(Ref:  Challenges in Australia policy processes for disinvestment from existing, ineffective healthcare practices, 31/10/2007, Adam G Elshaug, Janet E Hiller,  Sean R Tunis, John R Moss,

Australia & New Zealand Health Policy 2007 4..23)

1.       A leading advocate for healthcare disinvestment in Australia is A/Prof Adam Elshaug [also a member of the MBS Review Committee], a public health academic currently with the University of Sydney and the Menzies Centre for Health Policy. He was also a guest on the recent ABC Four Corners program entitled, Wasted.

2.       The paper is written in collaboration with Prof Janet Hiller of the Adelaide Health Technology Assessment (AHTA) which contracts to complete health evaluations in new technologies, A/Prof John R Moss who provides health technology assessments to the Australia Government, Dr Sean Tunis who is Founder and Director of the Centre of Medical Technology Policy in San Francisco.

3.       The premise is that although considerable effort and resources are invested in Australia in developing “well defined criteria and evidenced based policy processes for assessing new and emerging health technologies, surgical procedures and pharmaceuticals, the same processes are not used for existing services (even though this is within the mandate concept).

4.       The authors claim “a lack of published studies that clearly demonstrate that existing technologies/practices provide little or no benefit” and that “the bearer of financial risk for the cost of healthcare perhaps has the greatest incentive to drive a disinvestment agenda”.

5.       The authors also claim “adding an item to the schedule of benefits (or its equivalent in international terms) is beholden to the “balance of probabilities standard whereas removal of an item requires a standard of evidence that is beyond a reasonable doubt.”

6.       A/Prof Elshaug  maintains “in Australia we therefore appear to be stuck with the old and overwhelmed by the new” and in order to overcome this limitation  which may be in part “a result of the political and professional complexities associated with disinvesting existing practices” we will need “a political paradigm shift in order to foster policy driven disinvestment capacity”

7.       The authors admits that disinvestment is easier “when adverse events occur” but “more complex when individual are not harmed by existing practices but over treated or ineffectively treated.  That is subject to a diagnosis or treatment that is safe but little or no meaningful clinical benefit”

8.       The authors state that the current MSAC model appears geared (and effectively so) towards “controlling the tap as is turned on” not towards “neutralising the flow through active disinvestment”.

9.       The authors also warn against premature disinvestment of the comparator [what is being superceded] which they claim “may disadvantage patients where the new service was not yet available and raises issues of access and equity” and that “decision-making in disinvestment must take account of these factors”.

10.   According to the authors, resistance to disinvestment includes “dynamic conservatism” and that for the clinician “there is often concern disinvestment represents a blunt instrument of rationing, one that may restrict clinical autonomy and reduce patient choice”.

11.   The authors seek to justify dismissing the above concern by asking the question, but can continued investment in healthcare occur without thoughtful measured disinvestmentThere is an economic imperative to do for the sake of sustainability” and that “disinvestment will free up resources for those practices that have demonstrated effectiveness.”  [Edit:  this assumes that savings from disinvestment will be reinvested in clinical care or new technology and at times of budget pressure this is a brave assumption.]

12.    The authors offer the process of “measured retraction” including “restricting the indicators for particular services” as a way of overcoming the above.

13.   The authors cite Wennberg JE (undated) whose work was “disseminated in the Dartmouth Atlas highlighting geographic variation in the use of a range of procedures” as an example of inappropriate application of otherwise effective technologies.  (Ref:  www.dartmouthatlas.org) [Edit:  this was probably the inspiration for the Australian Atlas just released – there is nothing new, we continue to copy and paste from overseas gurus].

14.   The authorsmaintain where evidence for effectiveness “is either less clear or is negative, the practice persists, in these instances partial or complete removal from funding may be necessary” and that “substantial challenges exist, particularly around adequate and timely definition and acceptable proof of inferiority.  This is not only conceptually difficult but also limited by data availability and interpretation.  Further complicating this is the lag that often exists in the reliable reporting of health outcomes data based on clinical practice.

15.   The authors state that health technology agencies (HTA) “together with health services and policy researchers generally are well positioned to take a lead role in supporting the disinvestment of existing health care practices … and that “recently announced funding increase from the NHMRC are for health services research offers potential here.”  [Edit:  this appears to be code for ‘we welcome increased funding and we are available to help’]

16.   The authors recommend “capacity building” [presumably more funding) to improve “linkage and exchange between policy advisers /makers and academic researchers  (HTA specialists)” which “could support processes that policy makers need” [Edit:  we are here to help]

17.   The authors quote as a note of caution to the policy makers (politicians) the UK Treasury Report on the “NICE [National Institute for Healthcare Excellence] Disinvestment Agenda” which states, The delivery of robust scientific appraisal for technologies is coming under increasing challenge as a result of its reliance on methodologies that, it is widely recognized, need further development, given that Health Technology Assessment (HTA) is a relatively new science.  Appropriate research is required to address these challenges.  In particular, research into methodology for … disinvestment”

Stephen Milgate
Director & CEO
Australian Doctors’ Fund