Delivering  on  the  benefits  of  ancillary  services  in  

PHI  cover

Dr.  Jennifer  HunterBMed,  MScPH,  PhD

Ancillary  Services

• Ancillary  services  and  the  benefits  in  health  promotion

• The  impact  of  low  cover  products  on  community  ratings

• Review  of  the  PHI  rebate  for  homeopathy

• Evidence  based  science  and  natural  remedies

PHI  in  Australia

• Hybrid  (½  UK  :  ½  USA)  disconnected  healthcare  system

• Regulations  and  tax  incentives  distorting  market  signals

• No  direct  financial  return  for  improving  patient  outcomes

• Unsustainable  projections  for  public  and  private  healthcare

• And  so  on….

Ancillary  care  is  a  doctor-­‐centric  term

Ancillary  Care  refers  to  the  wide  range  of  healthcare  services  provided  to  support  the  work  of  a  primary  physician.

Ancillary  definition:adjective  1.  subordinate;  subsidiary2.  auxiliary;  assisting

Allied  Health  refers  to  the  wide  range  of  healthcare  services  professionals  able  to  operate  autonomously

Ally  definition:verb1.  To  formally  cooperate,  combine  or  unite  a  resource  or  commodity  with  another  for  mutual  benefit

Allied  Health  a  better  term  than  ancillary?

Doctor-­‐centric  model  of  healthcareStrengths• Acute  medicine  • Specialised• High-­‐tech• Curative

Weaknesses• Increasingly  expensive• Chronic  disease• Disease  prevention• Health  promotion

Time  bomb  chronic  disease

• Aging  population

• Physical,  psychological,  cognitive

• Many  have  multiple  chronic  diseases

• Unsustainable  healthcare  model

“we  have  an  acute  disease  system  for  an  aging,  chronic  disease  population”

“You  can  make  bad  decisions  now  that  will  have  massive  repercussions”

Warwick  Thornton(Samson  &  Delilah)The  future   is  unforgiving

Anna  Schwartz  GalleryMelbourne   17  July  – 22  August  2015

Allied  Health  services  and  the  benefits  in  health  prevention

• Who  are  they?

• What  do  they  do?Allied  health  practitioners  work  autonomously  within  their  scope  of  practiceHuge  list  of  APHRA  registered  along  non-­‐registered  practitioners

Physiotherapist,  Chiropractors,  Osteopaths,  Massage  therapistsAcupuncturists,   TCM  herbalistsNaturopaths,  Nutritionists,  DietitiansPsychologists,  Occupational  therapistsPharmacists,  Podiatrists,  Optometrists  and  so  on…

Australian  Health  Practitioner  Regulation  Agency  2015National  Infrastructure  Audit  CM  Practitioners  2015  (unofficial)

Australian  healthcare  workforce  Doctor15%

Dentist3%

Nurse  Midwife55%

Pharmacist4%

Psychologist5%

CM  registered2%

CM  unregistered6%

Other  allied  health10%

≈27%  Allied  Health

Underutilised  Allied  Health  for  chronic  disease  management

• Bullet  points

40%

9% 7%

30%

10% 10%20%17%

Australian  Health  Survey  ABS  2011-­‐2012

healthinsurancecomparison.com.au

Intergenerational  Report  2015

Wardle  J  et.al.  Australian  Journal  of  Rural  Health 19(4);  197-­‐204

Rural  /  Remote  NSWRatio  of  primary  care  CM  to  GPs

Why  do  people  use  CM?

• Adjuvantnot a  replacement  for  ‘medical  care’

• Wellness  (51%)1

• Wellness  and  disease  management  (35%) 1

• Manage  top  5  priority  health  conditions  2

1.  National  Health  Interview  Survey,  USA  2007  2.  National  Health  Survey,  Australia  2004-­‐05    

Who  uses  complementary  medicine  -­‐ CM?

• 20  primary  care;  up  to  70%  use  generally

• 25  -­‐64  y.o,    female,  educated,  wealthier

• Less  illness,  better  self  reported  health,  healthier  lifestyle

• PHI extras  cover60%  who  saw  a  CM  practitioner  in  last  2  weeks  had  PHI  extras(compared  to  41%  total  population)

National  Health  Survey,  Australia  2004-­‐05    

Extras  Cover  – which  one  will  you  choose?

Imagine  PHI  providers  as  leaders  inhealth  and  people  care  (not  just  disease  care)

• Build  strong,  healthy,  resilient,  vital  people  who  areactively  participating  in  our  community

• New  and  innovative  ways  to  encourage  and  reward  healthy  living

• Holistic approach  -­‐ physical,  cognitive,  emotional,  social,  occupational,  financial,  spiritual

• Patient-­‐centred,  individualised  services

• Practitioner  incentives  to  promote  health  that  is  more  than  the  absence  of  disease

1.9M  same  day  procedures   (+6%)1.4M  overnight  procedures   (+2.5%)Hospital  treatment  $1,206,  or  $3,217  per  episodeApprox.  $25M  increase  hospital  costs

85M  allied  health  services  (+3.4%)10M  physiotherapy   (+4.1%)5.7M  natural  therapies  services  (+6.1%)$52  per  natural  therapy  consultationApprox.  $2,7M  increase  natural  therapy

Private  Healthcare  Australia  28  May  2015

Evidence  based  science  and  natural  remedies

Is  there  any  CM  Evidence?• Under  funded  researched  topic

• Difficult  to  undertake  high  quality  research

• Increasing  scientific  evidence

Acupuncture  in  combination  with  conventionaltreatment  for  chronic  lower  back  pain

1. Systematic  review  Cochrane  2005  -­‐ 35  RCT,  2861  patients  [1]

2.    Cost  effectiveness  Economic  modelling  for  Australia  [2]

3.    Clinical  guidelines2013  American  College  of  Physicians  &  American  Pain  Society:  Rec.72009  NICE:  Section  1.6.1

[1]  Spine  2013  Nov 15;38(24):2124-­‐38.[2]  Pain  Pract. 2013  Oct  21  [Epub ahead  of  print]

St.  John’s  Wort extract  for  mild  to  moderate  depression

1. Systematic  review  Cochrane  2008  -­‐Similar  efficacy  SSRIs,  >  placebo

2.    Cost  effectiveness  Economic  modelling  for  Australia  1,2

3.    Clinical  guidelinesYES BlackDog Institute  (hesitantly)

NO NICE,  Royal  ANZ  College  Psychiatry,  American  Psychiatric  Association

1.  NICM  Access  Economics  Report  20102.  Solomon.   Journal  of  Affective  Disorders  2013;  148(2-­‐3)

Plethora  of  clinical  guidelines

Often  do  not  consider  CMeven  when  good  evidence

Lack  transparency  about  the  decision  to  exclude  CM

Rarely  make  a  strong  recommendation  to  either  to  use  or  not  use  CM

Eur.  J  Integrative  Medicine.  2014;6(2):164-­‐75.

Clinical  guidelines  about  CM  use

NHMRC  review  of  natural  therapists

• Claim  bastions  science,  delivered  low  quality  methods

• Narrow  search  terms    -­‐>  no  evidence

• Incorrect  definitions  and  criteria

• Medical  professions  would  alsofail  the  test  

• Only  9%  oncology  practice  guidelineshigh  level  of  evidence  1

1.  J  Clin Oncol.  2011;29(2):186-­‐191

Efficacy  is  only  one  component  of  scientific  evidence-­‐based  medicine

• RCTs  strive  for  high  internal  validity  

• Narrow  inclusion  /  exclusion  criteria

• Randomisation  and  blinding

• BUT  low  external  validityaka  low  generalisability forreal  world  scenarios

“There  is  no  such  thing  as  an  ever  valid  hierarchy  of  evidence.  

There  is  only  evidence  that  has  a  higher  level  of  internal  validity,  and  

evidence  that  may  have  a  higher  level  of  external  validity.”

Walach,H &  Loef,M J  Clinical  Epidemiology   (2015),  doi:  10.1016/j.jclinepi.2015.03.027.

Comparative  Effectiveness  Research

• RCTs  >2  active  (non-­‐placebo)  intervention  arms

• Database  studies

• Observational  studies

• Model-­‐based  studies

• Decision  analysis

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Treatment   Comparison Treatment   Comparison Treatment   Comparison

Artifacts/Natural  history Non-­‐specific  effects/Placebo Specific   treatment  effect

Trend  suggestingdifference

Nodifference

Pre-­‐existing  belief  in  efficacy  increases  non-­‐specific  effects  and  placebo  effect

Consecutive  positive  results  increases  non-­‐specific  effect

Significant  difference

TIME  -­‐-­‐>

Walach,H &  Loef,M J  Clinical  Epidemiology   (2015),  doi:  10.1016/j.jclinepi.2015.03.027.

Placebo/  sham  treatments  that  work

• Four  placebo  tablets  work  better  than  two  in  gastric  ulcers  

• Pink  dummy  pills  are  better  at  maintaining  concentration  than  blue  ones  

• Placebo  injections  are  more  effective  than  placebo  pills  

• Placebo  painkillers  work  better  if  they're  believed  to  be  costly  than  if  they're  believed  to  be  cheap  

• Placebo  surgery  works  for  people  with  knee  pain

• Sham  acupuncture  for  pain  is  better  than  doing  nothing

Bad  Science,  Ben  Goldacre,  Fourth  Estate,  2008

When  is  placebo  a  bad  thing?

• Pretend  it’s  not

• Expensive

• Side  effects  

• Unsafe

• Opportunity  costs

Review  of  the  PHI  rebate  for  homeopathy

• NHMRC  review  of  reviews(poor  quality  methodology)

• Excluded  studies  promoting  health  or  wellbeing  (disease  only)

• Is  the  jury  is  still  out?

• The  clinical  trials  continue

• Quality  of  trials  improving  

Individualized  homeopathic  treatment  verses  fluoxetine  for  moderate  to  severe  depression

• 133  peri  &  post  menopausal  women

• Randomized,  double-­‐dummy,  double-­‐blind,  placebo-­‐controlled  trial

• 3  groups:  homeopathy,  fluoxetine,  placebo

• Homeopathy  &  fluoxetine  >  placebo  for  depression

• Homeopathy  >  placebo  for  menopausal  symptoms

• Fluoxetine  =  placebo  for  menopausal  symptoms

PLoS One.  2015;  10(3):  e0118440

Homeopathy  as  adjuvant  for  Rheumatoid  Arthritis

• Randomised,  double-­‐blind,  placebo  trial

• 83  adults  with  active  stable  RA  receiving  conventional  therapy

• Evidence  for  effectiveness  homeopathic  consultation

• Fund  homeopaths  but  not  the  homeopathic  medication?

Rheumatology   (Oxford).  2011  Jun;  50(6):  1070–1082.

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80

Treatment   Comparison Treatment   Comparison Treatment   Comparison

Artifacts/Natural  history Non-­‐specific  effects/Placebo Specific   treatment  effect

Trend  suggestingdifference

Nodifference

The  consultation  will  increase  the  non-­‐specific  /  placebo  effect

Significant  difference

Walach,H &  Loef,M J  Clinical  Epidemiology   (2015),  doi:  10.1016/j.jclinepi.2015.03.027.

How  can  PHI  promote  health  &  reduce  costs?• Think  outside  the  box  –

allied  health,  traditional  &  natural  medicine,  lifestyle  medicine,  self-­‐care,  antenatal  &  children,  employers

• Catch  the  horse  that  has  bolted –secondary  disease  prevention  interventionsmaximise  health,  minimise  disease  complications

• Reward  healthy  behaviour –without  compromising  community  rating  &  ethics

• BE  CREATIVE!

Thank You