New Item Numbers in Medicare could help Save Billions!

The Healthier Medicare Review of the MBS  schedule of fees offers a unique opportunity to indeed create a healthier Medicare by the inclusion of  Patient Reported Outcomes as a requirement for a variety of Primary Care as well as specialist surgical procedure item numbers.

Relevant item numbers would include those for operations on the prostate, cardiovascular, for cardiac surgery procedures and orthopaedics for a variety of spine, shoulder, elbow, wrist, hip and knee operations. We would recommend utilising the PROMs set out in ICHOM Standard Sets or those recommended by the American Association of Orthopaedic Surgeons.

By recording the PROM scores from: prior the operative intervention, immediately at discharge and at 3 month intervals or as set out by ICHOM in their follow up protocols.

Surgeons will be able to demonstrate the improvement achieved or otherwise in their patients functional health or the patients’ continuing health related Quality of Life in response to the surgical intervention.

In Primary Care an item number utilising a generic PROM such as the SF12 together with PROMs that measure risk factors such as smoking , alcohol consumption, vegetable daily intake, fruit consumption and physical exercise would enable GPs to have a predictive individual score for potential hospitalization within 6 months. This will enable them to prescribe lifestyle changes and non-hospitalization outpatient care such as social work, dietician, exercise physiologist etc. interventions that will help avoid the known 6.2% of potentially avoidable hospital admissions that have been monitored and stayed static over the last 7 years.

One aim of this initiative, for example, would be to identify and reduce potentially avoidable hospital admissions from 6.2% to 2.6% of all admissions (a 58% reduction). This would result in a saving in excess of $2 billion per annum in the current health budget. The calculation of this saving is as follows.

Australian figures reveal 10.5 million hospital admissions per year (see http://www.aihw.gov.au/publication-detail/?id=60129551440 ) and the Australian Bureau of Statistics reveals that 11.8% of the Australian population are admitted each year (that is 2.6 million persons) . Some patients (usually dialysis patients) have more than 4 admissions per year. see http://www.abs.gov.au/ausstats/abs@.nsf/Lookup/D6EC4DD7DC21B01DCA257B39000F2D00?opendocument )

Assuming 1 000 patient equivalents per GP on average each GP would have 118 of their patient population admitted to hospital per year. If each GP managed to reduce just 15 overnight hospital admissions per year by implementing the lifestyle and preventive prescriptions, then, at the current  cost of approximately $6 000 per admission, each GP could save the health budget $90 000 per year. Assuming all 24 000 FTE GPs adopt the changes, a total saving of approximately A$2.2 billion would ensue.

ScoresPredictHospitalisation

The above graphic displays the predictive capacity for the hospitalisation of an individual from their PCS score in SF12 PROM. The GP would be encouraged to set a goal to improve that patient’s score by 5 units such that the patient would move from their initial band (e.g. 35-40) to the next band (say 40-45 in the above graphic), thus, in aggregate, reducing the likelihood of hospitalisation of their total pool of patients.

There is ample evidence that preventive strategies have a higher probability of adoption where the patient is guided by their GP’s lifestyle prescription provided they are monitored monthly by completion of the ePROM and are provided with 4 well constructed reminders per week. (see http://jama.jamanetwork.com/article.aspx?articleid=2442937 )

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