30 March 2023

Joining the dots of our fragmented health system

Government Medicare

As a healthcare reformist with experience advancing person-centred care funding overseas, I have helped design systems founded on patient-centred care that yielded remarkable results.

These systems produced decreases in overall health expenditure and rapid improvements in patient care quality indexes.

The reform proposals released by the Strengthening Medicare Taskforce lead toward this. If successful, they will reduce overall general health expenditure and, more importantly, save many lives.

But there are quite a few hurdles to overcome to ensure that value-based, patient-centred care goes live.

My wife recently developed a mobility condition where she finds it difficult to move her fingers and grasp things with her right hand. She also has trouble moving the toes on her right foot and has acquired a slight limp. Her right hand and right foot show minimal visible swelling.

She first entered the health system for this condition via our GP office. The GP couldn’t diagnose her despite sending her for x-rays and other radiology scans like brain CT scans and ultrasounds. He spent no more than 10-20 minutes examining her each time.

The radiologists, with all the scans, ultrasounds and x-rays, could not find anything, nor did her lab work show anything.

After three months, the GP referred my wife to a neurologist and sent her to a physiotherapist while she waited for her specialist appointment. The waiting period to see a neurologist is over three months in Sydney. The cost to Medicare is amassing before any diagnosis is suspected.

My wife had four one-hour appointments with the physiotherapist. Using our MBS schedule, the cost to Medicare and out-of-pocket costs at this point roughly equated to $3500- $4000.

The neurologist (an excellent doctor) made the correct diagnosis after one hour of physical examination and a detailed assessment. My wife, unfortunately, was diagnosed with Parkinson’s.

The timeline was as follows:

  • Three to four months of agonising tests and ineffective remedies paid for by Medicare and out of our pockets.
  • Another three months to see the neurologist.
  • Once in the neurologist’s practice, without any use of reports from the GP, radiologist and physiotherapist, after a 65-minute examination, a final diagnosis of suspected Parkinson’s disease was established. The neurologist’s payment was private; 50% was reimbursable through Medicare.
  • An MRI was ordered, together with a prescription for dopamine enhancement. We needed these to ensure a final diagnosis and obtain the neurologist’s report for her disability pension. The treatment has visibly reduced the rate and intensity of my wife’s symptoms.

However, to add salt to the wound, while the physiotherapist documented my wife’s symptoms to the extent that they matched those of the neurologist, the GP documented her medication (painkillers for osteoarthritis) and nothing more than unexplained mobility issues in the right hand and foot on the specialist referral.

But what if, instead, my wife had choked or fallen backwards, hurt herself and landed in an ED?

The ED heroes, our nurses, would have meticulously assessed her to enable a symptom profile to be entered into a system. The ED doctors would have written further notes via an iPad or a station computer and then triaged my wife as an inpatient for further evaluation by the specialist neurologist on call.

Within one to three days, a diagnosis would have been established, and her medication and additional instructions for ongoing treatment would have been received upon separation.

The total cost to Medicare following this journey would be a diagnosis related group payment with a cost weight of 1, averaging approximately $1100.

And the patient satisfaction outcome? Much better than the actual nightmare pathway we had to go through.

And therein lies the dilemma. Six months of primary care costs roughly double that of a one-day hospital ED and inpatient admission.

So which pathway is best for the patient, which for the providers, and which for the Medicare coffer?

Value-based, patient-centred care allows us to determine the best pathway for the patient. The hospital stay pathway gave the patient the best and the quickest experience at a significantly lower cost than the six months of primary care.

Moreover, the bundling of diagnosis related groups created a barrier for overcharging,  non-essential diagnostic requests and non-essential allied health regimes without a diagnosis being established.

Gee, had I known this, perhaps I would have created a pseudo incident and rushed my wife to the ED.

So, what’s the message of this story?

We have to join the system up –  across all healthcare sectors – and hand this data to our researchers to create bundled payments and incentives for value.

There should be a nationwide inquiry into our healthcare governance across the barriers of independent, state and Commonwealth departments and their executive leadership.

At the same time, we should immediately invest in integrating all clinical and non-clinical data from all health sectors using standardised digital templates. This should be supported with an episode identifier and strong legislation, as well as financial incentives to gain user acceptance.

Let’s get behind the Strengthening Medicare Taskforce and perhaps rename it the Strengthening Healthcare Taskforce.

James Gounaris is a specialist in aligning organisational goals with restructuring and business re-engineering initiatives. He was mentored and schooled by the late George Palmer, one of the founding fathers of introducing Prospective Payment Systems in Australia. His experience includes technical project manager at Palladium LLC (KSA), project manager/consultant at Arcadis, and managing director/advisor to the Secretary, Greek Ministry of Health.

This story was originally posted on LinkedIn, and has been edited and shared with the author’s permission.

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Silvia Pfeiffer
Silvia Pfeiffer
1 year 2 months ago

An even shorter and cheaper pathway would be for the GP, realising they didn’t have the knowledge to diagnose this patient, sending her to the neurologist straight away and the neurologist not to have a 3 months waiting queue. That would have been roughly half the cost of a day in hospital. I believe that’s the goal we have to target.

How can we unclog specialist waiting queues (e.g. do we need to allow more neurologists in this country?) and how can we upskill GPs to refer faster (maybe they would if the waiting times weren’t that long).