UTS BUSINESS SCHOOL

DATA INFORMATION AND SYSTEMS: DRIVING SYSTEM IMPROVEMENTS AND OPTIMAL USE OF RESOURCESRichard De Abreu Lourenco

CHERE, UTS

DISINVESTMENT IN ACTION…MBS IN FOCUS?

“There's lots of things that are working well. I mean,

we do have a world class health system. But there

are many things that are not. 

The key thing is that the MBS, which has some

5,500 items, there's only about 10 per cent of them

that have ever been reviewed and removed. From

time to time this does happen- items come off and

items go on.”

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Hon. S Ley, ABC Radio, 22/04/15

MBS REVIEW

Do we have data to understand what is “working”?

At the population level?

At the patient level?

How do we define working?

How do we take things off the MBS:

Who will pay for services? Patients? States?

How will it impact on health outcomes?

THINKING ABOUT INVESTMENT/DISINVESTMENT

Implicit:

Adoption of Clinical Guidelines or new technology leads to attrition of current practice.

Explicit:

Reviews of comparative effectiveness (eg. HTA).

Program budgeting and marginal analysis; what is working and where can we best reallocate resources?

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FORMING COMPARISONS

Making decisions about resource use under conditions of scarcity.

Need data to understand: choices - alternative ways of allocating resources.

consequences – outcomes (good and bad) of choices made.

opportunity cost – outcomes forgone by using resources in one way compared with another.

HTA TO INFORM INVESTMENT AND DISINVESTMENT

Key input to investment decisions; eg. informed by MSAC and PBAC.

Is there value for money in the proposed new drug, intervention or service?

Broadly, compare costs and outcomes of two (or more) approaches to the same problem.

HTA TO INFORM INVESTMENT AND DISINVESTMENT

PBAC has capacity to recommend “disinvestment” of listed drugs : To date limited… antifungal preparations in late

90s, Anakinra for RA in bDMARDs 2010 review. Changing..new principles for delisting of OTC

medicines. MSAC recommendations have direct implications

for investment and disinvestment eg HPV cytology.

HPV SCREENING: FUNDING APPROACH TO INVESTMENT/DISINVESTMENT

MSAC recommendation to fund 5-yearly HPV cytology for cervical cancer screening. Implicit investment decision:

Effectiveness data. Modelled cost-effectiveness

data – compared with current approach.

Result – explicit disinvestment decision (no longer funding biannual pap-smear based screening program).

HPV SCREENING: FUNDING APPROACH TO INVESTMENT/DISINVESTMENT

Modelling suggests improved outcomes and costs. Improved acceptability to women due to lower

frequency? Will this increase participation, or will there be

confusion due to existence of HPV vaccines? Are freed resources being reinvested back into

“screening”?

BUT THERE IS MORE..

Comparative efficacy and safety only part of the picture.

It might not result in optimal use of resources; we need to understand incentives:

How do current funding arrangements influence behaviour of providers to recommend use?

What about consumers – do we understand their incentives eg. either financial or for reassurance and information?

REFORMING MBS..

Volume Quality Referral rate Time Cost

FFS Incentive for high

throughput

Unclear Disincentive to refer to other practitioners

Incentive to reduce time

with patients

Leads to higher costs for the

system

Salaries Potential to restrict

throughput

Unclear Promotes referrals and collaboration

Promotes increased time with patients

Leads to lower costs for the

system

Capitation Potential to restrict

throughput

Unclear Promotes referrals and collaboration

Promotes increased time with patients

Promotes cost containment

Do we need to change the restriction on access to x-rays for back-pain, or how we pay for services?

MBS REFORMS: THE IMPACT OF PAYMENT SYSTEMS…

There are trade-offs in how the different payment systems impact on behaviour and outcomes.

Perhaps…balance increased throughput and service volume against system cost, collaboration and patient interaction.

Can patient desire for reassurance and “health” be ignored as an outcome we are prepared to pay for?

MBS REVIEW: A REJOINDER

Do we have data to understand what is “working”?

At the population level? – ? not comparative

At the patient level? – conditional funding; equity?

How do we define working? – patient variability.

How do we take things off the MBS:

Who will pay for services? Patients equity? States cost-shifting/equity?

How will it impact on health outcomes often unknown?

AFFECTING CHANGE

Informed by what is happening currently and what is expected to happen. Are there costs and outcomes beyond the

immediate “health” sphere? Consider the broader institutional context:

What affects the behaviour of providers and consumers?

Could the same goals be achieved by changing the incentives around service provision?

HORSES FOR COURSES

There is a place for disinvestment: Don’t want to keep doing things that are unsafe,

ineffective or waste resources. BUT… Need to be clear this is the case. Consider the institutional framework (incentives)

within which services are provided. Might not be the services that are the question, but the

incentives driving their provision we want to modify to improve care and resource use.