Technology and backs

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Medical administration is a rewarding profession, but it comes with challenges. So what is it like and what should you do if confronted with a monumental administrative difficulty? This is the podcast that takes unfortunate scenarios and explores the essentials of clinical governance to find solutions. I'm Dr. David Rankin. A very experienced medical administrator and lead fellow with the Royal Australasian College of Medical Administrators. And this is Safeguarding. The essentials of clearing.

Today, technology Is there a potential conflict of interest with the surgeon, particularly with how they've approached this scenario and the fact that they are quite aggressive with presenting the facts? That's Dr. Emily Kirkpatrick, an experienced medical leader, board director, specialist general practitioner, and academic. She recently launched Ecology Health, a management consulting.

And I'm presenting her with a difficult scenario. There really is no single correct number as to how we can determine what is the right rate of intervention that we see. In today's scenario, you are the Executive Director of Medical Services at a large private hospital and you're asked to review a business case for a new robot that will assist in spinal fusion surgery.

You're aware that spinal fusion surgery has been strongly criticized for being low value, particularly when used to treat chronic low back pain. You're aware that the rate of spinal fusion in adults in the US is ten times higher than in the UK. In Australia, it is four times higher in Tasmania than in South Australia, with more than fivefold variation in different parts of New South Wales. On a population basis, spinal fusion is five times more frequent in private hospitals than in public.

When you approach the neurosurgeon who is championing this new robot, they aggressively respond that the research is simply wrong. However, they make a substantial income from their spinal surgery practice. They point out that the robot will be one of the first in Australia and will give the hospital a significant marketing advantage. The hospital does very well financially from spinal fusions.

Emily, I'd like to start off by asking what concerns the scenario raises for you. We know that evidence suggests that spinal fusion has low effectiveness, particularly for non-specific back pain. And this particular scenario for me raises really three key issues. The first thing is the hospital prioritising financial gain over patient outcomes?

The second for this really is is there a potential conflict of interest with the surgeon, particularly with how they've approached this scenario and the fact that they are quite aggressive with presenting the facts and discounting the evidence?

And finally, it does raise an issue for me around marketing and particularly when we see this marketing versus medicine concept, acquiring new technology for competitive branding. And while it may be lucrative as it's been described, Does it align to ethical care or population health outcomes? So let's have a look at the statistics. Why do we see such significant variation? I mean, why is spinal fusion five times more common in the US than the UK?

Why is it far more common in private hospitals in Australia than public? So what drives this extraordinary variation? There certainly is clinical variation across our community and it's as you said, it's an international issue where we see differences in healthcare processes or outcomes compared to peers. And particularly if we think about clinical variation first, where we know that

It's about variation from the gold standard based on an evidence-based guideline. We see that professional autonomy and individualism can really be important drivers of variation. But also on that there's different reasons why we see a shift. And if we look at the US versus the Australian concept here, we know that reimbursement models are a significant factor in this and particularly

fee for service where it rewards volume, not necessarily value. And private systems may see higher intervention rates due to the different funding models that sit across their particular health systems. We also know that cultural norms can be a factor here as well. And surgeons who are trained in a high use environment may perceive that frequent intervention is in fact standard practice for their specialty.

And then we also know that patient demand and misinformation can be a driver of where we see discrepancies between different countries. And patients may seek surgery after they've exhausted so many other options, but also may have been influenced by the media or anecdotal success stories.

So how do we tell wh what's too high and what's too low? I mean, is the US intervention rate the right intervention rate? Is the UK suppressing you know, is Tasmania got the right rate or is New South Wales got the right? How do we tell what's the correct rate? Oh, that's a great question. There really is no single correct number as to how we can determine what is the right rate of intervention that we see, which is why we need tools that really benchmark across jurisdictions and providers.

And we're fortunate in Australia to have the Australian Atlas of Healthcare variation through the national commission, which allows us really to understand better where there may be discrepancies in some of those rates. And it is important that we do have population health or match data sets that enable us to understand what potentially is a too high or too low rate, but they're

is not a right number. We do need to take into account that we are risk adjusting all the time based on our peers, what region we're in. And now we know that in fact patient reported outcome measures are fundamental when it comes to understanding what that rate is and where we can better adjust based on a patient or person centred care model. So this brings us to this whole idea of value. What is value? How do we know if we're getting value for our health dollar?

There's so much talk about value and it's often used as a buzzword I find, particularly across hospital services with clinicians. So I think if we go back to what the definition is around value-based healthcare. It's important for us to be clear, it's not about denying care. It's about ensuring that early intervention delivers meaningful outcomes for patients relative to the resources used.

And in particular, if we reflect on this scenario in the private system where profitability and innovation can sometimes overshadow appropriateness. We need to ask this simple question, is this intervention truly in the best interests of the patient? And that's how I approach generally a value concept.

coming back to person-centred or patient-centred care and being clear around what is the best interest of that patient. The challenge is that hospitals very seldom track their patients after discharge. We track hospital acquired complication rates, we retrack readmission rates, but we really very seldom ask the patient six months later, did your intervention in hospital improve your life?

What is the role of for the hospital in you talked about patient reported outcome measures. Should hospitals be checking on the outcome for the patients that they've operated on? Well, hospitals should really be accountable for long term patient outcomes, particularly when we see

high cost or high risk procedures being performed. It does you know, provide the need for clinicians and the hospitals together to understand what is the broader risk and are we undertaking reflective practice in terms of the procedures we're performing.

We do know that national and hospital level registries are very important for providing longitudinal insights. And particularly I do wonder if there's greater scope for the colleges and in particular the College of Surgeons to take a stronger role in terms of registries and outcome data that we see across the population here in Australia, for instance. So it is a challenge around who is actually responsible for that in terms of the clinician, the hospital or regulatory bodies as well.

I think it's important for us as a collective to be really clear that if we start to understand longer term outcomes, that will improve our practice. And if we come back to what is value and health outcomes over delivering of the cost of those particular services.

we can then start to work through and go, actually, are we measuring outcomes? So patient reported outcome measures and patient reported experience measures and how are these embedded into routine care, both postoperatively, but also from a longitudinal perspective when we look six, twelve months. two years down the track. So I think there is a role for the hospitals to really focus on long-term benefits and how that impacts delivering safe and value-based healthcare.

That raises an interesting question, is whose responsibility is it for defining and perhaps constraining value? I mean is it the federal government? who funds directly or indirectly. They certainly fund the Commission on Safety and Quality and Healthcare. Is it the state who funds the hospital? Is it the health insurers who pay the private hospitals? Is it the hospital itself? Is it the surgeon who should be taking responsibility for delivering this value?

What you've described, David, is a very complex funding system and I think we know Australia is really complicated in terms of how it is funded. We do have the federal government which sets the funding policy broadly through MBS reform, but also we know private health insurance legislation has a significant impact and in this scenario again raises a red flag around where the private health space really is.

pushing some of this agenda and where we need to come back to value and value based healthcare. We know the states as well are ensuring that public systems are delivering evidence-based equitable care, often under an activity-based funding model. Hospitals having that key stewardship role, particularly around not just

to do right things, but to do the right things at the right time aligned to person centered care. And then finally we know that clinicians have a key role here as well as custodians of evidence based practice. So when we start to bring in health insurers, the hospitals, the federal government funding, the state funding, it gets really complicated.

And we do know that as a collective, we need to be focused on where patient outcomes are really driving our health system to deliver better for our patients. You mentioned the issue of finance earlier. Finance is such a significant driver of treatment choice. Particularly at the interface between the surgeon who gets direct reimbursement for what they do, the private health insurer in a private hospital. What sort of financial mechanisms do we have to try and drive value?

Value and reform are really fundamental in this area, particularly if we look at where opportunities are under MBS IT numbers, for instance. to remove or restrict funding for low value procedures. And I suspect we'll see more and more movement in that space around funding linked to value based healthcare.

We also know that bundle payments and when we have linked payments for episodes of care and patient outcomes, we've seen really strong evidence that that can be a fundamental reform lever that can be used. And we finally also know that private health insurance contracting can both incentivise high performing hospitals and surgeons and particularly clinicians who are working in no gap models.

And there's opportunities I think more and more to see how we can use private health insurance as a lever and particularly the contracting of clinicians and hospital services. in being able to drive some of these changes that we need to be able to focus more on value and better patient outcomes.

That can be a real quandary because the surgeon can be a very strong advocate for the patient. In a past life, working with a health insurer, we tried to suppress cosmetics. type procedures which were not officially funded by the health insurer. And so we put in prior approval criteria. It took about six weeks for the surgeons to learn what the prior approval criteria were and include the right words. in all of their applications. So at the end of the day it made no difference.

How do we try and get this almost moral constraint on surgeons who are incentivized to undertake procedures that may be lower value? Well it's really interesting if we think about ethics and where moral judgment comes into this space as well and the obligation that we know as clinicians to provide informed choice and that is not only about informed consent when then deciding to proceed with the procedure but really understanding what that means for the patient using decision aids

What are the realistic expectations that a patient will have post a procedure or any form of intervention? And it is important, I think, as clinicians that we understand our obligation to provide informed choice. And in the particular scenario when we look at chronic back pain, which you know is a great example of where we see conservative options are fundamental to support holistic multidisciplinary care, particularly physiotherapy. We know now more about pain programmes.

and cognitive behaviour therapy as well, that these must be clearly presented. Now that can be a challenge for a surgeon who's got a particular scope of practice. where they're focused on what they can deliver for the patient with a particular intervention. And so we do need to ensure our clinicians have access to the resources but also referral opportunities to work in a more interprofessional environment. so that patients can both understand potential benefits

but also the real risks of proceeding with surgery when there may be other options that are best for that particular patient. And we saw that through the Choosing Wisely campaign, which was fundamental in Australia to change the behaviours around how clinicians were approaching particular treatment options and we're seeing that now with a shift towards the Australian Commission moving now on Better Care Everywhere initiative.

And I think we're going to see more and more in that way, David, around where clinicians are encouraged and incentivized to work in that team environment to support holistic person centred care.

That raises one of the tragedies, I guess, in the Australian health system is the lack of integration. Private health insurers are precluded from funding preventative measures in relation to hospital services, so there's no incentive or even capability for the private hospital to ensure that all the patients with low back pain who come forward for surgery have had intensive physiotherapy before they come are promoted for surgery.

Any thoughts on how we might develop a more integrated service to deliver value? Well, we've talked a little bit about governance levers in a sense of the funding that sits across some of the health services, and we do know more and more that if we can link funding to best practice and to patient outcomes. Then there is a real opportunity. We also know that if we're more transparent and particularly we use our performance data in different ways, that we can then help to

shift and push change in this space. And certainly my feedback and my experience working now with a number of boards is that we see clinical governance, performance metrics and quality data is really driving a shift and change. in how clinicians are approaching their own individual practice, but also in peer influence as well, where we know that we're seeing respected clinicians changing their practice or championing for change.

and using that peer influence piece. So there are many levers we can start to use in this space. But a lot of this will come down to transparency and we continue to see silos and how we deliver care and not through that interprofessional model that we know is so strong in improving person centered care and outcomes.

So let's move back to the surgeon. The surgeon said the research is simply wrong. You've looked at the research, you're pretty convinced that it's robust, that the evidence really does point to low value in spinal surgery for people, particularly people with chronic low back pain. How do you approach the surgeon?

It's a real challenge, particularly when you have an expert in their field presenting to a committee and We do need to acknowledge their expertise and be clear this is a safe and respectful place where we do want to see ideas, new business development coming up for discussion, but also What is the evidence and where is the organization's values here? Inviting them to have a more structured discussion outside of the committee in a less confrontational space.

and discussing around peer review where there's opportunities to benchmark What's the broader organisational values here? And where does shared decision making also come into some of these discussions as well? So taking the conversation away and working through it. with the surgeon around their expertise, ensuring they're valued, but also coming back to what is in the best interest of the patient and for the organisation as a whole and our values.

You talked about the impact of peers and discussion and we certainly saw that in arthroscopy of the knee where champions out of Sydney University worked very strongly. with their orthopaedic colleagues and managed to quite substantially reduce the rate of arthroscopy of the knee.

How would you go about facilitating or encouraging a similar process for spinal fusion? It's a great question if we look at peer influence, particularly if we can leverage the expertise of others we know that has a powerful, powerful impact. I'd really want to make sure that we have strong audit and feedback mechanisms in place. And particularly are we providing individual surgeons in our facility and in our service?

with outcome data to help compare both their outcomes with their peers but also benchmarking data on a national or international basis.

And it is a challenge for private health and for private hospitals to have strong benchmarking data that links across like facilities. And I think that's something whereby we can do better as a country to support some of these discussions and particularly where do we see registry data to be able to better inform some of these discussions around outcomes but also on low value procedures across a number of different subspecialties.

The other area that I strongly do believe that we need to be using our influence and pushing here is around data, as I mentioned. And often it's about bringing that data back to the clinicians, enabling to have these peer-to-peer discussions. and supporting them in understanding where their data sits, where the opportunities are and how patient outcomes are really being driven by the performance in our health service.

You've also got your chief executive, who's probably most focused on the financial performance. of the hospital. Here's a high margin intervention that they're quite keen to champion. How do you influence the chief executive? always a challenge when you have uh financial performance driving and really sort of pushing you to sort of think and push into different ways that you don't necessarily feel comfortable with.

And we saw this with the example of we could be a leading hospital in this scenario for the nation if we were the first to have this particular approach. So we do need to then come back to the discussion around where we see clinical governance and corporate governance align with our financial incentives.

and strong medical leadership and strong clinical leadership is fundamental to come back to value based healthcare and where we see patient outcomes really improved and delivering for our community and we see the clinicians working hand in hand. So influence comes down to data and where we can use data to drive those decisions. And if we can start to really drive and benchmark some of this, it's incredible where you do see executives really come on board when they can see an improvement.

reduction in clinical variation, therefore reduced length of stay, improved metrics overall financially. you then see a real shift often in perspective. So I'm a big believer in data, David, and where we see that can be used to influence and drive these executive conversations so that we do get person-centred best practice healthcare for our patients.

Thanks Emily. Clinical governance is all about quality and safety. This includes making sure that the right patient gets the right treatment at the right time. or a value focused approach. How do we move Australia away from the almost purely financial target? to this value based outcomes versus cost equation across our population. If we don't have embedded clinical governance or specific key performance indicators,

in our service level agreements, we are going to really struggle to move toward more value-based healthcare. And we have to then also come back to say, how are our values as a health service aligning with a more value-based approach to healthcare? And then where I'm seeing really a really big movement and change is around lived experience and consumer import into driving and co-creating new models of care.

We have to think about how we are more transparent and support patient-reported outcomes and patient-reported experience measures, driving a shift and change towards value-based healthcare. It's about empowering patients that they can receive. high quality care that is aligned to what their best interests are Thank you very much, Emily, for the time. It is an extraordinarily complex issue moving from procedure-based to outcome-based metrics.

Collecting data and making sure we get the best treatment to our patients. Thank you very much for your time. Thank you. That was Dr. Emily Kirkpatrick from Ecology. And that brings us to the end of this episode of Safeguarding Home. I'm Dr. David Rainkin. Follow safeguarding healthcare free on Apple Podcasts, Google Podcasts, Spotify, or wherever you listen to podcasts. This podcast is produced by Sound Cartel for the Royal Australasian Administrator.