Clinical input to health financing proposals
The current proposal for a mandatory $7 co-payment for general practice, pathology and diagnostic imaging services, and increasing co-payments for PBS medications, is a timely and topical example of a long-standing problem: the lack of clinical input to health financing proposals and decisions.
Led by the AMA, most public commentary on the co-payment proposal noted that this is not a health policy; it is essentially a financial policy, driven by financial considerations and with a view to financial gains, not health impacts.
As AMA President Associate Professor Brian Owler has said, the AMA is always willing to work with the Government of the day to come up with solutions, but that hasn’t occurred in this case.
A lot of the current co-payment proposal actually goes against the grain of health policy in terms of preventive health care, GPs managing people out of hospital with timely access to diagnostic services, keeping them well and preventing expensive hospital care.
Without genuine clinical input, a purely financial solution for a complex health policy is always a recipe for disaster.
Of course, the co-payment proposal is just the most recent example. Health financing proposals and decisions at all levels have rarely benefited from sufficient clinical consideration and input.
The problem is clear. How can clinical care and clinical perspectives be made a central and mandatory consideration in health financing decisions?
The AMA, by virtue of those it represents, is the most recognised and authoritative voice within the medical profession, particularly in bringing a clinical perspective to bear on issues. It is also a trusted and respected participant in public debates, and its views are regularly sought by the media.
The AMA is exploring how it can most effectively use its authority, and the wealth of clinical expertise of its members, to ensure the clinical perspective is taken as the most important reference point for those making health financing decisions.
One way of considering this issue of clinical input is from the focus of sustainability – can expenditure on health care be sustained at affordable levels into the foreseeable future? If decisions about sustainability don’t include clinical input, we will be left to deal with the health impacts of financial policies.
The broad area of end-of-life care, and the issue of futile care at the end of life, is one area where the issues of health financing sustainability and the potential for clinical input to financing decisions can intersect.
Work across a range of organisations reflects growing awareness of these issues in end-of-life care, including by the Australian and New Zealand Intensive Care Society (ANZICS) and the Australian Commission for Safety and Quality in Health Care (ACSQHC). It is an area that I have a strong interest in given my specialty of emergency medicine. I have also had the privilege of supporting two close family members, whose final months were spent at home enjoying wonderful palliative care. I am determined that other Australians and their loved ones should benefit in similar ways.
Issues of clinical input are being recognised internationally. Canada’s Premiers, meeting as the Council of the Federation, have highlighted the need for a systematic approach to clinical practice guidelines in collaboration with health care providers. They also recognise the need to look at the appropriateness of care, given mounting evidence that some patients receive treatments that may not be best suited to their actual needs. Collaboration between providers and their institutions and organisations can also identify and propose practices that governments may be interested in funding and implementing.
The Charter for the UK’s National Institute for Health and Care Excellence (NICE) includes a responsibility to ensure careful and targeted use of finite resources, with NICE guidance setting out an evidence-based case for investment and disinvestment. All NICE guidance and quality standards are developed by independent committees of experts that include lay members and representatives from clinical practice, public health, social care and, where appropriate, from industry.
The current Budget proposals highlight the need for the AMA to be able to assess and provide clinical advice on health financing proposals. This need applies both in terms of reacting to external proposals and proactively identifying and providing clinical input on health financing changes that we see as required – which could include investment and disinvestment proposals.
While other countries are giving more recognition to the need for clinical input and involvement, there is no overseas model that is a perfect fit for our needs and the specific circumstances of our health system (such as our mix of private and public health care).
We need to consider how this should operate in our context: do we want to take charge and manage this within our profession; or do we look to Government to provide supporting infrastructure and processes, and provide our input through them.
I welcome your ideas and suggestions about areas and priorities where your clinical perspective suggests changes to support sustainable health financing.
This could include your views on areas such as futile end-of-life care, unnecessary red tape, better use of e-health, or other areas of clinical care.
Any suggestions, more broadly, about how the AMA can identify and advise on the clinical impact of financing proposals are also welcome.