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Privacy risk on Medicare outsourcing

The AMA has raised concerns that any move to outsourcing Medicare payments to the private sector could compromise patient privacy and further fragment their care.

Prime Minister Malcolm Turnbull has confirmed an overhaul of the Medicare payments system is under active consideration, with Health Minister Sussan Ley revealing the Health Department is investigating ways to digitise “transaction technology for payments”.

Though the Government has not explicitly said it is looking at outsourcing the payments system to the private sector, the AMA said such a move would be in keeping with the Commonwealth’s broader policy agenda to increasingly offload responsibility for funding and providing health care.

According to a report in the West Australian newspaper, the Government is well advanced in plans to outsource the processing of Medicare, Pharmaceutical Benefits Scheme and aged care claims and payments, as well as the administration of eligibility criteria.

The newspaper reported that the change was likely to be unveiled in the forthcoming Budget, with a call for tenders issued soon after.

It has been suggested that Australia Post, Telstra and the big banks, as well as overseas firms including Serco, Fuji-Xerox and Accenture, may bid for the work.

AMA Vice President Dr Stephen Parnis said such a move would raise serious privacy issues.

“There are concerns raised about the way that the administrators of these programs would handle confidential medical data; how their input may influence or undermine the doctor-patient relationship in terms of its funding,” Dr Parnis told ABC Radio.

He said it raised the prospect that a Medicare benefit item “might be administered, or potentially even refused, by someone who isn’t necessarily accountable to Government”. 

The outsourcing idea is the latest move by the Federal Government to change Medicare, after its failed attempts to introduce a GP co-payment, the institution of a four-year rebate freeze, a review of the Medicare Benefits Schedule, and cuts to bulk billing incentives for pathology and diagnostic imaging services.

But Mr Turnbull insisted that Government was “totally committed” to Medicare, and any change to its payments system was aimed at improving the service for consumers.

“What we are looking at, as we look at in every area, is improving the delivery of Government services, looking at ways to take the health and aged-care payment system into the 21st century,” the Prime Minister told Parliament. “This is about making it simpler and faster for patients to be able to transact with Medicare to get the services they are entitled to.”

Ms Ley said that “every day, Australians use cards to make ‘tap and go’ payments, and apps to make payments, and yet Medicare has not kept up with these new technologies”.

She said the Health Department was working with “business innovation and technology experts to determine the best and most up-to-date payment technologies available on the market for consumers and health and aged care service providers”.

The infrastructure of Medicare’s payments system is more than 30 years old, and although it processes more than 370 million patient rebates each year, the system’s age means it is becoming harder to add new types of payments.

The Opposition has slammed the outsourcing proposal, characterising it as an attempt to privatise Medicare, and there are concerns the policy would cause more than 1400 Department of Human Services workers involved in processing and payments to lose their jobs.

Adrian Rollins

 

Cut jail time to build on Indigenous health gains

Soaring Indigenous imprisonment rates and a stubbornly wide life expectancy gap underline calls for the Federal Government to fully fund the National Aboriginal and Torres Strait Islander Health Plan.

AMA President Professor Brian Owler said the latest update on Indigenous health and welfare from the Close the Gap Steering Committee was “a mixed bag”, showing improvement on measures such as child mortality and year 12 attainment, but weak gains in others.

The report found the target to halve the gap in child mortality by 2018 was on track, supported by a lift in immunisation rates that has seen more Indigenous children vaccinated by age five compared with their non-Indigenous counterparts, and Indigenous mortality rates, particularly from heart disease and stroke, are declining.

But the gap in life expectancy is not narrowing fast enough to close by the Council of Australian Government’s 2031 target.

The Close the Gap report shows that between 2005 and 2012, the life expectancy of Indigenous men increased by 1.6 years to 69.1 years, and for Indigenous women 0.6 of a year to 73.7 years (the life expectancy of non-Indigenous men in 2012 was 79.7 year and women, 83.1 years).

But the report’s authors cautioned that the improvements were within the margin of error “and could, in fact, be non-existent”.

Indigenous life expectancy is improving at an annual rate of 0.32 years for men and 0.12 years for women, but the Steering Committee said this would have to increase to between 0.6 and 0.8 years annually to reach the 2030 target.

Driving much of the improvement has been a 40 per cent fall in deaths from heart attacks and strokes, and fatal respiratory illnesses have declined by 27 per cent.

Despite this, heart attacks a strokes remain a major killer, accounting for a quarter of all Indigenous deaths between 2008 and 2012, while suicide was the leading cause of death due to external causes.

“It is disappointing that the target to close the gap in life expectancy by 2031 is not on track,” Professor Owler said. “This is a clear signal that we have to put politics aside and work together to reach this important milestone. Above all, we need consistent funding and support from all governments.”

In his report on Closing the Gap, Prime Minister Malcolm Turnbull agreed that a more concerted effort was needed.

“As a nation, we are a work in progress, and closing the substantial gaps in outcomes between Aboriginal and Torres Strait Islander people and other Australians is one of our most important tasks,” Mr Turnbull said. “There has been encouraging progress…but it is undeniable that progress…has been variable.”

Professor Owler said that to make improved gains, the Federal Government should reverse Budget cuts to programs like the Indigenous Advancement Strategy and the Indigenous Australian Health Program, and commit to genuine engagement with Aboriginal community controlled health services.

Nonetheless, a rapid narrowing of the health gap for infants and young children gives hope that eventually it will narrow for adults as well.

Though the infant mortality rate for Indigenous infants is 1.7 times that of other Australians, it declined 64 per cent between 1998 and 2012, making the gap 83 per cent narrower.

Close the Gap Campaign Co-Chair Dr Jackie Huggins said the long term impact of such improvements were yet to be seen and would take time to measure. The report advised no measurable improvements should be expected before 2018.

Furthermore, Dr Huggins said, “this should not be cause for complacency, because the overall health of Aboriginal and Torres Strait Islander peoples still lags behind the rest of the nation”.

The Campaign backed the AMA in calling for governments to reduce Indigenous incarceration rates.

It warned the nation was on track to have a record 10,000 Indigenous people behind bars this year, which is described as “a grim milestone”.

An AMA report highlighted that imprisonment exacerbated serious health problems and Indigenous incarceration rates needed to be reduced if the country was to close the health gap.

Adrian Rollins

 

[Comment] Reductions in stillbirths—more than a triple return on investment

The Lancet Series on Ending preventable stillbirths shows that in 2015 2·6 million babies were stillborn, of which 1·3 million occurred during labour and delivery.1 Normally, fully functional maternity services should have detected complications by the time labour starts and provided women and families with all the essential interventions2 and the quality maternal and newborn care3 for a healthy newborn baby.

[Series] Why invest, and what it will take to improve breastfeeding practices?

Despite its established benefits, breastfeeding is no longer a norm in many communities. Multifactorial determinants of breastfeeding need supportive measures at many levels, from legal and policy directives to social attitudes and values, women’s work and employment conditions, and health-care services to enable women to breastfeed. When relevant interventions are delivered adequately, breastfeeding practices are responsive and can improve rapidly. The best outcomes are achieved when interventions are implemented concurrently through several channels.

Therapeutic advances and risk factor management: our best chance to tackle dementia?

An update on research advances in this field that may help tackle this growing challenge more effectively

Increasing life expectancy has fuelled the growth in the prevalence of dementia. In 2015, there were an estimated 47 million people with dementia worldwide (including 343 000 in Australia), a number that will double every 20 years to 131 million by 2050 (900 000 in Australia).1 The global cost of dementia in 2015 was estimated to be US$818 billion.1 Low-to-middle income countries will experience the greatest rate of population ageing, and the disproportionate growth in dementia cases in these nations will be exacerbated by a relative lack of resources.

The diagnostic criteria for dementia (relabelled “major neurocognitive disorder”) of the American Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5)2 include a significant decline in one or more cognitive domains that is clinically evident, that interferes with independence in everyday activities, and is not caused by delirium or other mental illness. Whether the new diagnostic label catches on remains to be seen. The most common type of dementia is Alzheimer’s disease (AD) (50–70% of patients with dementia), followed by vascular dementia (10–20%), dementia with Lewy bodies (10%) and fronto-temporal dementia (4%).3 These percentages are imprecise, as patients often present with mixed pathology.

Our discussion will focus on AD because it receives significant research attention as the most common cause of dementia. The two hallmark pathological changes associated with neuronal death in AD are deposition of β-amyloid plaques, and tau protein neurofibrillary tangles. Understanding this process has been enhanced by prospective cohort studies, such as the Australian Imaging Biomarkers and Lifestyle (AIBL) study.4 As shown in the Box, the results of this research indicate that the degree of β-amyloid deposition exceeds a predefined threshold about 17 years before the symptoms of dementia are detectable. In the absence of an alternative model, the amyloid cascade remains the most compelling hypothesis for the pathogenesis of AD. This is supported by the fact that early onset familial AD is caused by mutations in chromosome 21 that result in the production of abnormal amyloid precursor protein (APP), or by mutations in chromosomes 1 or 14 that result in abnormal presenilin, each of which increase amyloid deposition. The extra copy of chromosome 21 in Down syndrome also leads to faster amyloid deposition and the earlier onset of AD. Further, the symptoms of AD are correlated with imaging of amyloid in the living brain and with cerebrospinal fluid biomarkers that are now included in new diagnostic criteria for AD and which will enable suitable participants to be selected for trials of drugs that may prevent or modify the disease,2 in particular to determine whether anti-amyloid agents are useful for delaying or treating AD.

At present, cholinesterase inhibitors (donepezil, galantamine and rivastigmine) and the N-methyl-D-aspartate (NMDA) receptor antagonist memantine are licensed for treating AD dementia, and produce modest but measurable benefits for some patients. These medications are thought to work by increasing cholinergic signalling and reducing glutamatergic activity respectively, partially redressing neurochemical abnormalities caused by the amyloid cascade.5 More than 200 other drugs advanced to at least Phase II development between 1984 and 2014, but none has yet entered routine clinical use.6 Lack of efficacy in clinical trials may be the result of their being introduced at a rather late stage of the disease process; hippocampal damage is so profound by the time individuals present with AD dementia that attempting to slow their decline with an anti-amyloid agent may be analogous to starting statins in patients on a heart transplantation waiting list. As it provides the most compelling hypothesis for AD, the amyloid cascade remains the main target for developments in treatment. Treatment trials in people with preclinical or prodromal AD will in due course determine its validity.

Recent developments include promising results for treating prodromal AD with passive vaccines containing monoclonal antibodies directed against β-amyloid, such as solanezumab and aducanumab. This may point the way to treatments in the next decade that delay the onset of dementia in people with developing AD pathology.7,8

The identification of risk factors for AD may lead to risk reduction strategies. Recent randomised controlled trials of multidomain interventions, such as the Finnish Geriatric Intervention Study to Prevent Cognitive Impairment and Disability (FINGER) study (a 2-year program including dietary, exercise, cognitive training and vascular risk monitoring components), show that such interventions could improve or maintain cognition in at-risk older people in the general population.9 Greater risk reduction might be attained by intervening 10 to 20 years before the first clinical signs of cognitive impairment are presented. A recent review of 25 risk and protective factors associated with AD concluded that “the evidence is now strong enough to support personalized recommendations for risk reduction by increasing levels of education in young adulthood, increasing physical, cognitive and social activity throughout adulthood, reducing cardiovascular risk factors including diabetes in middle-age, through lifestyle and medication, treating depression, adopting a healthy diet and physical activity, avoiding pesticides and heavy air pollution and teaching avoidance of all potential dangers to brain health while enhancing potential protective factors”.10 These risk factors, and particularly vascular risk factors, are implicated in neurodegeneration pathology in a number of dementia processes.

While the search for effective preventive strategies and access to evidence-based pharmacological treatments and psychosocial interventions are critical, there are still delays in diagnosis and a failure to utilise existing available resources.1,3 The introduction of the federal government-funded, state-based Dementia Behaviour Management Advisory Services (DBMAS), the initiation of severe behaviour response teams, and increased funding for research should be applauded, but there needs to be greater coordination of service delivery systems for patients and carers at every stage, from prevention through to end-of-life care, and the medical profession needs to do more to ensure that all existing and trainee practitioners are well informed about what we can do for people with dementia right now.

Box –
Relationship of ß-amyloid deposition with other parameters in Alzheimer disease


Aß-amyloid = ß-amyloid; CDR = Clinical Dementia Rating. Reproduced with permission from Villemagne et al (2004).4

[Editorial] Screening for perinatal depression: a missed opportunity

All pregnant and post-partum women should be routinely screened for depression, according to a new statement from the US Preventive Services Task Force (USPSTF). This controversial recommendation is part of the USPSTF’s updated 2016 guidance recommending routine screening for depression in adults, published on Jan 26, which for the first time has been expanded to include information related to pregnant and post-partum women. The task force’s proposals were widely welcomed by the mainstream media—but given the limited evidence in this area, are such bold recommendations warranted?

[Correspondence] Faith-based health care

We thank Jill Olivier and colleagues for their helpful overview of faith-based health care in Africa.1 As a not-for-profit provider of faith-based health care in a hard to reach rural region of southwest Uganda, Kisiizi Hospital has recognised that a fundamental difficulty with public services in remote locations is the availability of health-care staff in facilities.

Concerns persist over rural health fix

The Federal Government has rebuffed calls for an increase in the quota of medical students who come from rural backgrounds despite concerns initiatives to boost medical services in country areas will continue to fall short.

The Government has been accused of sending mixed messages on its rural medical workforce policy after using some of the funds freed up from cutting almost $600 million from health and aged care workforce spending to fund new programs intended to improve rural training opportunities.

It used its 2015-16 Mid Year Economic and Fiscal Outlook (MYEFO) to unveil a $93.8 million Integrated Rural Training Pipeline intended to improve the retention of postgraduate prevocational doctors in country areas.

The Pipeline includes the establishment of 30 regional training hubs (which will receive $14 million a year); at least $10 million a year for a Rural Junior Doctor Training Innovation Fund to foster new training approaches; and $16 million a year to fund up to an extra 100 places in the Specialist Training Program through to 2018.

Minister for Rural Health Fiona Nash said the funds for the initiative had been obtained by improving the targeting of existing health workforce programs and activities.

“The Australian Government invests more than $1 billion a year in programs to build the health workforce,” Senator Nash said, citing as an example the fact that, in 2014, almost 80 per cent of clinical placements were in metropolitan areas.

A further $130 million of health workforce spending is to be redirected into an expansion of the Rural Health Multidisciplinary Training program, with particular focus on addressing workforce shortages and increasing support for training in nursing, midwifery and allied health.

“Our objective is to provide the most effective support for health students to train in areas of need,” Senator Nash said.

But the impact of the announcement has been tempered by concerns that the overall effect of the changes is a net loss of funding for health workforce programs.

Health Minister Sussan Ley admitted as much when, in a statement released on 15 December, she confirmed that only a proportion of the $461.3 million the Government expects to save by “rationalising” existing workforce programs would go to fund the new initiatives, with the rest “being sensibly invested into Budget repair”.

Prior to the release of MYEFO, the AMA had urged the Government to make it mandatory that one in every three medical students be recruited from a rural background, and that the proportion required to undertake at last a year of clinical training in a rural area be increased from 25 to 33 per cent.

The AMA has welcomed the expansion of the Specialist Training Program, but President Professor Brian Owler said that country areas were still struggling to attract and retain sufficient locally-trained doctors despite record numbers of medical graduates.

“The ‘trickle down’ approach to solving workforce maldistribution is not working,” he said. “Australia has enough medical students, and the focus must now shift to how to better distribute the medical workforce.”

The AMA President said there was good evidence that medical students from a rural background, or those who undertook extended training in rural areas, were more likely to take up practice in the country upon graduation.

The AMA said less than 28 per cent of commencing domestic medical students came from a rural background, and recommended that the Government increase the current intake target from 25 to 33 per cent.

Professor Owler said significant action was needed, with a recent survey showing less than a quarter of domestic medical graduates lived outside the nation’s capital cities.

“The implementation of more ambitious targets may prove challenging in the short term, but there is evidence that this approach would be more successful in getting more young doctors living and working in rural Australia,” he said.

But the Government has so far resisted the suggestion.

Instead of increasing the rural medical student quota, universities have been directed to set their own targets for rural background students.

A Health Department spokesperson told Medical Observer that, even without a higher quota, a third of medical students in 2014 were of rural origin.

Adrian Rollins

Medical practices to be hit in under-pay crackdown

Medical practices have been put on notice to expect a visit from Fair Work inspectors in the coming months to ensure staff are receiving appropriate pay and allowances.

The workplace watchdog has announced it will be carrying out spot checks to examine conditions for receptionists, managers and other staff at 600 health and residential care workplaces around the country, including medical practices.

Fair Work Ombudsman Natalie James said on average more than 3000 people a month from the health care and social assistance sector contacted her organisation concerned about pay and work arrangements, and the forthcoming campaign of inspections had been developed with “intelligence and advice from key stakeholders”.

Ms James said Fair Work inspectors will be checking to make sure employers are paying correct minimum hourly rates, penalty rates, allowances and loadings and providing appropriate meal breaks. They will also be ensuring compliance with record-keeping and pay-slip obligations.

The blitz reflects ongoing concern about the behaviour of some employers in the sector, which includes not only medical practices but allied health services and residential care operators.

Since 2010, the watchdog has recovered more than $7 million on behalf of 5300 underpaid workers in the industry, which employees more than 1.4 million, almost 80 per cent of them women, and includes around 10,000 457 visa holders.

In the past three financial years, the Ombudsman has taken seven matters concerning employers in the sector before the courts, and a further 43 have been issued formal Letters of Caution about their workplace practices, putting them on notice that further contraventions may result in enforcement action. Eight received on-the-spot fines for technical infringements.

Ms James said one of the campaign’s aims was to ensure employers were aware of their responsibilities.

For medical practices, the Ombudsman will focus on employees covered by the Health Professionals and Support Services Award.

The AMA has advised practice owners unsure of their obligations under the award or their record keeping requirements to contact their local State or Territory AMA for advice.

Adrian Rollins

Australia Day honours

Former AMA President Dr Brendan Nelson and former Treasurer Peter Ford are among almost 30 AMA members recognised for their outstanding service to medicine and the community in the 2016 Australia Day honours.

Dr Nelson, who led the AMA between 1993 and 1995 before entering federal politics and rising to become Defence Minister in the Howard Government and Opposition leader after the Coalition’s defeat in 2007, served as Australia’s ambassador to the European Union before returning to Australia to become Director of the Australian War Memorial.

Dr Nelson has been made an Officer (AO) in the general division of the Order of Australia, in recognition of distinguished service to Federal Parliament, the advancement of Australia’s international relations and service to major cultural institutions.

Several other AMA members were similarly honoured, including Monash University Pro Vice Chancellor Professor David Copolov, anaesthetist Professor Kate Leslie, clinical immunologist Professor Robyn O’Hehir, ophthalmologist Professor Minas Coroneo and gastroenterologist Professor Finlay Macrae.

Adelaide GP Dr Ford, who served in several senior roles within the AMA including as Federal Treasurer, was awarded an Order of Australia (AM) for his work representing the medical profession and promoting the delivery of health care for the elderly.

Another GP, Dr Vlasis Efstathis, was also awarded an AM for services to community health and medicine. Dr Efstathis has been a GP since 1972 and was team leader of the tsunami relief effort in Banda Aceh in 2004.

Former Royal Australian and New Zealand College of Obstetricians and Gynaecologists President Dr Ted Weaver, was awarded a Medal in the general division of the Order of Australia, as was Australian National University Adjunct Associate Professor Rashmi Sharma, who told Medical Observer the honour showed that “little GPs in the suburbs can sometimes be recognised”.

The following AMA members were recognised in the Australia Day honours:

Officer (AO) in the general division

Professor David Copolov
Professor Minas Coroneo
Professor Katherine Leslie
Professor Finlay Macrae
The Honourable Dr Brendan Nelson
Professor Robyn O’Hehir

Member (AM) in the general division

Mr Ian Carlisle
Dr Jay Chandra
Dr Timothy Cooper
Dr Vlasis Efstathis
Dr Peter Ford
Professor Mark Frydenberg
Dr Michael Gardner
Dr Myrle Gray
Dr Paul Mara
Dr Peter Pratten
Dr Lyon Robinson
Dr Brian Spain
Dr Roderic Sutherland
Dr John Vorrath
Associate Professor David Watson
Associate Professor Julian White

Medal (OAM) in the general division

Dr Creston Magasdi
Dr John Paradice
Adjunct Associate Professor Rashmi Sharma
Dr John Tucker
Dr Edward Weaver

 

Adrian Rollins