Thread by @jilltomlinson

What’s the AMA’s position on #Medicare use & misuse (aka health care resource stewardship)?

It’s a lengthy position statement, but relevant to the current #MBS debate.

#MBS 🧵

1.1 Health care resources need to be appropriately managed so that all patients can continue to receive the best quality care, now and in the future.

1.2 Individual doctors (medical practitioners) affect health care expenditure through their clinical
recommendations and decisions regarding patient treatment. As such, doctors have an important role as stewards of health care resources.

1.3 Stewardship refers to avoiding or eliminating wasteful expenditure in health care. Stewardship aims to maximise quality of care and protect patients from harm while ensuring affordable care in the future.

1.4 The primary ethical duty of the doctor is to care for, & protect the health care interests of, the individual patient. There is a secondary ethical duty to protect the interests of other patients & the wider community.

This secondary duty involves managing health care expenditure to ensure resources are available for others.

1.5 While decisions involving health care expenditure are often undertaken at a higher institutional,
systems or government level, the individual doctor can play a pivotal role in reducing wasteful expenditure through responsible stewardship of their day-to-day practices.

For example, through
appropriate clinical decision-making, minimising diagnostic error and eliminating tests, treatments or
procedures that are unnecessary, inappropriate or unwanted by the patient.

2.1.1 Doctors must balance their obligation to minimise wastage of resources with their primary obligation to care for, and protect the health care interests of, the individual patient.

Through effective stewardship, the doctor’s obligations to the patient and the wider community in terms of health care resources should generally not conflict.

2.1.2 Effective stewardship positively influences quality of care. Diagnostic error, inappropriate, unnecessary tests, treatments or procedures can potentially result in physical harm as well as emotional & financial stress for the patient.

Eliminating these potentially harmful practices improves the quality of patient care while reducing a burden on the health care budget.

2.1.3 Doctors have a responsibility to continually keep their medical knowledge up-to-date and to
reflect upon and improve their own clinical practices in order to ensure that patients receive the most
appropriate, best available, evidence-based treatments.

2.2.1 Doctors also have a responsibility to support patients in making informed health care decisions. This involves effective communication, where doctors support and guide patients (and patients’ substitute decision-makers) in making informed health care decisions.

2.2.2 As part of supporting and guiding patients, it is important for the doctor to elicit the patient’s
values & goals of care (this is particularly relevant to end of life care).

This information allows the doctor to recommend tests, treatments and procedures that align with the patient’s goals & preferences.

2.2.3 It is also important for doctors to ensure patients’ expectations of care are realistic & that they
understand the appropriateness (or not) of recommending certain tests, treatments & procedures.

Doctors are not required to offer treatment options they consider neither medically beneficial nor
clinically appropriate.

2.2.4 Once the patient has the appropriate clinical information, realistic expectations of treatment & defined their own values and goals of care, the patient can

make informed health care decisions that will assist them in receiving the care they want & avoiding the tests, treatments and procedures they do not want.

2.2.5 Reducing unwanted tests, treatments and procedures not only respects the patient’s autonomy
but may result in the use of less costly and invasive interventions as well.

3.1.1 The wider health care system must provide an environment that promotes responsible stewardship.

3.1.2 Improved health literacy through government funded education programs would help patients to make informed health care decisions and support doctors as stewards of the health system.

3.2.1 Where decisions involving the allocation of health care resources are being made, doctors have a responsibility to advocate for the best interests of patients.

3.2.2 Doctors should use their knowledge and skills to assist those responsible for allocating health care resources to make informed, reasonable policies.

This can be at the individual practice or institution (eg. hospital) level as well as the higher government or organisational level (eg., health insurers).

3.2.3 Doctors can contribute their medical knowledge and expertise to matters of resource allocation and also help to identify where resources in the community are unacceptably restricted.

3.2.4 The process for developing and revising health care resourcing and expenditure policies should be transparent, consultative, have appropriate oversight and be consistent with good medical practice.

3.3.1 Doctors must retain their clinical independence and professional autonomy so they can make health care decisions based on the best interests of the patient and not the interests of third parties
such as insurers, governments or employers.

3.3.2 All patients are unique. Even where best practice guidance recommends against using
particular tests, treatments or procedures in certain circumstances, doctors must be able to facilitate
access for individual patients

for whom such tests, treatments or procedures are clinically warranted.

3.4.1 Medical schools, postgraduate & continuing professional development (CPD) curricula should
teach about actual health care costs & how to practise effective stewardship including how their
own clinical decision-making can affect health care expenditure.

3.4.2 These curricula should also address the efficacy and cost of new and current technologies, tests, treatments and procedures so doctors can make informed recommendations as to the most
relevant, cost-effective tests, treatments and procedures for their patients.

3.4.3 Individual institutions should inform doctors about institutional health care costs.

3.5.1 Clinical practice guidelines should always be developed and continually updated in consultation
with doctors. Such guidelines should assist doctors in determining the most appropriate tests, treatments and procedures for their individual patients.

3.6.1 Defensive medicine, where tests, treatments and procedures are undertaken to help protect the
doctor from medical liability, undermines effective stewardship and may be potentially harmful to the
patient.

3.6.2 A doctor practicing in accordance with good medical practice should be able to practice
responsible stewardship without fear of medico-legal reprisal.

4.1 Patients and the wider community should be educated to ensure realistic expectations of certain tests, treatments and procedures, health care costs and limitations on health care resources.

5.1 The medical profession itself has a responsibility to educate & promote stewardship amongst its own members, promoting messages such as:
▶️ More treatment is not always better treatment;
▶️ Expensive treatment is not always better treatment;

▶️ The ‘newest’ treatment is not always better treatment;
▶️ Be prepared to identify and change established practices that are ineffective or less effective than alternative treatments.

Source: AMA Position Statement on the Doctor’s Role in Stewardship in Health Care Resources

ama.com.au/sites/default/…