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Piggy in the middle

Having attended the American Society of Echocardiography meeting in Washington DC, we would like to devote this issue to the many discussions that centred around how to balance our ethical and legal responsibility to provide medical services that comply with the guidelines as specified by our learned colleagues, in an environment where the pressure is to provide state of the art treatment on an ever decreasing budget.

04 Jul 2010

Dr Penny Astridge, Dr Christiane Grimm-Blenk, Dr Geoffrey Oldfield and Dr Sue Flanagan

Having attended the American Society of Echocardiography meeting in Washington DC, we would like to devote this issue to the many discussions that centred around how to balance our ethical and legal responsibility to provide medical services that comply with the guidelines as specified by our learned colleagues, in an environment where the pressure is to provide state of the art treatment on an ever decreasing budget.

The problem for us all, in every area of medicine, is that, as the gatekeepers, we must decide what to do for our patients; which symptoms to investigate, which medication to use, which test to order, and so on.

Previously, this was much easier. The number of alternatives in every aspect of medicine was fewer and the amount that the government rebated to the patient was relatively much greater.

With more “fat on the lamb”, we could indulge our patients and ourselves and practise quality medicine for free.

In Australia as well as in America, the medical profession is finding itself with conflicting demands. There is a requirement to provide a quality service with increasing costs (such as wages, accreditation, higher costs of equipment etc) all funded with decreasing fee rebates, either in absolute or in relative terms. Yet somehow, we are the ones who are still ultimately held accountable in both the ethical and legal senses, for the outcome.

Different areas of medicine are funded differently; however, ultimately, we either are now, or will be, confronted with the situation in medicine where either the standard of what we provide must decrease or the patient must pay a gap payment. It is not possible for us to accommodate endlessly the diametrically opposed forces of inappropriate rebates and quality outcomes.

Diagnostic imaging has faced this issue for some time and more severely than most.

The Medicare rebate for a cardiac ultrasound in 1993 was $215.35: in 2009 it was $196.10, a reduction not only in terms of inflation but also in absolute terms.

A recent email from the Cardiac Society informs us that the government proposes not to increase the schedule fees for cardiac ultrasound for the next two years. In the past, they have decreased fees so this is also a realistic possibility. Additionally, Medicare has stated they will institute a policy of equipment replacement every five years. The rebate on any study performed on equipment older than five years (irregardless of whether or not it has the most up to date software) will be halved i.e. $98.05.

How do we maintain standards, as well as embrace the future, on fees that have not increased for 16 years?

Three-dimensional echocardiography is around the corner. How will we as a nation afford this new technology? Are we at the point of saying the gap the patients must pay for a quality test with this new technology is not affordable to most so we will walk away from the new techniques now and forever?

What do we as a profession do? Do we cut the standard of the cardiac ultrasound test by scanning for an ever-decreasing amount of time? Does the study that should take 45 minutes to an hour according to the guidelines (including 5-10 minutes of set up time, 20-35 minutes of scanning time, 10 minutes of calculations and report writing plus the cardiologist’s reporting time) become reduced to a 5-10 minute procedure - a “quick flick”, with dubious results? In our practice we have always said “no” to this option.

The problem is more sinister and far reaching for the medical profession as a whole. The referring doctor is held accountable, both ethically and legally, for their management of the patient, which is based on the results they receive. In the past we have always assumed a quality report. Suddenly, the practitioner who refers for any service, be it radiology, pathology, diagnostic cardiac testing and so on, must now not only assess the result itself, but also the quality of the result before relying on it. We are all intertwined. A problem for one sector of our profession is a problem for us all.

Do we take this to the government and say “You must bear the responsibility to fund quality medicine that is affordable for all”? The answer we have had in the past is “You must set the standards with which you are comfortable and charge a gap if required”.

What will we do when, as the years pass by, the gaps become larger and non sustainable? Will we “cut our cloth to suit” and provide suboptimal care, or will we find ourselves with a system where only the affluent can afford to be treated properly and those who cannot afford to pay take second best?

When do we as a profession say “enough is enough” and call the system unsustainable?

We have always been the guardians of our patients. Are we really looking after their best interests by always compromising between where we practise and knowing what the optimum is? We are the gatekeepers by default, yet we seem powerless to impact on the funding available. If we are not careful, we will react only when it is too late and the standards we cherish have gone, the skill sets are lost and the advances of medicine are way beyond the reach of our patients.

This was the food for thought at the conference; it is timely and relevant for us all.

The ball is high above us. We truly are “piggy in the middle”.

This article was first published in the July 2009 issue of Cardiac Murmurs.


Published: 04 Jul 2010