Election 2016 – what the major parties say

Health, as befits one of the major functions of Government, is shaping as a key battleground in the 2016 Federal Election.

In its first term in office, the Coalition Government has left no area of health policy untouched. Medicare rebates have been frozen, there is a thoroughgoing review of 5700 MBS items underway, Medicare Locals have been replaced by Primary Health Networks, Health Care Homes and the My Health Record are being trialled, national agreements on public hospital funding were abandoned as part of plans to renegotiate the Federation, and the role of the private sector, especially health insurers, in providing health services is being examined.

These changes have come against the backdrop of steadily increasing demand for health services. Advances in health care and medicine have meant that Australians are living longer than ever, and as lives extend, the number of patients living with multiple chronic health conditions has risen. Caring for these patients is imposing ever-increasing demands on GPs, specialists and hospitals.

Coincidentally, advances in medical science are delivering new and more effective treatments that are saving and improving lives – but often at a hefty cost.

In this Australian Medicine special, each of Health Minister Sussan Ley, Shadow Health Minister Catherine King, and Australian Greens leader Senator Richard Di Natale lays out their broad vision for health policy.

These should be seen as their first, rather than final, word on health during this Federal Election, and Australian Medicine will provide comprehensive coverage of the detailed policy pronouncements as they are made during the course of one of the longest campaigns in Australia’s recent political history.

Health Minister Sussan Ley

Building a 21st century health system for all Australians

The health policy directions we have outlined in the recent Federal Budget are underpinned by a key and very important objective; to ensure patients and consumers are at the centre of all our decision making.

Ultimately, we are all here to ensure patients have a better health outcome, and this can only be achieved by working together to make sure our service delivery is well-integrated, efficient and focused.

It is well documented that the Commonwealth needs to spend its health dollar wisely, landing that funding as close to patients as possible.

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.

In the last 12 months, through the Council of Australian Governments, (COAG), every State and Territory has had significant input into what the primary and health care sector needs to look like in coming years.

Central to these discussions is our desire to reduce the barrier patients face across a fragmented system, with an aim of keeping people well at home and, where possible, out of hospital.

Since becoming Health Minister, I have consulted widely with many of you on the ground, and we are now undertaking important reforms like Health Care Homes, not only because it is the right policy but as a show faith for your co-operation and support in this process.

Health Care Homes will trial a new way of funding chronic and complex care, which will ensure patients receive integrated, coordinated care to better meet their needs.

It’s important to note in addition to the $21 million already committed to complete trials over two years, bundled payment models during this period will be funded as certain Chronic Disease Management MBS items and cashed out to support this initiative.

Moving closer to a national rollout, we will obviously assess what further funds may be required in consultation with you and your representatives.

There are a number of other integrated reforms that we are undertaking to help build a Healthier Medicare and put patients first.

Our clinician-led review of all 5700 items on the MBS is also progressing steadily, under the careful consideration and advice of your peers.

At the most recent COAG, it was agreed an additional $2.9 billion in Commonwealth investment for public hospitals was required for ongoing needs, but with a greater focus on patient outcomes, quality and safety, particularly for those being treated for a chronic illness.

All children and concession card holders will now be eligible for affordable access to dental care through a new national public dental scheme, which will see the Commonwealth double its contribution towards frontline public dental services from July this year.

Australians with mental health issues will also begin receiving the integrated care they need from 1 July, as we begin trialing new once-a-new generation reforms providing patients with personalised care packages.

Our world-class Pharmaceutical Benefits Scheme gives Australians access to affordable medicines, with the Government’s reforms saving patients as much as $20 per script on common everyday medicines, with further price cuts to come.

We’ve also ensured savings to taxpayers are being reinvested in new innovative medicines, with the Turnbull Government making nearly 1000 listings on the PBS over the past three years – triple that of the previous Government.

This includes our watershed commitment of over $1 billion to eradicate hepatitis C within a generation.

This is being supported by new reforms announced in the Budget, allowing patients to get faster access to life-saving medicines and medical devices up to two years earlier, by breaking down international trade barriers and red tape.

We are actively working to protect and increase immunisation rates against deadly and debilitating viruses, with incentives for GPs to catch up overdue children, a national all-age vaccination register and ‘no-jab, no pay’ deterrents.

Also, with an eye to the future, we want patients to find it easier to navigate the health system through the digital ‘My Health Record’, which will allow everything from a patient storing prescription information, through to doctors having life-saving access to someone’s allergies in a medical emergency.

There are many more initiatives, and I encourage you to visit www.health.gov.au to find out more at

Can I take this opportunity to acknowledge your outgoing AMA President, Professor Brian Owler. While we have not always arrived at the same position in relation to health policy, I acknowledge his fierce advocacy on behalf of the AMA and its members.

I look forward to a collegial working relationship with his forthcoming successor and hope we can work together to develop policies which ensure every dollar ‘works’ in a constrained budgetary environment.

The Turnbull Government also appreciates the efforts of many GPs to keep costs down during the current Medicare rebate indexation pause, which was first introduced under the previous Government back in 2013-14.

I would like to reaffirm my commitment to the possibility of a review of this pause as further improvements and inefficiencies are identified through our Healthier Medicare reforms.

In closing, be assured across all areas of the health sector I continue to have an open ear, open door approach, and welcome constructive dialogue in balancing our joint desire to maintain and build a progressive health system for all Australians.

My email is Minister.Ley@health.gov.au if you would ever like to raise any ideas or questions.

Shadow Health Minister Catherine King

General practice is the heart of Medicare and deserves respect

One of the most disappointing aspects of Malcolm Turnbull’s election manifesto is its continuing attack on primary care.

After being devalued in the Coalition’s first two Budgets by the GP Tax and then the four year freeze, the profession could have been forgiven for hoping a change of leader marked a change in approach to general practice.

Sadly, as we now know, this was not the case, and the shock decision to extend the freeze out to six years effectively signals that under the Coalition, Medicare rebates are now effectively locked at their current rates.

The signal this sends is that the Coalition does not value general practice, and does not believe the services rendered by GPs are worth being properly renumerated for.

I can give you an assurance that Labor most emphatically does not share this view, and a Shorten Labor Government will place general practice at the forefront of Australia’s healthcare system.

By the time voters go to the polls, our health policy will leave the profession and their patients in no doubt about the contrast between Labor’s respect for general practice, and the Coalition’s approach of the last three years.

That is because Labor believes general practice is the heart of Medicare, acting as the first line of preventive health care, catching and managing illness and disease before far worse outcomes lead to greater costs for both patients and the health system.

Indeed, all of the evidence internationally is that the stronger a country’s primary health care system, the better its health outcomes are.

We know from a number of studies that “health systems with strong primary health care are more efficient, have lower rates of hospitalisation, fewer health inequalities and better health outcomes including lower mortality, than those that do not”.

That is why, when last in Government, Labor did introduce a number of measures to improve general practice, including continuing incentives that improved access and increased bulk billing rates; being properly renumerated for the treatment of chronic disease; provided incentive payments for the treatment of practice nurses and a number of other measures.

But as we look to the future of general practice, we are also conscious of the way Medicare has evolved over more than 30 years now.

No serious health expert disputes the need for Australia’s health system to better manage patients with chronic conditions, and Labor welcomes the proposals of the Primary Health Care Advisory Group to better manage the care of the one-in-five Australians living with two or more chronic health conditions.

Last year’s OECD Health Care Quality Review warned Australia’s ageing population will lead to a growing burden of chronic disease, and highlighted the need for greater investment in primary care to tackle the rise in chronic disease.

But unlike the current Government, a Shorten Labor Government will pay more than lip service to general practice being central to care coordination, as will be made clear in our primary care policy.

Labor understands these reforms can only be achieved in co-operation with doctors, and that co-operation can never succeed if the profession is constantly blindsided by Budget night surprise raids and politically inspired attacks on the integrity of doctors.

I know doctors want to be a major part of the solution.

So too does Labor, and if Labor is elected to Government I can assure you we would want to be advised by you as GPs about what the best system should look like, and how patients can best be looked after.

Australian Greens leader Dr Richard Di Natale

Investing in health care

The Greens believe good health care is an investment, not a cost. As a wealthy country we are lucky to have the opportunity and the means to make high-quality healthcare available to everyone.

Of course we should always seek to ensure we get the best value for our money, but as effective new treatments become available we believe securing affordable, universal access should be the objective.

Spending that leads to better health outcomes and longer lives represents good value for money, and should be prioritised. Australia’s health spending is not unusual by comparable global standards. Among OECD countries, the average spend on health is about 9 per cent of gross domestic product – not much different from where Australia sits now. By contrast, the European average is greater than 11 per cent, and the United States spends 17.1 per cent of GDP on health in a system that delivers worse outcomes.

And yet under this Government, which sees health merely as a cost to the bottom line, the harsh cuts continue. This year’s Budget has seen the Government extend the freeze on indexation of the MBS. This is a co-payment by stealth, which we recognise will force doctors to make a difficult choice about passing on the costs to patients, knowing that hitting patients will almost certainly lead to avoidable and costly presentations to hospital in some cases.

Deeper cuts to the Flexible Funds, with still no certainty about where the axe will fall, is leaving providers of essential services vulnerable and patients at risk.

There is so much to do to extend true universal access to all, including in particular to Aboriginal and Torres Strait Islander Australians whose health outcomes continue to lag behind the rest of the nation. We need secure, targeted investment, not cutbacks, and it was a huge disappointment to see the Government commit no funding at all for the Implementation Plan of the National Aboriginal and Torres Strait Islander Health Plan in this year’s Budget.

The Greens believe in a system which meets the challenges of changing demographics and rising chronic disease. It is time for a real plan for the future of our primary care system, which puts patients at the centre of their care, with continuity of care and appropriate funding. The Government’s Healthcare Homes plan risks this important reform by under-resourcing the trial.

The Greens have long championed the Denticare scheme, believing that the mouth should be treated like any other part of the body in terms of access to the health system. We continue support its expansion, seeking universal dental care for all Australians over time.

Spending more on health care is not unsustainable – it is a matter of priorities, and the Greens choose to prioritise good health care.

The Greens are committed to maintaining a health care system that is publicly funded, of the highest quality, and available to all. We want Australians to have access to the latest drugs and treatments that medical science has to offer. All Australians, no matter where they live, should share equally in the benefits of our health system.

The Greens will be announcing a suite of fully costed health policies throughout the election campaign, setting out our vision for the health system in Australia. We encourage AMA members to watch out for our announcements – which will provide a positive, equitable plan for the future.

[Comment] Making the case for supervised injection services

More than 90 supervised injection services (SIS) operate globally, most within eight European countries, one in Australia, and two in Vancouver, Canada.1 SIS are legally sanctioned spaces where people can inject illegal drugs, typically heroin or cocaine, under the supervision of trained health staff and without fear of prosecution. These services allow safer injection, are associated with decreased overdoses, facilitate referrals for drug treatment, and benefit public order.1,2 In response to the increase in opioid use and associated harms,3 activists and officials in Canada,4 the USA,5,6 Scotland,7 and Ireland8 are exploring supervised injection services, but implementation is controversial.

Don’t shoot the messenger

The Turnbull Government, led by Health Minister Sussan Ley, has recently made a habit of launching attacks on health professionals to justify its health policy decisions, especially the cuts to funding and services and the cost shifting.

It has not just been doctors in the firing line, although the Government has made a habit of demonising GPs, surgeons, radiologists, pathologists, and anaesthetists on a regular basis.

If not through direct attack, it has been via friendly journalists on the drip, or under cover of disenchanted private health insurers desperate to avoid the spotlight as their own sector is under forensic review.

Dentists have been copping it lately, joining the growing queue of health professionals being blamed for the Government’s health policy mistakes and misadventures. Pharmacists and nurses have also come under attack, and they are not amused, and do not take these attacks lightly.

None of the health professions appreciate being criticised publicly in the media, especially when these attacks do not reflect what is discussed in private meetings.

The public – voters – do not like it, either.

Every poll of the professions in living memory has doctors, nurses, and pharmacists rated as the most trusted professions in the community. People trust their doctors and other health professionals. They do not like the ugly spectacle of politicians and some in the media attacking the integrity of health professionals. Needless to say, politicians rate very low on the trusted profession scale.

So, what is behind the misguided strategy of demonising doctors and other health professionals so close to an election? There can’t be any votes in it.

You would think that an incumbent Government would want to win the hearts and minds of health sector leaders in the months ahead of a Federal Election, and on the eve of the Federal Budget, which will shape the direction of the Coalition’s election health policies.

But this is not the case.

Doctors, pharmacists, nurses, Aboriginal health services, and even medical receptionists, have in the past week been blamed for rorts and waste in the system, with incorrect and inaccurate statistics being used to push these mischievous claims.

This is all subterfuge to keep the public focus off the main game – the fact that the Government’s health policies, in the main, are all about making savings to the Budget, not improving access to quality affordable health care for all Australians.

The Government’s ongoing justification for its extreme health savings measures, including cuts to public hospital funding, has been that Australia’s health spending is unsustainable. This is simply not true.

The most recent comparative figures reported by the OECD show Australia’s health expenditure as a proportion of GDP was below the OECD average and lower than 18 other OECD countries.

Australia’s health costs (8.8 per cent), as assessed by the OECD, were just over half the corresponding proportion for the USA (16.4 per cent). Australia achieves better health outcomes for its significantly lower proportional spend than the USA and many other countries, with the second highest life expectancy in the world, with the exception of Indigenous Australians.

Moreover, the Commonwealth Government’s total health expenditure is reducing as a percentage of the total Commonwealth Budget. In the 2014-15 Commonwealth Budget, health was 16.13 per cent of the total, down from 18.09 per cent in 2006-07. It reduced further in the 2015-16 Budget, representing only 15.97 per cent of the total Commonwealth Budget.

Clearly, total health spending is not out of control. Nor is spending on medical services.

The reality is that today we are not spending any more on medical services as a proportion of total health spending than we were a decade ago.

The proportion today is 18.2 per cent, compared with 18.5 per cent a decade ago. While we are spending more on health in total, we are spending less on medical services.

Today, 86 per cent of privately insured medical services are charged at no gap by the doctor – which means that the doctor accepts the fee level set by the patient’s private health insurer.

A further 6.4 per cent are charged under ‘known’ gap arrangements. This means that less than 8 per cent of privately insured patients may be charged fees exceeding private health insurance levels, including known gap amounts.

The number of doctors charging ‘excessive’ fees is in the absolute minority, and the AMA continues to work with the relevant specialist colleges, associations and societies to address this.

Nor are doctors’ fees contributing to Budget woes, with specialist fees in many cases not being indexed for up to a decade.

Contrary to the line being pushed by the Government and the private health insurers, medical services are not an issue for the insurers or for patients.

Some insurers have been only too eager to vilify doctors even though the publicly listed PHIs have posted record profits, their executives are paid multimillion dollar salaries, and when doctors charge above the PHI schedule, i.e. a gap, the PHI contribution falls to 25 per cent of the scheduled fee.

During the December 2015 quarter, insurers paid $3,542 million in hospital treatment benefits. This was broken down into 70 per cent on hospital services such as accommodation and nursing, approximately 15 per cent on medical services, and 14 per cent on prostheses.

General practice, too, has demonstrated a real willingness to work with the Government to deliver high quality reforms, particularly in relation to the treatment of patients with complex and chronic disease.

The 2016 Budget provided the Government with a real opportunity to steer a new course and a new strategy of health policy and health sector engagement, but they passed on this opportunity. We can only hope the Government is saving some health largesse to be announced ahead of the election.

Doctors and the other health professions are restless and demanding better health policy, better consultation, and greater respect in public conversations and pronouncements. We need a mature and honest exchanges of views, not sneaky media leaks and cheap attacks on our integrity and professionalism.

Doctors see millions of Australians face-to-face every day. Multiply that number when you count radiology and pathology centres, pharmacies, and other health professionals.

Some groups have already commenced campaigns against Government health policies. More will join them if there is not a change in policy direction and a change in the Government’s public relationship with the health sector.

* An edited version of this column first appeared in the Australian Financial Review on 4 May 2016.

Public hospitals – $2.9 billion just a down-payment – AMA

The almost $2.9 billion restoration in funding for public hospitals goes nowhere near meeting growing demand, AMA President Professor Brian Owler said.

In what one health academic described as a “pea and thimble” Federal Budget, Treasurer Scott Morrison delivered no surprises in public hospitals funding.

There was no increase to the agreement negotiated at the 1 April Council of Australian Governments meeting to restore almost $2.9 billion over three years, from the billions cut in the 2014 and 2015 Budgets.

“The AMA welcomes confirmation of the almost $2.9 billion in COAG funding for public hospitals, but we see this as a down-payment only,” Professor Owler said.

“The States and Territories will need significant extra funding if they are to build hospital capacity to meet growing demand.”

Mike Woods, Professor of Health Economics at the University of Technology Sydney, agreed, noting that growth in total Commonwealth funding will be capped at 6.5 per cent a year for three years from 2017-18 – at a time when expenditure is forecast to rise by 9.9 per cent.

“This is very much a stop-gap measure to get the federal government through the upcoming election,” Professor Woods wrote in The Conversation.

“The underlying problem for the states is the escalating cost of delivering public hospital care. The issue may have been deferred, but it hasn’t gone away.

“Health is the single largest expenditure item in all of their budgets. And expenditure has been growing at around 5 per cent in real terms over the past decade. This isn’t sustainable.

“Over the next three years the incoming federal government, of whatever political persuasion, will need to sit down with the states and territories and agree on reforms to reduce the rate of growth of health expenditure.”

Stephen Duckett, the director of the Grattan Institute’s health program, described it as a “pea and thimble” budget which attempted to erase memories of previous cuts under the Abbott and Hockey administration.

“The most significant apparent budget spend is on public hospitals. The deal reached with the Premiers on April Fool’s day is costed at almost $2.9 billion,” Dr Duckett said.

“This can be spun two ways: that it is almost a $3 billion injection into the public hospital system or that it is still an effective cut on what was promised by both Labor and Liberal prior to the 2013 election.”

The Australian Healthcare and Hospitals Association (AHHA) welcomed the Government’s shift away from its previous stance on funding based only on population and CPI growth.

While the return to activity-based funding based on a national efficient price was sensible, further work was needed with a focus on safety, quality and reducing preventable hospitalisations.

“While the improved support for hospital funding until 2020 has provided some relief for the hospitals sector, concerted efforts will be required to reduce the increasing demand for hospital services,” AHHA chief executive Alison Verhoeven said.

“Savings flagged in the aged care provider funding of $1.2 billion over four years will also potentially impact on hospitals who traditionally pick up complex care when the aged and community care sector cannot deliver appropriate support to elderly people.

“Unfortunately for the states and territories, and for Australians who rely on public hospitals, hospital funding remains a hole that is only partly plugged.”

Maria Hawthorne

Govt targets big savings in Medicare crackdown

Main points

Medicare crackdown to save $66 million
Axing, amending MBS items delivers $56 million

The Federal Government expects to save more than $120 million by cracking down on Medicare waste and fraud and axing obsolete service items.

As the Government intensifies its hunt for savings, Health Minister Sussan Ley has announced she will toughen Medicare compliance activities and expects to save $66.2 million over the next four years by using advanced data analysis techniques to “better detect fraud, abuse, waste and errors in Medicare claims”.

The Health Department said it will audit an extra 500 providers each year, and will use sophisticated software to identify irregular payments and behaviours.

It said similar methods used by private insurers had in some instances achieved a 10-fold increase in the number of non-compliant activities detected.

The Government expects to achieve a further $56 million in savings by removing and amending listings on the Medicare Benefits Schedule.

In the first instalment of savings delivered by the MBS Review Taskforce led by Professor Bruce Robinson, the Budget has revealed the Government expects to save $5.1 million over the next four years by deleting 24 items and restricting access to two others.

These include gall bladder x-rays, larynx biopsies, the injection of hormones to manage habitual miscarriage and the use of x-rays to diagnose deep vein thrombosis.

In addition to these changes, the Government estimates it will save $51.4 million by axing a further 60 items identified by the Medical Services Advisory Committee and replacing them with around 30 new items.

These items include skin patch tests used by dermatologists, hip arthroscopy changes, fat grafting in spinal surgery and skin flap items for small excisions.

While the AMA supports work to modernise the MBS and remove obsolete or dangerous items, it is wary that it is being used by the Government as primarily a cost-cutting exercise.

Professor Robinson told an AMA-hosted forum earlier this year that his task was “not to save money. The Government may make savings, but I hope that the money is reinvested in health”.

AMA President Professor Brian Owler acknowledged the review was like to deliver some savings, but warned the medical profession’s goodwill and support for the process was contingent on any savings made being “held within health, to provide better services to patients”.

Against the $122 million of Medicare savings identified in the Budget, the Government announced it would spend $33.8 million over four years on tests for Indigenous people whose eyesight is threatened by diabetic retinopathy.

In addition, the Government has allocated $3 million over the next four years to provide for magnetic resonance imaging for breast cancer patients where conventional techniques fail to show the source of the tumour.

Adrian Rollins

Budget another hit on households

Main points

Medicare rebate freeze extended to 2020
Indexation delays cost households $370m
Bulk billing set to fall
$2.9 billion for public hospitals
$60 million for new drugs

The Federal Government is increasingly pushing the cost of care onto patients and households as it screws down on health spending, undermining Medicare and putting the poorest and sickest at risk, AMA President Professor Brian Owler has warned.

As the Federal Government prepares for a 2 July election, it has raided Medicare for almost $1 billion in savings by extending the rebate freeze, pushing the system to the point where GPs will be forced to cut back on bulk billing and begin charging patients, Professor Owler said.

At the same time, it has taken an axe to aged care, public dentistry and community health program funding, is targeting the Medicare Benefits Schedule for multi-million dollar savings, and has further delayed indexation of the Medicare Levy Surcharge and the Private Health Insurance Rebate thresholds, costing families an extra $370.9 million between 2018-19 and 2019-20.

Professor Owler said the Budget continued the Government’s “stranglehold” on the Medicare system, constituted “another hit to household budgets, and represent extra disincentives to people accessing health care when they need it”.

The Government’s decision to extend the freeze on Medicare rebates to 202 would be the “tipping point” for many medical practices, the AMA President warned, forcing many to wind back bulk billing and begin charging patients.

The Budget confirmed Prime Minister Malcolm Turnbull’s pledge to provide an extra $2.9 billion for public hospitals, and included more than $57 million for new drugs, almost $10 million to help protect the nation against the overuse of antibiotics, more than $33 million for Indigenous eye tests and $21 million for a trial of Health Care homes.

Health Minister Sussan Ley said the Budget showed the Government would lift its spending on health, aged care and sport to $89.5 billion next financial year – a 4.1 per cent increase from 2015-16.

“Our reforms are targeted to meet the growing needs and expectations of the modern consumer and are bold and broad, but also affordable, achievable and, most importantly, fair,” Ms Ley said.

The Minister said the Government had a “clear focus” on integration and innovation, and she pledged that it would “eliminate waste, inefficiency and duplication wherever we find it”.

“The Turnbull Government will make sure every health dollar lands as close to the patient as possible,” Ms Ley said.

But Professor Owler said the positive initiatives in the Budget had been overshadowed by the cuts, and the document was a missed opportunity for the Government to “steer a new course and a new strategy of health policy and health sector engagement”.

The AMA President said that instead, the Government’s strategy had been to attack health professionals.

“Doctors, pharmacists, nurses, Aboriginal health services, and even medical receptionists, have in the past week been blamed for rorts and waste in the system, with incorrect and inaccurate statistics being used to push these mischievous claims,” he said.

Professor Owler said the attacks were a subterfuge being used by the Government to distract public attention from “the main game – the fact that the Government’s health policies, in the main, are all about making savings to the Budget, not improving access to quality affordable health care for all Australians”.

The AMA President said it was a myth that health spending was out of control, as the Government has claimed – this financial year it comprised less than 16 per cent of the Commonwealth Budget, down from 18 per cent a decade ago.

He also took issue with health insurer complaints that doctors were driving up their costs, pointing out that in many cases specialist fees had not been indexed in a decade.

“Contrary to the line being pushed by the Government and the private health insurers, medical services are not an issue for the insurers or for patients,” Professor Owler said. “Some insurers have been only too eager to vilify doctors even though the publicly listed PHIs have posted record profits, their executives are paid multimillion dollar salaries, and when doctors charge above the PHI schedule, ithe PHI contribution falls to 25 per cent of the scheduled fee.”

The Government already faces a campaign from pathologists and diagnostic imaging providers over its decision to axe and reduce bulk billing incentives, and Professor Owler warned it ran the risk of more health groups joining them if it did not change policy direction and improve it public relationship with the health sector.

What they said

“Tonight we’ve seen an extension of the Medicare rebate freeze, and that means that the Government has extended its stranglehold on patients’ rebates. That means 925 more million dollars out of the pockets of everyday Australians; it means that people are going to have to pay more out of their own pockets when they receive medical treatment” – AMA President Professor Brian Owler

“This is a plan that will ensure our children and our grandchildren enjoy the great opportunities these times offer them. This is a responsible economic plan for growth and for jobs” – Prime Minster Malcolm Turnbull

“If you earn less than $80,000, which is 75 per cent of all Australian workers, you will not get a cent out of this budget, but your schools will be cut, the hospitals will be cut and we will see precious little action on climate change” – Opposition leader Bill Shorten

“Our reforms are targeted to meet the growing needs and expectations of the modern consumer and are bold and broad, but also affordable, achievable and, most importantly, fair” – Health Minister Sussan Ley

“Mr Turnbull has again smashed Australia’s health system, ripping another $2.1 billion out of health spending and keeping the GP tax in place for another two years – a measure that will cost Australian families $925 million” – Shadow Health Minister Catherine King

“It [the Medicare rebate freeze] will very likely see consumers paying greater gap payments as the price the Government pays for Medicare services won’t even keep up with inflation” – CHOICE CEO Alan Kirkland

“The 2016 Federal Budget has done absolutely nothing to reverse the increasing pressure on Australia’s world-class health care system” Royal Australian College of General Practitioners President Dr Frank Jones

Adrian Rollins

Cuts to aged care need closer examination – Owler

Main points

Aged Care Funding Instrument to be ‘refined’
Indexation increase to Complex Health Care to be halved
$1.2 billion to be saved

An unexpected blowout in complex health care funding claims in aged care homes has led the Government to change the way it funds the sector.

The Government used the Budget to announce plans to save $1.2 billion from aged care from 2015-16 to 2019-20.

But AMA President Professor Brian Owler says the proposed cuts need more scrutiny.

“There are … significant cuts to the aged care sector which require closer examination,” Professor Owler said.

The Government plans to refine its Aged Care Funding Instrument (ACFI) so that it does not “encourage distortions in claiming behaviour and care delivery” after higher than expected growth in funding claims.

“The Government has increased funding estimates for residential aged care by $3.8 billion over five years from 2016-17 to 2019-20,” the Budget papers say.

“Growth in ACFI funding has been driven by higher than anticipated claims in the Complex Health Care (CHC) domain. This growth cannot be attributed to a natural increase in frailty as it is two and a half times the growth in the other two care domains (ie Activities of Daily Living and Behaviour) and increased sharply.

“In developing the measure, the Government consulted with the sector to understand the areas of ACFI that could be better aligned with contemporary care practices.”

Some of the savings will be reinvested, including $102 million to improve services in rural and remote areas, and $10.1 million to allow the Australian Aged Care Quality Agency to continue unannounced site visits to aged care homes.

But Associate Professor Helen Dickinson, from the University of Melbourne’s School of Government said aged care, like disability, had been targeted for unrealistic projected savings.

“In aged care, $1.2 billion will be saved through the ‘better use of funding’,” A/Prof Dickinson said.

“Some of the $249 million reinvestments will be welcomed … yet it is difficult to see how these relatively small investments will meet the intended aims of ‘preventing a spending blowout’ in coming years and are likely to shift increasing costs of aged care to future governments.”

Maria Hawthorne

Hep C drug mystery

The Federal Government has not disclosed how much it intends to spend on its goal of virtually eradicating hepatitis C from the country within a generation.

In one of the Government’s most ambitious public health measures, all adults with chronic hepatitis C have been provided subsidised access to hugely expensive frontline drugs that have a high rate of success in eliminating the disease within months.

More than 230,000 are estimated to be currently living with hepatitis C, which kills around 700 a year, but for most the drugs that could cure their ailment – Sofosbuvir, Daclatasvir and Ribavirin – were prohibitively expensive, costing as much as up to $100,000 for a course of treatment.

But hepatitis C have, since 1 March, had subsidised access to the drugs through the Pharmaceutical Benefits Scheme – an arrangement confirmed in the Budget.

Announcing the measure at the time, Health Minister Sussan Ley said it provided “great hope we can not only halt the spread of this deadly infectious virus, but eliminate it altogether in time”.

The Minister has explicitly linked the decision with the highly controversial move to axe bulk billing incentives for pathology services and cut them for diagnostic imaging – a measure expected to save $650 million over four years.

But in the Budget the Health Department said the cost of the measure was “not for publication”.

By contrast, it has announced that $57.6 million has been set aside to fund new and amended listings of drugs on the PBS and the Life Saving Drugs Program.

The Department said the PBS would cost $10.1 billion overall in 2016-17.

In addition, the Government has revealed it will spend $20.4 million to improve speed and efficiency of the system to regulate therapeutic goods, with the aim of bringing new drugs to market more quickly – in some cases up to two years sooner.

Under the plan, the number of committees advising the TGA will be cut from 11 to seven, costs and administrative burden for industry will be reduced, and the time taken to assess products will be reduced by up to three months by drawing on the work of comparable regulators overseas, such as the US Food and Drug Administration.

In addition, commercial organisations approved by the TGA will be allowed to undertake assessments of medical devices, and there will be new approval pathways for sponsors to add medicines and devices.

Adrian Rollins

Dental details still unclear

Main points

· $1.7 billion for new Child and Adult Public Dental Scheme
· Payments to be made directly to States and Territories
· Savings of $17 million over the forward estimates

Health experts say the details of the new $1.7 billion Child and Adult Public Dental Scheme remain sketchy, even after Treasurer Scott Morrison handed down the Federal Budget on 3 May.

Details of the scheme were leaked a fortnight before the Budget, sparking criticism from dentists and the opposition that it amounted to a $1 billion funding cut.

At the time of the announcement, Health Minister Sussan Ley’s office said the States would get a 40 per cent increase in funding under the changes.

The Budget papers said payments would be made directly to States and Territories to improve patient waiting times and help more concession card holders.

But Dr Stephen Duckett, director of the Grattan Institute’s health program, said it was still not clear how the scheme would work.

“The details are still not clear but it appears States will be asked to contribute to funding this policy,” Dr Duckett said.

“The Commonwealth funding comes from chopping the Child Dental Benefits Scheme so in fact this is a savings initiative over the forward estimates to the tune of $17 million.”

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

But the Australian Dental Association (ADA) described the new scheme as “smoke and mirrors” that effectively reduced funding from $615 million a year to $425 million.

“Supposedly the new Plan will see a reduction in Commonwealth funding which will magically make dental services available to more Australians by enabling them to access the public sector for care,” ADA President Rick Olive said.

“This is fanciful. The State and Territory public sector dental services are already over extended with waiting lists of between nine months to three years depending which state you consider. What is happening is the Government is promising delivery but it is doing it in such a way that the services will not, in fact, be accessible. It’s smoke and mirrors.”

Shadow Health Minister Catherine King said scrapping the Child Dental Benefits Scheme would deny millions of Australian children, many of whom had never before been able to afford dental treatment, access to ongoing affordable dental care.

Maria Hawthorne

Tick a box – For the good of whom?

As a new intern, I am an infant in medicine and Indigenous medicine. I chose to study medicine because I wanted to work in the area of Indigenous social justice, with a particular interest in research and mental health. Seeing the medical world from a professional perspective has informally and formally educated me about Indigenous health, but also highlighted the ways that the health system can disempower and discriminate against Indigenous people. Although I currently have limited clinical experience in Indigenous health, I have a breadth of personal experience that I would like to share.

I identify with two Aboriginal communities from the north of Western Australia. On my father’s side the Palku people and on my mother’s side the Yindjibarndi people, who are both situated in the Pilbara region of Western Australia. Although I identify with both these communities, I have never lived in them, and grew up in Perth until high school when I moved to Sydney. I have always been proud of my heritage, keen to learn about it and tell others about it. Growing up in a Perth suburb where you and your brother are the only Indigenous students in your primary school however means I have always felt somewhat different. Despite this, being judged for being Indigenous and being a victim of racism has been a relatively uncommon experience in my life. This has been due to the fact that I do not fit the stereotype. I don’t look, speak and act as people expect of an Indigenous person. I have never thought of myself as, nor have been, disadvantaged: I went to a great school, my parents and family are all successful in their chosen careers and I have never gone without. Throughout my life I have found that many in Australian society equate being Indigenous with poverty and disadvantage, and therefore I do not fit the common stereotype of Aboriginality. Not being perceived as Aboriginal has been a challenge in medicine and my personal life because it means that people speak freely about Indigenous people in front of me, and say things they probably would not, if they knew I was Indigenous. I feel like a spy: secretly gathering racial intelligence in the medical world. This is equally true for my experience of seeing how doctors treat their Indigenous patients and my own experiences as an Indigenous patient.

Three years ago I took my nine-month-old daughter to the emergency department with a broken arm after she fell from a trampoline. It was one of those injuries every parent has a story about – one second of lapsed supervision leading to disaster. While in the waiting room I filled out the generic admission form and ticked the ‘Yes Aboriginal’ box. I did not hesitate. After all, why should it matter? There are posters everywhere about how knowing this information helps the hospital to treat you better and helps the health system by contributing to public health data. And I am proud to be Aboriginal. There is no reason to be ashamed. However during our admission my partner and I were interrogated multiple times about the circumstances of the injury, my GP to whom I had first presented was called to ask what kind of people we were and we were reported to the Department of Family and Community Services with a concern of child abuse. I felt my morals and parenting were judged. I felt that all my interactions with my daughter thereafter were being scrutinised. There was no single moment or comment that made me think the way we were treated was related to our Indigenous status but somehow I felt like it contributed. She had to have a cast which meant a lot of sleepless nights with a very annoyed child, but she recovered well. As for the report I assume it has been filed in a database, as we never had any other contact regarding the situation. I do not blame the doctor who was managing us. I know they were doing their job and in matters of child abuse nobody wants to miss something by under-calling a situation. But I did feel as if my, and my daughter’s Aboriginality, rather than our individual clinical picture, played too much into the decision to take that pathway, and I can’t help but wonder if things may have turned out differently if I hadn’t ticked that box.

Other members of my family and friends have had similar experiences: where they have felt their identification as Aboriginal impacted negatively on the perceptions of the professionals treating them or their children. Where parenting integrity has been called into question or our children are seen to be automatically disadvantaged because of their heritage. Where we are guilty until proven innocent. The overwhelming experience is one where we are left feeling either degraded and judged or pitied and patronised. This encounter made me reluctant to take my children to the emergency department for any reason after that, despite the fact that I have a positive view of the healthcare system. So I can easily see how someone who has been disenfranchised or experienced racism in other areas of their life, could easily become distrusting of health care institutions. In addition, when someone is encountering a system they do not know particularly well, it would be easy to attribute how you have been treated to your race, rather than thinking that this is just how everyone is treated in a similar situation.

National health guideline recommendations clearly encourage the use of standardised identification of Aboriginal and Torres Strait Islander clients in order to maximise the ability to collect reliable data about service delivery, service effectiveness and inform policies on healthcare strategy (Australian Institute of Health and Welfare, 2010). Nowhere in the recommendations is it suggested that a client’s identification as Indigenous should have a bearing on the treatment they are given and more specifically

‘the collection of Indigenous status as a routine administrative procedure does not in itself contravene a service’s commitment to equitable service provision’.

Additionally, failure to ask about Indigenous status has been identified as a barrier in the uptake and application of Indigenous specific services. Knowing if someone is Indigenous can improve management by allowing them to maximise the in-hospital and community services that might be available. It allows us as providers to think holistically about our patient and what we as a service can offer to benefit them moving forward. However, it is not the asking of the question that is the issue. Tick box systems and asking patients outright should be standard practice. However it is the response to the answer that becomes a more important outcome of the interaction due to the potential for discrimination or scrutiny based on Indigenous status alone.

Presuming Aboriginality is associated with poverty and disadvantage is a flawed and disempowering stereotype. Although, disappointingly Aboriginality and poverty are often interconnected, they are not interchangeable. It seems there is a pervading discourse within the health care system, structures and policies that frame Indigenous people with the assumption of deficit and inferiority.

We are taught to approach each patient with an aim to understand their current complaint in the context of the multitude of factors that individually contribute to that person’s health, including their past medical, familial, social and racial characteristics. Viewing every Aboriginal patient as a representation of statistics that are drawn from national data means that patient centered care is erroneously replaced with pattern centered care.

The key to understanding Aboriginal patients, I believe, is not presuming to know them; by not presuming in either a good or bad way to know their story, their history or their health concerns. Be open-minded. If we believe we know, then we stop trying to learn. I never claim to know medicine despite having a wealth of information at the end of a grueling medical degree. Because if I think I know medicine I will stop trying to learn it. Not knowing medicine is what makes it exciting and challenging and it is why, for the rest of my working life, I will have the privilege of being a student. The medical profession has a lot more learning to do about the best way to manage Indigenous health care needs and delivery of effective services. In addition, it is important to change the discourse surrounding Indigenous people to one where patients can feel empowered by their Indigenous status rather than inadequate. Research into Indigenous health is a great place to begin, but allowing Indigenous patients to tell their stories and feel safe doing so is something that each clinician should strive for.

I cannot know with certainty how ticking the box that day in the ED impacted my treatment. But I still regret it. I felt for the rest of my time in that emergency department I was treated, not with less care, but differently. If a patient has a pre-conception of how they will be treated, our actions can be misinterpreted as racially driven, rather than standard practice. Nevertheless, there are innumerable encounters between health professionals and Indigenous and non-Indigenous people everyday. If every encounter became an opportunity to educate, reassure, or reassess our own perspectives the medical community would become a force for change for the better.

This blog was first published for onthewards on 12 March 2016 and can be read at its original location at Tick a box – For the good of whom?. onthewards.org is a free open access medical education website and not for profit organisation that aims to improve the availability of resources for medical students and junior doctors. If you work in healthcare and have a blog topic you would like to write for doctorportal, please get in touch.

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Photo: Oliver Tacke