A healthy dose of disinvestment

It’s easy to forget that the evidence-based approach to medicine is still relatively new, and that a substantial part of health care is not supported by gold-standard evaluation. New procedures, until very recently, have had no requirement for rigorous testing, unlike new drugs. Of the more than 5000 items on the Medicare Benefits Schedule (MBS) today, most “have never been comprehensively assessed for their safety, effectiveness and/or cost-effectiveness”.1 But now many more interventions will be exposed to the chill winds of evaluation. And those that don’t shape up could become targets for “disinvestment” — withdrawal of funding from existing treatments.

Although not explicitly mentioned, disinvestment is part of the thinking behind recent developments in Canberra. Announced in the current Budget, a “comprehensive management framework” for Medicare strengthens assessment of new treatments, and introduces “rolling reviews” of existing interventions, to assess quality, safety and fee levels.2 Systematic methods will be developed to inform “appropriate amendment or removal of existing MBS items”.

Judging by the progress of several “demonstration reviews”, clinicians nervous about threats to their livelihoods needn’t worry too much. Sensitive about perceptions of taking something away, the federal government is treading warily — using maximum engagement with affected specialties. For example, despite finding colonoscopy use had jumped an extraordinary 84% in just a decade, the review of this procedure gave it a big thumbs up.3

The most comprehensive review is the ongoing whole-of-specialty review of ophthalmology. A report has been produced by Adelaide Health Technology Assessment, at the University of Adelaide, advised by a clinical working group from the Royal Australian and New Zealand College of Ophthalmologists (RANZCO) — in close collaboration with the health department.4 The report suggests a number of minor changes, including tightening the patient pool for a handful of Medicare items, but little in it is controversial. Importantly, assessing costs was strictly excluded.

A key challenge in reviewing the evidence behind all the tests and treatments used by ophthalmologists was actually finding the evidence. Sometimes there was little published literature, so reviewers relied on guidelines built on consensus rather than on solid evidence. And existing procedures tended to be treated more leniently in the review than new procedures seeking funding today. Alex Hunyor, a representative of RANZCO who is intimately involved in the review, says some treatments, particularly medicines, lend themselves to randomised controlled trials, whereas with surgery often “the evidence is not necessarily of the type we’d like it to be”. He adds that, in cases where technology is evolving quickly, “we can’t necessarily say, ‘here’s the hard evidence’”.

A high-profile example of a procedure without hard evidence from another specialty area is vertebroplasty. After a long battle between proponents and critics, trials showing no meaningful benefit, and an independent review, the government’s Medical Services Advisory Committee recommended dropping the procedure — a powerful example of disinvestment.5 Three clinical advisers disagreed with the recommendation, but it was accepted. The procedure no longer carries a Medicare rebate. In the United States, the failure to similarly disinvest in vertebroplasty has become a case study in the difficulty of withdrawing support from well established procedures unsupported by good evidence.6 Even in the United Kingdom, where debate is well advanced, decisions to disinvest are often not implemented in practice.

Not surprisingly, the term “disinvestment” is little loved, rather than being seen as a positive attempt to bring scientific accountability to health care funding. “We’re trying to work together to get better value for money” is how the process is described by Ian Larmour from the Southern Health network of hospitals in Victoria, which has generated considerable savings using “therapeutic equivalence” to seek lower-cost medicines.7

It’s vitally important that Medicare’s rolling reviews are as rigorous and independent as they can be, to bring much needed scientific scrutiny to medicine’s vast back catalogue. Outcomes would be more credible if the influence of vested interests in the process was diluted, and the effectiveness, safety and cost of existing treatments was assessed with the same rigour applied to new ones. A healthy dose of disinvestment — no matter how unpleasant the term — may be required for those treatments where the balance of benefits, costs and harms is unfavourable. It’s not unhealthy rationing, it’s rational health policy.