[Editorial] Unfinished business: women’s health inequality in the USA

Not so long ago, women in the USA faced overt institutional sex discrimination in access to health care. “Gender rating” meant some women could be charged up to 50% more for health-care insurance than men, while many services that women required—such as sexual, reproductive, and maternity services—were often excluded from insurance plans. One of the key aims of the Patient Protection and Affordable Care Act (ACA), introduced in 2010, was to address women’s unequal access to affordable health care.

More doctors opting for specialist roles

The number of medical practitioners opting for specialist roles over general practice has spiked in the last decade.

The supply of specialists-in-training has more than doubled from 7,269 to 15,336 in the past ten years – that’s a jump from 43.4 to 74.8 specialists-in-training per 100,000 people – according to a report released by the Australian Institute of Health and welfare (AIHW).

The Medical practitioner workforce 2015 data shows general practitioner numbers have not had the same upward trend, remaining comparatively stagnant with 109 GPs per 100,000 people in 2008 to 114 in 2015.

AIHW spokesperson Dr Adrian Webster said that despite the slower increase in GP numbers, the supply had stayed abreast of Australia’s growing population.

Assistant minister for Rural Health Dr David Gillespie said the sharp increase in the supply of specialists wasn’t reflected with better access to their services in remote communities.

“Many people in rural and regional communities must still travel for long distances and experience lengthy delays in order to see a specialist for diagnosis or treatment. This must change,” he said.

Dr Gillespie, a former rural physician, said the data did reflect improved availability of general practitioners for Australians living in regional and remote areas.

“The overall number of medical practitioners is continuing to increase and access to GPs in regional areas is now comparable to access in metropolitan areas,” he said.

The AIHW cautioned, however, that the remote area figures could be skewed based on the different delivery models and higher levels of demand in some regions.”

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Bumper profits come at a heavy price

Medibank Private has headlined a year of bumper returns for private health insurers, announcing a 46 per cent surge in after-tax profits to reach $417.6 million, underlining concerns that the industry is pursuing financial returns at the expense of patients and service providers.

The latest snapshot of health fund finances shows that premium revenue across the industry surged by 6.4 per cent in the year to 30 June to reach $22 billion, far outstripping a 5.3 per cent increase in payouts ($19 billion), delivering insurers a healthy after-tax profit of $1.21 billion – up 8.8 per cent from the previous financial year.

The stunning results come amid widespread discontent about the behaviour of the health insurance, including large premium increases, complex and poorly explained health policies, arbitrary changes in coverage, routinely contesting and delaying payouts, and aggressive negotiation tactics with hospitals and other providers.

The Federal Government has announced changes to improve the value of health policies, including mandating minimum levels of cover and banning junk public hospital-only policies, and in his speech to the National Press Club AMA President Dr Michael Gannon lambasted the sector for prioritising profits over patients.

“Increasingly, we are seeing behaviour by large private health insurers that reflects that their ultimate accountability is to their shareholders,” Dr Gannon said. “If the actions of the funds continue unchecked and uncontested – especially their aggressive negotiations with hospitals and their attacks on the professionalism of doctors – we will inevitably see US-style managed care arrangements in place in Australia.”

While Medibank attributes much of its strong profit result to unexpectedly low claims, it has also been aggressively cutting costs and undertaking “claim control” initiatives.

Across the industry, insurers are looking to claim day on payouts, including by pushing more of the cost of treatment on to policyholders.

Patients faced a 6.9 per cent jump in out-of-pocket costs for hospital services last year, paying out on average $301.22.

Worryingly for Medibank and other insurers, there are signs that disenchanted policyholders are starting to vote with their wallets.

Medibank has reported a 2.6 per cent decline in customers, while premium revenue grew by just 5.1 per cent despite a Government-approved increase of 6.59 per cent, showing that many chose to downgrade their cover.

Industry-wide, the number of policies sold increased by just 0.57 per cent, less than half the rate of population growth, and the number insured grew only 0.46 per cent.

The industry’s struggles are only likely to intensify in coming months. Government measures to extend the freeze the threshold for the Medicare Levy Surcharge, $180,000 a year for families and $90,000 a year for singles, have come into effect. The thresholds will be frozen at current levels until 2021, when they will be roughly equivalent with average full-time incomes.

The Government is also planning to put a three-year freeze on the thresholds for the Private Health Insurance rebate before Parliament, which would see an increasing proportion of households kicked off the rebate.

Adding to Medibank’s woes, the consumer watchdog has taken the insurer to the Federal Court alleging it engaged in misleading and unconscionable conduct by cutting the benefits it would pay without informing policyholders.

Nonetheless, the industry is well placed financially. Total assets increased by almost a billion last financial year to reach $12.8 billion, and are growing at double the rate of liabilities, which were just $5.7 billion in 2015-16.

Adrian Rollins

Invest in health to avoid political disaster, Gannon tells Govt

The Federal Government must boost investment in general practice and public hospitals if it wants to avoid “a major Medicare headache” at the next election, AMA President Dr Michael Gannon has warned.

As the re-elected Turnbull Government finalises plans to put $6.5 billion of spending cuts, including in health, before the new Parliament, Dr Gannon has called for a change in the Coalition’s mindset away from seeing health as a cost and instead view it as an investment, warning that the Government’s political survival is at stake.

In his inaugural address to the National Press Club, the AMA President said the knife-edge result of the Federal election showed that Australians were “very comfortable with the state being in charge of their health and education” and did not like political parties messing with the system.

“There is no doubt that health was a game-changer in the election. It was very nearly a government-changer, too,” Dr Gannon said. “For many Australians, the health system – doctors, nurses, allied health, hospitals – is called Medicare. They see any threat to Medicare as bad.”

Prime Minister Malcolm Turnbull has acknowledged the political damage the Government inflicted on itself through its plans to introduce a co-payment for GP services and its cuts to public hospital funding, and has already had several meetings with Dr Gannon in an effort to try and improve his Government’s relationship with the medical profession.

But Dr Gannon said that, while the more consultative approach was welcome, it had to result in better policy, reiterating the AMA’s demands for an end to the Medicare rebate freeze, increased funding for public hospitals, the restoration of bulk billing incentives for pathology and diagnostic imaging tests and increased investment in preventive health.

The Government has so far shown no signs of budging on its decision to freeze Medicare rebates until 2020 as it tries to hold health expenditure down.

But Dr Gannon said the policy was a false economy because it was hurting GPs, who were providing the most cost-effective care in the health system. Furthermore, it would result in more patients deferring seeing their family doctor and eventually requiring much more expensive hospital care, and was undermining the goodwill of GPs, which would be needed for the successful implementation of the Health Care Homes initiative.

Just 6 per cent of the Government’s health spending goes on GP services, and Dr Gannon said general practice represented “very, very good value for money”.

But instead of getting support, GPs were being crushed in a “diabolical squeeze” as funding has been held down and cut even as demand for their services has continued to climb.

“GPs are now at breaking point,” the AMA President said. “Unless there is substantial investment in general practice, there is no doubt that the quality of care will start to suffer – and patients will face growing out of pocket costs.”

He warned that patients who are currently bulk billed may face out-of-pocket costs of $20 or more and “without a big re-think on the range of policies that affect general practice, the Government could have another major Medicare headache at the next election”.

Health Care Homes

One of the Government’s boldest reforms is to establish the Health Care Home model of care for patients with chronic illness. Under the plan GPs would, in addition to their current fee-for-service remuneration, be paid to help the chronically ill manage their disease.

Dr Gannon said it was “potentially one of the biggest reforms to Medicare in decades”, and the AMA was keen for it to succeed.

But he warned that it faced major obstacles without a change in approach by Government.

So far, the Government has only committed $21 million for a trial of the concept, none of which will go toward patient care.

Dr Gannon said that asking GP to provide enhanced care without any extra support “simply does not stack up”.

The Government also need to overcome the “significant trust and goodwill deficit” it had with general practitioners.

“Unless the Government restores some goodwill by unravelling the freeze and invests the extra funding that is required for enhanced patient services, GPs will not engage with the trial, and will walk away from this essential reform,” he said.

Prevention better than cure

Dr Gannon used his Press Club speech to intensify the pressure on the health insurance industry, accusing health funds of putting profits before patients and warning of a slide toward US-style managed care if they had their way.

The Government has acted on mounting discontent with the quality of health cover by announcing plans to ban ‘junk’ public hospital-only policies, mandating minimum levels of cover and introducing a simplified rating system for policies.

The AMA President said these were important steps, but the Commonwealth needed to provide much greater support for public hospitals.

In 2014, the Abbott Government controversially walked away from the previous Labor Government’s hospital funding agreement with the states, at a cost of $57 billion over 10 years.

Dr Gannon said public hospitals were “an everyday saviour for Australian families”, but were failing to meet waiting time and treatment targets as “a direct consequence of the Commonwealth’s failure to fund their share”.

He said the States and Territories did not have the revenue base to increase their funding, and the “Commonwealth Government needs to step up”.

To help contain this cost in the long term, Dr Gannon said the Government should lift its investment in preventive health.

He said health literacy levels were low, and every day people were making bad choices about what they ate, drink and did that would have consequences for their own health and for demand for health care.

“Preventive health is not about implementing a ‘nanny state’ or taking away people’s ‘choices’,” Dr Gannon said. “There are not enough public health campaigns and we continue to fund, at tremendous expense, the consequences of failures to prevent chronic health conditions.”

He said the success of action to curb smoking showed what could be achieved, and it was time alcohol was taken out of the ‘too hard’ basket.

In his speech, Dr Gannon also highlighted the urgency for action to improve Indigenous health. He expressed strong support for the Royal Commission into juvenile detention in the Northern Territory, and backed constitutional recognition as a way to “help heal some of the wounds that underlie Indigenous disadvantage”.

Adrian Rollins

Exploring transitions between drug treatment and homelessness in Australia

There is much research to suggest a considerable overlap between people experiencing precarious housing, and drug and alcohol misuse. Linking client data from specialist homelessness services and alcohol and other drug treatment services, this report provides a picture of the intersection of these two issues on a national scale. It reveals a vulnerable population, in which Indigenous Australians and experiences of domestic and family violence and mental health issues were all over-represented. Their poorer drug treatment and housing outcomes highlight the level of difficulty faced in assisting these people to achieve long-term outcomes.

Exploring drug treatment and homelessness in Australia: 1 July 2011 to 30 June 2014

Under the microscope

Hereditary blindness cured?

A Tasmanian-led research team has successfully altered eye tissue in a laboratory by replacing genes that cause blindness with normal genes.

The team used molecular gene shears deployed through a simple injection into the eye. The shears latched on to individual eye cells, chopped out DNA fragments containing rogue genes, and replaced them with normal genes.

Lead researcher Associate Professor Alex Hewitt, from the University of Tasmania’s Menzies Institute, said regulators would need to be satisfied that the technique was safe, and that the shears could be turned off once they had done their job before starting human trials.

Human medical trials are expected to commence in less than five years.

For more information visit http://www.menzies.utas.edu.au/home/nested-content/feature-large/our-research-is-leading-the-way-towards-prevention-and-better-treatment-of-inherited-eye-diseases

Low rates of cervical cancer screening

A report by the Australian Institute of Health and Welfare has found that only three in five eligible Australian women had a pap test in the past two years.

In 2013-2014, 3.8 million women aged 20 to 69 years (57 per cent) participated in cervical screening.

Despite the low participation rate, Australia’s cervical cancer rates are considered low by international standards.

In 2012, there were 725 new cases of cervical cancer diagnosed and in 2013 there were 149 deaths. This is equivalent to between nine and ten new cases of cervical cancer diagnosed per 100,000 women and two deaths from cervical cancer per 100,000 women.

For more information the report, Cervical screening in Australia 2013-2014, can be found at http://www.aihw.gov.au/publication-detail/?id=60129554885

Pain leading cause of severe behaviour in dementia

Existing or undiagnosed pain has been linked to severe behavioural symptoms associated with dementia, according to Australian researchers.

Associate Professor Stephen Macfarlane, Head of the Clinical Governance for the Dementia Centre for HammondCare, and his research team identified that in 65 per cent of cases, pain was the main contributing factor to severe behaviours in dementia patients. Other leading factors included environment (60 per cent), limited carer knowledge (38 per cent), and depression (21 per cent).

Associate Professor Macfarlane said that it was common to find that, instances where pain contributed to behaviours involving aggression, agitation, and anxiety for dementia patients, that once it was alleviated the intensity of such behaviours was significantly reduced.

“Pain is an enormous issue for people living with dementia, and for older people generally, and is often undiagnosed as a contributing factor to behaviours,” Associate Professor Macfarlane said.

For more information visit – http://www.hammond.com.au/news/pain-major-contributing-factor-for-severe-behaviours-in-dementia

Malaria’s weakness exploited

Australian National University researchers have found that changes in the protein that enables a malaria parasite to evade several anti-malaria drugs also make the parasite hyper-sensitive to other therapies – a weakness that could be exploited to cure the deadly disease.

The researchers said the findings could prolong the use of several anti-malarial drugs to treat the disease which kills 600,000 people around the world each year.

Lead researcher Dr Rowena Martin said the interactions of the modified protein with certain drugs were so intense that it was unable to effectively perform its normal role, which was essential to the parasite’s survival.

“Essentially, the parasite can’t have its cake and eat it too. So if an anti-malaria drug is paired with a drug that is super-active against the modified protein, no matter what the parasite tries to do it’s checkmate for malaria.”

The study was published in the PLOS Pathogens journal.

Whole-genome testing now available

Australia has its first clinical whole-genome sequencing service which could triple the diagnosis rates for Australians living with rare and genetic conditions.

The service was launched by the Garvan Institute of Medical Research’s Kinghorn Centre for Clinical Genomics. Director Professor John Mattick said the service marked a turning point in disease diagnosis and health care in Australia.

Patients seeking a diagnosis for a possible genetic condition will be referred to a clinical genetic service which will work with NSW Health Pathology to assess whether whole genome sequencing can provide an answer.

Those who may benefit will then be able to access the service, which will screen all 20,000 genes at one time.

The simple blood test costs $4300, and has the capacity to identify the biological cause of illnesses so rare only a handful of people have the condition worldwide.

For more information visit http://www.garvan.org.au/research/kinghorn-centre-for-clinical-genomics/clinical-genomics/sequencing-services

Kirsty Waterford

[Series] Performance of private sector health care: implications for universal health coverage

Although the private sector is an important health-care provider in many low-income and middle-income countries, its role in progress towards universal health coverage varies. Studies of the performance of the private sector have focused on three main dimensions: quality, equity of access, and efficiency. The characteristics of patients, the structures of both the public and private sectors, and the regulation of the sector influence the types of health services delivered, and outcomes. Combined with characteristics of private providers—including their size, objectives, and technical competence—the interaction of these factors affects how the sector performs in different contexts.

Health Care Home success depends on GP goodwill

General practice is the corner stone of primary care. I am sure you will all agree with this. General practice in Australia has an exemplary record compared with many other countries around the world. It is efficient and extremely low cost, especially compared with an uncomplicated ED presentation.

The public, and the public purse, is extremely well served by general practice. The cost of MBS expenditure on general practice is just 6 per cent of total Government spending on health. Fee for service (FFS) has been the predominant funding model of general practice over that time.

The Government’s Health Care Home (HCH) is a model of care for patients with chronic disease. It is also known as the Medical Home. Under the model, patients have a continuing relationship with a particular GP to coordinate the care delivered by all members of the patient’s care team.

Do we need it? Especially when we consider the exceptional current performance and achievements of GP in Australia?

The significant twin burdens of burgeoning chronic disease and advancing age presentations are challenging the economic resources for delivering primary care. In an environment where fiscal resources are tight, the FFS model’s ability to cope with the pressure on the public purse is under the microscope.

Superimpose this on years of cuts to GPs – years of continued underfunding and non-investment by successive governments in general practice has brought GPs to the brink.

BEACH data shows that GPs are managing more chronic disease than ever before. GPs are already under substantial financial pressure due to the Medicare freeze and a range of other funding cuts. The HCH model is certainly not a way for the Government to arrange funding to general practice in the current Medicare rebate freeze environment.

The Medical Home is fundamental to the concept of the family doctor who can provide holistic and longitudinal care and, in leading the multidisciplinary care team, safeguard the appropriateness and continuity of care.

All this is academic if the funding for HCH is not appropriate, and not simply at the expense of FFS. Which brings us to the trial (or as the Health Department wishes to view it, as phase one of the implementation).

In March, the Government committed $21 million to allow about 65,000 Australians to participate in an initial two-year trial involving up to 200 medical practices from 1 July 2017. This funding is not for services, just for the infrastructure required to support the trial, as well as its evaluation.

The Health Department is busily preparing for this implementation. There is a hive of activity as it seeks to implement this key part of the Government’s strategy for reform. The overarching implementation advisory group will liaise to ensure that best practice and appropriate strategies are followed in the trial. AMA is on both the implementation group and underpinning subgroups involved in the mechanics of selecting patients and the economics of payment mechanisms.

The next few months will see many announcements, including the identification of the Primary Health Network (PHN) regions and an invitation for expressions of interest from practices in those regions to be part of the trials. The success of this policy initative will also depend on developments and further progress on the MyHealth Record and the PHNs (not without their challenges also).

The Department rightly understands that the goodwill of GPs is crucial for the success of the trial.

That goodwill will evaporate significantly if there is not the appropriate funding. However, I have made it clear that with additional funding support, GPs can provide more preventive care services and greater management and coordination of care. More important still, they can keep patients healthier and out of hospital, saving unnecessary and more expensive presentations and hospital admissions down the track – a measure which will form a key part of the evaluation of the success of the trial.

Private insurers being brought to account

The AMA’s activities over several years to shed light on the egregious behaviour of certain private health insurers is now bearing fruit.

The Australian Competition and Consumer Commission (ACCC), the Commonwealth Ombudsman and the Federal Government are now taking action to curb unacceptable practices and shift the focus onto consumer needs, informed by AMA advice and submissions.

As part of its work in this area, the AMA recently made a submission to the Government’s review of private health insurance policy. Our submission called for the Government to abolish ‘junk’ policies; prevent insurers from arbitrarily introducing exclusions in policies and benefit payment schedules without prior advice; and prohibit insurers from encouraging consumers to purchase a product, or downgrade their cover to a level that is inappropriate to their health care needs.

In addition, the AMA’s inaugural AMA Private Health Insurance Report Card issued in February this year sent a clear message that consumers could not take at face value information provided by their health insurer. We warned consumers to avoid ‘junk policies’ – those that provide cover only for treatment in public hospitals – and to ensure they clearly understood the level of benefits paid by their insurer and likely out-of-pocket costs.

In response, the Government has now announced that it will eliminate junk policies as a part of its program of private health insurance reforms.

The Government also intends to create a three-tiered system of policies that will allow consumers to more easily choose a product that is right for them. It will mandate minimum levels of cover for policies, and develop standardised terminology for medical procedures.

These proposals will require detailed consideration to ensure an appropriate balance between private and public health care is maintained. This work will keep the Medical Practice Committee busy this year.

The Government has also responded to our complaints that the operations of third party comparator sites for private health insurance are not transparent; ‘comparisons of best value’ exclude some policies and commissions are kept secret. The Government will require third party comparator sites to publish commissions they receive, similar to the requirements for other financial services.

The Commonwealth Ombudsman is also investigating those insurers who are insisting on seeking ‘pre-approvals’ for plastic and reconstructive procedures. Many of our surgeon members have been affected by this practice in which insurers require private hospitals to get surgeons to fill in and ‘certify’ a form providing clinical details of the procedure and the reasons why it is necessary.

While insurers continue to claim that this process is not compulsory and does not constitute a ‘preapproval’, we understand that patients, hospitals and medical practitioners are being told that if forms are not submitted, benefits will not be paid.

In direct response to AMA concerns, the Department of Health wrote to all insurers in 2015 reminding them that, under law, they must pay benefits for a hospital treatment when an insured member undergoes a procedure for which a Medicare benefit is payable, and which is covered by their health insurance product.

Clearly this advice has been ignored, but the Ombudsman’s investigation will hopefully put a stop to this practice.

Finally, the ACCC is taking legal action against Medibank Private for allegedly misleading consumers – specifically, failing to give notice to members on its decision to limit benefits paid for in-hospital pathology and radiology services.

As mentioned earlier, we raised the issue of arbitrary changes to policies and benefits in our submission to the Government’s private health insurance review last year, but we also brought this to the attention of the ACCC in our 2016 submission concerning insurer activities designed to erode the value of private health insurance cover and maximise insurer profits.

Commenting on its legal action, the ACCC said: “Consumers are entitled to expect that they will be informed in advance of important changes to their private health insurance cover, as these changes can have significant financial consequences”.

The AMA wholeheartedly agrees.