Four corners “unbalanced” says AMA

The AMA has laid into the controversial Four Corners program, which claimed 30% of the health budget is being wasted on unnecessary tests and procedures, accusing the program of being unbalanced and in places factually incorrect.

In an interview on ABC’s Breakfast show on radio national  AMA president Professor Brian Owler said the program was “somewhat unbalanced” particularly when it came to his areas of expertise such as spinal surgery.

“They went from a discussion of talking about tests to fusion for acute back pain, which is a very rare circumstance, to concluding that all spinal fusions don’t work, which we know is absolutely not the case” he told Fran Kelly.

GPs were also “quite upset” about the program, which suggested they were largely to blame for going against guidelines and referring patients with lower back pain for imaging, Professor Owler said.

The data that comes from Medicare doesn’t say where along the pathway patients were actually referred, he said.

“It doesn’t tell you that they’re first-visit patients that are suddenly being referred off. I mean they may have been seeing their GP over a number of weeks with that particular problem.”

Health Minister Sussan Ley defended the documentary saying eminent medical specialists and health researchers had put their professional reputations on the line to provide important insight into billions of dollars being spent on unnecessary, outdated, inefficient and even potentially harmful procedures for conditions such as back pain, knee pain and heart problems in Australia.

“Last night’s Four Corners program hasn’t come out of the blue; neither has the Federal Government’s review of all 5700 items on the Medicare Benefits Schedule and the rules and regulations around their use”, she said.

Last week the MBS Review Taskforce released two consultation papers. One for a broad audience and another more detailed version which is more directed at organisations and people with expert knowledge of the MBS.

These papers set out the background and context for the MBS Reviews as well as the proposed process for undertaking the reviews, and background on the MBS as well as a focus on some specific important issues.

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You can read  the full transcript of the interview between Professor Owler and Fran Kelly on the ABC’s Breakfast show on Radio National below:

FRAN KELLY:  I wonder what your response was to Norman Swan’s Four Corners report that billions of taxpayer-funded dollars are spent on scans and tests that the evidence shows quite clearly are unnecessary.

BRIAN OWLER: They went from a discussion of talking about tests to fusion for acute back pain, which is a very rare circumstance, to concluding that all spinal fusions don’t work, which we know is absolutely not the case, and there is strong evidence behind spinal fusion, particularly in most of the indications such as instability or severe leg pain.

FRAN KELLY: [Interrupts] So the claim on that issue was, I think, on Four Corners, that we spend each year for Medicare alone $220 million, but the claim is the majority of that money is a complete waste.

BRIAN OWLER: Yeah, so, and I think we’ve got to be very careful about the way that people are talking about the literature that’s out there.

So this figure of 30%, or a third of what we do is unsafe or unnecessary, is factually incorrect. There were two papers from the United States [whose] conclusion was that [there was] probably about 30% of waste in the US healthcare system.

Now, that wasn’t actually just patient care. It included particularly their administrative process, some of their regulatory processes, and somehow that’s now been translated to Australia where, in Australia, even in those papers, they point out that Australia’s healthcare spend is about half that of the United States per capita, and we get much better results.

So, suddenly we’re translating figures that seem to have no, I guess … not able to be translated to the Australian healthcare system, but people seem to be readily doing it.


BRIAN OWLER: And likewise, the Australian papers are very … you know, there’s a paper from the University of Sydney that identified 150 items [as potentially low value]. Now, that’s out of 5700. And in that 150 what they say is that they may be unnecessary or ineffectual in some clinical circumstances, and recommend that they be reviewed.

FRAN KELLY: So they may, that’s the question, they may and are we out- I mean we’re trying to wind back the cost of our public health spend because it is enormous and it is burgeoning. And there’s always a lot of talk about potential over-servicing.

Again going back to the specifics from Four Corners, let’s just stick with back pain for a minute, lower back pain. Do you think it’s appropriate for a GP to refer first-visit patients presenting with acute lower back pain for an X-ray, an MRI, or a CT scan? Is that the right response?

BRIAN OWLER: No, but many GPs don’t. And I think the GPs are quite upset about the program.

FRAN KELLY: But a lot are doing it according to the Medicare Schedule figures though.

BRIAN OWLER: Well, actually the … the data that comes from Medicare doesn’t say which consultation, where along the pathway those patients were actually referred. It doesn’t tell you that they’re first-visit patients that are suddenly being referred off. I mean they may have been seeing their GP over a number of weeks with that particular problem.

So, the Medicare data doesn’t actually tell you those answers, and so to say that GPs are suddenly just referring people off, that’s not what the data actually says. We know that there are a large number of tests that are done, and some of those may be unnecessary; but the MBS is also not the only way that we can actually influence the behaviour and practices of GPs and other health practitioners.

FRAN KELLY: I think it’s important to say, and the [Federal Health] Minister said this on our program and they said it in Four Corners too, that the accusation is not of widespread fraud by doctors. That’s not it.

It’s whether the system of pay for service incentivises tests, or if patients themselves are demanding these tests when they don’t help, and therefore what we do about that.

If we look about the claim on Four Corners for instance that there’s good evidence that stenting, putting stents in for stable angina, is no more effective than medication and lifestyle advice.

What’s your response to that?

BRIAN OWLER: Well I’m not quite sure that — I mean again, that’s a pretty broad sweeping statement. And the accusation was that GPs are incompetent at looking after stable angina, so they had to go and see a cardiologist and get a stent.

Now … I think a lot of GPs have taken exception to that, because as they admitted in the program they have no idea about how many of those patients have actually been treated by their GP before they’ve even been sent to the cardiologist. So, again, it’s taking the data and leaping to a conclusion where a lot of the data is actually missing in the middle.

FRAN KELLY: There’s a lot of interest in this office, in particular about the knees, the findings about knees. Two doctors on Four Corners said it is now proven that arthroscopy to treat knee osteoarthritis in over-50s is no more effective than placebo, but taxpayers spend $215 million a year on these procedures.

Is that fair, and even if it is, is that a fair risk for Australians to pay for through the Medicare system [when] 50-50 you might get it right sometimes? I mean the problem is I guess a doctor doesn’t know which one’s going to work and which one doesn’t.

BRIAN OWLER: Exactly, and the big question is always what’s the alternative? And it may be that’s done before more drastic surgery is undertaken, and it may be that they’ve already had a period of trying to change lifestyle, going through exercise, trying physiotherapy.

I mean, in my own practice I see many patients who have tried all of those things before they actually get to surgery, and you know, it ends up that doesn’t work.

So, look, knee arthroscopy is one of the ones that has been identified, but let me say from the outset that the AMA supports the MBS reviews and have been engaged with the Government doing MBS reviews since 1990.

In the last five years or so, we’ve engaged in reviews of the MBS in 26 areas.

So this is not something that’s new to the AMA. Now we have said that we support the review, and where there are these issues being brought up let’s go through the evidence.

But I do take exception to the way that the narrative has been shaped so that there are these huge areas of savings that are to be had, that people are doing inappropriate practice, and let’s not pre-empt the outcome of the review.

FRAN KELLY: But Dr Owler …

BRIAN OWLER: [Interrupts] I mean, we seem to have jumped to a conclusion without actually having done the review and coming up with the evidence before we make the recommendation.

FRAN KELLY: Is it fair to say, though, that in a public health bill that is so massive, and growing at a rapid rate, there must be room for savings? And what Four Corners was trying to do was to put some of the areas where it looks like there’s room for savings on the table and point to some of the issues.

And one of the issues are that some doctors don’t have confidence in their own practical experience and therefore as a risk management thing they refer on to specialists, and also that consumers, clients, patients want action. So when you say, with the arthroscopy, what’s the alternative, is that the issue here?

That we have to accept, as they said on Four Corners, Norman Swan laid out, that as we age some of our things, parts of us deteriorate and there might not be an answer, and we have to start having that conversation more starkly with patients?

BRIAN OWLER: Yep, but that’s easy for us to say. But if you’re living with debilitating pain and you’re actually not able to walk or mobilise, it’s not long before you get a whole bunch of other health problems as well.

So I don’t think in a 65-year-old saying look you know you can’t walk because of your knee, sorry that’s it, and send you off to live out the rest of your days…walking in a 10 metre radius. I mean that’s not the sort of country that we live in. I mean let’s not forget that we have one of the most effective but also efficient healthcare services in the world.

Our spending’s about 9.8% of GDP. It’s about the average of OECD countries, yet we have the fourth-longest life expectancy. We get excellent outcomes for the amount that we do spend.

Can we save money? Yes, and the AMA’s more than happy to engage in that process, but let’s actually go through and do the reviews and come up with the evidence before we actually pre-empt what the outcome is and what procedures might have conditions or be removed from the Schedule.

FRAN KELLY: Isn’t evidence the key here? I mean I don’t think anyone’s suggesting no treatment, but the desire is for evidence-based treatment and there’s many things on the MBS there that are there that are paid out without evidence base.

BRIAN OWLER: Well, look, there are things that haven’t gone through the evidence process and, again, look, there’s narratives that’s been shaped. There’s 5700 items on the MBS, thereabouts, 3%  have been through the evidence [Medical Services Advisory Committee] process.

But that doesn’t mean that there’s not evidence behind all of the other things that we do, and this doesn’t mean that we actually need to have evidence-based reviews of whether you need a general anaesthetic, whether you need the lifesaving operation.

I don’t need an evidence-based review to say that I should remove the tumour from a child that presents through the emergency department because I know they’re going to end up dead within the week if I don’t do it.

So there are some things that yes, we need to evidence-based review but there are many on the schedule that don’t, and saying that 97% doesn’t have evidence is, I think, quite misleading

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