Identifying existing health care services that do not provide value for money

In Australia, one projection of total health expenditure (in 2002–03 dollars) envisages an increase from $71.4 billion in 2002–03 to $162.3 billion in 2032–33.1 As a proportion of total gross domestic product (GDP), this represents an increase from 9.4% in 2002–03 to 10.8% in 2032–331 — an annual growth of 0.5% above the overall economic growth rate. Coupled with this projected increase in cost are concerns for the sustainability and quality of the Australian health care system.2 Debate continues on issues such as hospital emergency and surgery waiting lists, models of funding and care, pharmaceutical benefit subsidies, workforce shortages, Indigenous health disadvantage and the role of primary prevention — to name but a few.

To address the problems, federal and state/territory jurisdictions have several options, including accepting the increase in the proportion of GDP allocated to health care expenditure, thereby constraining spending in other portfolios, such as education and defence. However, we propose that potential exists for a cost-saving or cost-neutral agenda of resource reallocation within the existing health budget, aimed at improving the quality of care and health outcomes. In Australia, there is scope to identify ineffective interventions (relative to the cost of their subsidy by the taxpayer) and to assess the potential for reducing their use or removing them from government and insurance funding schedules. This would allow reallocation of funding to interventions and programs that offer more in terms of overall health gain and (cost-) effectiveness. As the resources available for health care are finite, this would reduce the extent of unnecessary suffering and premature death arising from the use of health technologies and practices that deliver less than the best-available value for money.3,4

Here, we propose a dedicated program in Australian health policy that explicitly supports this undertaking. Internationally, the process has been referred to as “disinvestment”,5-7 although it perhaps aligns better with notions of displacement and reallocation, or reinvestment. In the United Kingdom, disinvestment has been adopted by the National Health Service — utilising the services of the National Institute for Health and Clinical Excellence (NICE) — as a formal policy entitled “optimal practice reviews”.8 Spain, France and Canada are also considering, or have adopted, similar formal policy initiatives.

These countries recognise that the strategy offers promise in the face of ageing populations, increasing chronic disease, and the ensuing strain on health care sustainability. It also appears ethical to strive for appropriate, high-quality and effective care for the populations (and taxpayers), served at a cost they can afford. Finally, this strategy aligns with one of the “top ideas” developed from the long-term health strategy stream of the Australia 2020 Summit:

A policy of identifying and assessing ineffective or non-cost-effective practices, reducing their existing use (and redirecting those resources) undoubtedly represents an option for improving sustainability and quality in health care. However, Australia has a poor track record in achieving this, particularly outside the area of pharmaceutical assessment.5-7 A significant challenge is the need for, and requisite development of, a fair and systematic method to identify practices for which assessment is appropriate, based on an agreed framework.7 Failure to undertake this in a systematic and transparent manner has the potential to entrench stakeholder resistance. Mechanisms already exist to identify interventions that can be demonstrated to be harmful or ineffective before they are adopted in Australia. As well as enhancing and extending these mechanisms to consider interventions in current use, a further step would be to identify interventions that, although safe and effective, are not sufficiently cost-effective to warrant widespread use in routine practice.

Box 1 lists examples from a 2008 report from the Institute of Medicine in the United States of widely adopted health interventions now deemed “ineffective or harmful”,10 although arguably the list focuses on those that are harmful. Additional items are shown in Box 2 where the concern is less about safety and more about clinical and cost-effectiveness — although in some cases these cannot readily be separated. This list is not exhaustive, nor do we infer judgement of (in)effectiveness or cost-ineffectiveness. Rather, as these practices have been debated in recent peer-reviewed publications, we present them as potential candidates for assessment.

Items listed in Box 2 have attracted much debate regarding whether (or to what extent) their use is justified in modern, subsidised health care. To ensure a maximally productive debate, any process for selecting health care practices with a view to evaluating them for displacement should follow a protocol with pre-specified, transparent selection criteria.

In the field of health technology assessment (HTA), criteria have been developed for determining priorities for assessing individual new or emerging health interventions. In Box 3, we build on these criteria to propose a framework to facilitate systematic and transparent identification of existing, potentially cost-ineffective practices. The categories in this framework are a guide for identifying technologies that warrant evaluation. Box 4 explores criteria that might inform the prioritisation of candidates for detailed assessment.

Two key questions remain. First, who should be responsible for funding, oversight, assessment, decision making, and implementation in this process? Second, after selection, assessment and a decision, should reductions in use be sought through the development and implementation of clinical practice guidelines and/or through policy-guided controls (leverage) on reimbursement drivers (such as removing or restricting item numbers, or tightening indications)? A complication is the reality of multiple funding sources in Australia, including federal, state/territory and private health insurers.

In a recent qualitative investigation, a group of Australian policy stakeholders suggested that responsibility is best situated within an expanded Medical Services Advisory Committee (MSAC) or parallel committee.7 The process for assessing new practices and technologies for listing on the Medicare Benefits Schedule is seen as a foundation for this new undertaking.23 This responsibility sits within the mandate of the MSAC — to advise the Minister for Health and Ageing on evidence for safety and (cost)-effectiveness of medical technologies and procedures. However, the considerable workload of this committee in assessing new technologies limits its activity in assessing existing items.7 Some also include the National Institute of Clinical Studies and the Australian Commission on Safety and Quality in Health Care as having important roles in this process, as well as state health departments. Southern Health, the largest health network in Victoria, is currently exploring these processes within the local health service setting.

To prevent duplication, the process could be jointly funded by all relevant stakeholders but centrally administered. HTA groups could be resourced to undertake the identification and assessment processes and to liaise with clinicians, consumers and funding stakeholders, who would direct which practices take priority for assessment. Further, we propose that proponents of identified technologies carry the burden of providing sufficient (new or revised) evidence of cost-effectiveness in order to have continued government funding, as occurs under current review processes for pharmaceutical benefits.

While some items listed in Box 3 are used in HTA for identifying and assessing new practices, the criteria framework outlined has not yet been tested for existing practices with questionable cost-effectiveness. There is, therefore, scope for it to be tested and evaluated for impact and outcome, and for marginal analyses of benefits derived from the implied resource reallocation.24 There is a need for empirical investigation to identify categories that best identify technologies ripe for disinvestment, and to shape decision rules for prioritisation. These analyses must incorporate the complexities of assessing practices and technologies that have existed for some time within the health care system, as opposed to assessing new technologies.6

We can sometimes improve the health system by making it more efficient and accountable, and enhancing quality of care, without necessarily asking for additional resources. A recent report into disinvestment planning by NICE showed that there are risks associated with identifying practices and technologies as ineffective in some circumstances, suggesting that there may have been considerable training and infrastructure development, and that some stakeholders may prefer that the status quo be maintained.25 The report concludes that “these are not reasons not to ask the difficult questions nor to shy away from making unpopular recommendations”. Given these sensitivities, a framework such as the one proposed here may improve consultation, transparency and overall governance.

If governments, the professions and the community really want and expect a “better” health system, then it is time to start asking questions about resource reallocation, in a spirit of transparency, with an explicit statement of values, and supported by a systematic and evidence-informed framework. The answers have the potential to enhance the sustainability and quality of health care.