1. UTS BUSINESS SCHOOL DATA INFORMATION AND SYSTEMS: DRIVING SYSTEM IMPROVEMENTS AND OPTIMAL USE OF RESOURCES Richard De Abreu Lourenco CHERE, UTS

2. DISINVESTMENT IN ACTION…MBS IN FOCUS? “ There's lots of things that are working well. I mean, we do have a world class health system. But there are many things that are not. The key thing is that the MBS, which has some 5,500 items, there's only about 10 per cent of them that have ever been reviewed and removed. From time to time this does happen- items come off and items go on.” 2 Hon. S Ley, ABC Radio, 22/04/15

3. MBS REVIEW  Do we have data to understand what is “working”?  At the population level?  At the patient level?  How do we define working?  How do we take things off the MBS:  Who will pay for services? Patients? States?  How will it impact on health outcomes?

4. THINKING ABOUT INVESTMENT/DISINVESTMENT  Implicit:  Adoption of Clinical Guidelines or new technology leads to attrition of current practice.  Explicit:  Reviews of comparative effectiveness (eg. HTA).  Program budgeting and marginal analysis; what is working and where can we best reallocate resources? 4

5. FORMING COMPARISONS  Making decisions about resource use under conditions of scarcity.  Need data to understand:  choices - alternative ways of allocating resources.  consequences – outcomes (good and bad) of choices made.  opportunity cost – outcomes forgone by using resources in one way compared with another.

6. HTA TO INFORM INVESTMENT AND DISINVESTMENT  Key input to investment decisions; eg. informed by MSAC and PBAC.  Is there value for money in the proposed new drug, intervention or service?  Broadly, compare costs and outcomes of two (or more) approaches to the same problem.

7. HTA TO INFORM INVESTMENT AND DISINVESTMENT  PBAC has capacity to recommend “disinvestment” of listed drugs :  To date limited… antifungal preparations in late 90s, Anakinra for RA in bDMARDs 2010 review.  Changing..new principles for delisting of OTC medicines.  MSAC recommendations have direct implications for investment and disinvestment eg HPV cytology.

8. HPV SCREENING: FUNDING APPROACH TO INVESTMENT/DISINVESTMENT  MSAC recommendation to fund 5-yearly HPV cytology for cervical cancer screening.  Implicit investment decision:  Effectiveness data.  Modelled cost-effectiveness data – compared with current approach.  Result – explicit disinvestment decision (no longer funding biannual pap-smear based screening program).

9. HPV SCREENING: FUNDING APPROACH TO INVESTMENT/DISINVESTMENT  Modelling suggests improved outcomes and costs.  Improved acceptability to women due to lower frequency?  Will this increase participation, or will there be confusion due to existence of HPV vaccines?  Are freed resources being reinvested back into “screening”?

10. BUT THERE IS MORE..  Comparative efficacy and safety only part of the picture.  It might not result in optimal use of resources; we need to understand incentives:  How do current funding arrangements influence behaviour of providers to recommend use?  What about consumers – do we understand their incentives eg. either financial or for reassurance and information?

11. REFORMING MBS.. VolumeQualityReferral rateTimeCost FFS Incentive for high throughput Unclear Disincentive to refer to other practitioners Incentive to reduce time with patients Leads to higher costs for the system Salaries Potential to restrict throughput Unclear Promotes referrals and collaboration Promotes increased time with patients Leads to lower costs for the system CapitationPotential to restrict throughput UnclearPromotes referrals and collaboration Promotes increased time with patients Promotes cost containment  Do we need to change the restriction on access to x- rays for back-pain, or how we pay for services?

12. MBS REFORMS: THE IMPACT OF PAYMENT SYSTEMS…  There are trade-offs in how the different payment systems impact on behaviour and outcomes.  Perhaps…balance increased throughput and service volume against system cost, collaboration and patient interaction.  Can patient desire for reassurance and “health” be ignored as an outcome we are prepared to pay for?

13. MBS REVIEW: A REJOINDER  Do we have data to understand what is “working”?  At the population level? – ? not comparative  At the patient level? – conditional funding; equity?  How do we define working? – patient variability.  How do we take things off the MBS:  Who will pay for services? Patients equity? States cost-shifting/equity?  How will it impact on health outcomes often unknown?

14. AFFECTING CHANGE  Informed by what is happening currently and what is expected to happen.  Are there costs and outcomes beyond the immediate “health” sphere?  Consider the broader institutional context:  What affects the behaviour of providers and consumers?  Could the same goals be achieved by changing the incentives around service provision?

15. HORSES FOR COURSES  There is a place for disinvestment:  Don’t want to keep doing things that are unsafe, ineffective or waste resources.  BUT…  Need to be clear this is the case.  Consider the institutional framework (incentives) within which services are provided.  Might not be the services that are the question, but the incentives driving their provision we want to modify to improve care and resource use.