Greens make multi-billion commitment to chronic care

General practices would receive $1000 for each chronic disease patient enrolled with them under a plan outlined by Australian Greens leader Senator Richard Di Natale.

Upping the ante on Coalition policies regarding support for the treatment of chronic illness, Senator Di Natale said the Greens would inject $4.3 billion over four years to boost care.

Under the plan, not only would practices get an extra $1000 for each patient with a chronic illness who voluntarily enrolled with them, but $2.8 billion would be allocated to being allied health services within the public system and bolster Primary Health Networks to coordinated team-based care.

“Stretched GPs need a system which is set up to really support them in working with a team to better plan and organise care, and to improve outcomes for chronic disease patients over time,” Senator Di Natale said.

The Greens leader said the $4.3 billion commitment amounted to a “dramatic refocusing of our primary care sector to effectively respond to chronic disease”, and would establish a blended payment system that would complement the existing fee-for-service structure.

“As a former GP myself, I know the pressure that doctors are under to focus on responding to the immediate ailments of patients,” Senator Di Natale said. “But chronic illnesses are complex, and effective management requires long-term treatment and monitoring of symptoms by a range of health practitioners, working together.”

The Greens announcement follows the Government’s Health Care Homes initiative earlier this year, under which medical practices would receive bundled payments to provide integrated and coordinated care for patients with complex and chronic illnesses.

The Government has committed $21 million to a two-year trial of up to 200 Health Care Homes involving around 65,000 patients.

The AMA has welcomed the Health Care Home proposal but is critical that not more money has been allocated to the trial.

Senator Di Natale echoed the criticism, arguing that although the Health Care Homes initiative showed a welcome focus on an important area of care, “the trial is inadequately resourced and lacks any real detail”.

“Our plan is detailed, commits the funding necessary to be a success, and in the long-term will lead to savings as we better manage chronic disease and avoid hospital admissions,” he said.

Adrian Rollins

Only the Coalition has a credible, affordable plan for health: Ley

Only the Coalition has an affordable and sustainable vision for the future of the nation’s health care system, according to Health Minister Sussan Ley.

Seeking to frame the debate over health policy in terms of economic and financial management, Ms Ley told the AMA National Conference Gala Dinner that although Labor and the Australians Greens had unveiled policies with hefty price tags, only the Coalition had the fiscal discipline to be able to afford its health promises.

Labor has made health a centrepiece of its bid to win the 2 July election, announcing a succession of attention-grabbing policies including a $2.4 billion commitment to end the Medicare rebate freeze, $971 million to scrap increases to PBS co-payments and safety net thresholds, and $35 million for palliative care.

Not to be outdone, the Greens have matched Labor’s policy to resume Medicare rebate indexation, and have promised an extra $4 billion for public hospitals, $4.3 billion to support chronic disease treatment and $2 billion for domestic violence services.

But Ms Ley claimed that neither Labor nor the Greens had shown how they could afford their commitments and claimed the Coalition was the only party with a credible and affordable plan.

The Minister recently likened the approach of her political opponents to the use of a placebo: “Simply throwing more money at the system is tantamount to ‘placebo policy’: it may make some feel better but it won’t treat the cause.”

Ms Ley said a key focus of the Government was to lower the barriers patients face by reducing fragmentation across the health system and improving the coordination of care.

She said the Health Care Homes initiative was trialing a new way of funding the treatment of chronic and complex illnesses to ensure patients received integrated and coordinated care.

The Minister said the recent decision to inject an extra $2.9 billion into public hospitals was accompanied by a greater focus on patient outcomes, quality and safety.

Ms Ley recently suffered a hiccup on the campaign trail when she admitted that she had been overruled by Treasury and Finance in arguing against an extension of the Medicare rebate freeze.

But she told the AMA dinner that she looked forward to continue working with the medical profession to develop policies and identify efficiencies and savings so as to ensure that, in a constrained budgetary environment, every health dollar was used to maximum effect.

Adrian Rollins

Greens promise billions for hospitals, Medicare

The Australian Greens have committed to a multi-billion dollar boost to Medicare and hospital funding as part of a drive to increase investment in health.

Greens leader Senator Richard Di Natale told the AMA National Conference that his party would not only match Labor’s $2.4 billion promise to ditch the Medicare rebate freeze but would provide an extra $4 billion to restore Commonwealth funding for public hospitals, including providing 50 per cent of growth funding.

Senator Di Natale said the policies reflected the Greens’ commitment to universal and equitable access to health care, and an end to what he said was the Government’s “shameless exercise in cost shifting”.

Though opinion polls indicate the Greens stand no chance of forming government in their own right, they show that the election contest is finely balanced, opening the possibility the Greens could play a crucial balance of power role in forming the next government – making their views on health policy potentially significant.

In his speech, Senator Di Natale lambasted the Coalition’s cuts to health spending and detailed plans to increase Commonwealth support for hospitals, GPs, allied health workers and health services for Indigenous Australians and other disadvantaged patients.

“We should never be fooled, by those who see health as a cost more than an investment, into believing that cuts to the heart of the health system are a necessity,” he said, arguing that Australia’s spending on health was around the average among developed economies.

Senator Di Natale said that while it was important to ensure health funds were spent effectively, health expenditure would increase.

“As exciting new treatments become available and our country’s demographics change, we will need to spend more on health care to enjoy a better quality of life,” he said. “That, we believe, is a clear and legitimate choice for a wealthy nation to make. Spending more on health care is not unsustainable or irresponsible – it is a key priority and an investment we are luck to make.”

On the highly controversial topic of assisted dying, Senator Di Natale said the Greens believed patients should have “access to voluntary euthanasia and physician care for dying with dignity”.

The Greens leader said policies on Indigenous health, drug and alcohol treatment services and preventive health would be detailed later in the election campaign.

Adrian Rollins

Financial toxicity in clinical care today: a “menu without prices”

Out-of-pocket costs are rising rapidly and can influence treatment decisions and health outcomes

Australia delivers health outcomes that rank well internationally, with per capita spending demonstrably less than that of the United States. Of concern, Australia’s out-of-pocket costs for health care are sixth highest among Organisation for Economic Co-operation and Development countries,2 despite universal health insurance. These out-of-pocket expenses accounted for 57% of non-government health expenditure in 2011–12, or over 17% of all health care expenditure.3 Health care costs in Australia continue to rise well above the consumer price index. The net burden of costs are reported by clinicians to influence some decisions that patients make, with the potential for detrimental health outcomes for individuals and for Australia’s health as a whole.

The average equivalised weekly disposable household income in 2013–14 was $998, with a median of $844.4 About half of all households therefore have a weekly net income of less than $844, yet that income has to support out-of-pocket health expenses. There are also limits to what is covered under different aspects of the safety net. Further, many aspects of community-based care are associated with part or all of the cost being borne by the patient, in many cases with no safety net provisions (wound dressings, incontinence pads, community nursing and allied health visits).

In cancer care, patients often face tough decisions as new unsubsidised therapies become available. An ageing population, innovations (some with very marginal benefits) and the risk that some procedures are overused or harmful all contribute to unnecessary financial (and emotional) pressure on patients and their families. Procedures and interventions, at times with marginal health gains, are being promoted actively, frequently with high costs and little meaningful benefit in terms of quality of life or survival. In the context of ongoing outcome disparities based on socio-economic status, our aim must be timely access to world class care for all Australians, regardless of financial circumstances.

In the Australian context, financial disclosure is not only how much a procedure will cost but, crucially, whether there are alternatives that offer similar benefits at less cost to the patient. This may be as important to the patient as the side effects or risks of an intervention. Most starkly, the omission of information from a private clinician regarding options in the public sector reduces informed financial choice and increases the potential for significant financial and health disadvantages.

Failing to inform patients about comparative waiting times in public and private systems falls short of fully informed (financial) consent. Indeed, national data demonstrate that public surgical waiting times for a sample of cancers are very short.5 Publicly available data on waiting times and service quality are critical for supporting informed treatment decisions, especially when out-of-pocket expenses can vary from zero to tens of thousands of dollars for the same procedure.

Value in health care is defined as outcomes relative to cost.6 In considering this from a patient’s perspective, it is imperative to not only question outcomes but to understand the true cost for the whole episode of care — the out-of-pocket expenses, the contribution made by the community through Medicare, and any supplementary private insurance. Informed choice should be based on more than the costs charged by an individual practitioner and those incurred by related pathology, imaging and anaesthetics. Informed choice now needs also to account for the extreme variations in the prices charged by identically credentialed practitioners within Australia undertaking the identical procedure.7

International data suggest that the consequences of high out-of-pocket costs include the potential for poorer compliance with ideal care, including prescribed medications that are necessary for best outcomes.8,9 To make decisions about what is often a long treatment pathway across multiple modalities, patients need a comprehensive and early understanding of the financial impacts of treatment, time away from work and other costs, and the opportunity to seek financial advice and assistance early as needed. Indeed, in one survey, people only sought help when the financial burden was starting to cause significant difficulties.9

Arguably, failure by medical practitioners to disclose all of the financial costs affecting patients’ decisions is a cause of avoidable suffering for tens of thousands of households across Australia each year.10 A new standard for financial disclosure is required — a standard that moves beyond disclosure of the costs of a single procedure to one that accounts for the costs of a full pathway of treatment and all the alternatives open to the patient. The issue of financial toxicity in Australian health care requires open debate supported by population- and individual-level data on rapidly rising out-of-pocket costs, and advocacy that places patients’ outcomes at the centre of any debate about the profession’s increasing demands on patients’ wallets.

Medibank actions ‘unconscionable’: ACCC

The consumer watchdog is taking the nation’s largest health insurer to court alleging it engaged in misleading and unconscionable conduct after it reduced benefits without informing policyholders.

In damning accusations that reflect widespread public discontent over the conduct of private health funds, the Australian Competition and Consumer Commission has launched legal action against Medibank Private claiming it deliberately withheld information about a cut in benefits for in-hospital radiology and pathology services to make money and avoid hurting its image ahead of its public float.

“We think these are very serious allegations, and we think the behaviour we’re alleging should change right across the industry,” ACCC Chairman Rod Sims told The Australian.

In a strongly-worded statement, the ACCC claimed Medibank made a calculated decision to keep communications about the change “contained and reactive” for fear that if it was disclosed members might leave the fund, and the bad publicity could damage its reputation and “have a negative impact on its planned initial public offering of securities”.

The issue arose when, in September 2014, Medibank terminated and phased out agreements with pathology and radiology providers to pay the gap for in-hospital services. As a result, the ACCC said, policyholders were left with average out-of-pocket expenses of $151 for pathology services, and $83 for radiology services.

The ACCC alleges Medibank failed to give members with advance notice of the changes despite previously committing to do so, and that representations it made that members would not face out-of-pocket expenses for in-hospital pathology and pathology services were, from 1 September 2014, false and misleading.

“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 at a time when consumers may be vulnerable,” Mr Sims said. “Private health insurers must ensure their disclosure practices comply with the Australian Consumer Law.”

Medibank has rejected the ACCC’s allegations.

“Medibank take sits obligations under the Australian Consumer Law seriously, and has appropriate processes in place to ensure compliance,” a spokesman for the health fund said. “We have been working cooperatively with the ACCC throughout its investigation.”

AMA President Dr Michael Gannon welcomed the ACCC’s action.

Dr Gannon said the AMA has long been highly critical of the actions of insurers making changes to their health cover without informing policy holders, and it was pleasing to see that at least one was now being held to account.

“It has become a distressingly common experience for patients to think they are covered for the cost of medical treatment, only to find that they are lumbered with unexpected out-of-pocket costs,” Dr Gannon said.

“It is completely unacceptable for insurers to make changes to the cover they provide without informing policyholders, and it is very important that this type of behaviour is now being called out.”

The ACCC’s action follows the release earlier this year of the AMA Private Health Insurance Report Card, which showed that many policies offered by health insurers were no better than junk, while others did not provide the cover expected.

The AMA’s analysis of the 40,000 policies offered by the nation’s 33 private health funds has found that Medibank Private, NIB, HCF, HBF, which together account for more than 55 per cent of the health insurance market, are marketing products that, because of multiple exclusions, provide barely more cover than Medicare or, in many instances, provide no additional entitlement at all.

The ACCC last year launched a report highly critical of the quality and accuracy of information provided by the health funds, which the watchdog said served to confuse consumers about what they were covered for and hampered their ability to make informed choices.

Health Minister Sussan Ley has commissioned a review of the private health insurance industry amid widespread discontent about rising premiums and shrinking cover, and the Coalition has promised that if it is re-elected it will institute a rating system for health cover and “weed out” junk policies by mandating a minimum level of cover.

Dr Gannon said it was time insurers were held accountable for their actions, which often caused great financial and emotional distress for patients caught unaware by surprise out-of-pocket expenses.

“Policyholders need to know exactly what they are covered for and are entitled to, rather than being hit with shock bills when they are ill or at their most vulnerable,” he said.

The AMA Private Health Insurance Report Card 2016 is at ama-private-health-insurance-report-card-2016

Adrian Rollins

Alcohol and other drug treatment services in Australia 2014–15

In 2014–15, around 850 alcohol and other drug treatment services provided just over 170,000 treatment episodes to around 115,000 clients.The top 4 drugs that led clients to seek treatment were alcohol (38% of treatment episodes), cannabis (24%), amphetamines (20%) and heroin (6%). The proportion of episodes where clients were receiving treatment for amphetamines has continued to increase over the last 10 years, from 11% of treatment episodes in 2005–06 to 20% in 2014–15. The median age of clients in AOD treatment services is increasing, 33 years in 2014–15, up from 31 in 2005–06.

[Correspondence] Alcohol use disorders

In their Seminar (March 5, p 988), Jason Connor and colleagues1 stressed that a comprehensive psychiatric assessment is essential to the identification of the primary disorder (psychiatric or alcohol use disorder). They also emphasised that research into health services is needed to improve the identification and treatment of the most common and remediable forms of psychiatric comorbidities in patients with alcohol use disorder, particularly anxiety disorders.

Disability support services: services provided under the National Disability Agreement 2014–15

In 2014–15, around 333,800 people used disability support services under the National Disability Agreement (NDA), including around 1,900 who transitioned to the National Disability Insurance Scheme (NDIS) during the year. Many (44%) had an intellectual or learning disability, more than half (52%) lived with their families, and close to one-third (30%) of those aged 15 and over were not in the labour force.

[Comment] Increases in general practice workload in England

Primary care services form the backbone of health care in most high-income countries. Yet, there are growing concerns about the effects that numerous changes in the content and delivery of primary care have had on the workload of primary care practitioners. In a retrospective analysis in The Lancet, F D Richard Hobbs and colleagues1 investigated the direct clinical workload of general practitioners (GPs) and practice nurses in primary care in the UK, and present data from consultations of patients registered at 398 English general practices between April, 2007, and March, 2014.

Margaret Anne Burgess

A remarkable paediatrician who pioneered research into vaccines and vaccine-preventable diseases in Australia

Margaret Burgess (nee Menser, 1937–) was born in Sydney, and it is Sydney alone that can claim credit for her education and the achievements of a career spanning, unusually, laboratory, clinical and population-based research. Her contributions to medicine are of international importance to our understanding of congenital rubella and its prevention, and to clinical and public health aspects of the control of vaccine-preventable disease more generally. With more than 250 published articles and 20 book chapters, and an Order of Australia for services to public health, Margaret can rightly be considered a pre-eminent paediatric researcher of her generation.

Margaret’s intellectual and personal qualities first became evident as captain of Fort Street Girls High School in 1954. She went on to study medicine at the University of Sydney, where she was active in the University Women’s Union. On graduating in 1961, she won the Dagmar Berne Prize for first place among women candidates and was first in the year in surgery. The link with Dagmar Berne, who was the first woman to enrol in medicine in Australia in 1885, but who needed to transfer to London to evade obstruction to her graduation in Sydney, is apposite. In 1964, Margaret became the first woman appointed as a medical or surgical registrar at the Royal Prince Alfred Hospital (RPAH) since the end of World War II, and had to deal with a number of obstacles on her path — but more of this later.

Margaret Burgess, Director of the National Centre for Immunisation Research and Surveillance of Vaccine-Preventable Diseases, 2003.

Her inclination towards paediatrics and child health began when she was a medical student. This was prompted first by the tragic but expected death of her sister Lynette, after surgery for cyanotic congenital heart disease, and second by the inspirational teaching of Australia’s first Professor of Paediatrics, Sir Lorimer Dods. He encouraged her to stay at RPAH to study for membership of the Royal Australasian College of Physicians (MRACP), as there was no separate paediatric examination, and Margaret qualified as MRACP in 1965. She immediately began research work with Lorimer Dods at the Children’s Medical Research Foundation (CMRF) and began a lifelong association with the Royal Alexandra Hospital for Children.

The year 1965 was a propitious one to commence a paediatric research career. There was a rubella outbreak in Sydney, which followed epidemics in the United States. The large number of newborns in the US with severe sequelae, such as blindness, deafness and congenital heart disease, together with the isolation of the rubella virus in 1962, galvanised efforts to develop a vaccine to prevent rubella infection. Sydney already had a strong association with rubella. In 1941 ophthalmologist (later Sir) Norman Gregg had noted that mothers of infants with cataract frequently gave a history consistent with rubella (then believed to be no more than a mild illness with rash) during their pregnancy. Thus, Margaret could draw on a cohort of congenital rubella survivors for study, starting with those from 1941.

Her first article on the late sequelae and associations of rubella appeared in The Lancet in 1966, and described “renal artery stenosis in the rubella syndrome”.1 After publishing seven additional articles in The Lancet, including landmarks such as the isolation of the rubella virus from the lens of a child with cataract,2 Margaret, with medical school friend Jill Forrest and husband John Burgess, reported the propensity of congenital rubella survivors to develop diabetes.3 This important article was published in 1971, the year she was awarded her Doctor of Medicine (MD) degree.

During this period of great research productivity, Margaret married endocrinologist John Austin Burgess in 1968, and had given birth to their two sons, Michael (1970) and David (1972). David was delivered at home after an unexpectedly rapid labour while his father was, by his own account, “still looking for the textbook”. Careers for married women, and certainly for those with children, were a novelty in the Australia of the 1960s. For Margaret, time out after the birth of her sons was limited to accumulated leave.

Margaret with a congenital rubella patient at the Royal Alexandra Hospital for Children, 1967.

In 1968, an opportunity arose — which combined Margaret’s awareness of the needs of deaf children through her congenital rubella work and of the needs of professional women — to advocate for a childcare centre at the University of Sydney. The Shepherd Centre for education of the deaf (named after orthopaedic surgeon Bruce Shepherd and his wife Annette who had two deaf children), was being planned, and there was room on the ground floor for a childcare centre. An appointment was arranged to the see the University Registrar, who listened to the four women in the delegation with studied disinterest before declaring “I see no more reason why the University should provide a childcare centre than a petrol station”. This kindled both anger and — in the tradition of Dagmar Berne — a steely determination to overcome the insolence of office. Margaret and her co-conspirators were put in touch with the wife of Vice-Chancellor (Sir) Bruce Williams (who had five daughters) and the childcare centre was born in 1970.

Later in the 1970s, while her children were still young, the next phase of Margaret’s career began — conducting clinical trials of rubella vaccine allied with epidemiological and public health aspects of vaccines and vaccination programs. Her work on the rubella vaccine expanded over the next 30 years to include vaccines against measles, mumps, pertussis, varicella, hepatitis B and rotavirus, to name only some. In 1978, Margaret published a trial of a new rubella vaccine in schoolgirls and seroprevalence studies in The Medical Journal of Australia, and in 1984, she reported the impact of rubella vaccine in Australia in The Lancet,4 all while working on a busy roster in clinical oncology. There were competing approaches to rubella vaccination at the time. Australia, like the United Kingdom, gave rubella vaccine only to girls in early high school whereas the United States gave rubella vaccine to young children. Later, it became apparent that both strategies in both sexes were needed to eliminate the indigenous transmission of rubella, thus minimising risks to the developing fetus.5

Eliminating measles — an even greater challenge than rubella — was tackled through the national Measles Control Campaign (MCC) of 1998, which provided combined measles, mumps and rubella (MMR) vaccine to all Australian primary school children.6 The MCC had been preceded in 1997 by the Immunise Australia Program or “Seven Point Plan”, which had as one of its seven points the establishment of a National Centre for Immunisation Research and Surveillance of Vaccine-Preventable Diseases (NCIRS). Margaret led the successful tender, becoming the founding Director of NCIRS in August 1997 and Professor of Paediatrics and Preventive Medicine at the University of Sydney in 1998. This late recognition reflects the slow ascension of women to higher academic appointments of the time — Margaret had attained the rank of Clinical Associate Professor only in 1992, despite academic achievements many years previously that today would justify full professorial appointment.

As a key component of the bid for the NCIRS, Margaret, in collaboration with Lyn Gilbert at the Institute of Clinical Pathology and Medical Research, proposed the now regular national serosurvey, which examines age-specific prevalence of protective levels of antibodies to vaccine-preventable diseases at a population level. The national serosurvey proved to be a critical component of the evaluation of the MCC, demonstrating its success in increasing population immunity.5 This evidence later underpinned the declaration of elimination of indigenous transmission of measles and rubella in Australia. Margaret’s tenure as Director of NCIRS from 1997 to 2003 coincided with an enormous expansion of immunisation programs in Australia, with national funding for the purchase of vaccines increasing more than tenfold. Margaret played a large role in paving the way for the addition of varicella vaccine (in 2005) and rotavirus vaccine (in 2007) to the National Immunisation Program.

Less well known is Margaret’s vision in drawing attention to the need for strengthened monitoring and reporting of vaccine safety in the 1990s,7 a time when this was not a popular cause. She emphasised the special importance of safety monitoring during national campaigns — groundwork that proved vital when Australia had challenges relating to the safety of vaccines against human papillomavirus in 2007 and influenza in 2010.

Despite (or perhaps aided by) her personal modesty, others have recognised the calibre of Margaret’s achievements. In Australia, she was awarded the Queen Elizabeth II Silver Jubilee Medal for services to the community in 1997 and the Howard Williams Medal of the Royal Australasian College of Physicians in 2006. Internationally, she was invited to join the Strategic Advisory Group of Experts (SAGE) of the World Health Organization’s Department of Vaccines and Biologicals in 2001, and was awarded an Order of Australia in 2003 for her services to public health in Australia and overseas, particularly through providing policy advice to government and research into vaccine-preventable diseases. In his foreword to the NCIRS biennial report in 2006, Sir Gustav Nossal commented that Margaret’s “legacy is evident underlying the productivity of NCIRS through its team spirit, flexibility of work practices and mutual supportiveness, which takes a long time to nurture”.

Perhaps the greatest testimony to Margaret’s personal and professional qualities is the universal regard she engendered in so many who were in positions elevated and humble, academic and at the coalface. Those treated to dinner at their Killara home remember with enormous affection the hospitality and unfailing courtesy of both Margaret and her late husband John, who sadly passed away in 2010. A giant photograph of Margaret and John adorned billboards outside the Chris O’Brien Lighthouse at RPAH during its construction. Margaret is actively engaged in the lives of her twin grand-daughters, Eleanor and Jacqueline, and although steadfastly maintaining she is retired, still reads The Lancet and New England Journal of Medicine every week. She leaves a lasting legacy to the fields of paediatrics, immunisation and public health. As a role model, to borrow the words of Kathryn North, a paediatrician who trained at the Royal Alexandra Hospital for Children and who is now Chair of the National Health and Medical Research Council Research Committee: “Margaret is a fabulous mentor — she leads by example, she listens, she cares. She has been an amazing role model for so many. I want to be just like her when I grow up”.