The Australian

by Lesley Russell

As US President Barack Obama successfully concludes his campaign to enact healthcare reform legislation and looks to begin the long-term task of implementation, Kevin Rudd is taking the initial steps to turn his 2007 election commitments on health into reality. 

Curiously, the Prime Minister initially has chosen to focus on hospital funding and governance. While there's no doubt this is an area where improvements are needed -- it's a touchstone issue voters care about, the media consistently reports on the problems, and it's a key part of those 2007 commitments -- this is a very 20th-century place to start healthcare reform.

All those committees and reports the Prime Minister and his Health Minister Nicola Roxon commissioned were unanimous in their advice that the healthcare system of the 21st century must focus on prevention, better management of chronic illness and the co-ordination of care.

When these services are provided effectively, they can keep people -- even the chronically ill and frail elderly -- out of hospital, thus helping to address problems such as crowded emergency departments and the need for more hospital beds and staff.

Often what's needed is not medical care but help with managing travel to medical appointments, complicated medication regimes and out-of-pocket costs that limit patients' compliance with recommended treatment.

It used to be that Australians looked at the US as an example of what health care should not be. Now, in terms of innovative ways to deliver and fund health care, there are effective American models we could look to implement. Such models provide better outcomes at reduced cost.

The US healthcare reform package has a raft of measures that will fund and expand these new models. Among them: financially rewarding primary care practices that provide care co-ordination programs using, for example, nurse care co-ordinators and home-based monitoring; bundling payments for entire treatment needs or cycles of care, rather than paying for individual visits or procedures, with rewards for the delivery of care that improves patient outcomes; and limiting payments for hospital readmissions that result from hospital-acquired infections and preventable errors.

The principle here is to fund quality, not quantity, and value, not volume.

None of these approaches are untested. For instance, the Camden Coalition of Healthcare Providers in New Jersey is a multidisciplinary outreach team that provides care management to the highest users of Camden emergency departments and hospitals. The team -- a nurse practitioner, a bilingual paramedic and a social casework manager -- visits homes, housing shelters and even the streets to co-ordinate care in a patient-centred approach.

Evaluation after just one year showed patient hospital and emergency department visits decreased by 40 per cent and health system costs for these patients was reduced by 56 per cent.

Australia isn't bereft of such innovative approaches, although too many successful pilots have gone nowhere, victims of short-term funding and failure to capitalise on what has been learned.

A case in point: Melbourne's Sunshine Hospital has substantial data showing that care facilitators can help older people with multiple health problems identify and access the health care they need and help them communicate with their healthcare providers. The Sunshine Hospital study estimates that care facilitators for 74 people can save 284 unnecessary presentations at the emergency department each year.

Other examples of where there's room for dramatic improvements in service delivery include management of people with chronic conditions. Fewer than one-third of patients get the recommended care for their asthma and diabetes, and only a fraction of patients discharged from hospital following a heart attack get the cardiac rehabilitation that will prevent an early readmission.

The US healthcare reform legislation includes mechanisms for ensuring that innovation is a consistent driver, not just a series of isolated projects. A new centre for innovation is established and funded within the Department of Health and Human Services with broad authority to develop, implement, expand and evaluate new payment models outside the traditional fee-for-service model, with preference to be given to those models that reduce costs while enhancing quality.

In addition, the Health Secretary can expand the duration and scope of successful models and terminate or modify those that don't work, without needing further legislative authority. The most promising practices can be scaled up nationwide.

Here, such a centre could serve as a place where innovative ideas are developed, tested and translated into large-scale programs.

In his National Press Club debate this week, Rudd promised that his government has more health policies to deliver. We should hope that he'll be bold enough to borrow some ideas from Obama. In doing so, he could tackle the health and the hospital elements of his planned National Health and Hospitals Network and move way from the antiquated notion the health care is just about treating people when they are sick.

Lesley Russell is Menzies Foundation fellow at the Menzies Centre for Health Policy, University of Sydney-Australian National University; research associate at the US Studies Centre, University of Sydney; and visiting fellow at the Centre for American Progress, Washington, DC.