Justin Bowra - The Elephant In The Living Room
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Justin Bowra - The elephant in the living room Justin Bowra takes a break from ultrasound to broach the uncool but crucial subject of health care economics. Health care spending make up a large proportion of the budgets of OECD nations, and it is increasing in relation to GDP. This is an unsustainable situation and something has got to give. In part 1 of Justin’s talk, he asks the question, where is the money going? The commonly asserted points of the aging population, better medical treatments, litigation and corporatisation of health care contribute. Justin argues, however, that the biggest problem is the system itself. To acknowledge the elephant in the living room is to acknowledge that we as doctors contribute to the problem, but we also have the greatest responsibility to be part of the solution. In part 2, Justin briefly discusses ways in which the system can be fixed. He touches on taming special interests, shared decision making, surrendering autonomy and to look at the big picture - remembering that what we do for each individual patient has consequences for everyone else.
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Justin Bowra - The Elephant In The Living Room
- 1. A presentation in two acts By Justin Bowra, Sydney Adventist & Royal North Shore Hospitals, Australia SMACC 2015 The Elephant in the Living Room
- 2. DISCLOSURE
- 3. PROLOGUE
- 4. PART I The Elephant in the Living Room
- 7. But…
- 8. AUSTRALIA Health spending 1995: 7.5% of GDP 2012: 9.1% Australian Institute of Health and Welfare
- 11. AT THIS RATE… 2050 Australia 13% USA 25%
- 12. What’s going on?
- 15. ‘On average, a 50-year-old now is seeing doctors more often, having more tests and operations…’
- 17. ‘Health systems themselves are becoming a threat to society’s wellbeing.’ Atul Gawande, Reith lectures
- 19. Doctors
- 20. Plumbers
- 22. PART II Fixing the system
- 24. Doctors
- 25. HOW CAN THE ELEPHANT HELP?
- 26. 1. Look at the big picture
- 27. 2. End-of-life discussion about the healthcare budget
- 31. 1. Look at the big picture 2. Shared decision making across society 3. Surrender our autonomy
- 32. A challenge
- 33. FINAL THOUGHT ‘Business as usual’ is not an option
- 35. THANKS Rob Day, Mark Gillett, Cath Herlihy, Sally McCarthy, Stella McGinn, Larry Melniker & Nick Stow
- 36. REFERENCES
- 37. Armstong K, Tess D. Fault versus No Fault- Reviewing the International Evidence. Institute of Actuaries of Australia Seminar, 2008. Dartmuth Atlas of Healthcare http://www.dartmouthatlas.org/ Gawande, A. Reith lectures Gawande, A. The cost conundrum. New Yorker, June 2009 [link] Godlee, F. Tackling practice variation. BMJ 2011. 342:d1884 [link] Gortmaker SL, Bickford AF, Mathewson HO, et al. A successful experiment to reduce unnecessary laboratory use in a community hospital. Med Care 1988; 26: 631-642.
- 38. Kennedy PJ, Leathley CM, Hughes CF. Clinical practice variation. Med J Aust. 2010 Oct 18;193(8 Suppl):S97-9. PubMed PMID: 20955142. [Fulltext] Magnan S, Fisher E, Kindig D, et al. Achieving accountability for health and health care. Minn Med. 2012;95:37-39. O’Callaghan G et al. Choosing wisely: the message, messenger and method. MJA 2015 202 (4): 175-8. Oberlander J et al. Rationing medical care: rhetoric and reality in the Oregon Health Plan. CMAJ 2001;164(11):1583-7
- 39. Stuart PJ et al An interventional program for diagnostic testing in the emergency department MJA 2002 177 (3): 131‐134 Wennberg, JE, Thomson PY. Time to tackle unwarranted variations in practice. BMJ 2011. 342:d1513 [link]
- 40. http://americannewsreport.com/arthroscopic-knee-surgery- questioned-8816014 Australian Bureau of Statistics www.abs.gov.au Australian Institute of Health & Welfare http://www.aihw.gov.au/ http://www.aihw.gov.au/WorkArea/DownloadAsset.aspx?id=6442457 479 http://www.cnbc.com/id/100840148 http://fc07.deviantart.net/fs71/f/2011/194/7/7/mad_doctor_by_diz oider-d3nsl64.jpg
Notes de l'éditeur
- In the pay of Signostics More importantly, have worked in diff states in Oz, UK, Ireland But not in the USA or Canada
- Cardiologist v nephrologist story …OR… My hospital was bunged. Standing room only. The DMS has recently asked everyone to avoid TF in from out of area I received news that a hand P was coming from across our state- past several other hand hospitals- to us! I rang the hand surgeon- please don’t He heard me out and said- I’m going to do it anyway.
- What do these headlines have in common?
- Whether the state or the individual pays, the money’s running out
- But something doesn’t add up…
- Countries are getting richer Health spending growing faster than GDP!
- USA: even higher Source: 2012 OECD data via https://theconversation.com/infographic-comparing-international-health-systems-30784
- So more & more money is being pumped into the system… but still the money is running out. Clearly, the rise in healthcare costs is not sustainable: something’s gotta give. By the time I need to open the healthcare cupboard for my own care, I hope there’ll still be something in it.
- We know it’s not inflation.
- Is it the ageing population? Or population growth? No. ‘Received wisdom is that rising health costs are all about demographic change, but this is not true. Together, population growth and the ageing population structure accounted for only a quarter of government expenditure growth above CPI since 2002-2003.’ [Ref- ‘The conversation how to reign in rising healthcare costs’]
- Is it just that people are getting better healthcare, and this is making them live longer? Well… partly. [Ref- ‘The conversation how to reign in rising healthcare costs’] ‘On average, a 50-year-old now is seeing doctors more often, having more tests and operations, and taking more prescription drugs, than a 50-year-old did ten years ago… and there are new treatments that did not exist in 2003.’
- But perhaps this partly explains it… MRI for knee instead of XR – different tests not more
- Or maybe this… In USA in 2013, 9.3% healthcare budget was prescription drugs http://www.cdc.gov/nchs/fastats/health-expenditures.htm There’s a lot of fat in the system Big Pharma Big Law Big Insurance In other words…
- …the system is the problem. Let’s talk about systems. When I asked people what they would say in this talk… who’s to blame? What’s to blame? Some blame the insurers, others the lawyers, others the consumers… But nearly everyone shook their heads & said ‘It’s the system that’s to blame.’ Even the wealthiest of my private colleagues complained of being small cogs in a system gone out of control. {Oh to be so helpless and yet so wealthy…] But what makes up the system?
- Here are the components. Each component is making decisions more or less in a vacuum. Consumers demanding more & better treatments & perfect outcomes Governments & insurers set the budgets Hospitals try & get the patient thru ASAP Lawyers sue the doctors Special interests send the drs to Hawaii for conferences
- But what about these guys? The govt can’t change the system if we don’t come to the party But what about the doctors? We are the single component of the system that has: the most knowledge of how it works, how it can be changed safely the most public respect The greatest responsibility to make it work … …and warn society when it isn’t working And every day that we bury our heads in the sand is a day closer to the system buckling under the strain. And that means it’s a day closer to someone pointing the finger of blame at us, and saying that DOCTORS are the problem.
- Atul Gawande came up with this analogy in one of his New Yorker articles: Imagine if you were building a house and you paid an electrician for every outlet he installs, a plumber for every faucet, and a carpenter for every cabinet. What would you get? A house with a thousand outlets, faucets, and cabinets, at three times the cost you expected. And that’s our healthcare system.
- So this is the elephant in the living room: we are the missing piece of the puzzle. Unless we change our behaviour, then no matter what else gets done, the system will not be fixed. It’s the way that anyone with the title ‘Dr’ can order just about any test s/he wants and prescribe just about anything. Last week in Sydney they ran a news item about a bunch of rogue drs who’d set up private ketamine clinics to treat depression. One of them decided to hand out syringes of ketamine to patients to take home and self medicate. These guys are obviously the lunatic fringe. But each one of us acts like a little god. Now, we don’t think we are. Each one of us is out there doing their level best for their patient. But each one of us is acting in isolation. Remember my DMS story in the prologue? Each specialist was doing it because each honestly believed that the patient would get better care at our hospital…
- So how do we fix the system? The following list isn’t mine. It comes from my own colleagues including my wife… doctors and healthcare workers like you and me. General principle: For every simple question there’s a simple answer… and it’s usually wrong. There is no simple answer to this problem. It will require hard work. But it’s not impossible. Let’s look at some ideas…
- Let’s look at each part of the system. Consumers- take some responsibility! Special interests- govt needs to tame them eg Big Pharma Lawyers – end the adversarial legal system Hospitals- reduce waste Insurers – start taking an interest in preventative healthcare / stop ripping off patients & sending them bankrupt Government- change the system – NHS – Oregon – Obamacare 2010 Affordable Care Act
- But what about these guys? The govt can’t change the system if we don’t come to the party
- Let’s be part of the solution. I’d like to offer two simple suggestions:
- Last month I attended a talk by Atul Gawande in Sydney: spruiking his latest book ‘Being Mortal’ and saying that drs need to get a whole lot better at looking the patient in the eye & saying you have 1 year to live. You can’t have everything. What’s important to you? He’s talking about shared care, of course. It’s like hot apple pie, we all agree it’s a good thing. But let’s not do it just on an individual basis… let’s do it with our society. I’m not talking about the death of an individual. I’m talking about the death of a budget. As a profession, doctors need to sit down with all the other players in the system: the consumers, the government, the insurers… We need to hold their hands and look deep into their eyes And say ‘The healthcare budget is heading over a cliff’ ‘Our society can’t afford every new medication and every new intervention for everyone.’ So let’s decide: what shall we ration? Primary healthcare? Scott Weingart’s Intensive care? Cliff Reid’s Helicopters? And how shall we ration it? on the basis of age? Of economic productivity? Or how close you live to a city?
- Last month I attended a talk by Atul Gawande in Sydney: spruiking his latest book ‘Being Mortal’ and saying that drs need to get a whole lot better at looking the patient in the eye & saying you have 1 year to live. You can’t have everything. What’s important to you? He’s talking about shared care, of course. It’s like hot apple pie, we all agree it’s a good thing. But let’s not do it just on an individual basis… let’s do it with our society. I’m not talking about the death of an individual. I’m talking about the death of a budget. As a profession, doctors need to sit down with all the other players in the system: the consumers, the government, the insurers… We need to hold their hands and look deep into their eyes And say ‘The healthcare budget is heading over a cliff’ ‘Our society can’t afford every new medication and every new intervention for everyone.’ So let’s decide: what shall we ration? Primary healthcare? Scott Weingart’s Intensive care? Cliff Reid’s Helicopters? And how shall we ration it? on the basis of age? Of economic productivity? Or how close you live to a city?
- I accept that this sounds like an evil thing to say… and I’m certainly not advocating for any one thing over another- I love intensive care units that fly as much as the next guy. BUT that’s why we need to start talking about this properly As a society Because you know what? Many of us are doing this anyway… as individuals … without adequate training in ethics and health economics …and without any idea about how our decisions affect everyone else in the system. I understand those who say ‘But this has all been tried before and it didn’t work.’ I mentioned the Oregon Health Plan earlier: it was an explicit attempt at system change: expand insurance to cover all the uninsured By rationing healthcare If you look at it one way, it didn’t work: in fact it caused budget blowouts! And for awhile they had to close it to new enrolment (in 2004)… they even tried to bring in a lottery based system (in 2008). Why didn’t it work? A Canadian Med Assocn analysis in 2001 stated that it fell prey to political hacking due to constituency pressures, and from well-intentioned gaming by healthcare providers... In other words, system change doesn’t work unless all the parts of the system come along for the ride. [Oberlander CMAJ 2001] And for all its faults… it boosted health coverage from 86 to 89% at a time when national average fell from 85 to 84%
- Which brings me back… to us. For the system to work, we need to break the ‘can do = will do’ mentality. How about we beef up those items on the Choosing Wisely lists? And how about we make the list mandatory? The basic idea is simple enough: the traffic light system for tests …
- Here’s the list they came up with in POWH ED, in 2004 Green = no restrictions e.g. FBC Amber = senior ED dr signature e.g. D-dimer Red = senior inpatient dr signature e.g. Serum lipids. Tumour markers. Guess how much money they saved? $50K AUD per month [that’s in 2004 dollars] … in one ED … and that’s only with limiting the tests they ordered! What if we included procedures? Some stuff is easy to put in the red zone e.g. narcotics for migraine, abx for the common cold. Some stuff is more controversial and I guess must be helpful in some cases e.g. knee arthroscopy for OA So any list needs to be evidence based & outcome based, and drawn up with the consent of all the stakeholders. And needs to be enforceable!
- So that’s how the elephant can help. Let’s start behaving as though we’re part of a system, and let’s have that ‘end of budget’ discussion with all of society. And let’s break the ‘can do’ = ‘will do’ mentality. It’s not such a bad thing, being more accountable and transparent for our actions. Maybe I’m biased, but let me share my dream with you: the cowboy cardiologist tries to book angio on 99yo with ESRF… and is turned down bc our society said no.
- We need organisations to speak on our behalf. Organisations that are known to be free of bias and self-interest. In Australia, probably best model is the Agency for Clinical Innovation in NSW…(its goal is to use rigorous methodology & collaborate with healthcare providers and consumers to improve the quality, effectiveness and efficiency of services.) In the USA? In Canada? What about SMACC? Is SMACC just for social chatter & free education? Or to help patients? If you FOAMers and tweeters really want to change the world with social media, then take on this issue. Someone needs to start this conversation for real.
- Way too many of my colleagues have contended that left alone, drs will never police themselves. (Middlemarch quotation here) Maybe that’s true. But if it becomes clear that doctors aren’t willing to take on resource stewardship, and to make the tough decisions, then those decisions will be made without us. We aren’t the only health practitioners you know, and the health system can probably exist without us. I’ve been comparing drs to elephants. But maybe I should compare us to dinosaurs. That was another group of huge beasts that thought they’d live forever They didn’t see the asteroid coming… and they were wiped out But we don’t have that excuse. We know what our asteroid will look like.
- As Nick Talley, president of the RACP, said at a recent meeting of EVOLVE, doctors can either lead — or wait to be led.