Only The Sangfroid

Mark is of fair average intelligence, who is neither perverse, nor morbid or suspicious of mind, nor avid for scandal. He does live in an ivory tower.

These are his draft thoughts…

Quick Post: How far off base was Four Corners’ ‘Wasted’ about health costs?

With breathtaking speed, ABC’s Four Corners went from a statement with which nearly everybody agrees — there’s waste in the healthcare system — to assertions and arguments so bizarre and random that they would feel more at home in a History Channel documentary about how aliens built the pyramids.  Where last year the claim was that waste was caused by too many poor people getting free healthcare (solvable only with a $5 co-payment), ‘Wasted‘ argues that the waste is caused by GPs ordering too many unnecessary tests.  We spend eleventy gajillion dollars on healthcare and maybe up to spleventy bajillion of that is wasted on unnecessary and possibly dangerous and clinically unproven procedures.

At the first hurdle, these numbers don’t actually mean anything but they seem scary.  Depending on how you interpret the various terms — what’s included in our spend on healthcare and what isn’t?  — you get wildly different numbers.  Further, nobody really agrees on what an ‘unnecessary’ procedure is, and it’s not possible to reverse engineer their numbers to work out what they’re including as an unnecessary procedure.

There’s a reason why everything seems a bit flimsy and thin: ‘Wasted’ doesn’t cite anything heavy hitting.  On the website, the ‘Background Information’ is mostly sensationalist news articles.  Excluding the section ‘news coverage’, there are ten links for further information about the claims made; five of these are more news articles.  The other links don’t have enough weight to substantiate the very courageous claims made in the programme.  So we just have to take people’s word for it: maybe a third of the healthcare budget is being wasted… trust us.

The core analogy of the programme was a train journey.  Healthcare is a bit like a journey, we are told, where you go through diagnosis and treatment to arrive at health again.  But what happens if your GP puts you on the wrong train?!

The problem is that this suggest some sort of linear process — like a train journey — to a very specific destination — like a train station.  But healthcare isn’t like this at all.  Five different GPs might put you on five different trains and they’d all be clinically correct to do so.  Being a good GP is being able to use professional (personal) judgement to make subjective calls about complex issues.  This approach is outright disparaged by one of the talking heads on the programme who criticises GPs for using their personal opinions…

So is an unnecessary procedure one that doesn’t reveal a health condition?  Clearly not.  When my stomach erupted last year and I was rushed to hospital, we did a number of tests to rule things out.  If the doctor didn’t put me on every one of those trains, would they have been a better doctor?  Was I subjected to a whole lot of invasive, unnecessary treatments simply because they didn’t determine what was wrong?

On the other hand, it would have been wrong if I had been subjected to procedures that were irrelevant to my symptoms, if my doctor had ordered tests that no competent practicing doctor would have ordered.  I’m not a competent practicing doctor, so how would I know?

Fortunately, the Medical Benefits Scheme (MBS) system has an inbuilt detector for doctors who order unnecessary (in this specialised sense) tests.  It is assumed that every doctor with a similar caseload of patients will have a similar billing profile.  So Drs McCoy, Xavier, and Zaius should all see the same number of coughs, colds, knee injuries, back injuries, bumps, cuts, and babies.  If Dr Zaius is ordering knee scans a higher rate than McCoy and Xavier, the system spots him and notifies him that something looks quirky with his billing profile.  If it continues to look quirky, he is asked to submit his patient files to a panel of other doctors who will assess whether his practices are consistent with the practices of other competent, practicing doctors.  This is known as Professional Services Review (PSR).

So was ‘Wasted’ claiming that the PSR process wasn’t picking up unnecessary (in any sense) procedures?  We don’t know.  Over on Twitter, I got a few messages from somebody who appeared to be a researcher for the programme but he didn’t know anything about PSR.  This is but one of the many problems when journalists pretend to be policy experts; some areas of policy are extremely complex…

The programme would make a number of very odd statements about the MBS, including the claim that many were ‘clinically unproven’.  Let’s choose a simple case.  MBS billing number ‘3’ is a consultation by a GP at a consultation room ‘used for obvious and straightforward cases’.  So how would you clinically prove that?  It makes literally zero sense to state that all MBS billing numbers should be ‘clinically proven’ because many of them (all 187 pages of Category One billing codes, for example) are professional attendances.  The Four Corners researchers probably would have noticed that if they’d just looked at it.

The show made a number of contentious remarks in a way that suggested they were irrefutable facts.  The most glaring of these was the prostate check discussion.  For a number of years, sensible, rational, and well meaning people have disagreed vehemently on the correct approach to screening for prostate cancer.  Some groups claim that it’s essential to get checked for cancer regularly, while others claim that this is unnecessary and increases the rate of false positives.  The show claimed that the procedure was obviously unnecessary and another example of waste.

The show also made several comments about the value of early detection and prevention, claiming that a lot of waste was due to a recent focus on early intervention.  Again, this depends more upon your intuitions about medicine, and sensible, rational, and well meaning people disagree on this.

The show also repeated the comment that GPs were referring people for tests when they were ‘uncertain’.  Call me crazy, but if my GP doesn’t know what’s wrong with me and I’m complaining about some kind of persistent ailment, I’d prefer it if they’d refer me for some tests to find out what’s wrong with me.

Ultimately, the programme grounded itself on the mantra of conspiracy theorists: each individual person should distrust expertise and make sure the experts explained things to them first.  We will remember that this is the same reasoning behind most climate change denialism and the rallying call of the ‘Wind Turbines Gave Me AIDS’ crowds.  I don’t have a degree in medicine.  My doctor does.  If there’s a question about what procedures I need to have undertaken, he’s going to have a better idea than me.

If you don’t trust your doctor, find a new doctor.  For some people, that’s harder than others.  Rural areas have very limited numbers of doctors (when I was a kid, we had to travel to the next town to find a doctor that the family trusted) and people in poorer socioeconomic situations need to rely on bulk billing doctors who are increasingly scarce.

But we live in a world where people are disregarding the advice of their doctors because they went home, consulted Dr Google, and decided the doctor got it wrong.  Why on Earth is the ABC encouraging people to challenge the expertise of their GPs?

‘Wasted’ was poorly researched, poorly argued, and poorly executed.  When the presenter opined that umpty quingillion dollars was being wasted on a particular procedure and rhetorically asked if we’d prefer that money to go towards suicide prevention, I couldn’t help but think I’d have preferred the budget of Four Corners to go to suicide prevention as well.  That’s the problem with this kind of argument: there’s always something else on which we’d prefer the money to be spent.

Four Corners failed to identify any waste in the MBS and failed to give the public an insight into the current discussions and debates about the future of healthcare funding in Australia.  Everybody involved should be ashamed of themselves.

2 responses to “Quick Post: How far off base was Four Corners’ ‘Wasted’ about health costs?”

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