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CHA Brisbane

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Nicholas Graves

on 9 September 2014

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Transcript of CHA Brisbane

wants > means
incentives for decision makers
Nicholas Graves
Scarcity, Decision-Making and Health Services Research
technology


lifestyle



ageing
$6000 * 22.6M = $135,600,000,000
$25,000,000,000
annual health spending per Australian
25%
50%
25%
Economics is the study of choices
Stopping all routine follow up ...cost savings between $6.5M & $11.9M
gains of between 1.8 and 8.8 QALYs
ability to pay for them
health needs
70%
5%
25%
Private enterprise wants a return on capital






Bureaucrats want job security and to maximise bureaucratic transactions





Doctors want to maximise health for their patients






Politicians want to get re-elected
Allocate resources to cost-effective services

Supply services at lowest cost

Current incentives
and a simple economic system
do things right
do the right things
days in hospital during 24 weeks after first discharge
770 years of life foregone
2,203
4,051
4155
universal leucodeplation of blood reduces years of life among the Australian population by
every year

118,000 Quality Adjusted Life Years gained

$333,000,000 saved
for annual investment of $60M in Universal Leucodeplation .......
enhanced discharge planning
normal discharge planning
"extra nursing & physiotherapy"
"improve strength, balance and diet"
"24 weeks of telephone follow up and home visits"
For the at risk Australian population
Hospital discharge planning
Generic drugs to lower cholesterol
Each year
Routine follow up for hip replacements
Costs between $9.1M and $11.9M
Laminar airflow in operating rooms
Leucodepleted blood products
1
2
3
4
5
$1,300M lost
budget and status maximisers
rational bureaucrats will,

“always and everywhere seek to increase their budgets in order to increase their own power”

Barnes observes,

“We want politicians to be honest and incorruptible, and yet because they are good we also want them to do what is necessary to win the election, even if it means lying and making deals with corrupt power brokers (for they will do us no good if not elected).”



The result,

“It seems impossible to be a successful politician without making various unsavory deals and alliances.”
We pay between 6 and 2o times more than NZ for the same drugs
bad choices for society
better choices for society
Private Enterprise
Health Bureaucrats
Doctors
Politicians
Imagine a fixed budget
Philip Clarke
health care dollars
For 30,000 primary hip replacements

179 more deep infections
4 more deaths (lose 127 QALYs)
$4.5M extra costs from infection
?
Elshaug MJA
small health gains
large gains to health
vs.


3% MBS items judged against criterion of cost-effectiveness





Disinvestment rare





Processes hijacked by bureaucracy



some bad decisions are made
$69,545
$795,329
Doctors set 'quantity' and 'price'



mean cost hip replacements

19 US hospitals

$11,000 to $125, 798
have just about kept up....until now
how we respond is very important
choose the best health services
tipping point
Five examples
education
environment
social services
health
defence
infrastructure
$50,000
$1,300
Scarcity
economic pressures
appropriate responses
Decision Making
some poor decisions
incentives for decison makers
Health Services Research
hips & hearts
Why ?
trained and compensated for treating patients
vs.
PBAC
MSAC
older, weaker & sicker patients

more difficult surgery and anesthesia...leads to higher costs

uncertain health benefits?
1999 to 2005

300% increase >80 years

quantity
variability for:

professional fees

prostheses

follow ups
price
Funding Agency


Research Development & Training


Consulting projects
a community of researchers
PRINCIPLES FOR FUNDING
partnership

improve health services

good ideas trump track record

applications are easy

feedback ............ re-submit
will improve health services
Current incentives for decision makers
are they fixed on efficiency



doing the right things
doing things right
?
have I got a deal for you
and....will say and do almost anything to do so
Thanks for listening
18,500 cases
~30% of pop
do the right things
do things right
do the right things
do things right
?
Allocate resources to cost-effective services

Supply services at lowest cost

do things right
do the right things
too much and largely irrelevant information

massive lumbering process (risk aversion?)

fail to focus on the decision
11-fold variation
every year
joint replacement surgery
> decision making
> health services research
most health return per $
more efficient
and be efficient
Are powerful decision makers fixated on efficiency?
choices must be made
effect of laminar airflow on deep infections
gain 153 years of life
the study of the funding, organisation and delivery of health services and it involves multidisciplinary perspectives. Outcomes are usually at the population level rather than the individual. This contrasts with clinical research which emphasises individuals.
study design
epidemiology
cost-effectiveness
statistics
40 groups supported in 2.5 years
research development and training
success at 2nd and 3rd tries
We are ambitious
hard budget constraint for health spending
maximize health benefits from scarce resources
information gaps

advocacy for cost-effectiveness

education & training

better policy

better incentives
“Procedures should be ranked so that activities that generate more gains to health for every dollar of resources take priority over those that generate less; thus the general standard of health in the community would be correspondingly higher”

Alan Williams BMJ, 3 August 1985

BUILT A CULTURE OF COST-EFFECTIVENESS FOR THE NHS
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