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Preference: Administration and Health Services

2

Female representation at Australasian specialty conferences

A gender imbalance has been noted at medical conferences internationally, with typically more male than female speakers.1–3

We conducted a retrospective observational study to assess the proportion of female program speakers and the time allocated to them at the annual scientific meetings (ASMs) of six Australasian specialty colleges from 2012 to 2014 (n = 17). For 2013, female ASM representation was compared with published data on female workforce participation for each specialty.4 The six colleges evaluated were the Australasian College for Emergency Medicine (ACEM), Australian and New Zealand College of Anaesthetists (ANZCA), College of Intensive Care Medicine of Australia and New Zealand (CICM), Royal Australasian College of Physicians (RACP), Royal Australasian College of Surgeons (RACS) and Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG).

We audited official ASM programs and included all sessions with allocated speaking times. We compared distributed data using the Mann–Whitney U test and categorical variables using a χ2 test. A two-sided P < 0.05 was taken to indicate statistical significance.

The proportion of male speakers exceeded the proportion of female speakers at every conference (Box). The proportion of female speakers ranged from 8% (3/37) at CICM 2012 to 42% (39/93) at RANZCOG 2012. At seven of the 17 ASMs (all RACS ASMs, CICM 2012 and 2014, ANZCA 2012 and RANZCOG 2013), the median time allocated per speaker was significantly higher for male than female speakers. At the other ten conferences, there was no statistically significant difference.

In 2013, for all colleges except RACS, the proportion of female speakers was lower than the proportion of female doctors in the corresponding specialty workforce; however, this did not reach statistical significance. In contrast, the proportion of female speakers at RACS 2013 exceeded the proportion of women in the surgical workforce (P < 0.001).

Our results indicate that the gender imbalance among college ASM speakers largely reflects gender representation in the specialty workforce.

The longer median speaking time for male speakers may reflect the greater proportion of men at senior levels in the specialty workforce. As ASM programs did not always distinguish between invited speakers and those selected from abstract submissions, we could not compare these selection pathways. A limitation of the workforce comparison is that each specialty workforce includes practitioners who do not undertake research and are unlikely to speak at conferences; conversely, ASM speakers are not exclusively drawn from the specialty workforce.

Our findings raise an important question — should the proportion of female speakers at conferences reflect their representation within the college membership? Or should conference organisers be striving for greater female representation? Improving the balance of male and female speakers at conferences may improve workforce gender balance by encouraging women to pursue research and advancing the careers of female speakers. Colleges represent themselves to the medical community through their ASM programming choices. Efforts to improve gender balance in the medical community should therefore include consideration of speakers at medical conferences.

Box –
Proportion of annual scientific meeting (ASM) speakers, by gender

ACEM = Australasian College for Emergency Medicine. ANZCA = Australian and New Zealand College of Anaesthetists. CICM = College of Intensive Care Medicine of Australia and New Zealand. RACP = Royal Australasian College of Physicians. RACS = Royal Australasian College of Surgeons. RANZCOG = Royal Australian and New Zealand College of Obstetricians and Gynaecologists. * RANZCOG did not hold an ASM in 2014.

[Review] Costs, affordability, and feasibility of an essential package of cancer control interventions in low-income and middle-income countries: key messages from Disease Control Priorities, 3rd edition

Investments in cancer control—prevention, detection, diagnosis, surgery, other treatment, and palliative care—are increasingly needed in low-income and particularly in middle-income countries, where most of the world’s cancer deaths occur without treatment or palliation. To help countries expand locally appropriate services, Cancer (the third volume of nine in Disease Control Priorities, 3rd edition) developed an essential package of potentially cost-effective measures for countries to consider and adapt.

Heard on the hustings

“We need to control the way we spend the health dollar within the limited means we have, to enable us to have the funding to put new drugs on the Pharmaceutical Benefits Scheme” – Prime Minister Malcolm Turnbull explains why the Medicare rebate had to be frozen until 2020.

“I understand for doctors that the GP freeze has been difficult and I appreciate their working with us. I have said to doctors that 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” – Health Minister Sussan Ley says the rebate freeze extension isn’t her doing.

“Nobody wants to head down the same path as America when it comes to our health system. We will reverse Mr Turnbull’s cuts, which will reduce bulk billing and hit Australian families every time they visit the doctor” – Opposition leader Bill Shorten makes the first big announcement of the election campaign, unveiling Labor’s $12.2 billion plan to restore Medicare rebate indexation from next year – to be paid for by axing company tax cuts and the new baby bonus.

“What happened in 2011 was a previous Government” – Bill Shorten ducks responsibility for Labor’s decision to freeze Medicare rebates in November 2013.

 “The Government is shifting its responsibility from providing health care services back to the hip pocket of patients. It is inevitable that, under the freeze, out-of-pocket expenses are going to rise. Labor’s policy protects the Medicare rebate. It actually supports and cements one of the most important factors in our Medicare system, and that is its universality” – AMA President Professor Brian Owler welcomes Labor’s announcement.

“One thing that I’m pleased about is that the many medical practitioners who are out there, on the first of July, they will get a company tax cut, those who are operating in those structures, but also those who are in unincorporated structures” – Treasurer Scott Morrison argues the Government’s company tax cuts will offset the hit to doctor incomes from the Medicare freeze.

“Bill Shorten and Labor can’t pay for their health spending promises, and what they can’t pay for they will never deliver. Bulk billing rates remain higher under the Coalition than Labor. Many GPs are also small business owners and employers, and the Coalition’s 10-year enterprise tax plan will benefit them directly” – Sussan Ley.

“The issue about the Medicare systems is the payments. It’s not actually about the doctors’ incomes. And certainly, the cost pressures that doctors are experiencing in their practices have nothing to do with tax cuts. It has to do with the rising costs of staff, leases, equipment and all of the things that go along with that” – Professor Brian Owler says the Coalition is missing the point.

“To be frank, on the current rebate we make less than $1 per consultation, which doesn’t provide for the renewal of fixed assets. You get by day-to-day but you don’t have the capacity for future provision” – Dr Rodney Beckwith, who owns a medical practice on the NSW central coast.

“At this stage, the black hole of unfunded promises keeps on getting deeper and darker” – Malcolm Turnbull tries to shift the focus from health to financial management.

 

 

Pathology deal a fresh assault on medical practices

The Federal Government has intensified its assault on medical practice incomes, promising to clamp down on rents charged for pathology collection centres in exchange for an end to the pathology sector’s damaging campaign over cuts to bulk billing incentives.

Just two weeks after it announced a two-year extension of the Medicare rebate freeze to 2020, ripping $925 million out of primary and specialist care, the Government has sliced further into practice earnings by stitching up a peace deal with Pathology Australia that analysts predict will force collection centre rents down by 30 per cent and leave major players like Sonic Healthcare and Primary Healthcare up to $100 million a year better off.

Prime Minister Malcom Turnbull announced the agreement during his first televised debate with Opposition leader Bill Shorten, declaring that it meant that “the concern that has been expressed about patients who go to have their blood tests done and so forth being charged extra, not being bulk billed, is… that concern is gone; the pathologists have agreed to continue bulk billing”.

But the Prime Minister’s boast could be premature.

Primary Healthcare, which holds 34 per cent of the market and is not a member of Pathology Australia, has written to doctors to distance itself from the deal, and smaller pathology providers complain it does little for them and they will have to begin charging patients a co-payment of up to $50.

AMA President Professor Brian Owler said the deal “doesn’t guarantee anything”.

“The cut to bulk billing incentives for pathology has merely been deferred. The cuts are still there, they’re still taking $650 million out of health over the next four years,” Professor Owler said.

Professor Owler said he had been in contact with Pathology Australia about the deal, and they had admitted there was no guarantee the pathologists would continue to bulk bill.

“They don’t have the ability to make that guarantee, and it will be up to the individual pathology companies to actually make that decision over time,” he said.

Under the deal, the Government has committed that, if it is re-elected, it will delay bulk billing incentive cuts by around three months while it introduces provisions to the Health Insurance Act to clarify what is meant by ‘market value’ and link it with local commercial market rents.

This will be backed by “appropriate compliance mechanisms”, and those seeking to register collection centres will need to provide more information.

Pathology Australia said the reduced rents would enable its members to absorb the bulk billing incentive cuts and sustain current rates of bulk billing. As a result, the organisation has agreed to drop its national “Don’t Kill Bulk Bill” campaign.

The announcement amounts to a backflip by Health Minister Sussan Ley.

In a review of Approved Pathology Collection centre arrangements last year, Ms Ley rejected pathology sector calls for a change in the definition of ‘market value’ and determined that existing regulations regarding prohibited practices and market rent were appropriate.

Macquarie Securities analyst Craig Collie told Guardian Australia that Sonic Healthcare could be up to $70 million a year better off under the Government deal.

Mr Collie estimated the company would save about $116 million a year on rent at its 2000 collection centres, which more than offset the $50 million cost of losing the bulk billing incentive.

Guardian Australia reported that both Sonic and Pathology Australia have been major Coalition donors in recent years.

There are around 4000 collection centres across the country, and medical practitioners have warned the Government will need to consult closely with general practice to ensure that the new regulations are not simply a form of price control that puts many existing leases into jeopardy.

The Government has declared there will be a moratorium on any new collection centre approvals until the new regulations are in place, and “the measure to remove bulk billing incentives will commence at the date that the changes to the regulatory framework take effect”.

But Professor Owler said that, even with the deal, there was no getting away from the fact that the Government was ripping hundreds of millions of dollars out of pathology services.

“To suggest that somehow the concern is now gone I think overstates the results of the agreement that was reached between the Government and Pathology Australia,” he said. “There will be some easing of costs pressures through this change to rents, but at the end of the day they are still experiencing a very significant cut.”

St Vincent’s Health Australia Chief Executive Toby Hall told the Adelaide Advertiser the axing of the bulk billing incentive would rip $3 million from his organisation’s bottom line, forcing them to consider “some form of patient co-payment. I think we’d have to look at between $20 and $50”.

And the deal has done nothing to address the cut to bulk billing incentives for diagnostic imaging services.

The Australian Diagnostic Imaging Association warned patients still faced cuts to their rebates for x-rays, CT scans, MRIs and ultrasounds, and smaller pathology companies cautioned they would be forced to charge out-of-pocket expenses despite the Government’s deal.

Adrian Rollins

 

Pathology ducks MBS review

Pathology services will be quarantined from the Federal Government’s overhaul of Medicare in a major concession secured by the profession in exchange for dropping its campaign against the axing of bulk billing incentives.

The Government has opened the door to special deals regarding its MBS Review after agreeing to leave the Pathology Services Table, which lists the tests Medicare will cover and how much it will pay, untouched for the next three years.

Under the deal, the Government said it would “not change the Pathology Services Table, excluding those from the MBS Review, for the next three years, without consultation and agreement with the sector”.

Royal College of Pathologists of Australasia President, Dr Michael Harrison, said the arrangement meant “there will be a moratorium for the next three years on any further changes to [the] Pathology Services Table without agreement from the profession”.

The arrangement deepens questions about the Government’s rationale for the Medicare Review, suggesting its focus is primarily on savings rather than updating the MBS per se.

AMA President Professor Brian Owler told Sky News the AMA had been “quite happy” to participate in the review on the understanding that its primary goal was to modernise the MBS and deliver better outcomes for patients. This would involve ploughing a share of any savings made back into health, including lifting the Medicare rebate freeze.

“The conversations that I had with the former Prime Minister went along the lines of investing some of that money, if there were savings from that review, back into health,” Professor Owler said. “And it was very clear that one of the things that we’re aiming to do was to lift the MBS freeze. Now all of that seems to have fallen away. Clearly there’s no effort to lift the freeze and what this Government is determined to do is to continue the freeze…and pass the cost from the Government, through the doctor, onto patients.”

Adrian Rollins

Govt fails to put bite on dental scheme

A free dental care scheme for children, axed in the Federal Budget, will continue to operate beyond 30 June after Parliament failed to abolish it before the election.

The Government said it was abolishing the former Labor government’s Child Dental Benefits Scheme (CDBS) because it was a failure, treating less than one-third of eligible children and with $4 million of incorrect claims being investigated.

It proposed a new $1.7 billion Child and Adult Public Dental Scheme (caPDS), with the Commonwealth’s contribution to the states and territories capped at 40 per cent of the national effective price for dental services, and funding available on a first-come, first-served basis.

The CDBS was due to end on 30 June, but the Government failed to get the legislation through Parliament before it was prorogued ahead of the 2 July election.

The Australian Dental Association (ADA), which is running a campaign against the closure, has urged families to take advantage of the delay.

“The ADA is encouraging all eligible patients to make appointments for treatment under the CDBS with their preferred dentist as soon as possible,” ADA President Rick Olive said.

Dr Olive said that the lack of an agreed funding distribution model “raises the spectre of a Hunger Games-style scenario” where some states and territories ended up with the lion’s share of funding, leaving the remainder with insufficient funds to meet the new demands on their public health systems.

“Additionally there is no guarantee that eligible patients from rural areas will be able to access a public dental clinic close enough to receive treatment, widening the accessibility to dental services divide still further between rural and regional Australian and their city brethren,” Dr Olive said.
In contrast, under the CDBS, rural and regional patients can simply go to their nearest participating local dentist to receive treatment.

People living in towns like Chinchilla in Queensland and Casterton in Victoria will be forced to travel long distances for dental care, or wait for services to come to them.

“The ADA supports enshrining funding for states and territories in legislation,” Dr Olive said.

“However, without a fair distribution model and guarantees that eligible patients have the choice to either access public clinics or their local dentist appropriate to their specific circumstances, patients from smaller states and regional and rural areas stand a real risk of missing out on dental care under the Coalition’s caPDS.”

Maria Hawthorne

 

Aged care sector prepares for fight with Government

Aged care providers are preparing to campaign against the Government, accusing it of stripping $3.1 billion from the sector over the past year alone.

The Government plans to save $1.2 billion by “refining” the Aged Care Funding Instrument (ACFI) so that fewer patients fall into the complex health care (CHC) category, following a blowout in claims.

Currently, almost 50 per cent of patients are classified in the highest CHC bracket, receiving $66.82 a day on top of the usual subsidies.

Treasurer Scott Morrison said the ACFI needed fine tuning so it did not “encourage distortions in claiming behaviour and care delivery”.

Health and Aged Care Minister Sussan Ley told The Australian that ongoing overclaiming by providers “demonstrates a clear need to restructure the way (funding) is assessed”.

While the move received support from the Council on the Ageing, it was condemned by the peak lobby group, Leading Aged Services Australia (LASA), which accused the Government of cutting $3.1 billion nationally over the past year.

Individual providers and Aged and Community Services Australia (ACSA) also criticised the measure, with ACSA launching a federal election campaign called Old, Frail, and Invisible.

“There is significant and growing concern about the impact of the 2016-17 Budget cuts arising from changes around the ACFI, ACSA President Paul Sadler said.

“These will directly impact on older people in our residential care facilities that need specialised and complex care and support.

“These changes to ACFI have not been implemented in the spirit of consultation, and the modelling of the impacts we have seen so far has caused considerable distress in our sector as we seek to provide the appropriate service, care and support to our current and future residents.”

Ansell Strategic, a consultancy specialising in aged care organisations, released projections showing that the changes would result in cuts of $350 million more than announced.

“While the cuts compromise the viability of the sector, the threats to the vulnerable aged are even more concerning,” managing director Cam Ansell said.

“The ACFI changes create a disincentive to admit high dependency people and will ultimately result in their displacement to hospitals.”

In a separate fight, Victoria’s largest provider, Shepparton Villages, has reportedly launched a campaign against a Government decision to shift almost 150 beds from the Shepparton region to Melbourne.

LASA’s Victorian policy and government relations director, Jenny Matic, told The Australian that the Shepparton region had been stripped of beds despite having the third highest rate of dementia in Australia.

“Four hundred residential aged care beds were meant to allocated, but only about 250 were. That’s a 40 per cent loss,” she was quoted as saying.

“There doesn’t seem to be a level of transparency around these deferred allocations. You don’t know who got what and how many.”

Shepparton is in the federal seat of Murray, where the Liberal and National parties are each standing a candidate following the retirement of long-serving Liberal MP Sharman Stone.

Maria Hawthorne

 

 

Labor’s antifreeze policy puts heat on Coalition

Main points

  • Labor promises to resume Medicare rebate indexation
  • Policy to cost $12.2 billion over 10 years
  • Welcomed by AMA as a win for patients

Labor has pledged to resume indexation of the Medicare patient rebate from 1 January next year if it wins the Federal Election, in a $12 billion commitment hailed as a big win for patients.

Seeking to outflank the Coalition on health, Opposition leader Bill Shorten has announced that a Labor Government would lift the Medicare rebate freeze and reinstate indexation, at a cost of $2.4 billion over four years and $12.2 billion over a decade.

The announcement came just days after the AMA launched a national campaign against the freeze, warning it would force many GPs to abandon bulk billing and begin charging patients up to $20 or more per visit.

“Nobody wants to head down the same path as America when it comes to our health system,” Mr Shorten said. “We will reverse Mr Turnbull’s cuts, which will reduce bulk billing and hit Australian families every time they visit the doctor.”

AMA President Professor Brian Owler said Labor’s announcement established a “real difference” between the major parties on health policy.

“Labor’s promise to lift the Medicare rebate freeze will be welcomed by doctors – GPs and other specialists – and patients across the country,” Professor Owler said. “Patients are the big winners from this announcement, especially working families with a few kids, the elderly, the chronically ill, and the most vulnerable in the community.”

In its Budget unveiled earlier this month, the Government announced that it would save $925 million by extending the Medicare rebate freeze, already in place from 2014 to 2018, through to 2020.

Medicare rebates were first frozen by Labor in November 2013 for eight months, but they have since been extended twice by the Coalition Government after failing in its attempts to introduce a patient co-payment.

Professor Owler said the freeze amounted to a “co-payment by stealth” by forcing medical practices to dump bulk billing and begin charging patients if they were to remain financially viable.

He said that for years GPs have done their best to shelter patients from the impact of the freeze, but the decision to extend it to 2020 would push many medical practices over the edge.

“Many GPs are now at a tipping point. With the freeze stretching out for seven years, they have no choice but to pass on the increased costs of running their practices to patients,” the AMA President said. “The Medicare rebate freeze is bad policy, and it should be scrapped.”

Bulk billing climbs

Last week, Health Minister Sussan Ley trumpeted official figures showing the GP bulk billing rate climbed to 84.8 per cent between July last year and March this year to argue that the Government was investing heavily in Medicare.

But Professor Owler said that the Government’s Budget decision to hold Medicare rebates down for a further two years was causing medical practices across the country to reconsider their finances and billing arrangements.

“The extension of the freeze for another two years under the last Budget has prompted many doctors now to contact the AMA requesting our help to transition them from bulk billing practices to ones that charge a fee,” he told Sky News. “Unless the freeze is lifted, I think we are going to see more costs being passed on to patients and so that’s why Labour’s announcement today is indeed very welcome by GPs but I think also by patients around the country.”

Labor’s promise has been costed by the Parliamentary Budget Office, and Opposition said it would be paid for by scrapping the $1000 bonus for single-income families with a child younger than one year, (saving $1.4 billion over 10 years), capping vocational education loans at $8000 ($6 billion over 10 years) and axing business tax cuts, saving more than $4.7 billion over four years (Labor would retain some relief for businesses with a turnover of less than $2 million).

The funding arrangement means Labor will be able to campaign on the claim that it is putting access to primary health care before tax cuts for business.

“This is about choices,” Shaodw Helath Minster Catherine King said on ABC Radio. “People get sick. We want people to go to what is in fact, the cheapest and most efficient part of our system, your GP, to stay well, to manage your chronic conditions, manage episodic illness, because if we don’t do that, people end up in the more expensive part of the system, the acute system where we are again, facing increasing demand.”

Ms King said that by reducing the barriers to people seeing their GP, the policy would help contain the growth in health costs.

“What we want to be able to do is actually have as many people going to your general practitioner because it is our cheapest part of the system, frankly. It’s the most efficient part of the system,” she said. “We want people to go for prevention. We want people to go and get advice about how do you manage obesity, if you find that you’ve got heart disease in the family, we want them to go and use the Medicare system to stay well and that is how you contain costs in the more expensive part of the system, our hospital system, by actually keeping people well.” 

But Labor has so far resisted calls to reinstate bulk billing incentives for pathology and diagnostic imaging services.

Adrian Rollins

INTEGRATING CARE FOR PATIENTS WITH SERIOUS AND CONTINUING ILLNESS

Rising numbers of patients with serious and continuing illness are set to change the way we provide medical care.  They need care that like their ailments, is both serious and continuing.  

This is not a new insight.  We have known about the increasing load of chronic illness for decades.  We know its pattern has changed.  We know that while it mainly afflicts older people; children and adolescents who would have died decades ago live on now.  They, too, need continuing care. Middle-aged people with cancer or heart disease or mental illness saved from death from an acute illness now likewise need continuing care. 

This changing pattern of illness means that hospital and out-of-hospital care must, be better joined up because neither form of care is at its best when managing independent episodes in a long-running story. It means that the way we provide care in future should be built around what is best for the patient, namely, continuous and linked.  We have known all this, too – but now the pressure to do better is coming from the community itself. 

When the community becomes concerned, politicians respond.  The prime minister, Malcolm Turnbull, has committed $38 million this year to trying out ways of linking care for patients with chronic problems, placing the general practitioner in the driving seat.  

Meet George Henderson – lets give him that name.  I saw him at home several years ago when I was working at the Respiratory Ambulatory Care Service (RACS) at Blacktown Hospital.  Two of the nurses who do most of the work of the clinic took me to see him.  They had a panel of over 100 patients who had been through the their six week program and were living at home.   

George lived in a community-services house.  His principal carer was his former wife who had come back for this purpose as their children threatened not to speak to her again unless she did!

We arrived at 10am.  He came slowly to the door in pyjamas, trailing a long cord to an oxygen concentrator in his kitchen. He was exhausted when we got him to bed.  It was a tiny, lonely room. There was a bedside torch, copious bottles of tablets and on the shelves several small and intricate balsa boat models that he made as his hobby.

The nurses chatted, examined his chest, measured his blood pressure and oxygen saturation.  How did he bathe?  I asked.  He had to clamber over the edge of a bath.  There were no handrails.  Could we get them installed?  One nurse told me this would require authorisation from the hospital social worker.  When can she come? I asked. ‘Oh!,’ the nurse laughed.  ‘To this suburb?  Four weeks!  To [an up market neighbouring suburb] one week!’  If he slipped and survived with a broken femur who would be to blame?  We would all pay.

I noticed when I assessed him that his teeth were poor.  A dental appointment at a hospital outpatient department would take many months.  One nurse told me that when they found an acute and serious dental problem, they would send the patient to hospital ‘with an exacerbation’. That way, the nurse said, his dental problem would be speedily sorted. But getting him to hospital ran the risk of oxygen overdose on the way and ICU on arrival for hypercapnia.

To expect a general practitioner to be the centrepiece of George’s care would require remuneration that matched the cost. The doctor would need allied health professional staff immediately at his or her call – physios, nurses and more.  Connection to a specialist would have to be immediately available.  To give George a sense of confidence he would need to be able to talk to someone who knew and understood him 24/7.  

One of the nurses who was on the RACS 24/7 roster told me how George had called at 2am one day, acutely breathless and anxious.  She was able to ‘talk him down’, encourage him to breathe as he had been taught, make a cup of tea.  She avoided a hugely disruptive emergency visit to hospital. 

There is more to integrating care for patients with serious and continuing illness than can be written  in bureaucratic documents and business charts. It is a matter, most fundamentally, of our response to the real, grounded problems of the people we care for,  the way we respond to growing human needs.  Money matters, but it can be found. As a profession we should consider joining our voices to those of our patients in seeking better ways of caring for those with chronic problems.