Better doctor-patient communication, as per the Open Notes project, could save billions of dollars and improve health in Australia.
Let’s have a more visionary approach to reducing health costs. While most see the need to reduce health costs, wouldn’t it be refreshing if our politicians and their advisers looked at more visionary ways of cost reduction instead of a $7 co-payment, a scheme which will become a cost-shifting exercise as patients reluctant or unable to pay this amount will just turn up at already overburdened emergency departments?
While it’s true that health costs are rising as the population ages, we aren’t all that different from other developed countries. At 9.5 per cent of GDP our health expenditure is a little above the OECD average of 9.3 per cent and well below the US at 17.9 per cent, the only OECD country without universal health coverage and with a strong focus on privatisation.
Tom Delbanco, a Harvard professor, has helped to reduce costs. He had the audacity to suggest patients have access to their medical notes. His colleagues were aghast, saying this would be time consuming for doctors and cause anxiety in patients. Delbanco persisted.
In 2011 he persuaded over 100 doctors to participate in the Open Notes project. Despite initial anxiety, by the end of the trial there was overwhelming support by participating doctors. They found it made doctor-patient communication more effective and actually saved time as better-informed patients did not make unnecessary visits.
Patients liked it too. Sometimes they were able to point out that their notes did not accurately reflect what they’d told the doctor, resulting in better treatment and often fewer tests. Most felt empowered by the trust and respect that came with having access to their personal information.
The recent Australian patient controlled electronic health record is an important step in this direction, giving people a summary of their health records, but the Open Notes concept shows patients exactly what the doctor has written. This makes doctors write better notes, avoids confusing abbreviations, makes patients partners in their own care and according to Delbanco, reduces the cost of care.
Another opportunity to reduce health costs is in the last year of a person’s life. A Canadian study showed 33 per cent of healthcare expenditure occurred during the last year of life, particularly the last few weeks. In the US the figure is 22 per cent. Research from Victoria found average hospital costs increase almost ten-fold in the last month of life.
At 81, David Munro* had a large brain haemorrhage, leaving him in a coma, able to breathe only with mechanical help. On medical advice his two daughters felt he should be allowed to die peacefully. His son, who’d had little contact with his father, disagreed. He insisted “everything” be done, every investigation and every possible treatment. So they persisted. David slowly deteriorated and died seven weeks later. By then the extra costs had reached $270,000.
Like David, many people undergo heroic, but often futile medical treatments near the end of their lives: extra blood tests, invasive radiologic procedures, biopsies, surgery, even life support. It’s not just the fault of some doctors who are uncomfortable letting a person die without trying everything possible. The doctors often don’t know what the patient wants, relatives often disagree about what is best and so ‘‘everything’’ is done. If everyone of mature age made an advanced care directive, relatives and doctors would know exactly what the person wanted. Some might want everything possible done, but many others would ask for no heroics and document that they wanted to die with dignity, respect and free of pain.
Advanced care directives go hand in hand with good palliative care. They have nothing to do with euthanasia. They are a well-accepted way of documenting what level of medical care a person wants as they approach death.
A third way to make major inroads into health costs, improving care at the same time, is to reduce medical error.
Pauline* caught a severe infection in hospital while recovering from kidney surgery. She spent an extra 12 days in hospital, two of them in intensive care. “Adverse events” add enormously to costs and can have devastating effects on people’s lives.
Each year over 10,000 Australians die in hospital from adverse events. Many more suffer complications. Extra time is spent in hospital, health costs increase and time from work is lost. The annual cost to the health system is estimated to be $450 million to $900 million.
These three examples: giving patients complete access to their medical records, widespread use of advanced care directives and reducing medical error could save billions of dollars and improve health. But concepts like these require more vision from governments than just closing preventive health agencies and adding a few dollars to a GP consultation.
Kim Oates is an Emeritus Professor of Paediatrics at Sydney Medical School, University of Sydney
* Not their real names