Wednesday, February 13, 2013

Hospital Blame Game: Fixable or Just Not Possible?

A reaction to an ABC report on 10% budget cuts in Victorian hospitals.

"Federal and State governments in hospital cuts blame game"

There are 3 systems effects that as yet have been ignored by Hospital Administrators and Politicians:
  • "stitch in time" funding to avoid increasing total costs by over-waiting
  • reduce budgets by dropping the least vital work. "cut floors, not corners"
  • "Don't throw good money after bad", reduce spending where patient lifestyle affects outcomes and they won't change.

There are two healthcare systems in crisis that we don't want to follow: USA & UK:
  • the USA spends 18% of it's GDP on Healthcare and gets the worst outcomes globally on all scores but "rescue care"
  • The UK's public health costs 7-9% of GDP, like ours, but underservices people by maintaining excessive waiting lists, resulting in massive avoidable complication rates or death.
If we as a community don't actively choose what & how we spend our health dollar on, we'll end up in one of these end-game scenarios:
  • unlimited money spent on Healthcare, or
  • very poor value-for-money and systemic avoidable injuries and death.

1. 'Stitch in Time'.
Conditions that worsen with time HAVE to be treated quickly to reduce total health care costs. The UK has had to confront this lesson.

Converting a $5-10,000 procedure into $50-500,000 is Bad Business and Bad Management, especially when the system makes the promise "Turn up in Emergency Room in real trouble and you'll get fixed, not matter what it costs".

The Hostpitals might "not have the money" to correct simple conditions quickly, but they certainly don't have the money to pay for the inevitable complications that increase the total demand and blow their budget.

2. Budgeting 101:
You spend less by cutting things out & keeping essentials, not by skimping on everything.
One of the principles behind the Oregon Healthcare Plan (OHP), is that the system-wide costs of service delivery were computed and prioritised by Community Benefit. Spending $250,000 saving the life of an 85yo might be heroic, but is of less community benefit than spending $500,000 to
save a 30yo parent.

Every person on a fixed-income viscerally knows this:
When money is tight, you have to chose "what won't I spend money on?"
You have to draw a line and say "we can't afford this, even if we'd like it".
If it's a choice between eating and paying rent, you live on the streets.

The Politicians must set this policy and allow/make the Administrators to budget like this.
Doctors have to learn to say "Sorry, but your condition is not covered by Public Funding".

3. Throwing Good Money after Bad...
If people make Lifestyle choices to not improve their conditions, they are NOT entitled to unlimited Public Funding.

Another principle of the OHP is that "non-compliant" patients don't get unlimited public funding. If you have a heart condition and get surgery but then WONT give up smoking, change your diet and exercise, then for your next heart attack, your treatment options will be severely limited.

If you don't choose to look after yourself, then why do you expect unlimited Public Funding?

The flipside is that extraordinary levels of help, support and non-medical programs are available for people that are willing to address their underlying health issues.
For obese patients that want to lose weight and address many chronic conditions (heart disease, diabetes, stroke, ...), there are very well funded programs, including free on-going psychological support for them: with the caveat - funding only continues while you continue to lose weight.

Yes, the Federal Government is to Blame for changing its promises mid-year.

But the state Healthcare systems, especially Victoria, are equally, or more culpable, for not making hard decisions and having the courage to have a difficult public conversation that starts, "We cannot afford all possible care for everyone, now what do we do?"

One place to start is by discussing "End of Life Care".

Over 50% of lifetime healthcare costs per person are spent on their final treatment. There is no dignity or respect in dying unconscious in Intensive Care surrounded by strangers, nor can unlimited piles of cash do more than prolong this not-really-living by more hours, days or weeks. It benefits nobody but those selling the expensive inputs to the system, not the healthcare staff, not the patients and certainly not the families. So, who decided we'd do this?? "Mr Nobody?"

Australia has better, cheaper and more accessible healthcare than the USA and a better Public Health system than the UK.
It is NOT the best Healthcare system in the word and can be improved.

BUT, we are renowned for 'thinking outside the box', being prepared to ask hard questions and to take on vested interests, like Big Parma with the PBS.

We need to act before all the wheels come off.

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