more_vertOn June 4, 2015, the High Court of Cassation and Justice in Romania made the decision to criminalise the act of public sector physicians receiving any informal payments from patients.1 The decision sparked an intense debate. Although some physicians and patients support physicians’ right to be compensated for the services provided, others reject informal payments, mainly because the practice prevents those who cannot pay from accessing health care, and can be embarrassing for the physicians who receive them.
Preference: Administration and Health Services
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National licensing scheme for medicinal cannabis: Ley
Minister for Health Sussan Ley has announced there will be a nationally controlled licensing scheme regulating the cultivation of medical marijuana.
This scheme would reduce the need for states and territories to set up individual schemes and ensure laws are consistent for growers.
“Allowing controlled cultivation locally will provide the critical “missing piece” for a sustainable legal supply of safe medicinal cannabis products for Australian patients in the future,” she said.
Related: MJA – Medical cannabis: time for clear thinking
There has been consultation with state and territory governments and law enforcement agencies over the past month,
“We want to not only ensure these legislative amendments are rock solid, but that we can all work together to pass them in a bipartisan fashion as quickly as possible,” Ms Ley said.
“The important point is legislative changes are drafted and we’ve hit the start button for change.”
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FBT cap: we are not entertained
Patients could face a blow-out in waiting times for elective surgery if the Federal Government pushes ahead with controversial plans to cap tax concessions on entertainment benefits for hospital employees, the AMA has warned.
The nation’s peak medical group had told Treasury its proposal to impose a $5000 cap on salary sacrificed meal and entertainment expenses that are eligible for fringe benefit tax exemptions would harm the ability of public hospitals and other not-for-profit health groups to attract and retain skilled medical staff, undermining the services they are able to provide.
In its May Budget, the Federal Government claimed the tax concession – currently worth around $17,000 a year – was being exploited and abused, and estimated its crackdown on the perk would raise $295 million over four years.
But AMA Vice President Dr Stephen Parnis said the Government had not provided any substantive evidence to back its claim FBT concessions were being used unfairly, and urged it to proceed with great caution in making any changes.
“The AMA is deeply concerned that the reforms canvassed in the exposure draft could significantly affect the ability of institutions, including public hospitals, to recruit and retain staff,” Dr Parnis said, warning this could cause treatment waiting times to blow out.
“If the current supply of medical specialists decreases, we believe it is reasonable to predict a lengthening of waiting lists for elective surgery and outpatient clinics.”
Public hospitals and not-for-profits have relied on the FBT concession to help them compete with the private sector for the services of doctors and other health workers.
Dr Parnis said that many practitioners chose to forego higher wages on offer in the private sector to work in public hospitals because of the chance to practice advanced acute care, undertake research and provide teaching and training.
But he said they still deserved to be fairly remunerated for their skills and experience, and the FBT tax concession helped to make the salaries hospitals could offer competitive.
The AMA has warned that putting a cap on the concession would have a number of serious unintended consequences for the health care system, particularly the supply of medical specialists.
In the short-term, any drift of medical specialists away from the public system will likely cause waiting lists for surgery to blow out.
In the longer term, because the health system relies on senior and experienced hospital medical staff to help train the next generation of practitioners, Dr Parnis said the loss of even some of these workers to the private sector because of reduced tax breaks would undermine teaching capacity.
He said this was particularly worrying because it was coming at a time when the pressure on hospital teaching capacity had never been greater as a result of rapid growth in the number of medical graduates.
Several organisations have written to Treasury urging that the $5000 cap on entertainment expenses that are eligible for FBT exemptions be raised.
St John’s Ambulance said it relied on the FBT exemption to help attract and retain skilled staff, and suggest the cap be increased to $20,000, while the Fred Hollows Foundation recommended it be set at $30,000.
The Salvation Army, meanwhile, warned a $5000 cap would hit the salaries of half its staff.
The Tax Institute recommended the bcap be set at $15,000.
The tax change is due to come into effect from 1 April 2016.
Adrian Rollins
Medical briefs
No sugar tax in sight
The Federal Government has signalled it is unlikely to implement a sugar tax or other financial incentives to influence eating habits.
Convening the first meeting of its Healthy Food Partnership, Rural Health Minister Fiona Nash – who also has oversight of food policy – indicated that although the Federal Government wanted to encourage consumers to make healthier food choices, it would not seek to “force feed” them.
“Government can’t force feed healthy food to its citizens,” Senator Nash said. “It is up to individuals to take responsibility for what they eat. Government’s role is to educate and provide tools to help people make healthy choices.”
The Partnership includes representatives from food manufacturers and producers, industry groups, the Public Health Association and the Heart Foundation.
Senator Nash said it had been formed to come up with strategies to increase the consumption of fresh fruit and vegetables, as well as to reformulate food to make it healthier, and to “deal with” issues of portion and serve sizes.
Organ donations on the rise
There was a 10 per cent increase in the number of deceased organ donors in the first nine months of the year.
Australian and New Zealand Organ Donation Registry figure show there were 320 deceased donors between January and September, and there were 907 transplant recipients – including 48 who received multiple organs.
AMA President Professor Brian Owler said the increase was encouraging but, with about 1600 people waiting for a transplant at any one time, many more donors were needed.
Professor Owler encouraged people to think about becoming a donor, and urged families to respect the wishes of those who chose to become a donor.
Rural health talks
Rural Health Minister Fiona Nash has convened a meeting of 17 organisations representing rural health professionals, students and instructors as part of an effort to boost health services in the bush.
Senator Nash said a key focus of discussions was ways to increase the number of doctors and other health professionals working in rural and regional areas.
The Minister said that it was not just more doctors who were needed in rural areas, but the whole gamut of other health professionals, including nurses, physiotherapists and dentists.
Fmr NSW Health Minster joins Medical Deans
Former New South Wales Deputy Premier and Health Minister, Carmel Tebbutt, has become head of the peak body representing the nation’s Medical Deans.
Ms Tebbutt, who entered NSW Parliament in 1998 and served in a variety of ministerial portfolios while in government, did not contest the 2015 State election.
She is married to Federal Labor frontbencher Anthony Albanese.
Online credential check for overseas doctors
Overseas medical graduates looking to work in Australia will now have their qualifications verified through a web-based system that will also allow them to keep electronic records of education, training and licensing credential following an agreement struck by the Australian Medical Council and the US-based Educational Commission for Foreign Medical Graduates.
Under the deal the AMC, which provides a centralised service for specialist medical colleges and other organisations to check the credentials of international applicants, requires overseas medical graduates (OMGs) to have their qualifications and experience verified by the Commission from primary sources through its Electronic Portfolio of International Credential (EPIC) program.
The AMC said the EPIC program provided it with a secure, web-based platform for authenticating the credentials of applicants, and enabled paperless processing and record-keeping.
The Commission said OMGs could use EPIC to build a “digital portfolio” of verified credentials accessible anywhere, and could be used to satisfy the requirements of regulators, potential employers and other organisations.
Put cancer drugs on fast track
The Federal Government should speed up approval processes for new cancer drugs and look at developing a national medicines register, a Senate inquiry has recommended.
An investigation into the availability of specialist cancer drugs said that the current trend toward a larger range of treatments that are targeted at small populations of patients is likely to continue, putting increasing pressure on the medicines approval process.
Senator Catryna Bilyk, who was a member of the inquiry, told Parliament that there was increasingly a personalised medicine approach in which the genetics of tumours are established and high-throughput screening of existing medications is undertaken to determine which drugs that show activity against the tumour. This is used by oncologists to inform their treatment.
“More targeted medicines and therapies have the ability to increase the range of treatment options for cancer patients, resulting in improved quality of life and survival for many patients,” Senator Bilyk said.
But such treatments can be very expensive, and often patients face a lengthy wait before they can get subsidised access while regulators, medical experts and ministers assess them for efficacy and cost effectiveness.
The inquiry recommended a comprehensive review of the system, including looking at fast-track processes used overseas, and suggested the Government consider setting up a national register of cancer medicines.
National registration for paramedics
The Federal Government has opposed a move to establish a single national registration scheme for paramedics.
A majority of the nation’s health ministers agreed to include paramedics in the National Registration Accreditation Scheme at a meeting in Adelaide last month, overriding the objections of Federal Health Minister Sussan Ley.
The move is seen as consistent with a push to establish nationally-recognised qualifications across a range of occupations.
But New South Wales has reserved its right to opt out of the process, and, according to a communique from the meeting, Ms Ley argued it was “not consistent with the principles of the NRAS as a national regulatory reform”.
Adrian Rollins
Hospital cuts cloud reform outlook
The states are seeking to exert increasing pressure on the Federal Government over its $57 billion cut to public hospital funding amid speculation of a radical overhaul of Commonwealth-State health arrangements.
Queensland Health Minister Cameron Dick told a meeting of the nation’s health ministers last month that the Coalition Government’s decision to rip up the National Partnership Agreement on health services and reduce the indexation of Commonwealth hospital payments to population plus inflation would cut $11.8 billion from the State’s hospital system – the equivalent of 4500 doctors, nurses and allied health professionals.
This follows claims from the Victorian Government that the Commonwealth’s decision will rip $17.7 billion from its health system over the next decade, while New South Wales has figured a $16.5 billion loss, South Australia $4.6 billion, Western Australia $4.8 billion and Tasmania $1.1 billion.
Victorian health officials told a Senate inquiry the impact of the Federal Government’s cuts would be equivalent to shutting down two major hospitals and axing 23,000 elective surgery procedures every two years.
“[It] would equate to the level of service delivery of two health services the size of Melbourne Health [which operates the Royal Melbourne Hospital],” acting Victorian Health Department Secretary Kym Peake told the inquiry.
The big cuts form a challenging backdrop for discussions of reform to Federal-State relations that include proposals for Commonwealth public hospital funding to be replaced by a “hospital benefit payment” that would follow individuals, similar to Medicare.
Government discussions of changes to the private health insurance industry have included reference to option two in the Reform of the Federation Discussion Paper, which proposes a Medicare-style payment for hospital services, regardless of whether they are provided in the public or private system.
Under the arrangement, the price of hospital procedures would be set by an independent body and the Commonwealth would pay a proportion. For patients in the public system, the states would be expected to make up the difference, while in private hospitals the gap would be covered either by insurers or the patients themselves.
States would retain responsibility and operational control of public hospitals and would be able to commission services from the private sector, while the Commonwealth would discontinue the private health insurance rebate.
But the Federal Government is likely to encounter significant resistance to such a change from the states unless it comes up with more money.
The revenue raised from the GST, which is funnelled directly to the states, has been growing far more slowly than expenditure, tightening the squeeze on state budgets and their health funding.
When it was introduced in 2000, GST applied to 55 per cent of spending, but since then its share has shrunk to 47 per cent this year, and consultancy Deloitte Access Economics estimates it will apply to just 42 per cent by 2024-25.
The squeeze on funding has shown up in disappointing public hospital performance.
The latest report from the Australian Institute of Health and Welfare shows that hospitals are struggling to make headway in the face of increasing demand for emergency care.
The proportion of urgent patients receiving treatment within the recommended time fell back in 2014-15 to just 68 per cent – well short of the target of 80 per cent.
The goal for all emergency department visits to be completed within four hours, which was meant to be achieved this year, has also been missed.
The results bear out warnings made by the AMA earlier this year that the Commonwealth’s funding cuts for hospitals would undermine the delivery of care.
Launching the AMA’s annual Public Hospital Report Card, President Professor Brian Owler said the Federal Government’s cuts had created “a huge black hole in public hospital funding”.
“It’s the perfect storm for our public hospital system,” he said. “There’s no way that states and territories can even maintain their current frontline clinical services under that sort of funding regime, let alone build any capacity we actually need to address the shortfalls now.”
Health Minister Sussan Ley rejected the warnings at the time, but the latest evidence of declining performance are likely to make it increasingly difficult for the Government to win State backing for an overhaul of funding arrangements without more money on the table.
Adrian Rollins
Who are you? 7 facts about the average doctor in Australia
An annual workforce report by the Australian Institute of Health and Welfare has provided a statistical snapshot of medical practitioners in Australia.
The AIHW uses survey data from APHRA about the 98,807 medical practitioners registered in 2014, which has increased by 7.4% in two years.
Other key facts are:
1. A third of medical practitioners are GPs
In the last 10 years, there has been a steady rate of supply of general practitioners, with 111 per 100,000 population in 2014. There were 32,606 registered GPs in 2014, making up 33% of medical practitioners in Australia.
2. There are more specialists now than 10 years ago
In the last 10 years there has been growth in the rate of specialist supply, from 110 to 132 per 100,000 population. Specialists working as clinicians increased from 19,043 in 2004 to 28,403 in 2014.
3. Anaesthesia is the most common speciality
The five most common specialities account for 38.7% of clinician specialists. Anaesthesia is the most common with 3,775 or 13.3% of clinician specialists followed by psychiatry, Diagnostic radiology, General surgery and Specialist obstetrician and gynaecologist.
4. The number of female doctors is increasing
The proportion of women employed as medical practitioners has increased steadily in the past 10 years. In 2014, women made up 39.4% of the medical workforce. There are substantially more men in the older age groups and more women than men in the 20-34 age group.
Graph: AIHW
5. Average age gap between men and women is decreasing
The average age of men is 48 in 2014 and has been relatively steady since 2004. The average age for women is 42 in 2014 however the average age gap over this period has narrowed slightly from 6.8 years in 2004 to 6.1 years in 2014.
6. Working hours have remained steady but on average, men work longer
The report found that medical practitioners work an average of 42.5 hours per week, which has remained steady since 2010. Men work on average 45.1 hour and women work on average 38.6 hours per week.
7. About a third of medical practitioners gained their qualifications overseas
66.4% of employed medical practitioners said they obtained their initial medical qualification in Australia. Among those who obtained their qualification overseas, those who qualified in India was the largest group followed by England and New Zealand.
Read more of the report on the AIHW website.
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Atlas charts course to improved care
The first detailed national appraisal of variations in health practice has found that Australians are among the world’s heaviest users of antibiotics and antidepressants, and within the country there are major differences in the use of common drugs and treatments for everything from colonoscopies and cataract surgery to antipsychotic medicines for the elderly and hyperactivity drugs for the young.
In what is seen as the first step toward addressing unwarranted variations in the care patients receive, the Australian Commission on Safety and Quality in Healthcare has released a report identifying wide discrepancies in the use of everyday medicines and procedures.
Among its findings, the Australian Atlas of Healthcare Variation has revealed that children in some parts of the country, particularly in NSW, are seven times more likely to be prescribed drugs for ADHD than those in other areas, while cataract surgery, hysterectomies, tonsillectomies were three times more common in some areas than others, and patients in some parts were 30 times more likely to undergo a colonoscopy.
AMA President Professor Brian Owler said that, by reflecting how the delivery of health care was organised, the Atlas provided a useful illustration of differences in access to care.
But he highlighted the fact that the Commission itself made no claim about the degree to which differences in care was unwarranted.
“The Atlas is a welcome starting point for further research and examination of health service distribution,” Professor Owler said. “It is not proof that unnecessary or wasteful care is being provided to Australians, and should not be interpreted that way.”
The Commission said that some variation was “desirable and warranted” to the extent that it reflected differences in preferences and the need for care.
It added that “it is not possible at this time to conclude what proportion of this variation is unwarranted, or to comment on the relative performance of health services and clinicians in one area compared with another”.
Senior clinical adviser to the Commission, Professor Anne Duggan, said the average frequency of various services and procedures provided in the Atlas were not necessarily the ideal, and observed that “high or low rates are not necessarily good or bad”.
Nonetheless, she said the weight of local and international evidence suggested much of the differences observed was likely to be unwarranted.
“It may reflect differences in clinicians’ practices, in the organisation of health care, and in people’s access to services,” Professor Duggan said. “It may also reflect poor-quality care that is not in accordance with evidence-based practice.”
Many of the variations identified in the Atlas have been linked to wealth and reduced access to health care in disadvantaged areas.
Professor Duggan said the less well-off tended to have poorer health and so a greater need for care, while some procedures are used more often in wealthier areas.
She said the Atlas showed that rates of cataract surgery were lowest in areas of disadvantage, and increased in better-off locales.
But Professor Owler said the example showed the need to be very careful in drawing conclusions about the reasons for variation.
He said the Atlas showed that the incidence of cataract surgery was highest in the remotest parts of far north Queensland.
“This is because there are no public services available, with private ophthalmologists delivering eye care to Indigenous communities, which is covered by Medicare,” the AMA President said.
He said identifying variation in health care was essential, but this was the first step before determining the causes of variation.
“The Atlas doesn’t tell us what should be the best rates for different interventions and treatments.”
In addition to identifying variations in health care within the country, the Atlas also explored how the care provided in Australia compared internationally.
While acknowledging that differences in the type and quality of data made it difficult to draw direct comparisons, the Atlas nonetheless reported that Australia has “very high” rates of antibiotic use compared with some countries, and Professor Duggan said that, among rich countries, Australia was second only to Iceland in the extant of use of antidepressants.
Professor Owler said that, with the publication of the Atlas, the challenge now was to develop a process to identify variations in practice that were “actually unwarranted, not just assumed to be” and to develop and fund strategies to reduce them by supporting clinically appropriate care, such as by providing clinical services where they are needed.
To view the Atlas, visit: http://www.safetyandquality.gov.au/atlas/
Adrian Rollins
Big questions hang over mental health reforms
Primary health care networks will be paid by the Commonwealth to provide tailored “integrated care packages” for patients with mental health problems in a major overhaul of the mental health system unveiled by the Federal Government.
In its long-awaited response to the National Mental Health Commission’s review of the system, the Government announced a fundamental shift away from direct funding and program delivery. Instead, it will set up a pool of funds which can be used to pay the nation’s 31 Primary Health Networks (PHN) to plan and commission local services for mental health patients.
“Just like any other chronic disease, mental illness is often complex and requires access to multiple health professionals and support services to address it properly,” Health Minister Sussan Ley said. “Experts recognise many patients with severe or complex mental health needs would benefit from an integrated health care package tailored to their individual needs, and that’s what we’re delivering.”
While patients can still choose to have Medicare-subsidised psychology sessions through GP-designed mental health plans, the Government expects a large proportion will opt instead for care packages provided by PHNs in partnership with Local Hospital Networks.
But AMA President Professor Brian Owler said that although the changes were well-intentioned, much hinged on funding and the capacity of the PHNs.
Professor Owler said the focus on tailoring care to individual need and local service planning and delivery was welcome, but a lack of detail on funding and service delivery left big questions hanging.
“The success of this new direction in mental health service delivery will depend very much on the capacity and capability of PHNs,” the AMA President said.
Professor Owler said the new framework needed to deliver genuine patient-centred care, rather than simply giving PHNs the power to determine what package of care patients can have, based on the services it has chosen to organise.
“It is particularly important that the system neither reduces nor compromises the patient’s choice of health care provider, and their ability to plan and manage their care with their GP,” he said. “It is equally important that the system does not lock people into a package of care provided or commissioned by the PHN with predetermined providers, with limited or no ability to change providers once the package has commenced.”
In addition to questions about the capacity of PHNs to develop and organise tailored care packages, concerns have been raised that the arrangements will add to administrative costs by essentially funnelling funding through an additional layer of bureaucracy.
In addition to commissioning PHNs to deliver tailored care packages, the Government will establish a phone and internet service to act as a single gateway for patients to access the full range of mental health services, and will redesign primary mental health care program to a “stepped care” model to better target services.
National Mental Health Commission Chair Professor Alan Fels said the Government’s plans were a “ringing endorsement” of the Commission’s Contributing Lives, Thriving Communities review, which condemned current arrangements as fragmented and inefficient.
“These reforms have far-reaching potential to improve the lives of millions of Australians,” Professor Fels said. “The focus must now be on effective and efficient implementation.”
But a key recommendation from the Commission that $1 billion be redirected from hospital mental health care services to bolster primary care has been rejected by the Government, underlining concerns about the adequacy of resources to be provided to GPs under the new arrangements.
The overhaul has also raised questions about the general approach the Federal Government is taking to reforms in health care.
Professor Owler said the fact that the new framework entailed Commonwealth withdrawal from funding and program delivery to instead assume a “strategic leadership” role was of concern.
He said the AMA would be watching closely to see whether the Turnbull Government adopted a similar approach in primary care and private health insurance policy, and tried to unload greater responsibilities onto the states and territories and the private sector.
Ms Ley said there would be a trial of the new arrangements this financial year, and they would be phased in over three years from early 2016-17.
Adrian Rollins
The health of Australia’s prisoners 2015
The health of Australia’s prisoners 2015 is the 4th report produced by the Australian Institute of Health and Welfare on the health and wellbeing of prisoners. The report explores the conditions and diseases experienced by prisoners; compares, where possible, the health of prisoners to the general Australian community and provides valuable insight into the use of prison health services. New to the 2015 report are data on the disabilities or long-term health conditions of prisoners entering the prison system (prison entrants), self-assessed mental and physical health status of prisoners and data on smoke-free prisons.
Cut Indigenous imprisonment to help close health gap
Sky-high rates of Indigenous incarceration need to be dramatically reduced if the nation is to close the health gap blighting the lives of Aboriginal and Torres Strait Islander people, according to AMA President Professor Brian Owler.
Launching the AMA’s Indigenous Health Report Card 2015, Professor Owler said being imprisoned had devastating lifelong effects on health, significantly contributing to chronic disease and reduced life expectancy.
“Our Report Card recognises that shorter life expectancy and poorer overall health for Indigenous Australians is most definitely linked to prison and incarceration,” the AMA President said.
Aboriginal and Torres Strait Islander people are hugely over-represented in the nation’s prisons – almost 30 per cent of all sentenced prisoners are Indigenous.
While some progress has been made in recent years in improving infant and maternal health, the AMA President said that imprisonment rates were rising, and the country was set to reach a “grim milestone” next July when, on current trends, the number of Indigenous people in custody will reach 10,000, including 1000 women.
In its Report Card, launched by Rural Health Minister Fiona Nash, the AMA has urged Federal, State and Territory governments to set a national target for cutting rates of Indigenous imprisonment.
The call has come just days after disturbing details of the death of a young Aboriginal woman who was being held in police custody for failing to pay $3622 of fines.
A West Australian coronial inquest has been told the 22-year-old woman, known as Miss Dhu for cultural reasons, was in a violent relationship and using drugs at the time of her arrest last year. While in the South Hedland Police Station she collapsed after complaining of pain and difficulty breathing.
It was later found she had several broken ribs following an attack by her partner, and died from a lethal combination of pneumonia and septicaemia.
Miss Dhu’s death has fuelled calls for WA to overhaul laws regarding the imprisonment of fine defaulters.
But the AMA has said a much broader approach needs to be taken.
Indigenous adults are 13 times more likely to be jailed than other Australians, and among 10 to 17 year-olds the rate jumps to 17 times.
Professor Owler said it was possible to isolate the health issues that led to so many Aboriginal and Torres Strait Islander people landing in prison, and they included mental health conditions, alcohol and drug use, substance abuse disorders and cognitive disabilities.
He said the “imprisonment gap” was symptomatic of the health gap, and the high rates of imprisonment of Aboriginal and Torres Strait Islander people, and the resultant health problems, needed to be treated as a priority issue.
In particular, he said, the health issues identified as being the most significant drivers of Indigenous imprisonment “must be targeted as a part of an integrated effort to reduce Indigenous imprisonment rates”.
Professor Owler said the evidence showed that Aboriginal and Torres Strait Islander people continued to be let down by both the health and justice systems, and firm and effective action was required.
“It is not credible to suggest that Australia, one of the world’s wealthiest nations, cannot solve a health and justice crisis affecting 3 per cent of it citizens,” he said.
Reconciliation Australia Co-Chair Professor Tom Calma said the AMA’s “very substantial” Report Card was latest in a long list of reports identifying the need for action, and urged governments to “get on with it”.
Professor Calma said there had been “some really good outcomes” from recent initiatives to improve prisoner health, particularly moves in many states to ban smoking in jails.
But he said more needed to be done to tackle recidivism, citing figures showing 50 per cent of Indigenous prisoners reoffended.
The Indigenous leader said that this was not surprising because often people getting out of prison returned to the same situation that got them into trouble in the first place, and urged action to tackle the causes of offending in the place, such as alcohol and drug abuse.
Among its recommendations, the AMA has called for funds freed up from reduced rates of Indigenous incarceration to be reinvested in diversion programs; for governments to support the expansion of chronic health and prevention programs by Aboriginal Community Controlled Health Organisations; for such organisations to work in partnership with prison health authorities to improve health and reduce imprisonment rates; and to directly employ Indigenous health workers in prison health services.
Adrian Rollins