre for Independent Studies: argued that increasing government funding to increase the number of public hospital beds by 15 per cent is a one-off solution that will not solve the issue. Instead, the National Health and Hospitals Reform Commission, which has made 123 recommendations to improve the nation’s health system, should have focused on cutting bureaucracy. Dr Sammut is the author of a report, issued last week that finds Australia’s public hospital beds rate 2.5 per 1000 people is well below the OECD average of four beds.

Allied health: The National Health and Hospital Reform Commission has called for extra investment of $140m to $330m a year to dramatically expand the number of services provided by allied health services on referral from a general practitioner. The commission also proposes allied health workers be able to refer patients to medical specialists to ease the logjam at doctors’ surgeries.

Tony Abbott’s plan for hospitals: A Coalition Government would devolve the running of the nation’s public hospitals to the private sector, community groups and charities, Opposition frontbencher Tony Abbott says. “We wouldn’t run them with public servants,” he told the Ten Network on Sunday. Mr Abbott, a health minister in the previous Howard coalition government, said it was time to give the public hospital system back to the people. His vision includes the establishment of local hospital boards with the power to appoint their own chief executive and the ability to retain revenue from privately-insured patients. “It is a dog’s breakfast of divided responsibility,” Mr Abbott said of the present system where the states blamed the Commonwealth for lack of funding. The Commonwealth, under a coalition government, would devolve management of public hospitals in the same the way it did for the employment services network and nursing homes.

My TOP 4 summary:

1. Encourage the establishment of primary care centres where allied health and GP’s work as a team. There are too many disincentives to go into general practice at present.
2. Open up health training to make roles and responsibilities more flexible (prevent closed-shop systems).
3. Give patients more tools to manage their own health including better information about prevention, access and treatment options.
4. Sell the hospitals, or at least make them accountable (I agree with Tony).

Australian MBS and PBS Update

Legislation for nurses and midwives to be given access to the Medical Benefits Schedule (MBS) and Pharmaceutical Benefits Scheme (PBS) for the first time has been introduced to the House of Representatives by Health Minister Nicola Roxon.

The Health Legislation Amendment (Midwives and Nurse Practitioners) Bill 2009 will mean that patients who receive prescriptions from nurses will pay the PBS price rather than the private prescription price. It would not become effective until November 2010, Ms Roxon said.

“The Pharmaceutical Benefits Advisory Committee will be consulted about the range of medicines nurses and midwives will be able to prescribe and the circumstances under which medicines can be prescribed. Advice will also be sought from clinical experts and health professionals practising in the relevant clinical fields,” a statement from the minister said.

As debate on the bill continues, the Pharmaceutical Society (PSA) has suggested we also begin to consider prescribing by pharmacists to help facilitate a more efficient health system.

Distinction between EHR and EMR

I didn’t know there was one, but according to the Health Information and Management Systems Society, there is! Read about that difference here.