AMA letting legislators know its views on pharmacy review

Below is an edited version of the AMA’s submission to the Pharmacy Remuneration and Regulation Review Interim Report.

Overall, the AMA considers the recommendations, if implemented, will benefit consumers by improving access to affordable medicines and enhancing the quality of medicines related care provided by pharmacists.

The AMA’s submission focuses on the recommendations and options described in the interim report which impact patient care.

The recommendations and options relating to patient access to medicines and their experiences within pharmacies appear sensible and well considered.

In particular, the AMA supports:

improvements to the PBS Safety Net which would enhance patients’ understanding and access, for example, the introduction of a central electronic system that automatically tracks individual patient PBS expenditure;
audits of pharmacy compliance with medicines dispensing requirements, such as correct medicines labelling and the provision of Consumer Medicines Information leaflets, in line with State/Territory legislation and Pharmacy Board of Australia and Pharmaceutical Society of Australia guidelines; and
improvements to electronic prescription systems and medication records to enhance continuity of care and reduce medication errors. However, the AMA notes that prescribing software would require updating to enable full electronic prescribing and that a small, but still significant, proportion of medical practitioners do not use these systems, especially in rural/remote locations with poor internet connections.

The AMA supports the Review recommendation that homeopathic products should not be sold in PBS-approved pharmacies. Selling these products in pharmacies encourages consumers to believe they are efficacious when they are not.

The AMA notes the interim report proposal that if pharmacists provide a service that is also offered by alternative primary healthcare professionals, the same Government payment should be applied to that service. While a service may superficially appear the same, it is important to recognise that the delivery, quality and comprehensiveness of that service may differ between health professionals and the context within which it is provided.

For example, a patient administered a flu vaccine in a pharmacy just receives a flu vaccine. A patient receiving a flu vaccine administered by a General Practitioner also receives a preceding consultation which includes a health assessment specific to that patient, based on a sound understanding of the patient’s past history and health needs.

This might include a check whether the patient’s other recommended vaccinations are up-to-date, whether a cervical screening test is due, a blood pressure check if appropriate, a check of the patient’s adherence and tolerance of any prescription medicines, and any other appropriate and (evidence-based) opportunistic preventative health care.

Even if the General Practice employs nurse practitioners to deliver the vaccine itself, a patient has first been assessed by a General Practitioner who continues to be close at hand if needed.

If the Commonwealth Government were to consider paying pharmacists to administer flu vaccines to high risk populations, the services provided by a pharmacist and a medical practitioner in this context would not be equivalent.

Clearly there would also need to be research on whether flu vaccinations in pharmacies are cost-effective in comparison to a flu vaccination in a General Practice clinic given the value-add provided in the latter service.

Any cost-benefit analysis would also need to take into account the indirect costs of delayed or missed diagnoses leading to higher cost care, that are more likely when care is fragmented by patients relying on health care provided by a pharmacist.

The AMA agrees with the recommendations in the interim report that government-funded services should be evidence-based and cost-effective. Pharmacy-based services that do not meet these criteria, such as the Amcal’s Pathology Health Screening Service targeting “relatively young and fit customers … for general health purposes … as opposed to risk assessment or diagnosis” should not be eligible for government funding.

The AMA’s earlier submission to this review expanded in some detail regarding the push by the Pharmacy Guild, motivated by revenue generation, to expand the scope of practice of pharmacists into the provision of medical services.

The AMA has already stated its views on the barriers imposed by current pharmacy location rules in its previous submission to the Review, and in numerous earlier submissions to Government. The AMA supports changes to pharmacy regulation which would allow more pharmacies and medical practices to be co-located. The current restrictions are inflexible and are difficult to justify in terms of public benefit.

AMA understands that the Australian Government has entered into an agreement with the Pharmacy Guild of Australia to continue indefinitely the current protections the rules provide to Guild members. However, the AMA is disappointed that the Government has made this decision despite the obvious benefits that would accrue by allowing access to high quality primary health care services in a way that is convenient to patients, enhances patient access and improves collaboration between healthcare professionals.

Facilitating collaboration between medical practitioners and pharmacists will only improve patient outcomes through less medication mismanagement and better medication compliance.

The AMA agrees there are benefits in future community pharmacy agreements being limited to remuneration for the dispensing of PBS medicines and associated regulation. This would allow pharmacy programs, such as medication adherence and management services currently funded under the Agreement, to be funded in ways that are more consistent with how other primary care health services are funded.

Given these programs are about providing health services, rather than medicines dispensing per se, it makes sense for them to be assessed, monitored, evaluated and audited in a similar way to medical services under the MBS.

Approximately $1.2 billion has been provided to pharmacies under the current community pharmacy agreement without this level of transparency and accountability. No evaluations of pharmacy programs under the Sixth Community Pharmacy Agreement have been made public.

Moving pharmacist health services outside of the Agreement would also open the way for more flexible models of funding, for example, support for pharmacists working within a General Practice team and other innovative, patient-focused models of care.

The AMA would also welcome inclusion in future consultations undertaken prior to the finalisation of the next community pharmacy agreement, as proposed in the Review interim report. The AMA recognises the valuable contribution pharmacists make in improving the quality use of medicines.

Pharmacists working with doctors and patients can help ensure medication adherence, improve medication management, and provide education about medication safety. The AMA fully supports ongoing and adequate funding of evidence-based pharmacist services such as home medicine reviews and the provision of dose administration aids.

It is important that Government-funded pharmacy programs are monitored and evaluated for effectiveness and cost effectiveness to ensure the expenditure provides tax payers with value for money. The findings from these evaluations will help improve and strengthen the programs.

The AMA fully supports the recommendations made to enhance access to medicines programs for Indigenous Australians and to support Aboriginal Health Service pharmacy ownership and operations.

The full submission can be found at:

system/tdf/documents/AMA%20Submission%20-%20Interim%20report%20-%20Pharmacy%20remuneration%20and%20regulation%20review%20Jul17.pdf?file=1&type=node&id=46835

Political message in National Press Club speech

AMA President Dr Michael Gannon has called on all sides of politics to take some of the politicking out of health, for the good of the nation.

Addressing the National Press Club of Australia, Dr Gannon said some health issues needed bipartisan support and all politicians should acknowledge that.

“Some of the structural pillars of our health system – public hospitals, private health, the balance between the two systems, primary care, the need to invest in health prevention – Let’s make these bipartisan,” he said.

“Let’s take the point scoring out of them. Both sides should publicly commit to supporting and funding these foundations. The public – our patients – expect no less.”

During the nationally televised address, broadcast live as he delivered it on August 23, Dr Gannon warned political leaders that the next election was anyone’s to win and so they should pay close attention to health policy.

“Last year we had a very close election, and health policy was a major factor in the closeness of the result,” he said.

“The Coalition very nearly ended up in Opposition because of its poor health policies. Labor ran a very effective Mediscare campaign.

“As I have noted, the Government appears to have learnt its lesson on health, and is now more engaged and consultative – with the AMA and other health groups.

“The next election is due in two years. There could possibly be one earlier. A lot earlier.

“As we head to the next election, I ask that we try to take some of the ideology and hard-nosed politicking out of health.”

In a wide-ranging speech, the AMA President outlined the organisation’s priorities, while also explaining the ground it has covered in helping to deliver good outcomes for both patients and doctors.

The AMA’s priorities extend to Indigenous health, medical training and workforce, the Pharmaceutical Benefits Scheme, and the many public health issues facing the Australian community – most notably tobacco, immunisation, obesity, and alcohol abuse.

“I have called for the establishment of a no-fault compensation scheme for the very small number of individuals injured by vaccines,” Dr Gannon said.

“I have called on the other States and Territories to mirror the Western Australian law, which exempts treating doctors from mandatory reporting and stops them getting help.

“We also need to deal with ongoing problems in aged care, palliative care, mental health, euthanasia, and the scope of practice of other health professions.

“In the past 12 months, the AMA has released statements on infant nutrition, female genital mutilation, and addiction.

“In coming months, we will have more to say on cost of living, homelessness, elder abuse, and road safety, to name but a few.

“Then there are the prominent highly political and social issues that have a health dimension, and require an AMA position and AMA comment.

“All these things have health impacts. As the peak health and medical advocacy group in the country, the community expects us to have a view and to make public comment. And we do.

“Not everybody agrees with us. But our positions are based on evidence, in medical science, and our unique knowledge and experience of medicine and human health.

“Health policy is ever-evolving. Health reform never sleeps.”

The address covered, among other things, health economics: “Health should never be considered just an expensive line item in a budget – it is an investment in the welfare, wellbeing, and productivity of the Australian people.”

Public hospital funding: “The idea that a financial disincentive, applied against the hospital, will somehow ‘encourage’ doctors to take better care of patients than they already do is ludicrous.”

Private health: “If we do not get reforms to private health insurance right – and soon – we may see essential parts of health care disappear from the private sector.

The medical workforce: “We do not need more medical school places. The focus needs to be further downstream.

“Unfortunately, we are seeing universities continuing to ignore community need and lobbying for new medical schools or extra places.

“This is a totally arrogant and irresponsible approach, fuelled by a desire for the prestige of a medical school and their bottom line.

“Macquarie University is just the latest case in point.”

And general practice: “General practice is under pressure, yet it continues to deliver great outcomes for patients.

“GPs are delivering high quality care, and remain the most cost effective part of our health system. But they still work long and hard, often under enormous pressure.

“The decision to progressively lift the Medicare freeze on GP services is a step in the right direction.”

On even more controversial topics, Dr Gannon stressed that the AMA is completely independent of governments.

While sometimes it gets accused of being too conservative, he said, it was not surprising to see the reaction to the AMA’s position on some issues – like marriage equality.

“Our Position Statement outlines the health implications of excluding LGBTIQ individuals from the institution of marriage,” he said.

“Things like bullying, harassment, victimisation, depression, fear, exclusion, and discrimination, all impact on physical and mental health.

“I received correspondence from AMA members and the general public. The overwhelming majority applauded the AMA position.

“Those who opposed the AMA stance said that we were being too progressive, and wading into areas of social policy.

“The AMA will from time to time weigh in on social issues. We should call out discrimination and inequity in all forms, especially when their consequences affect people’s health and wellbeing.”

Last year, the AMA released an updated Position Statement on Euthanasia and Physician Assisted Suicide.

It came at a time when a number of States, most notably South Australia and Victoria, were considering voluntary euthanasia legislation.

There was an expectation in some quarters that the AMA would come out with a radical new direction. But it didn’t.

“The AMA maintains its position that doctors should not be involved in interventions that have as their primary intention the ending of a person’s life,” Dr Gannon said.

“This does not include the discontinuation of treatments that are of no medical benefit to a dying patient. This is not euthanasia.

“Doctors have an ethical duty to care for dying patients so that they can die in comfort and with dignity.”

The AMA also takes Indigenous health very seriously.

Dr Gannon travelled to Darwin last year to launch the AMA’s annual Indigenous Health Report Card, which focused on Rheumatic Heart Disease.

“In simple terms, RHD is a bacterial infection from the throat or the skin that damages heart valves and ultimately causes heart failure,” he said.

“It is a disease that has virtually been expunged from the non-Indigenous community. It is a disease of poverty.

“RHD is perhaps the classic example of a Social Determinant of Health. It proves why investment in clean water, adequate housing, and sanitation is just as important as echocardiography and open heart surgery.

“The significance of challenging social issues like Indigenous health, marriage equality, and euthanasia is that they highlight the unique position and strengths of the AMA.

“The AMA was recently ranked the most ethical organisation in the country in the Ethics Index produced by the Governance Institute of Australia.

“People want and expect us to have a view – an opinion. Sometimes a second opinion.”

Chris Johnson

A transcript of the full address can be found here:
media/dr-gannon-national-press-club-address-0

Six keys for aspiring medical leaders

Good medical leadership is critical to delivering high-quality care to patients. In hospitals and other large medical institutions, doctors in management or executive positions add a considerable amount of value by forming a bridge between the needs of clinicians and patients and those of the administration, government or funder.

And yet leadership skills have traditionally been a low priority in medical training, which puts far more emphasis on technical and academic ability. But moving from a caregiver role to a leadership one isn’t easy.

Being an effective medical leader clearly requires different skills than what’s needed from a good clinician. In fact, the skills set can sometimes be diametrically opposite. A good clinician, for example, needs to be something of a micromanager, personally checking and ensuring that all ordered tests have been done and the results transmitted. But good leaders can’t micromanage; they need to be comfortable delegating responsibilities to others.

Here are some key tips for aspiring medical leaders:

Seek out experience and mentoring from an established leader: you learn to be a leader by being a leader yourself, and by learning the skills from others;

Research the skills you need, get an understanding of what you’re not so good at, and seek training. If public speaking isn’t your forte, for example, you can be coached into being a better speaker.

Communication is key: it’s critical to be able to create and communicate a vision, setting a clear direction and working collaboratively towards it.

Communication also means listening: this doesn’t always come easy to clinicians, who often spend a lot of time telling patients about their condition and explaining to them what they need to do. But in leadership roles, you need to seek out the opinions of the team in forming your decisions.

Don’t get lost in minutiae: deal with the here-and-now, but keep an eye on what the future should look like. Good medical leaders have the ability to step back and focus on the big picture, taking a macroscopic view of healthcare and resource allocation.

Stay positive and empathic: you’re working in a very high-pressure sector rife with burnout and depression. You must be encouraging and positive, and impart your positivity to your staff.

Sources: BMJ, MJA.

Click here to access information on the AMA’s Diploma of Leadership and Management – a nationally recognised qualification for doctors and healthcare providers seeking to develop their skills in the management of staff, workplace relations, operational planning, project administration, financial and budget management.

[Viewpoint] Universal health coverage, priority setting, and the human right to health

Following endorsement by WHO,1,2 the World Bank,3 and the UN’s Sustainable Development Goals,4 the drive towards universal health coverage (UHC) is now one of the most prominent global health policies. As countries progress towards UHC, they are forced to make difficult choices about how to prioritise health issues and expenditure: which services to expand first, whom to include first, and how to shift from out-of-pocket payment towards prepayment. Building on extensive philosophical literature on the ethics of priority setting in health care, a 2014 WHO report provided guidance about how states can resolve these issues.

Internship Uncertainty – It’s time for a national application process

BY DOUG ROCHE, VICE PRESIDENT (EXTERNAL) AUSTRALIAN MEDICAL STUDENTS’ ASSOCIATION

Right now, final year medical students are receiving offers of internship from hospitals around the country. For each student, this follows a long process from considering which hospitals to preference, to preparing applications, and finally submitting them. However, with a shortage of internship positions, it’s uncertain as to whether many students, particularly international students, will even get to the point of receiving an offer.

Final year students who miss out on an offer in the initial round are put in an extremely difficult position. Many of these are full-fee-paying domestic or international students, and have invested $300,000 and a substantial portion of their life to get to this point, at which inadequate foresight in workforce planning has led to the prospect of never becoming a fully qualified doctor.

The shortage of positions means that students are advised to apply to multiple States and Territories (jurisdictions) to maximise their chances of obtaining an offer. For this year’s intake, almost 1200 students applied to multiple jurisdictions.

Such duplication incurs a number of costs, not just the direct cost to the jurisdiction. The principle cost is one of time and effort for the applicant. Internship applications occur during a busy year of clinical placements when most candidates are sitting final exams. They’re also trying to balance the extracurricular commitments needed to remain competitive for specialty training program selection, on top of maintaining healthy connections with friends and family.

For those who wait many months to receive an offer, the system is hampered by multiple offers being made to the same individual, increasing the time and level of uncertainty involved. The complexity is further increased by the different application systems implemented by each jurisdiction.

For domestic graduates, all States except Victoria offer a ballot-based system. The Victorian system, merit-based but termed ‘employer choice’, requires candidates to apply to individual hospital and health services.

There are broader harms to a merit-based internship process too. Metropolitan hospitals pride themselves on being able to select the “creme de la crème” of graduates. This results in a system where gaining employment at a top Melbourne hospital is a sign of success in and of itself, thus attracting high-achieving graduates who may not necessarily have only been attracted to metropolitan practice in the first place.

At the same time, outer metropolitan, regional and rural hospitals are filled with the remainder of students, many of whom, due to the preferencing system, are international students. Rural health becomes unnecessarily stigmatised as the option of last resort.

Given the importance of filling all available positions in a timely fashion, a national audit is conducted five times throughout the year. This involves each jurisdiction submitting their data on applications and offers. These data are then compared and candidates who are holding multiple offers are identified and asked to select one offer.

The situation for international students is unconscionable. International students are not guaranteed an internship, and job prospects are the major cause of stress in most international students’ lives. The transparency with which universities advise prospective international medical students of this fact varies considerably between institutions.

AMSA surveys show that 83 per cent of international students want to stay and work in Australia, and 85 per cent of these students are interested in working in regional and rural Australia. They are well acculturated to the Australian health care system. A national process would likely accelerate offers for international students and relieve some of the uncertainty associated with becoming fully qualified.

The solution to these problems is neither complex nor particularly costly. A national internship application process would involve one portal through which students apply, receive, accept and reject offers. AMSA has been calling for such a system since 2012.

For students, a streamlined national process would relieve a great amount of the pressure of becoming a fully qualified doctor. While ideally priority systems and methods of application would be aligned, this isn’t a necessary prerequisite for a national system. A computer algorithm would be able to take into account the differences between State and Territory preferencing system. The number of final year students racing against the clock to find an internship before the end of the year would be drastically reduced.

The benefits of a national process are not only to the individual student, but to jurisdictions as well. Administrative burdens of conducting a different scheme in each State and Territory would be minimised, and a national audit would no longer be necessary as multiple offers would be impossible. Hundreds of hours of work by departmental staff would be saved.

One of the great difficulties we face is that it’s impossible to track students as they flow through the fragmented system. Universities, AMSA and jurisdictions rely on reports of individual students and the somewhat delayed results of the national audit. We have no way of knowing how many graduating doctors fall through the cracks, and are forced to either take up an internship overseas or forfeit medicine as a career.

Australia is far behind in the implementation of a centralised process for internship applications – similar systems already exist in the US, UK, New Zealand and Canada. The US, UK and Canada have vastly more complex jurisdictional arrangements than Australia, and yet their ‘match’ systems are well-established.

It’s time for State, Territory and Commonwealth health ministers and departments to show some leadership in this area. The medical workforce challenges Australia faces are only going to compound. A National Internship Application Process would be a relatively simple step to addressing these, while creating a more certain future for the students on whom Australia’s future health relies.

Public Hospital Doctors role central to AMA

BY DR ROD McRAE, CHAIR, AMA COUNCIL OF PUBLIC HOSPITAL DOCTORS

I’d like to state my thanks for all the input and interest from PHD members at our recent National Conference. It was invigorating to experience your enthusiasm for the many issues directly affecting public hospital doctors. An important issue about which I do want to remind you is actually how you “describe” yourself for AMA membership purposes. In order to keep the CPHD vibrant and relevant to key issues, we must have a solid base. Today we can choose our membership category more accurately. I hope more doctors based in public hospitals, particularly those with a Specialist qualification, will choose to identify in the public hospital doctor membership category as opposed to their medical craft group if they have one, when it comes to identifying their AMA membership as you will be invited to do soon, and thus remain engaged with the CPHD.

Vale Dr Patrick Pritzwald-Stegmann

Multiple issues are before the CPHD. None is more relevant than safety in the workplace. On July 21, a Memorial Service was held for AMA member Dr Patrick Pritzwald-Stegmann, who died after substantial time ventilated in one of our ICUs after an alleged “coward’s punch” received in the foyer of a Melbourne metropolitan public hospital resulted in a profound brain injury. This is now a Coroner’s and police matter. I am regularly horrified at the experiences of violence in our community and our workplaces, but this is all the more poignant for me as Patrick was a recent close colleague of mine with whom I had worked extensively.

There are many intersecting issues in our community, most of which lead to the public hospital system. They include mental health issues, whether acute, chronic or acute-on-chronic, illicit drug use, perhaps loading up on mental health issues, increased passive tolerance of greater violence in and by the now metropolises (as opposed to tight-knit communities), and a general lack of respect for those providing any type of community service. Emergency service providers and our colleagues and other healthcare workers in emergency departments face the brunt, but it is throughout the public hospital system. I note that our population is growing remarkably, we have generated profound productivity improvements, but there remains a yawning gap of lack of public hospital capacity investment to match the essential hospital requirements of the complex, multi-system, elderly and/or obese, chronic illness sufferers. It is readily observable how “house full” messages contribute to patient frustration, then anger and venting in our workplace. It was equally offensive to see lauding of “this is what 182 blows to the head looks like” related to a recent violent “sport” designed to inflict brain injury. It is easy to see some might link these ingredients, resulting in an unsafe workplace for us.

In perhaps a curious coincidence, I am now chairing an Australian Standards committee revising the standard Security for Health Care Facilities. It will be a template for consideration of security risks for any and all health care facilities in Australia. Its origin related to large public hospitals, but changes in technology and hospital interventions means security issues are everywhere that medicine is practised, including hospital-in-the-home and all points travelling between, patient record security, medication and medical gas security, microorganism security, IT security, food security, let alone staff safety and security. I will be pleased to receive your thoughts on this topic. Obviously not everything will be totally relevant to all, but in these days of terrorism and bioterrorism, it will be a useful tool for risk analysis. It will be a sad day if every part time medical point of care in a high rise tower through to our major teaching hospitals needs to have the same security we now take for granted on getting to the airside of an airport, surveillance cameras or requires trained and authorised security personnel with Tasers and policing powers comparable to Protective Service Officers.

Of note, none of the above may have prevented Patrick’s injury, or some of them may have caused the alleged perpetrator to pause.

Public Hospital Funding

It is clear an expansion and greater funding of public hospital’s is required to meet the increasing demand, separate to security investments. This is about to accelerate in my view as more reduce private health insurance due to increasing premiums coupled with increasing mortgage, energy and education costs pressures. An important discussion will be how best to use the now billions of tax dollars shoring up publically listed health insurance companies’ profits and employee bonus payments, whilst squeezing the marketplace and offering frequently inadequate products to bamboozled patients seeking a tax break.

Recently the Government rejected a proposal to abolish the private health insurance rebate and effectively take funds it saves from that, along with hospital funding, to provide a standard benefit for services, regardless if they happen in a public or in a private hospital. This would effectively take Commonwealth funds from public hospitals and force patients to pay more for coverage. This would reduce the amount the Commonwealth contributes to the cost of public hospitals to a paltry 35 per cent. The 42 or 43 per cent funding we’re getting from the Commonwealth now is not sustainable for future public hospital operation.

A 35 per cent share would be a disaster in the super-stretched public system and in the private system for that matter. In recent years we’ve seen the Commonwealth’s share of funding to public hospitals drop below 45 per cent with a formula that only relies on growth in CPI and population. The AMA’s Public Hospital Report Card shows that performance in the system, such as wait times in the emergency department or for elective surgery, are not improving, or indeed are going backwards. So we can be thankful that this reduction has been ruled out.

But with consideration of the way hospitals are funded, we need to focus on priorities and things that might work in the hospital system. This especially includes quality and safety initiatives as well as increasing the utility of secondary hospitals or in the community. We must put more resources into primary care prevention as a long-term strategy for reducing the rate of increase of pressure on public hospitals.

Let’s hope governments see sense and realise that proper health care is a sound investment and saves money in the long term, and that engaging with doctors is the only way to develop sound health policy. I look forward to discussing these and other issues with you in upcoming CPHD meetings and other events.

AMA’s successful stand for sensible and safe pathology testing

BY PROFESSOR ROBYN LANGHAM, CHAIR, MEDICAL PRACTICE COMMITTEE

One could be forgiven for thinking that he AMA thinks little of pharmacists, given the nature of the media reports around the recent successful AMA campaign to stop Amcal pharmacies ordering unnecessary pathology screening tests.

The truth is quite the opposite. The AMA greatly respects the valuable contribution pharmacists make in improving the quality use of medicines. Pharmacists working with doctors and patients can help ensure better medication adherence, improved medication management, and also help in providing education about medication safety.

The AMA agrees that pharmacists’ expertise and training are under-utilised in a commercial pharmacy environment where they are necessarily distracted by retail imperatives.

That is why the AMA is fully engaged in the current review of pharmacy remuneration and regulation being undertaken by an independent panel appointed by the Federal Government.

In a comprehensive submission to the panel lodged last year, the AMA was supportive of alternate models of funding being explored that would encourage and reward a focus on professional, evidence-based interactions with patients. Our submission also supported ongoing funding of effective and cost-effective pharmacist medication management programs, particularly those targeting Aboriginal and Torres Strait Islanders, and a relaxation of the restrictive pharmacy location rules.

The panel has now released an interim report revealing its likely recommendations to Government on the future of pharmacy funding and regulation.

The proposed recommendations pick up on many of the AMA’s suggestions and concerns, and, if implemented, would radically improve the transparency of pharmacy funding and refocus government investment on evidence-based and cost effective services.

Unsurprisingly, the Pharmacy Guild of Australia is highly critical of the report, slamming it as “without merit”, “ill-considered”, “threatening” and “undermining” as well as stating it has “serious concerns about the true intention of the review”.

Some of the key recommendations supported by the AMA include:

banning the sale of homeopathic products from pharmacies altogether;

physically separating other complementary medicines from “pharmacy only” (schedule 2) and ‘pharmacist only’ (schedule 3) in pharmacies to better help consumers understand that these medicines have not been assessed for effectiveness in the same way as S2, S3 and prescription medicines;

moving the funding of pharmacist services programs from the Guild-controlled Community Pharmacy Agreement to other government funding streams to improve transparency and facilitate coordination with other primary health care programs;

removing current bureaucratic barriers to medicines programs and pharmacy services that hinder access to indigenous Australians; and

changing the pharmacy location rules with potential to improve options for pharmacy co-location with general practices.

The AMA is very supportive of the interim report and lodged a favourable submission in response in July.

Unfortunately, the Guild has already brokered a deal with the Coalition Government to shelve any changes to location rules in the foreseeable future. It will be interesting to see what appetite the Government has for taking up the panel’s final recommendations, particularly given the next Federal election date is not so far away.

Relationships with industry

BY DR CHRIS MOY, CHAIR. AMA ETHICS AND MEDICO LEGAL COMMITTEE

A major priority for the AMA’s Ethics and Medico-Legal Committee (EMLC) will be the review of the Position Statement on Medical Practitioners’ Relationships with Industry 2012. The statement provides guidance for doctors on maintaining ethical relationships with “industry”, including the pharmaceutical industry, medical device and technology industry, other health care product suppliers, health care facilities, medical services such as pathology and radiology, and other health services such as pharmacy and physiotherapy.

The current Statement encompasses the following sections:

medical education;
managing real and potential conflicts of interest;
industry sponsored research involving human participants including post-marketing surveillance studies;
meetings and activities organised independent of industry;
meetings and activities organised by industry;
hospitality and entertainment;
use of professional status to promote industry interests;
remuneration for services;
product samples;
dispensing and related issues; and
relationships involving industry representatives.

Doctors’ primary duty is to look after the best interests of their patients. To do so, doctors must maintain their professional autonomy, clinical independence and integrity, and have the freedom to exercise professional judgement in the care and treatment of patients without undue influence by third parties (such as the pharmaceutical industry or governments).

But what happens when the impetus to change the relationship with industry comes from within the profession itself? For example, the AMA’s current policy on doctors and dispensing states that:

11.1 Practising doctors who also have a financial interest in dispensing and selling pharmaceuticals or who offer their patients’ health-care related or other products are in a prima facie position of conflict of interest.

11.2 Doctors should not dispense pharmaceuticals or other therapeutic products unless there is no reasonable alternative. Where dispensing does occur, it should be undertaken with care and consideration of the patient’s circumstances.

In recent years, we have heard from members who believe this position is too strict and doctors should be able to dispense pharmaceutical products, arguing that it’s more convenient for patients and leads to better compliance. For example, patients may be more likely to fill their prescriptions onsite at the doctor’s office than if they have to go offsite to a pharmacy. In addition, the doctor is there to answer any questions relevant to the prescription which will reduce pharmacy call backs and waiting times.

Historically, the AMA has strongly advocated that doctors do not make money from prescriptions. Allowing doctors to dispense pharmaceuticals or other therapeutic products (other than in exceptional circumstances) would be a fundamental shift in this position – but is that a sufficient reason not to change it?

After all, dispensing pharmaceuticals or other therapeutic products is not in itself unethical so long as it is undertaken in accordance with good medical practice. Unfortunately, however, there can still be a strong perception of a conflict of interest, particularly if doctors are making a profit rather than just recovering costs. So for many doctors – but more importantly our patients and the wider community who are our ultimate judges – this is a line which should not be crossed.

These are the types of issues the EMLC will consider in reviewing this policy and we will endeavour to seek members’ views during the process.

The EMLC will also be developing an overarching policy on managing interests, highlighting the potential for professional and personal interests to intersect, and at times compete, during the course of a doctor’s career. While a real, or perceived, conflict of interest is by no means a moral failing, it is important that doctors are able resolve any potential for conflict in the best interests of patients.

The Position Statement on Medical Practitioners’ Relationships with Industry 2012 is accessible on the AMA’s website at position-statement/medical-practitioners-relationship…. If you would like to suggest any amendments to the current Statement, please forward them to ethics@ama.com.au.

Why it costs so much to see a specialist – and what the government should do about it

Australians pay too much when they go to medical specialists. The government can and should do more to drive prices down. A current Senate Inquiry on out-of-pocket costs will hopefully lead to some policy action.

The problem is clear to anyone who has had to see a specialist recently. About 85% of GP visits are bulk billed, but the rate of bulk billing for visits to a specialist is much lower, at around 30%. The out-of-pocket costs can be very high, hurting patients.

To work out how to reduce the out-of-pocket costs for specialist care, we first need to identify why they are so high. There are four potential reasons.

1. Government rebates?

It may be that rebates for some procedures or for attendances are set too low. Rebates are set by government and may bear no relation to the actual cost of providing a service. Unlike in Canada, there is no obligation in Australia for government to consult with medical practitioners before setting fees.

But this explanation cannot account for the very high variation in fees. If high levels of billing above the nominated fee were due to inadequacies in the fee paid by government, then this would apply to all specialists equally. But in fact, some specialists charge more than others.

2. Supply and demand?

It may be that a specialist’s ability to charge a substantial out-of-pocket premium is simply the result of high demand for a particular service in a particular location.

Certainly, if the market for specialist care was functioning perfectly, supply would adjust to meet demand. But the reality is that specialist care is not a perfect market. Even with the increase in the number of medical graduates in Australia over recent years, there are still shortages of specialists in rural and remote parts of the country.

Here, the government needs to do more. It should consider whether specialists’ productivity can be improved, or whether other health professionals could perform roles in areas of short supply. The Grattan Institute’s 2014 report, Unlocking skills in hospitals: better jobs, more care outlined some options such as nurses performing endoscopies or providing sedation, work mostly now done by medical specialists such as gastro-enterologists.

Left to their own devices, specialists tend to establish their practices in more salubrious, city locations. There’s no guarantee newly accredited specialists will set up shop where their services are needed most. So the government should offer some carrots and wield some sticks to encourage new specialists to practice in rural and remote areas.

– How much?! Seeing private specialists often costs more than you bargained for

– For real health reform, turn the spotlight on specialists’ fees

Carrots could include subsidies and other support for the first few years in rural or remote practice. Sticks might include restrictions on access to Medicare billing in areas of existing over-supply in particular specialties. This would not preclude specialists establishing practices in over-supplied areas, but rather would limit public subsidies in those areas and thus provide an incentive for newly-minted specialists to go where the need is greatest.

Medicare already provides differential rebates for general practice in different parts of the country (rural and regional compared to inner city). Why not do the same for specialist practice?

3. Market power?

High specialist charges and consequent high out-of-pocket costs may simply be the result of specialists using their market power to maximise their income. Even in areas of reasonable supply, specialists may be able to charge high fees because they benefit from established referral patterns. That is, local GPs, clinics and hospitals may refer patients to particular specialists almost by habit, without paying heed to the fees they change. Patients may not be aware of these fees until they’re committed to being treated by that specialist.

The government could limit rebates in built-up areas already serviced by other specialists.
from www.shutterstock.com

A good way to respond to market power is to strengthen the market, to use competition between specialists to drive prices down. And the first step to improving competition is to increase transparency about prices charged.

The government – and perhaps private health insurers too – should publish information on specialists’ fees: the proportion of visits that are bulk billed, how each specialist’s fees compare to the average of specialists in, say, a 10-kilometre radius, and so on.

The government should further discourage higher fees by eliminating a rebate when fees are significantly above the standard rebate. For example, rebates might be paid only if the specialist fee is less than twice the standard rebate.

4. Skill-based premiums?

The fourth reason there may be high out-of-pocket charges is that some specialists are able to charge a premium for skill – or at least they might claim that is the basis for their high fees. Unfortunately, patients have no way of knowing whether this skill-based premium is warranted.

Again, transparency can help here. Governments and private health insurers should publish information which would help patients and their GPs assess whether a specialist’s outcome-based premium is warranted.

There are, of course, challenges associated with publicly reporting indicators of specialists’ quality of care. Agreement would need to be reached on what the key quality indicators for a range of procedures are in each specialty. Imperfect measures can be gamed, or discourage specialists from treating high-risk patients. And not all differences in performance metrics reflect actual differences in performance.

But opportunities for gaming or over-interpreting performance metrics could largely be removed by reporting performance within broad bands – for example: the bottom 25%, the central half, and the top 25% of performers. In the first instance, reporting should simply state whether, based on the specialist’s record, future performance is likely to be of a high standard.

Excessive costs for specialist care hit patients in the hip pocket and can discourage some from seeking appropriate treatment. Driving these costs down would make Australia a fairer and healthier nation.

Stephen Duckett, Director, Health Program, Grattan Institute

This article was originally published on The Conversation. Read the original article.

Critical attention given to doctors’ health at COAG

Federal, State and Territory Health Ministers met in Brisbane this month at the COAG Health Council to discuss a range of national health issues.

During broad ranging discussions it was agreed to amend mandatory reporting provisions for treating health practitioners. Doctors should be able to seek treatment for health issues with confidentiality. They also acknowledged that protecting the public from harm is also important.

The resulting COAG communique said: “A nationally consistent approach to mandatory reporting provisions will provide confidence to health practitioner that they can feel able to seek treatment for their own health conditions anywhere in Australia.”

AMA President Dr Michael Gannon commended the decision, saying: “It has been acknowledged that there needs to be a change, that there’s a problem.

“Healthy doctors take better care of their patients.”

Other items discussed by Health Ministers included:

Family violence and primary care

The Health Ministers agreed to seek further advice from Primary Health Networks on existing family violence services, including Commonwealth, State and NGO service providers in their regions, with a view to developing an improved whole-of-system response to the complex needs of clients who disclose family violence.

This is supported by evidence given by Professor Kelsey Hegarty at the Victorian Royal Commission into Violence, when she said: “PHNs and other alliances across the health services sector have a significant role to play in supporting practitioner training about family violence.”

Fifth National Mental Health and Suicide Prevention Plan

Health Ministers endorsed the Fifth National Mental Health and Suicide Prevention Plan 2017-2022 and its Implementation Plan.

Federal Health Minister Greg Hunt said it stood out from previous plans with its focus on eating disorders and suicide prevention, keys areas that had been raised by lobbyists.

“The prevalence and the danger of (eating disorders) is still dramatically understated in Australia,” he said.

“The reality is that this is a silent killer, particularly women can be caught up for years, so there is a mutual determination to make progress.”

The plan will also focus on improving Aboriginal and Torres Strait Islander mental health and suicide prevention, reducing stigma and discrimination, and better coordinating treatment and support programs.

The National Psychosocial Supports Program

The 2017-18 Budget allowed for the establishment of a National Psychosocial Supports Program that aims to provide flexible, targeted services to people with severe mental illness resulting in psychosocial disability who are not eligible for the National Disability Insurance Scheme (NDIS).

The Health Ministers agreed to establish a time-limited working group to progress a National Psychosocial Supports Program to reduce the community mental health service gap, improve mental health outcomes and reduce the inequity in service availability.

National Digital Health Strategy and Australian Digital Health Agency Forward Work Plan 2018–2022

The COAG Health Council gave the green light to the National Digital Health Strategy. Currently, 5 million Australians have a My Health record – this strategy aims, among other things, to expand this non-compulsory offer to all Australians by 2018.

Expanding the public reporting of patient safety and quality measures

Ministers agreed that the Australian Commission on Safety and Quality in Health Care (ACSQHC) would undertake work with other interested jurisdictions to identify options in relation to aligning public reporting standards of quality healthcare and patient safety across public and private hospitals nationally.

The Australian Institute of Health and Welfare last month highlighted the gaps in reporting, and in some areas, the lack of data altogether, saying: “There is no routinely available information on some aspects of quality, such as the continuity and responsiveness of hospital services.”

Health Ministers at the COAG meeting also considered the development of the next iteration of the Implementation Plan for the National Aboriginal and Torres Strait Islander Health Plan 2013–2023; agreed to explore a National Human Biomonitoring Program by undertaking a feasibility assessment; agreed to proceed to Strengthen penalties and prohibition orders under the Health Practitioner Regulation National Law; and sought clarification of roles, responsibilities and relationships for national bodies established under the National Health Reform Agreement.

MEREDITH HORNE