Let’s be clear eyed while moving forward on private health insurance

BY ASSOCIATE PROFESSOR JULIAN RAIT, CHAIR, COUNCIL OF PRIVATE SPECIALIST PRACTICE

On October 11, Health Minister Greg Hunt announced the final rules that support the new private health insurance clinical categories and the Gold, Silver, Bronze and Basic classification system.

CPSP and the AMA have called on these reforms to deliver simplified, better value private health insurance products for consumers. A system that offers more comprehensive coverage, with clear definitions, and less caveats and carve outs. Will the new system deliver total clarity and transparency? Not quite, but it is going to be a lot simpler for consumers than trying to navigate through the current 70,000 policy offerings.

The AMA has always supported, two key aspects of these reforms:

Clarity about what medical conditions are covered in each tier of benefits; and
The use of standard clinical categories across all private health policies.

The new classification system categorises existing policies into easier to understand tiers. These tiers, in combination with new Private Health Information Statement (which includes mandatory information about what each policy covers), should make it easier for people to compare policies, to shop around and actually see what they are covered for.

This should enable consumers to know that when they book in for a procedure they are covered now and not have to wait an additional 12 months or try the public system.

The tiers outline minimum requirements, but they still allow insurers to add additional cover. The legislation clarifies that insurers can move people onto new products, closing old products, but introduces new protections about warning and information for consumers. Additionally, the Minister is on the record stating that “importantly consumers will not be forced to change their policy cover if they are happy with it”.

There are also some more hidden benefits that will come in with the new system.

That the system provides full mandatory cover for the medical conditions in each tier; partial cover is not permitted (except in Basic cover and for Psychiatry, Rehabilitation, and Palliative Care – except in Gold cover where there are no exclusions allowed at all);
The inclusion of gynaecology, breast surgery, cancer treatment, and breast reconstruction in bronze tier products;
That a clinical category covers the entire episode of hospital care for the investigation or treatment;
That an episode of hospital treatment covers the miscellaneous services allied to the primary service; and
Patients with limited cover for psychiatric care can upgrade their cover (once) to access higher benefits for in-hospital treatment without serving a waiting period.

While these look obvious, they haven’t always been included in policies. From next year they will be.

The Minister has called for an April 1, 2019 commencement to coincide with the annual announcement of new premiums. However, as with most major changes, not all groups can adapt as quickly as others. So, while the reforms start next year, insurers have a further 12 months to ensure that each of their products is compliant and to move people onto new products if required. This is not ideal, but the transition for the smaller insurers is likely to be very resource intensive. The Minister has stated that his expectation is that the great majority of policies will be ready to go by April 1 next year. He has also stated that these reforms will have an overall neutral to -0.3 per cent impact on premiums compared with current policy settings.

But we also need to be clear eyed here. This will not solve the wider issue of how to bridge the ongoing premium increases in the 4-5 per cent range, and wages growth at 2 per cent range. That fundamental paradox to a long-term, sustainable private health insurance system remains. These reforms will not address the concerns around private health insurer behavior, nor will they address the variation in rebates. These reforms are about making life a little easier for our patients, and our practices. But the AMA will need the support of all our members going forward – for clearly, the bigger problem is yet to be addressed.

Reflections on a rural medicine conference

BY DR SANDRA HIROWATARI, CHAIR, AMA COUNCIL OF RURAL DOCTORS

Rural Medicine Australia is the biggest Australian conference focusing on rural medical issues. There aren’t many of you rural doctors, too few of you as a matter of fact, but still we meet every October. This meeting is getting bigger and bigger, in fact there were over 750 delegates at RMA18 in Darwin this year – that’s big.

Representatives from both State and Federal politics attend this conference. I heard that this year Federal Department of Health representative quietly went to multiple sessions to listen and absorb what us rural doctors were troubled by and advocating for. Shadow Health Minister Catherine King came to us in person to address the crowd, Rural Health Minister Bridget McKenzie relayed a taped message.

The Keynote addresses were each inspiring:

Dr Jillann Farmer, the Medical Director of the United Nations’ Medical Services Division, and a former rural Australian GP who stated she was an expert of nothing, but her generalism was her strength.
Orange Sky Laundry, networking and peer support disguised by a free laundry service.
Donna Ah Chee, the CEO or the Central Australian Aboriginal Congress of NT, an inspiring powerful Aboriginal woman.
The Rural Health Commissioner, Emeritus Professor Paul Worley, discussing something other than the National Rural Generalist Pathway, talked about the backbone behind all rural doctors – our families.
Glenn Singleman, an extreme sport enthusiast and a rural doctor, taught us that whether it’s base jumping or remote resuscitations, it is all about perception and fear

There were plenty of skill enhancing sessions, such as ENT emergencies, ophthalmological emergencies, Rural emergency workshops, and, most memorably, trauma management done outside in the stinking humidity – a real life Australian simulation.

However, many of the workshops and break-out groups were focused on the business end of life in rural Australia. For students there were lessons for preparing for exams from those who have sat them and help with career planning. There were rural women workshops focusing on the subtleties of bullying. And then there were discussion on how to survive, with stories from as far as Japan and from each State and Territory and across the medical specialties.

Rural doctors also know how to party. Every night of the conference there were events happening. Even after the conference finished I noticed there were harbour cruises, surfing in the wave pool and visits to the RFDS museum.

I have been to many conferences over the years, but this one is unique. The networking among rural doctors is so much more important for rural doctors because it becomes our safety net when we go back to the isolated areas where we live and work. We learn names and see faces – new and old – and we begin to learn who we can turn to. We also learn who we need to provide support to and foster a career in this challenging but rewarding part of medicine.

We leave the conference inspired – with good memories and a to-do list of projects for the year that follows.

RMA19 will be at the Gold Coast in October next year. Mark it on your calendar and I will see you there.

Issues to be aware of when responding to compliance audits

BY DR RICHARD KIDD, CHAIR, AMA COUNCIL OF GENERAL PRACTICE

The Department of Health regularly conducts compliance audits of practitioners to ensure that the amounts claimed under the Medicare Benefits Schedule (MBS) are correct. I thought it might be beneficial to provide you with some information about the Department’s processes, your obligations and options when responding to an audit. The AMA’s Legal Counsel has assisted me in this to ensure you understand the process and are equipped to respond to any compliance concerns that may arise while still protecting patient privacy.

When conducting an audit, the Department’s general approach is to:

(1) identify the practitioners to be targeted in the audit. This could be through tip offs or data analysis;

(2) send the identified practitioners a letter asking them to verify their compliance; and

(3) depending on the audit target’s response, issue a Notice to Produce under section 129AAD of the Health Insurance Act 1973.

The following looks at the privacy and other issues that GPs and general practice managers need to be aware of at each stage of the process.

Initial letter

The initial letter will usually advise the practitioner of the concern that has given rise to the compliance action; and ask them to provide evidence that they have met the requirements of the items being audited. This evidence is usually in the form of some documentation.

Practitioners should note that this letter is asking practitioners to voluntarily:

provide documentation to support their claims; or
acknowledge where they have not fully met the requirement of the item claimed and thus have been overpaid.

Practitioners need to be mindful of protecting patient privacy when voluntarily providing documentation to support their claims. The sections below have more information on why and how.

Practitioners who think they may have claimed inappropriately may avoid an administrative penalty if they voluntarily acknowledge their error and the overpayment of benefits. Where the Department has already sent an initial letter, the maximum reduction of the administrative penalty is 50 per cent. Any overpayments plus any applicable penalty will then be raised as debt owing for repayment.

Notice to Produce

Depending on the outcome of the initial letter, the Department may issue a Notice to Produce.

A practitioner can still receive a reduction in the administrative penalty after a Notice to Produce is issued, if they voluntarily acknowledge the overpayment before the time to respond to the Notice to Produce expires. However, the maximum reduction is lower (25 per cent) than if the practitioner had acknowledged the error prior to receiving the Notice to Produce.

Practitioners will have at least 21 days to respond before the Notice to Produce expires and a debt for the claims in question is raised.

Privacy issues

Australian Privacy Principle 6 prohibits practitioners from disclosing their patient’s records unless an exception applies. A key exception is where disclosure is ‘required or authorised by law’ (APP 6.2).

A practitioner is legally required to comply with a Notice to Produce. This means that a practitioner will not be breaching the Privacy Act if they provide patient information in response to a Notice to Produce. However:

practitioners should only provide patient information to the extent necessary to comply with the Notice to Produce; and
the AMA recommends that practitioners exercise their statutory right to only provide documentation containing ‘clinical details relating to an individual’ to a departmental medical adviser.

By contrast, a practitioner may breach the Privacy Act if they provide any documentation containing health information prior to the Department issuing a Notice to Produce. This is because practitioners are not legally required to respond to the initial letter. This means that practitioners:

should not volunteer any patient information at the initial letter stage; and
if they do choose to respond, must redact enough personal information to protect the privacy of the patient.

So why does the Department send initial letters?

Part of the reason why the Department sends initial letters is that voluntary compliance avoids more expensive and difficult compliance processes.

The other reason is that section 129AAD of the Health Insurance Act provides that the CEO Medicare must give practitioners an opportunity to respond to a request for documents before they issue a Notice to Produce. In other words, they must ask you to provide supporting documentation even though it is not mandatory for you to do so, and if you do and that documentation contains patient information you will be breaching the Privacy Act, before they can issue a binding Notice to Produce, which then protects you under the Privacy Act for providing the information.

Other consequences of voluntary repayments

The AMA appreciates that practitioners may choose to voluntarily acknowledge an overpayment to avoid the administrative costs of locating records to prove their claims were legitimate. However, practitioners should be aware that if they voluntarily acknowledge an overpayment, any associated incentive payments claimed in conjunction with the payments for services that have been voluntarily acknowledged will also be recoverable.

The Department of Health also discourages practitioners from voluntarily acknowledging “no service” when a service was provided because of the flow on impacts on the patient’s My Health Record and MBS claim history.

Accordingly, it is recommended that practitioners consult with their medical defence organisation before responding or submitting any documentation to the Department to ensure they are aware and understand the financial and legal consequences.

BOOK REVIEW

Booming: A Life Changing Philosophy for Ageing Well

Marcus Riley

Marcus Riley is the Chief Executive Officer of BallyCara, a charitable organisation and public benevolent institution providing health, accommodation and care services for older people. He is also a Director and the Immediate Past Chair of the Global Alliance for the Rights of Older People. A United Nations agency – the Stakeholder Group on Ageing – has also appointed him its Asia-Pacific Region Focal Point.

So, it would seem that Riley is well qualified to write a book about ageing well. That assumption would be correct. Riley’s 20 years’ experience as a positive ageing advocate are evident throughout this highly readable book.

With some excellent tips for successful ageing, Booming easily serves as an engaging read for older people, but also as a tool for medical professionals to recommend to their patients. It is all about being positive and meeting head-on the challenges and delights of growing old.

“People can accept the negativity that abounds about getting older, concede that they will decline and wither on the vine – or we choose to seize the opportunity to revel in our extended later years with joy, passion and wisdom,” the author writes.

Promoted as a blueprint for successful ageing, Booming is very much an inspiring guide.

[Perspectives] Evan Atar Adaha: surgeon and tireless caregiver

“If I tell a patient I am sorry this I cannot treat, they say OK let me go back home and die there. That is the desperate situation of these people. Therefore, we cannot think of abandoning them, we have to continue”, says Evan Atar Adaha. It is this unwavering commitment that has driven 53-year-old Atar, a South Sudanese surgeon, to work tirelessly in one of the world’s most violent regions. Last month he was awarded UNHCR’s 2018 Nansen Refugee Award for his 20-year commitment to the provision of life-saving medical services to refugees forced to flee conflict and persecution in Sudan and South Sudan and to the communities that welcome them.

Bullying and harassment of health workers endangers patient safety

Bullying, harassment and other unprofessional behaviours are culturally ingrained in the Australian health-care system.

As we outline on Monday in the Medical Journal of Australia, between one-quarter and half of doctors and nurses in Australia have been bullied, discriminated against or harassed at work.

This impacts on the way they do their work, and the quality and safety of the care they’re able to provide patients.

From doctor depression to medical errors

Workplace bullying in hospitals has been shown to cause depression, anxiety and fatigue among health workers. It can also reduce performance and levels of self-esteem.

These symptoms, along with stress and poor staff satisfaction at work, leads to higher staff absenteeism, impacting continuity of patient care and increasing the workload in already overstretched hospital clinics and wards.

While we don’t have data from Australia, a survey of staff from more than 100 United States’ hospitals give us some clues about the impact. More than two-thirds (71%) of respondents – mainly nurses and doctors – agreed unprofessional behaviour and poor communication contributed to medical errors.

Worryingly, one-quarter of respondents (27%) believed unprofessional behaviour had contributed to a patient’s premature death.

Communication is compromised

Good communication among clinical teams is central to safe care. When team members feel unable to speak up due to negative consequences, care will be compromised.

One study showed medical teams who were treated rudely by an “expert observer” performed significantly worse in a simulated situation where they had to manage a sick infant compared to teams who were treated respectfully.

The teams subjected to rudeness shared less information with each other, and didn’t seek help as often. This led to poorer clinical outcomes for the patients in the simulation.

We can draw parallels with the experience of junior doctors and medical students in Australia, who report being routinely “taught by humiliation” and mistreated during clinical training rotations.

Junior clinicians are regularly subjected to rudeness, hostility and aggressive questioning from their teachers. These are the “expert advisors” they’re also supposed to approach for help to manage the patients in their care.

Poor outcomes for patients

Serious bullying is just the tip of the iceberg of behaviours that pose a risk to patient safety. Even more subtle unprofessional behaviours – such as passive aggression, public criticism of colleagues, or telling offensive jokes – may interfere with teamwork and the quality of patient care.

A large US study across multiple hospitals found patients’ observations of negative behaviours among surgeons could predict poor patient outcomes.

Hospitals implemented the “patient advocacy reporting system”, where patients were able to report their observations of a clinician’s behaviour while in hospital. This could be dismissing a patient’s questions, rushing them out of consultations, or being rude to other staff members in the patient’s presence.

Among a sample of more than 32,000, those patients who were operated on by surgeons who received a high number of negative patient reports in the past two years had a 14% higher rate of complications than patients whose surgeons acted professionally.

The authors suggest surgeons who are disrespectful to patients probably also behave disrespectfully towards colleagues in the operating theatre. This makes it more difficult to work with others and increases the risk of errors and poor outcomes for the patient.

Where do we go from here?

The effects of unprofessional behaviour of health workers are too great to ignore. But pronouncements of a “zero tolerance” for such behaviours are unlikely to bring about change.

Instead, we need evidence-based interventions to reduce the prevalence of negative behaviour, minimise its impact on staff and patients, and normalise a culture of safety and respect.

Culture change is incredibly hard. Unfortunately, there is very limited evidence about the types of interventions which work and bring about change.

We’re currently evaluating a large-scale system intervention, called Ethos, at St Vincent’s Hospitals across Australia.

The program aims to enable and empower staff to speak up when they see a problem via a confidential electronic reporting system. Trained colleagues then relay the information back to individual staff involved to encourage self-reflection and correction. Our four-year evaluation will measure how effective this program is at creating real change in behaviours.

We need more system-wide interventions to address the complex problem of bullying and harassment in our health system. But it’s important these interventions are subject to rigorous evaluations which measure both their effects on unprofessional behaviours and clinical outcomes.

Johanna Westbrook, Professor of Health Informatics and Patient Safety, Macquarie University and Neroli Sunderland, Research Fellow, Centre for Health Systems and Safety Research, Macquarie University

This article is republished from The Conversation under a Creative Commons license. Read the original article.

[The Lancet Commissions] The Lancet Commission on global mental health and sustainable development

The Sustainable Development Goals (SDGs) represent an exponential advance from the Millennium Development Goals, with a substantially broader agenda affecting all nations and requiring coordinated global actions. The specific references to mental health and substance use as targets within the health SDG reflect this transformative vision. In 2007, a series of papers in The Lancet synthesised decades of interdisciplinary research and practice in diverse contexts and called the global community to action to scale up services for people affected by mental disorders (including substance use disorders, self-harm, and dementia), in particular in low-income and middle-income countries in which the attainment of human rights to care and dignity were most seriously compromised.

New mental health program tells kids to just be you

Former Prime Minister Julia Gillard has launched a new school-based mental health initiative that aims to give teachers the tools to help students manage their mental health.

The Federal Government has invested $98.6 million.

The program Be You will be delivered by Beyond Blue – of which Ms Gillard is the chairwoman – in partnership with Headspace and Early Childhood Australia.

The program will be rolled-out by Beyond Blue in 6,000 schools and 2,000 early learning services in 2019.

Teachers and educators, including those still in training, will have access to free online courses and materials on mental health and suicide prevention.

The program will also be supported by more than 70 frontline staff from Early Childhood Australia and Headspace who will help schools and early learning services around the country implement the program, through online, telephone, and face to face consultations.

“Half of all lifelong mental health issues emerge before the age of 14,” Ms Gillard said.
“We have the opportunity to grow Australia’s most mentally healthy generation. It’s a big ambition and to achieve it we are asking everybody to get involved.”
Health Minister Greg Hunt said the program will provide Australian teachers with the skills and resources to be able to teach students how to manage their mental health and wellbeing, build resilience, and support the mental wellbeing of other students.
“It will ensure that students have all the support required for healthy social and emotional development,” Mr Hunt said.
“Be You will teach educators to identify any students who may be experiencing mental health difficulties, and to work with the families and local services to get the right help early on. It will also help educators look after their own mental health.”
Education Minister Dan Tehan added that Be You builds on the strengths of current school-based mental health programs, and complements the recently launched Australian Student Wellbeing Framework.
“I encourage all Australian schools and early learning providers to engage with beyondblue and Be You to support the mental health and wellbeing of our students,” Mr Tehan said.

“As half of all mental health disorders in Australia emerge before the age of 14, schools and early learning services in Australia represent one of the best opportunities for mental health issues to be detected early and managed.

“Schools also play a vital role in prevention by helping our children and young people learn the skills they need to look after their own mental health and wellbeing.”

The Government is also providing $2.36 million over four years to the University of Queensland to evaluate the program. This will assess the effectiveness and cost-effectiveness of the program, and identify opportunities to strengthen or improve it.

Minister announces two new listings on the PBS

Two major new listings on the Pharmaceutical Benefits Scheme (PBS) have the potential to extend the lives of Australians with advanced lung cancer and those at risk of a heart attack, saving patients almost $190,000 a year.

November is Lung Cancer Awareness Month and from November 1, patients with advanced lung cancer will have the treatment Keytruda^®subsidised for first-line treatment of metastatic non-small cell lung cancer (NSCLC).

Without PBS subsidy it would cost over $11,300 per script or $188,000 a year. Patients will now pay a maximum of $39.50 per script or just $6.40 per script for concessional patients, including pensioners.

This listing means that for the first time eligible patients with advanced lung cancer can avoid chemotherapy and be treated with this novel immunotherapy treatment Keytruda^®. It will benefit about 850 patients a year.

Keytruda® is an immunotherapy medicine working with a patient’s own immune system to recognise cancer cells and destroy them. Clinical trials of Keytruda® for lung cancer has shown that some patients became virtually cancer free after treatment.

This medicine is already listed on the PBS for classical Hodgkin’s lymphoma and unresectable Stage III or Stage IV malignant melanoma.

The Federal Government is also listing Repatha® from November 1 for the treatment of familial hypercholesterolaemia, which is a genetic high cholesterol condition.

More than 6,000 people with the condition, who are at risk of having a heart attack or stroke at an early age, will benefit from the treatment.

Patients would normally pay around $630 a script, or more than $8000 a year. With its listing on the PBS, eligible patients will pay a maximum of $39.50 per script for Repatha or just $6.40 with a concession card.

These listings with help the thousands of Australians and their families fighting lung cancer and the devastating impact of heart disease.

In announcing the new listings, Health Minister Greg Hunt said the Government was providing Australian patients with access to life-saving and life-changing medicines quicker than ever before.

“We are now making on average one new or amended PBS listing every single day,” Mr Hunt said.

“In the Budget we announced our commitment to invest $2.4 billion in new medicines to build on our commitment to guarantee those essential services that all Australians rely on.

“Our commitment to the PBS is rock solid. Together with Medicare, it is a foundation of our world-class health care system.”

The independent Pharmaceutical Benefits Advisory Committee (PBAC) recommended the listings that have been announced.

The Committee is independent of Government by law and in practice. By law, the Federal Government cannot list a new medicine without a positive recommendation from PBAC.

WMA updates advice on medically indicated termination of pregnancy

Revised advice to physicians on medically indicated termination of pregnancy has been issued by the World Medical Association.

At its recent annual General Assembly in Reykjavik, the WMA reiterated that where the law allows medically indicated termination of pregnancy to be performed, the procedure should be carried out by a competent physician.

However, it agreed that in extreme cases it could be performed by another qualified health care worker. An extreme case would be a situation where only an abortion would save the life of the mother and no physician was available, as might occur in many parts of the world. This amends previous WMA advice from 2006 that only physicians should undertake such procedures.

The meeting agreed that patients must be supported appropriately and provided with necessary medical and psychological treatment along with appropriate counselling if desired by the patient.

The revised policy emphasises that the convictions of both the physician and the patient should be respected. It adds that patients must be provided with necessary medical and psychological treatment along with appropriate counselling if desired.

In another change to WMA policy, the Assembly reaffirmed its view that physicians should continue to have a right to conscientious objection to performing an abortion, while ensuring the continuity of medical care by a qualified colleague. But it added that in all cases physicians must perform those procedures necessary to save the woman’s life and to prevent serious injury to her health.

Physicians must work with relevant institutions and authorities to ensure that no woman is harmed because medically-indicated termination of pregnancy services are unavailable.

The preamble to the revised policy states: “Medically indicated termination of pregnancy refers only to interruption of pregnancy due to health reasons, in accordance with principles of evidence-based medicine and good clinical practice. This Declaration does not include or imply any views on termination of pregnancy carried out for any reason other than medical indication.”

WMA President Dr. Leonid Eidelman said that the revised policy was part of the WMA’s procedure to review all policy that was 10 years old and follows two years of discussion and debate.

“As the document says, termination of pregnancy is a medical matter between the patient and the physician. But attitudes toward termination are a matter of individual conviction and conscience that should be respected,” Dr Eidelman said.

“A situation where a patient may be harmed by carrying the pregnancy to term presents a conflict between the life of the foetus and the health of the pregnant woman.

“Different responses to resolve this dilemma reflect the diverse cultural, legal, traditional, and regional standards of medical care throughout the world and the revised policy recognises this fact.”