NHMRC funding of mental health research

A case for better alignment of research funding with burden of disease

Mental health research has long been the poor cousin in medical research, despite mental illness being both an independent and comorbid risk factor for every major medical disease, and a significant contributor to morbidity and mortality. Of the five major non-communicable disease areas, mental illness has the largest impact on the world economy by reducing gross domestic product.1 Yet, 11 times more money is donated from the private and corporate sectors to cancer research than to mental health research. In addition, cancer research receives twice the funding from governments.2

This pattern is reflected in the funding distribution from the National Health and Medical Research Council (NHMRC) in Australia, where mental health research has received a lower proportion of NHMRC health funding compared with other National Health Priority Areas such as cancer, diabetes and cardiovascular disease. Between 2001 and 2010, for example, mental health received about 9.5% of NHMRC funding.3 NHMRC funding for suicide research was lower than funding for falls, skin cancer and motor vehicle accidents, despite the fact that suicide is responsible for more deaths.4 In 2015, when NHMRC announced the membership of its strategic committees, there were no members with mental health expertise, in contrast to previous years.

We tested whether the proportional NHMRC funding to mental health has changed since our 2010 analysis, by estimating the number and dollar value of NHMRC funding schemes awarded to mental health-related topics during 2015. We also compared burden of disease estimates with NHMRC funding for mental health to determine whether the proportion of funding allocated to mental health-related research is in line with its effect on the population.

Using data from the October–November 2015 announcement of NHMRC results, we conducted a search of the following fields: grant title, field of research, all keywords and research summary. Our search used the following text strings: mental health, mental illness, depressi*, anxi*, psychosis, schizophrenia, substance use, alcohol use, smoking, adhd, stimulants, cocaine, heroin, amphetamine, sleep, obsessive, autism, panic, ptsd, suicid* and bipolar. The search conservatively counted psychosocial research with any mental health component as 100% “mental health”.

In 2015, the NHMRC funded 1037 projects or fellowships across all health categories, which were worth a total of $763 million. Of these, 85 were on the topic of mental health, constituting 8.6% of funding (Box). In 2009, the proportion of the total funding allocated to mental health was 9.5%. Recent data from the Australian Institute of Health and Welfare5 suggest that the burden of disease for mental disorders is 12.1%, or 14.6% if suicide and self-inflicted injuries are included, with mental and substance misuse disorders accounting for the largest burden in younger age groups. If funding was proportional to the burden of disease (disability adjusted life years), mental health research was short $26.6 million or 41% of the total funding. A comparison of cancer, cardiovascular and diabetes research using a similar search strategy found that 14.3%, 15.5% and 5.7% of funding went to these areas. Based on the burden of disease for these disease areas (18.5%, 14.6% and 2.3% respectively), these funding figures represent a smaller relative shortfall for cancer research ($32.1 million, 29%), a small gain for cardiovascular research ($7.1 million, 6%) and a large net gain for diabetes research ($17.6 million, 41% gain).

Our analysis indicates that, in the major NHMRC funding announcement for 2015, mental health research received significantly less funding than its disease burden (8.6% versus 12.1%), and less total funding than the average received in the previous decade (8.6% versus 9.5% for 2001–2010). This funding pattern is in contrast to the United Kingdom, where the research investment in mental health by the government has increased as a proportion of overall spend by 1.5% over the decade 2004–2014.2 The present analysis had limitations, such as not being able to deal with the problem of infrastructure and clinical environment in detail, compare in detail the nature of cardiovascular and cancer research, or reconfirm the high quality of Australian mental health research.3

There are many potential reasons as to why mental health research does not receive NHMRC funding proportional to disease burden. Given that the problem is not the quality of the research (mental health research outperforms other disciplines on the world stage),3 the working hypothesis remains that the primary causes are capacity (limited number of active mental health researchers) and the nature of mental health research (NHMRC category descriptors do not favour translational research — real-world trials are rarely flawless). Considering the capacity concern, it is disappointing that the number of opportunities provided to early- and mid-career fellowship applicants in mental health remains low.

The prevalence of depression and suicide rate has not changed in the past decade, while the costs of mental health to the community are increasing rapidly. Recent figures indicate that the government spent about $4.5 billion on mental health with about 21% of this spent on hospital funding; 21% on carer funding and 20% on the Medicare Benefits Schedule. These spends represented an increase of between 13% and 53% over the past 7 years.6 Critically, this investment has not increased access to evidence-based mental health care, which remains low at 11–20%.7 Yet, research funding has remained stagnant over the same period, with considerable decreases after adjusting for inflation. Mental health research has the potential to transform the lives of Australians and to save costs.

So what is to be done? First, impress upon the public, scientists, government and politicians the importance of research as the key solution to managing the escalating costs of mental health — estimated to be $4.5 billion, which represents an increase of up to 53% over the past 7 years.6 Second, recognise that research funding in Australia has to change, as in the UK, where the proportion of funding to mental health has increased by 1.5% from 2004–2014.2 Third, we need to determine the reasons for low yields from philanthropy and non-government support for mental health, and actively overcome barriers and capture funds.

We call on the Australian government to develop a clear, empirical basis for using health priorities to allocate funding from the emerging Medical Research Future Fund that accounts for indices such as burden of disease and building capacity in underfunded areas. The government approved the establishment of the Medical Research Future Fund in 2015 to drive innovation in medical research, with funding guidelines currently being developed. The resulting doubling of investment in medical research in Australia offers a unique opportunity to overcome the gap in the funding of mental health research identified here. The mental health community (consumers, researchers, clinicians and the wider community) look forward to continuing to contribute ideas to the Australian Medical Research Advisory Board regarding a more equitable distribution of research funding.

Box –
Counts and funding for major NHMRC grants and fellowship categories announced on 9 November 2015

Category	Number awarded	Number awarded related to mental health	Total funding across all domains ($)	Funding related to mental health ($)

Career development fellowship	55	5 (9.1%)	23 915 192	2 184 844 (9.1%)
Early career fellowship	124	13 (10.5%)	38 102 059	3 779 955 (9.9%)
Research fellowship	69	8 (11.6%)	51 239 170	6 070 820 (11.8%)
Development grant	24	0	14 142 312	0
Standard project grant	483	48 (9.9%)	404 722 995	48 622 759 (12.0%)
NHMRC–ARC dementia research development fellowship	76	6 (7.9%)	43 669 587	3 308 618 (7.6%)
Total (all schemes)	1037	85 (8.2%)	$763 481 138	$65 746 208 (8.6%)

ARC = Australian Research Council. NHMRC = National Health and Medical Research Council.

Maternal mortality trends in Australia

Maternal death is low and decreasing in Australia, but continuing surveillance is important

The death of a mother or a baby has significant short and long term impacts for the surviving family members and for the community and health workers who cared for them. The World Health Organization estimates that 303 000 women died in pregnancy and childbirth in 2015, with 99% of these deaths occurring in low income countries.1

In Australia, a series of reports regarding maternal deaths has been published over the past five decades; the first in the series covered the 1964–1966 triennium.2 These reports examine the deaths that occurred during pregnancy or within 42 days of the end of pregnancy. They are compilations of data sourced from multidisciplinary state maternal mortality review committees that undertake detailed reviews of each case.

The incidence of maternal death is expressed as a maternal mortality ratio (MMR). The MMR is the number of deaths due to complications of the pregnancy (direct deaths) or aggravation of existing disease processes by the pregnancy (indirect deaths) per 100 000 women giving birth. The calculation does not include deaths from unrelated causes that occur in pregnancy or the puerperium (incidental deaths) and deaths that occur more than 42 days after the end of a pregnancy.

The MMR in Australia is low; it has decreased from 41.2 in the 1964–1966 period to 7.1 in the years 2008–2012.3 The comparable figures are 14.7 for the period 2010–2012 in New Zealand4 and 9.0 for the period 2011–2013 in the United Kingdom.5

Until now, publications in the Maternal deaths in Australia series have been irregular. The Australian Institute of Health and Welfare (AIHW) established the National Maternity Data Development Project (NMDDP) in response to the recommendations in the 2008 Maternity Services Review from the Commonwealth and the subsequent 2010–2015 National Maternity Services Plan.6 A recent report regarding the progress of the NMDDP notes that sustainable data collection on national maternal mortality will be established to facilitate “consistent and regular national reporting” of maternal mortality in the future.6

The genesis of the almost sixfold reduction in maternal death rates in Australia is multifactorial, including the improved general health of the population and the availability of better health care options, such as the availability of antibiotics, blood transfusion, safer anaesthesia and effective diagnostic ultrasound. Advanced maternal age, maternal obesity and caesarean deliveries3,5 are all associated with an increase in the risk of maternal death, and any future growth in their incidence will threaten the efforts to further reduce the maternal mortality rate.

In the list of most common causes of death, infection, abortion and pre-eclampsia have been replaced by maternal cardiovascular disease and psychosocial health problems, while obstetric haemorrhage and thromboembolism remain prominent. The current method of classifying maternal deaths into direct, indirect and incidental deaths was first used in the report on the 1973–1975 triennium.7 Between that first 1973–1975 report and the most recent one for 2008–2012, 944 direct and indirect maternal deaths have been reported in Australia. Over that 48-year period, cardiovascular disease (MMR, 1.5), sepsis (MMR, 1.3) and obstetric haemorrhage (MMR, 1.1) have been the most prominent causes of death.

Aboriginal and Torres Strait Islander women are twice as likely to die in association with pregnancy and childbirth as other Australian women. In 2008–2012, the Aboriginal and Torres Strait Islander MMR was 13.8 compared with 6.6 for non-Indigenous Australian women who gave birth.3 The differential between the MMRs is decreasing and caution should be exercised in drawing conclusions due to the small numbers analysed. The leading causes of maternal deaths among Aboriginal and Torres Strait Islander women were cardiovascular conditions, sepsis and psychosocial conditions.

Women aged 35 years or over were more than twice as likely as their younger counterparts to die in association with pregnancy and childbirth, and those aged 40 years or more were over three times more likely to die in association with pregnancy and childbirth.3

Of the six most prominent causes of maternal death between 1973 and 2012, psychosocial death is the only group where the MMR is rising; the incidence of maternal death due to cardiovascular disease, obstetric haemorrhage, thromboembolism, hypertensive disorders and sepsis are all decreasing. Most of the deaths classified as psychosocial deaths are due to suicide, although some are related to fatal complications of substance misuse and homicide in domestic situations. While some of that apparent rise may be due to changes in the ascertainment of maternal deaths in general and to problems reporting both maternal suicide and deaths due to substance misuse in particular, it is clear that more needs to be done in this sphere. There is a growing belief that a significant portion of late maternal deaths are related to suicide; however, without a clear review of the cases by multidisciplinary committees, the relationship between pregnancy and suicide more than 42 days after the end of pregnancy remains speculative.

It is not clear whether the incidence of suicide in association with pregnancy is more or less common than in comparable non-pregnant women. This comparison is fraught, as the true denominator for pregnancy is not known due to lack of information regarding pregnancies lost as a result of miscarriage and termination. Given that caveat, the overall suicide rate in the 15- to 45-year-old Australian female population in 2006–2010 was 6.0 per 100 000 women,8 while the maternal mortality rate due to psychosocial issues in the same period was 0.9 per 100 000 women giving birth. A similar finding has recently been noted in the United States.9 Nevertheless, the apparently increasing incidence of psychosocial maternal death is a matter of concern, given that pregnant women are among the most medically supervised members of the population.

Screening during pregnancy for mental health, substance misuse and domestic violence problems is recommended,10 but it is not universally undertaken. All maternity care providers should commit to making these items a standard part of their care delivery. The follow-up of identified concerns by the relevant specialist services must be a priority and should continue for a significant period after the end of pregnancy. Similar screening attention is needed for women who had miscarriages and pregnancy terminations.

In many cases, an autopsy is necessary to understand the true cause of a maternal death. A number of causes of maternal death, such as amniotic fluid embolism and pulmonary thromboembolism, may be easily confused clinically. In the case of amniotic fluid embolism, for example, the diagnosis can only be confirmed by autopsy. The question of an autopsy should be pursued with the family by a senior clinician, and the presumption of a diagnosis that has been made in an intensive care unit or similar setting should not be an excuse to not request this critical form of investigation.

Maternal death is one of the few defined core sentinel events in health care; however, it is disturbing to find that a significant portion of these deaths have not been subjected to a root cause analysis or similar review. The application of a systematic review to identify gaps in hospital systems and health care processes, which are not immediately apparent and may have contributed to the occurrence of an event, should be applied to all maternal deaths, whether occurring in the public or private health systems.

The question of the presence or absence of contributory factors is now being actively pursued by some state and territory maternal mortality review committees, and similar questions are also being raised internationally. A consolidation of such information is yet to be published in an Australia-wide context. Experience with such review in New Zealand11 has shown that more than 50% of maternal deaths were associated with contributory factors, and 35% of the deaths were potentially avoidable.

The Victorian Consultative Council on Obstetric and Paediatric Mortality and Morbidity model12 appears to be of value, and examines two questions:

Were suboptimal care factors identified?
What was the relevance of any suboptimal care factors identified?

Suboptimal care factors may be classified as factors related to the woman, her family and social situation, factors related to access to care and factors related to professional care. Moreover, these factors may be classified as identified but unlikely to have contributed to the outcome (insignificant), identified and might have contributed to the outcome (possible), or identified and likely to have contributed to the outcome (significant).

It is critical to maintain a continuing intensive surveillance of maternal death — with particular reference to recognised risk factors — and to examine the contributory factors. Health departments must require that all direct and indirect maternal deaths are subjected to a systematic review. At present, data on late maternal deaths — occurring more than 42 days after the end of pregnancy — are not collected in all states and territories and are not reported nationally. Reviews of late maternal deaths and of severe maternal morbidity are future necessities, but the resources and methodologies are not yet available at a national level.

[Articles] Global, regional, and national levels of maternal mortality, 1990–2015: a systematic analysis for the Global Burden of Disease Study 2015

Several challenges to improving reproductive health lie ahead in the SDG era. Countries should establish or renew systems for collection and timely dissemination of health data; expand coverage and improve quality of family planning services, including access to contraception and safe abortion to address high adolescent fertility; invest in improving health system capacity, including coverage of routine reproductive health care and of more advanced obstetric care—including EmOC; adapt health systems and data collection systems to monitor and reverse the increase in indirect, other direct, and late maternal deaths, especially in high SDI locations; and examine their own performance with respect to their SDI level, using that information to formulate strategies to improve performance and ensure optimum reproductive health of their population.

Ley refuses to set rebate freeze end date

Health Minister Sussan Ley has dumped on hopes of an imminent end to the Medicare rebate freeze, warning that it will not be lifted until there is an improvement in the Federal Government’s finances.

Talking down the prospects of financial relief for hard-pressed medical practices any time soon, Ms Ley refused to set a date for an end to the policy, and told ABC radio’s AM program that “we cannot lift the pause…any earlier than our financial circumstances permit”.

The Minister said any decisions made about the freeze would be made in the context of Budget discussions.

“I’m a Minister who signs up to the agenda of a Government that leads Budget repair and strong, stable economic management, so I’m absolutely not walking from our responsibilities,” she told Sky News. “These are decisions that are made through the MYEFO [Mid-Year Economic and Fiscal Outlook] and Budget process, and I’m not going to forecast when or what they might be.”

The Government is due to release the 2016-17 MYEFO before the end of the year, most likely early December.

Ms Ley backed away from comments she made during the Federal election that she had been blocked from ending the freeze by her senior Treasury and Finance colleagues.

In May, Ms Ley told ABC radio that: “I’ve said to doctors I want that freeze lifted as soon as possible but I appreciate that Finance and Treasury aren’t allowing me to do it just yet.”

But when ABC reporter Kim Landers said to the Minister today that, “you’ve previously said that you’ve wanted to lift it, but you were blocked by Treasury,” Ms Ley denied it.

“That’s not what I’ve said. What I’ve said is: as a responsible Minister in a Government that needs to undertake budget repair, I recognise that we cannot lift the pause that was introduced by Labor any earlier than our financial circumstances permit,” the Health Minister said.

The exchange came amid mounting warnings from the AMA and others that the rebate freeze is pushing medical practices to the financial brink, forcing many to abandon bulk billing and raising the prospect that patients will be charged up to $25 in out-of-pocket costs.

Ms Ley defended the rebate freeze as the right policy for the times, and said bulk billing rates had “never been higher”.

The Minister’s declaration, which is based on figures measuring the number of Medicare services performed rather than GP consults, has been disputed by those who claim that the real figure is closer to 69 per cent.

Regardless, AMA President Dr Michael Gannon expressed disbelief the rebate freeze would still be in place by the time of the next election in late 2019.

“I would be gobsmacked if the Government took an ongoing freeze to the next election,” the AMA President said following a meeting with Ms Ley earlier this year. “They got the scare of their life on health, and that was probably the policy which hurt them the most.”

Ms Ley said that she wanted the freeze to end “as soon as possible”, but refused to nominate an end date.

“I’m sure that others in the Cabinet and the Parliament want that day to be as soon as possible,” the Minister said. “But we also recognise our responsibilities in terms of our credit rating, in terms of the national debt, in terms of, as I said, the economic circumstances that Labor left us with.”

Adrian Rollins

Mental health services—in brief 2016

Mental health services—In brief 2016 provides an overview of data about the national response of the health and welfare system to the mental health care needs of Australians. It is designed to accompany the more comprehensive data on Australia’s mental health services available online at .

Government pathology changes could cost practices up to $150m

Federal Government plans to change the rules regarding rents for pathology collection centres could be a disaster for medical practices, ripping up to $150 million a year from their income, the AMA has warned.

AMA President Dr Michael Gannon has told Health Minister Sussan Ley that a significant number of general practices will become “collateral damage” if the Government persists with plans to change the definition of ‘market value’ that applies to rents for pathology collection centres, with serious consequences for the provision of health care.

Dr Gannon said the Minister needed to re-think the proposed changes and adopt a more nuanced approach “consistent with the original intent of the…laws”.

“If you do not get this right, a significant proportion of general practices will become collateral damage, which would be a disastrous policy outcome and contrary to your stated support for the specialty,” he told Ms Ley.

Last month it was revealed that the Government had put off plans to axe bulk billing incentives for pathology services and abandoned its threat to impose a moratorium on the development of new collection centres.

In a climb-down, the Government pulled back from its threat to scrap the incentives on 1 October and advised it would not be proceeding with the moratorium, which was announced during the Federal election in order to head off a protest campaign by the pathology industry against the axing of a bulk billing incentive.

Instead of a ban, the Government has directed that collection centre leases be put up for renewal every six months, down from the usual 12 months, until a new regulatory framework is put in place. Existing leases will be grandfathered for up to 12 months, after which the new rules will come into effect.

The bulk billing incentive cut, meanwhile, which was originally due to come into effect from 1 July and save $332 million, will now not be implemented until 1 January 2017.

“Bulk billing incentives for the pathology sector will continue until new regulatory arrangements are put in place and the Government will continue to consult with affected stakeholders,” a spokesman for Ms Ley told the Herald Sun.

But the Minister is persisting with plans to change the regulations governing rents for approved collection centres, particularly regarding the definition of market value as applied under the prohibited practices provisions of the Health Insurance Act.

Dr Gannon said that in talks earlier this year, the AMA had agreed with moves to strengthen compliance with existing regulations and “weed out examples of rents that are clearly inappropriate”.

But he said the Government at that stage had given no hint it was considering changes to the regulations, and its election announcement had taken all stakeholders, except Pathology Australia and Sonic Healthcare, by surprise.

Dr Gannon said the Government’s clear intent was to control collection centre rents, and the AMA opposed the proposed changes.

There are more than 5000 collection centres across the country, many co-located with medical practices.

“These practices are small businesses and have negotiated leases in good faith,” Dr Gannon said, and had made business decisions based on projected rental revenue streams, including staffing and investment.

He warned that ripping this source of revenue away could be disastrous for many.

“For many practices feeling the impact of the current MBS indexation freeze, this source of rental income has helped keep them viable,” he said, adding that AMA estimates were that the Government’s changes would cost practices between $100 million and $150 million a year in lost rent revenue.

“The magnitude of this cut goes well beyond an attempt to tackle inappropriate rental arrangements. It is causing significant distress, particularly for general practice,” Dr Gannon said. “I doubt the Government truly contemplated the extent of the impact of its election commitment when it was announced.”

Latest news

Modest health bill growth belies ‘unsustainable’ claims

Federal Government complaints about unsustainable growth in health spending have been undermined by figures showing its health bill is growing little faster than the pace of inflation.

Australian Institute of Health and Welfare figures show Commonwealth health spending increased by 2.4 per cent to $66.2 billion in 2014-15, compared with a 2.3 per cent rise in underlying inflation over the same period.

State and Territory government spending was even weaker, contracting by 0.4 per cent to $42 billion – the first such decline in a decade.

The results undermine the Government’s case for swingeing cuts in the health budget, which have been based on assertions that public spending on hospitals, GPs and other health services has been out of control.

The AIHW’s Health expenditure Australian 2014-15 report shows, instead, that Federal Government spending has slowed sharply in recent years. 2014-15 was the third year in a row where expenditure growth was below the annual average of 4 per cent.

The figures demonstrate that increasingly the burden of health funding is falling onto the shoulders of patients, either directly through rising out-of-pocket costs or indirectly via rising private health insurance premiums.

Between 2004-05 and 2014-15, the Commonwealth’s share of the nation’s health bill slipped from 43.9 to 41 per cent. Over the same period, the states’ and territories’ share increased from 24 to 26 per cent, for individuals it went from 17.4 to 17.7 per cent and for health funds, from 7.7 to 8.7 per cent.

The cost-shifting was particularly stark in the three years to 2014-15, when a 1.3 percentage point jump in the health insurer’s share coincided with a 2 percentage point plunge in the Federal Government’s share.

The AIHW said this was driven by changes in the Government’s private health insurance rebates that had the effect of cutting its contribution, with insurers (and, more particularly, policyholders) picking up the tab. The development casts attempts to blame the surge in premiums on doctor fees or procedure costs in a different light.

Partly the shift in the Federal Government’s share can be explained by changes in revenue. The Commonwealth’s tax take has been hammered by the global financial crisis and the wind-down of the mining boom, and shrank by 1.5 per cent in 2014-15. By contrast, State and Territory tax collections have been growing at an above-average pace for the past decade. This has meant that while health has been grabbing a greater share of tax revenue at the Federal Government level, at the State and Territory level it has been shrinking.

Overall, the nation’s spending on health increased by 2.8 per cent in 2014-15 to $161.6 billion – well down from the 10-year average growth rate of 4.6 per cent.

However, because of the slowdown in the broader economy, health expenditure as a proportion of GDP actually increased 0.2 of a percentage point to reach 10 per cent of total output for the first time.

This is higher than the developed country median of around 9.1 per cent, but is comparable with countries including New Zealand, Canada, the United Kingdom and Finland, and far below the United States, where health expenditure accounts for 16.6 per cent of GDP.

Per person, Australia spends $6657 on health – ranked 10^th highest among OECD countries but well below the US ($13,266), Switzerland ($9977) and Norway ($8940).

Adrian Rollins

Hospital trial turns night into day for US doctors, patients

Picture: Dr Timothy Buchman talks to a colleague in Atlanta from the ‘Turning Night Into Day’ centre at Macquarie University

Night has become day for a group of US doctors and critical care nurses, who are using new technology to remotely monitor their intensive care patients in hospitals in Atlanta from a Sydney health campus.

The intensivists and nurses from US health provider Emory Healthcare are part of a clinical trial to assess the health benefits for both patients and doctors of having highly experienced clinicians available to provide senior support around the clock.

Taking advantage of remote intensive care unit (eICU) technology and the 14-hour time difference, the medical teams are essentially working the Atlanta night shift during the day in Sydney.

“We’re in Australia because we are trying to look at a different model of care,” Cheryl Hiddleson, the director of Emory’s eICU Centre, told Australian Medicine.

“We were having our clinicians up all night while they were trying to do other things during the day – that’s just what happens. We know that working the night shift is tough.

“This study is to look at our staff and see how the difference in the times that they are working makes to their performance and their health.”

Under the trial, senior intensivists and critical care nurses from Emory are based in Sydney for six to eight week rotations.

They work at MQ Health at Macquarie University, using eICU technology developed by health technology maker Royal Philips, to provide continuous night-time critical care oversight to high-risk patients in Emory’s six hospitals across the state of Georgia.

“We intensive care folk have one mission, and that’s to deliver the right care for the right patients at the right time,” Dr Timothy Buchman, the chief of Emory’s Critical Care Services, said.

“Almost everything we do has to be done with both speed and care. That’s easy in a big hospital at 10am on a Monday, but that task becomes a lot harder in a remote or rural hospital at unsocial hours – on weekends, holiday, or especially at night.

“There are fewer people, and less experienced people, and patients can become sicker around the clock. Patients and their families deserve the best care, and this is about bringing that senior support to the bedside.”

The day before Dr Buchman spoke to Australian Medicine, he helped treat a patient who had been airlifted to one of Emory’s Atlanta hospitals at 2am US time – 4pm in Sydney.

The patient was suffering severe pancreatitis and respiratory failure, and was being treated by a relatively junior doctor.

“I had a complete echo of the bedside monitor, and was able to guide the doctor through the treatment,” Dr Buchman said.

“The attending physician would have been at home, probably asleep. But I was able to go in as if I was there and help implement care plans.”

Two hours later, another patient came in from a smaller hospital, suffering post-operative haemorrhaging.

“She was deeply anaemic, but she was also a Jehovah’s Witness and so was refusing blood products,” Dr Buchman said.

“The other hospital said we needed experimental therapies, so we accepted her admission. I was able to evaluate her remotely and provide the level of care she needed. When I came in to work this morning, I was able to check on her condition again.”

The previous night, just before 1am, the family of a terminally ill cancer patient, who had been intubated earlier in the day, requested a meeting to evaluate his care.

“I was able to talk to them – they could see me, I could see them – and they decided to shift from aggressive care to comfort,” Dr Buchman said.

“The patient was able to die. His family were able to be there and it was able to occur in a timely fashion. The family had come to a decision and acceptance, and they could have that meeting when they needed it, instead of having to wait for hours.”

Emory already uses the eICU to provide senior support to smaller and remote hospitals throughout Georgia. The time difference trial is intended to see if the technology can help keep senior clinicians in the workforce.

“People do function a lot better when they can do night work in day time,” Dr Buchman said.

“This technology is important, but it is only an enabler. The people – the staff, the patients – are what is important, and this technology gives us the ability to use this accumulated wisdom during daylight for patients on the other side of the world who would not normally have access to this level of expertise.”

Maria Hawthorne

Device reforms may be too late to prevent premium pain

The Federal Government is coming under pressure to speed up its review of prosthetic prices if consumers are to avoid another painful hike in private health insurance premiums.

Health funds have warned that unless the cost of medical devices on the Prostheses List falls into line with the much lower prices paid by public hospital in the next few weeks, policyholders will continue to pay an extra $150 to $300 on their premiums.

The warning is the latest shot in a tussle underway between insurers, medical device manufacturers and private hospitals other over the cost of prostheses, as documented in a series of articles in The Australian newspaper.

The health funds, increasingly worried about the backlash from consumers over rapidly rising premiums and complex and confusing insurance products, have set their sights on prostheses prices as a key way to contain costs.

They claim that existing pricing arrangements are woefully out of date and force insurers to pay grossly inflated prices for medical devices compared with public hospitals. According to insurers, they are being charged up to $3450 for a coronary stent that costs $1200 in the public system, while a defibrillator costing them $52,000 costs a WA public hospital just $22,555.

Altogether, the funds estimate they could save $800 million by bringing public and private prostheses prices into line, savings they say would be passed on in cheaper premiums for consumers.

But the Medical Technology Association of Australia, which represents medical device manufacturers, has defended the sector against what it considers to be false and misleading claims.

MTAA co-lead Andrea Kunca said the industry rejected accusations of inflated pricing and fully supported the work of a Government working group brought together earlier this year to work through “meaningful solutions” for reform of the Prostheses List.

The Australian has published claims that the MTAA, in concert with private hospital operators, has so far been successful in frustrating attempts by Health Minster Sussan Ley to reform the Prostheses List, and any changes are unlikely to come in time to head off another sharp increase in the health fund premiums next year.

According to The Australian, fierce lobbying by well-connected outfit CapitalHill Advisory on behalf of the MTAA derailed an early attempt by Ms Ley to cut implant prices.

Influential Senator Nick Xenophon has announced he will push for a Senate inquiry into private health insurance and the pricing of medical devices on the Prostheses List, a move welcomed by the MTAA.

“There have been a number of misleading and false claims put in the public arena in regards to the medical device industry,” Ms Kunca said. “A Senate inquiry will allow these false claims to be answered once and for all. From the MTAA’s perspective we look forward to presenting the facts rather than anecdotal misinformation put forward by some.”

Premium crunch time

The health funds have to submit proposals for their 2017 premiums, which have to be approved by the Health Minister and are announced in April, by early November.

Doctors, insurers and the Government fret that another 6.5 per cent premium increase could accelerate the shift among policyholders toward cheaper policies with multiple exclusions and less coverage, or even convince many to ditch private health cover altogether – the insurance industry has cited research that at least 20 per cent of current members would find premiums unaffordable in the next six years.

Ms Ley recently overhauled the membership of the Prostheses Listing Advisory Committee, appointing University of New South Wales Professor of Medicine Terry Campbell as Chair. Professor Campbell’s appointment was a belated replacement of long-serving Chair Professor John Horvath, who left last December to become a strategic adviser at Ramsay Health Care.

The stoush comes against the backdrop of rising dissatisfaction among doctors and consumers with the quality and value for money of private health insurance.

The AMA has been a vocal critic of the proliferation of complex and confusing policies, many with multiple exclusions that leave unsuspecting patients with inadequate cover.

AMA President Dr Michael Gannon has declared the medical profession’s support for Government reforms to improve the value of private health insurance by banning junk public hospital-only policies, standardising terms, mandating minimum levels of cover and preserving community rating.

Dr Gannon said doctors were doing the right thing, with 86 per cent of privately insured medical services charged on a no gap basis, and a further 6.4 per cent involving a known gap.

“This means that less than 8 per cent of privately insured patients are charged fees that exceed that paid by their private health insurance,” the AMA President told the National Press Club in August. “Put simply, the majority of doctors and hospitals understand the impact of gaps on patients and are doing the right thing by them.”

He said that because of these, doctors were deeply unimpressed with the behaviour of some insurers, “particularly the biggest and most profitable ones”, in putting profits ahead of the interests of patients.

Dr Gannon said that if such actions, including aggressive negotiations with private hospitals and attacks on the professionalism of doctors, continued unchecked “we will inevitably see US-style managed care arrangements in place in Australia”.

Adrian Rollins

Govt adviser calls for public hospitals to be ‘contestable’

Mortality rates and treatment outcomes for individual hospitals and medical practitioners could be made publicly available and patients given a choice of hospital and specialist under Productivity Commission proposals to improve the quality and accessibility of health services.

In the preliminary findings of a review initiated by Treasurer Scott Morrison into options for increased competition and consumer choice in the $300 billion human services sector, the Commission has proposed increased information disclosure by hospitals and practitioners and greater contestability between services.

“Greater competition, contestability and informed user choice could improve outcomes in many human services,” the PC said. “Well-designed reform, underpinned by strong government stewardship, could improve the quality of services, increase access…and help people have a greater say over the services they use and who provides them.”

Mr Morrison said he had ordered the review to improve the efficiency and cost effectiveness of human services.

But Opposition leader Bill Shorten, reprising Labor’s scare campaign during the Federal election on the privatisation of Medicare, said he feared it would be used to justify the wholesale handover of human services to the private sector.

“We’ve all seen this move before,” Mr Shorten said. “When Malcolm Turnbull and the Liberal Party start talking about changing human services it means that poor people get it in the neck.”

The Commission said that not all human services were amenable to increased competition, contestability and choice, but identified public hospitals and palliative care services among six priority areas targeted for reform.

While Australian public hospitals performed well by international standards, “there is scope to improve”, the PC said, including by matching domestic best practice and publicly disclosing more information.

“Public patients are often given little or no choice over who treats them or where. Overseas experience indicates that, when hospital patients are able to plan services in advance and access useful information to compare providers (doctors and hospitals), user choice can lead to improved service quality and efficiency,” the PC said.

It said that any reforms to boost user choice would have to be supported by “user-oriented information”, and suggested the English model in which increased choice is offered at the point where GPs refer patients to a specialist.

The Commission said experience in England had shown that patients given a choice of hospital and consultant-led team sought out better performing providers, and hospitals in locations where competition was most intense recorded the biggest improvements in service quality.

In order to exercise their choice, patients had access to web-based information enabling them to compare providers according to waiting times and mortality rates, and could use an online booking service.

The enormous variety of Australia’s public hospitals, including big differences in the populations they serve, workforce arrangements and characteristics and the complexity of their links to the rest of the health system, militate against like-for-like competition – something the Commission admitted.

If such issues or political considerations made fostering direct competition unfeasible, the Commission instead suggested exerting pressure for improved performance by making the position of senior hospital managers more precarious.

“There have been difficulties in the past commissioning non-government providers, and lessons from these attempts should not be forgotten,” it said. “As a result, it may be more feasible to implement contestability as a more transparent mechanism to replace an underperforming public hospital’s management team (or board of the local health network) rather than switch to a non-government provider.”

The Commission said State and Territory governments could also take a more contestable approach to commissioning services when renegotiating service agreements with local health networks.

On palliative care, the PC lamented that a dearth of comprehensive, publicly available national data hampered accountability and helped drive big differences in the quality and range of services available.

It said there was little evidence that low quality providers were being held to account.

The PC acknowledged that the “emotionally taxing and psychologically distressing” environment in which a person was approaching the end of their life militated against making choices about palliative care.

“Taboos about discussing death can prevent this from happening,” the Commission said. “Patients often rely on medical professionals to initiate conversations about palliative care, many of whom are inadequately trained about, and intimidated by, holding such conversations.”

Notwithstanding such challenges, the PC argued that introducing greater competition, contestability and user choice in palliative care would improve outcomes and reduce current substantial variation in the quality of, and access to, services in different areas of the country.

To achieve this, though, “would require careful design to ensure that the interests of patients and their families are well served. Special measures for consumer protection may be needed”.

Indeed, even where reform ushered in greater competition and contestability, the PC said the unique nature of human services meant the Government would need to maintain strong oversight.

“Government stewardship is critical,” the agency said. “This includes ensuring human services meet standards of quality, suitability and accessibility, giving people the support they need to make choices, ensuring the appropriate consumer safeguards are in place, and encouraging and adopting ongoing improvements to service provision.”

Other priority areas of human services nominated by the Commission for increased competition and contestability included public dental services, social housing, services in remote Indigenous communities and grant-based family and community services.

Among those areas assessed for reform but not identified as a priority by the PC at this stage were general practice, primary health networks (PHNs), mental health services, community health services and child and family health services.

The preliminary report is open for submissions until 27 October, and the Commission is due to deliver its final report by October 2017.

Adrian Rollins