The AMA Specialist Trainee Survey 2014: a survey of hospital-based specialty trainees and general practice registrars

In 2010, the Australian Medical Association (AMA) conducted its first Specialist Trainee Survey (STS)1 to provide medical colleges with feedback from trainees about key facets of their training and other aspects of their operations.

The AMA repeated the STS in May 2014,2 when it surveyed both hospital-based specialty trainees (the STS) and general practice registrars (the General Practice Registrar Survey) to monitor trends and emerging issues in vocational training.

Overall, hospital-based specialist trainees who responded to the 2014 STS reported a high level of satisfaction with their work and training, and have a more positive view about their training experience than those surveyed 4 years ago.

Trainees continue to express high levels of confidence about their career choice, level of supervision, standard of training, clinical experience and safety of the required working hours (Box 1).

It is notable that trainees’ opinions about whether they are working appropriate hours clearly improved between 2010 and 2014, with the proportion of those agreeing that college training requirements were compatible with safety rising from 69% to 79%. This is consistent with results of the AMA Safe Hours Audit,3 which found that hours of work and levels of fatigue risk have decreased over the past 10 years.

Notable improvements were also seen in areas relating to exam content, such as its relevance to practice and appropriateness for the level of training. Other areas of improvement included guidelines for the recognition of prior learning, and the time required to complete training for those with flexible training arrangements.

Disappointingly, many areas of trainee dissatisfaction had not changed since 2010. Responsiveness by the colleges to bullying and harassment, appeals and remediation processes, feedback, and the cost of training are ongoing areas where trainees are still dissatisfied. Trainees are also uncertain about how to gain access to academic streams and accredited overseas rotations as part of their training program (Box 2).

The ability to run two parallel surveys of hospital-based trainees and general practice registrars also provided valuable insight into these training environments. General practice registrars were more positive than specialist trainees about many aspects of their training program, most notably their employment prospects at the end of training, costs of training, availability of flexible training options, relevance and quality of educational activities, recognition of prior learning, and their personal health and wellbeing.

This survey continues to be one method for obtaining independent feedback from trainees about the quality of their training, in light of ongoing pressure on availability of vocational training places, changes to governance arrangements for health workforce planning and GP training, concerns about mental health of doctors, and an increasingly tight fiscal environment.

Notwithstanding its limitations, we hope that this report will prompt relevant institutions to internally review their education and training policies, focusing particularly on the areas that trainees are dissatisfied. The report also highlights areas requiring further scrutiny as part of the ongoing review by the Australian Medical Council of accreditation standards for specialist medical education programs. A single annual National Training Survey would be an excellent mechanism for efficiently monitoring and informing the quality of medical training. This approach has been successfully adopted in the United Kingdom.4

Ultimately, the AMA hopes that this survey continues to assist the improvement of trainees’ experiences and the quality of Australia’s medical education system.

1
Areas in which trainees were most satisfied in 2010 and 2014

2
Areas in which trainees were least satisfied in 2010 and 2014

Lost productive life years caused by chronic conditions in Australians aged 45–64 years, 2010–2030

Globally, there has been a substantial increase in the number of years lived with disability (YLDs) over the past 20 years. The YLDs for 1160 sequelae of 289 diseases and injuries were estimated as part of the 2010 Global Burden of Disease study: global YLDs from all causes had increased from 583 million in 1990 to 777 million in 2010.1 The main contributors to YLDs were mental and behavioural disorders, musculoskeletal disorders, and diabetes or endocrine diseases. While the Global Burden of Disease study measured YLDs at particular time points, governments have become increasingly concerned by lost productive life years (PLYs) caused by chronic disease at particular time points. We define PLYs as the loss of productivity that results from individuals not being able to participate in the labour force because of their chronic conditions. Few studies have undertaken a thorough assessment of the impact of chronic disease on labour productivity, and most have focused only on the burden of single diseases. Recent studies have shown that chronic disease can negatively affect the labour market and related outcomes, such as reduced income, greater welfare dependency and earlier retirement.2

The significant costs of premature retirement caused by chronic disease have been highlighted for most Organisation for Economic Co-operation and Development (OECD) countries.3 Premature retirement has attracted considerable attention in Australia, where unemployment is low (5.8% in June 2014) compared with other OECD countries4 and there are substantial labour shortages in a number of industries. The Australian Treasury maintains that Australia’s financial position can only be improved by increasing productivity, population growth and labour force participation.5 Having a large number of people excluded from the labour force by ill health is likely to constrain economic growth.

The impacts of an ageing population and labour shortages on a country’s fiscal position have featured heavily in recent reports by supranational organisations, such as the OECD and the World Health Organization,3,6 and national governments, including the Australian Government.5 A range of policies have been adopted by the six OECD countries participating in the Workforce Aging in the New Economy (WANE) project (including Australia) to encourage the labour force participation of older workers,7 including abolishing mandatory retirement; changes to national pension and welfare systems, and disability and employment insurance; active labour-market policies; and promoting phased or gradual retirements.

If chronic conditions are one of the main barriers to labour force participation, financial incentives alone may not be sufficient to maximise the contribution of older workers. Studies from the United States and Canada have shown that employment rates among older persons with musculoskeletal conditions,8 mental illness9 and other chronic conditions are lower than those among older people without these conditions.10 Similar studies from Australia and New Zealand have found that back pain,11 arthritis,12 mental illness,13 type 2 diabetes14 and cardiovascular disease15 are linked with lower labour force participation. With an ageing population, there is a risk that chronic conditions will further limit labour force capacity.

The aims of this study were to estimate (1) the PLYs lost to chronic conditions in Australians aged 45–64 years for each 5-year period from 2010 to 2030; and (2) the impact of these lost PLYs in terms of lost gross domestic product (GDP). The effects of population ageing, population growth, labour force trends and chronic disease trends are also captured in these estimates.

Methods

Data

We analysed output data from a microsimulation model called Health&WealthMOD2030,16 which is Australia’s first microsimulation model of the impact on long-term productivity over a 20-year period (2010–2030) of chronic disease and disability in the population aged 45–64 years.

The base population consists of unit record data from the cross-sectional Australian Bureau of Statistics (ABS) Surveys of Disability, Ageing and Carers (SDAC) 2003 and 2009.17,18 The records of persons aged 45–64 years and members of their family income unit were extracted. The records include data on demographic variables (age, sex, family type); socioeconomic variables (education, welfare payments); labour force variables (labour force participation, retirement); and health variables (chronic conditions, type and extent of disability).

The Australian Population and Policy Simulation Model (APPSIM)19 was used to age the SDAC data to represent the expected population in 2030. APPSIM is a dynamic population microsimulation model developed by the National Centre for Social and Economic Modelling (NATSEM) at the University of Canberra in collaboration with 12 Australian Government departments. APPSIM is based on a 1% sample from the 2001 ABS Census of Housing and Population (the ABS Household Sample File Australia 2001).19 It simulates all major lifetime events experienced by Australians on the basis of the probability of their occurring to people in Australia. Simulated snapshots of the Australian population from 2010 to 2030 generated by APPSIM were used in this study.

To account for epidemiological trends in chronic conditions, we applied the same trends in incidence that were used in the 2003 Australian Burden of Disease and Injury Study,16,20 which projected trends for the period 2003–2023, after which it was assumed that time rates would stabilise. We calculated proportional changes in the prevalence of chronic conditions and applied these to the corresponding diseases in the SDAC data, aggregated into the following categories: stroke, cancer (almost stable in men and women), ischaemic heart disease (decreasing rate in men and women), type 2 diabetes (increasing rate in men and women) and chronic obstructive pulmonary disease (stable in men; increasing rate in women). In the absence of data about trends, the rates for all other conditions were assumed to remain stable. Based on proportional changes, the prevalence of chronic conditions in Australians aged 45–64 years was projected for 2010 and 2030 by 5-year age groups and sex.

To account for population growth and trends in labour force participation in our PLY projections, we used 2013–2014 population and labour force projections provided by the Australian Treasury. We extracted population projections and projected full-time and part-time employment rates to 2030 for Australians aged 45–64 years by 5-year age groups and sex.16

The SDAC 2003 and 2009 data were separately reweighted to match the 2010 Australian population according to the ABS GREGWT reweighting algorithm,16 which takes into account key demographic and other changes in the population between 2003 and 2009. After reweighting, the datasets were combined and the weights halved so that the total weighted population in this new dataset matched the 2010 Australian population. A diagram of how the tools and datasets (both the source data and the datasets assembled thereafter) were used in this study is included in Appendix 1.

Our use of ABS SDAC 2003 and 2009 data was approved by the ABS Microdata Review Panel.

Labour force participation and chronic conditions

In the SDAC 2003 and 2009 surveys, respondents were asked to nominate their current labour force status, with the following options:

Employed working full-time;
Employed working part-time;
Unemployed looking for full-time work;
Unemployed looking for part-time work;
Not in the labour force; and
Not applicable.

For those who were not in the labour force, the main reason for not looking for work was also sought; in particular, respondents were asked whether they were out of the labour force because of their “own ill health or disability”. Respondents were also asked whether they had a long-term condition and, if so, to nominate the type of condition they had from a list of 80 conditions and injuries. Those identified as being out of the labour force due to ill health or disability were classified in this study as having lost PLYs because of a chronic condition.17,18

Statistical analysis

Outputs from Health&WealthMOD2030 were used to generate descriptive statistics of the relationship between chronic disease, PLYs lost and labour force participation of older workers in 2010, 2015, 2020, 2025 and 2030, by age group and sex.

We analysed the expected growth in the number of people aged 45–64 years who would lose PLYs (and the growth in the number of persons employed with and without chronic disease) at each of the five time points. Projected changes were driven by population growth, population ageing, chronic condition trends and labour force trends (by age group and sex). The contributions of each driver to the number of workers aged 45–64 years in each of the labour force groups to 2030 were disaggregated. All analyses were conducted in SAS V9.3 (SAS Institute).

GDP equation

The impact of PLYs lost to chronic disease in the 45–64-year-old age group on national GDP was calculated using the GDP formula of the Australian Treasury:

GDP = (GDP/H) × (H/EMP) × (EMP/LF) × (LF/Pop15+) × Pop15+

where H is the total number of hours worked, EMP is the total number of persons employed, LF is the size of the labour force, and Pop15+ is the population aged 15 years or more.21

Results

Of the 25 104 people aged 45–64 years surveyed in the combined SDACs 2003 and 2009, 1410 (5.62%) were out of the labour force because of a chronic condition, 12 682 (50.51%) were employed full-time, 5185 (20.65%) were employed part-time, and 5827 (23.21%) were unemployed or not in the labour force in 2010 for reasons other than ill health. After weighting, these data corresponded to 347 000 PLYs lost because individuals had withdrawn from the labour force due to ill health, 3 025 000 individuals employed full-time, 1 122 000 employed part-time and 1 086 000 unemployed or not in the labour force for reasons other than ill health (total population, 5 580 000 people). The projected number of PLYs for 2030 was 459 000 in a population of 7 130 000, an increase of 32.28%. In terms of persons in the labour force, it is projected that 3 979 000 individuals will be employed full-time, 1 576 000 part-time and 1 116 000 will be unemployed or not in the labour force for reasons other than ill health (Box 1). Growth in the number of people employed full- or part-time with a chronic condition (35.12% and 42.99%, respectively) was greater than growth in the number of people employed full- or part-time without a chronic condition (28.31% and 37.33%, respectively).

Box 2 shows the number of PLYs lost in those aged 45–64 years in 2010 and 2030, according to the main chronic condition. Back problems were the major contributors to PLYs lost at each time point (23.27% of PLYs lost to chronic conditions in 2010, 21.37% in 2030). Other important contributors were arthritis (13.26% in 2010, 13.31% in 2030), mental and behavioural disorders (other than depression; 9.58% in 2010, 9.49% in 2030) and depression (7.06% in 2010, 6.33% in 2030). There was little change over time in the relative proportions of people out of the labour force with each condition.

Box 3 shows the contributions of population growth, ageing, chronic disease trends and labour force trends to the increase in PLYs lost and labour force participation (with and without chronic illness) from 2010 to 2030. Of the projected 32.28% increase in PLYs lost to ill health between 2010 and 2030, 89.18% is due to population growth (including 3.97% attributable to ageing) and 8.28% to chronic disease trends. Population growth is the largest driver of full-time employment, whereas labour force trends are the largest driver of part-time employment.

The contribution of population growth, chronic condition trends and labour force trends to the estimated increase in PLYs lost for those aged 45–64 years (and the different labour force groups) from 2010 to 2030 (by age group and sex) are shown in Appendix 2. The largest projected increase in PLYs lost due to chronic conditions is for men aged 55–59 years (38.39%) and women aged 60–64 years (38.90%). There is also considerable projected growth in employment linked with Treasury’s projections of rising demand for labour and labour force participation trends.16 For men employed full-time, the largest increase in employment is projected to occur among those aged 60–64 years (37.51%); the largest increase for women is projected to occur among those aged 55–59 years (63.43%), almost twice the increase for older men.

Population growth makes the largest contribution to growth in both PLYs lost and in the labour force between 2010 and 2030. The contribution of disease trends to PLYs lost, after removing population and labour force trends, was largest for men out of the labour force because of ill health and who were aged 50–54 years (10.23%) or 55–59 years (9.62%). For women, the contribution of disease trends was greatest in those aged 60–64 years who were not in the labour force because of a chronic condition (13.04%). The positive contribution of labour trends to growth in full-time employment was larger in every age group for women than for men, reflecting changes in female labour force participation and education.5 For part-time employment, large reductions were projected for men aged 45–49 and 50–54 years (26.69% and 9.66%, respectively), and large increases for women of all ages (Appendix 2).

As a result of the 347 000 PLYs lost because of a chronic condition in individuals aged 45–64 years, there was an estimated loss of GDP of $37.79 billion in 2010. In 2030, the loss of 459 000 PLYs will result in a projected GDP loss of $63.73 billion (expressed in 2010 dollars; Box 4). These projected reductions in GDP correspond to 9.47% of GDP associated with the 45–64-year-old subpopulation in 2010 and to 10.29% in 2030.

If the projected growth in the prevalence of chronic conditions between 2010 and 2030 was only half that assumed by our main analysis, an estimated 453 000 PLYs would be lost by those aged 45–64 years because of chronic conditions in 2030, resulting in a projected loss of GDP of $62.89 billion. However, if the projected growth is doubled, the estimated PLYs lost would be 589 000 in 2030, resulting in a projected GDP loss of $81.78 billion (expressed in 2010 dollars).

Discussion

Using output from Health&WealthMOD2030, we projected the number of PLYs lost because of chronic health conditions in Australians aged 45–64 years from 2010 to 2030. We established that there were 347 000 PLYs lost due to chronic disease in those aged 45–64 years in 2010, projected to increase to 459 000 in 2030.

The PLYs lost among older workers due to chronic conditions are likely to have significant flow-on effects for individuals and governments. Our group has previously calculated the substantial impacts of ill health on all-source income, taxation and welfare payments for older workers (and government) in Australia in 2010.2,13 We also found that ill health resulted in significantly lower incomes and lower accumulated wealth and savings for those who had retired early because of their ill health22 and a greater risk of poverty.23

Our study has a number of limitations. First, the impact of chronic disease on labour force participation is based on respondents’ self-reports of their main chronic condition. Although self-reported health is considered a valid parameter,24 bias in the results cannot be excluded. Second, the SDACs 2003 and 2009 provided cross-sectional data. It is therefore possible to identify correlations but not causal relationships between parameters. It should be noted, however, the SDAC surveys included a specific category for being out of the labour force because of chronic disease (“own ill health or disability”) that could only be selected by those who had first stated they were not in the labour force. We thus identified those who are not in the labour force and then the main reason for their not being in the labour force (eg, ill health).

As the population ages, it is crucial that governments continue to adopt measures that retain as many working-age individuals in the labour force as possible. The former Federal Treasurer Wayne Swan noted in his 2011–12 Budget speech that: “… our economy can’t afford to waste a single pair of capable hands.”25 Retaining older people in the workforce will enable greater economic growth and provide government revenue for spending on vital services, including health care.5

Achieving these goals requires governments to take a more holistic approach to increasing labour force participation among older workers — an approach that considers the interaction of health, illness prevention, work capacity and government priorities (such as economic growth). Directing resources towards the introduction of effective interventions to prevent and treat the chronic conditions associated with the highest rates of premature exit from the labour force by older workers (back problems, arthritis, mental and behavioural disorders) is likely to improve the work capacity of this group (or, put another way, reduce the loss of PLYs predicted by our study) and thereby Australia’s future finances.

Box 1 –
Labour force status of Australians aged 45–64 years, projected to 2030

Labour force status	Survey records (%)	Weighted population (%)					Growth, 2010–2030
Labour force status	Survey records (%)	2010	2015	2020	2025	2030	Growth, 2010–2030

Employed full-time with a chronic condition	6076 (24.20%)	1 452 000 (26.03%)	1 565 000 (22.92%)	1 722 000 (27.02%)	1 830 000 (27.41%)	1 962 000 (27.52%)	35.12%
Employed full-time without a chronic condition	6606 (26.31%)	1 572 000 (28.18%)	1 653 000 (24.21%)	1 786 000 (28.02%)	1 864 000 (27.92%)	2 017 000 (28.29%)	28.31%
Employed part-time with a chronic condition	2812 (11.20%)	621 000 (11.13%)	1 565 000 (22.92%)	769 000 (12.06%)	825 000 (12.36%)	888 000 (12.45%)	42.99%
Employed part-time without a chronic condition	2373 (9.45%)	501 000 (8.98%)	536 000 (7.85%)	594 000 (9.32%)	632 000 (9.47%)	688 000 (9.65%)	37.33%
Unemployed or not in the labour force for reasons other than ill health	5827 (23.21%)	1 086 000 (19.47%)	1 129 000 (16.53%)	1 090 000 (17.10%)	1 092 000 (16.35%)	1 116 000 (15.65%)	2.76%
Productive life years lost due to chronic conditions in each year	1410 (5.62%)	347 000 (6.22%)	380 000 (5.57%)	413 000 (6.48%)	434 000 (6.50%)	459 000 (6.44%)	32.28%
Total population	25 104	5 580 000	5 945 000	6 374 000	6 677 000	7 130 000	27.80%

Box 2 –
Main chronic conditions of people aged 45–64 years not in the labour force due to ill health in 2010 and 2030

	Survey records		2010 population		2030 population		Ranking
	Number	%	Number	%	Number	%	2010 > 2030

Back problems (dorsopathies)	306	22.16%	79 000	23.27%	96 000	21.37%	1 > 1
Arthritis	208	15.06%	45 000	13.26%	60 000	13.31%	2 > 2
Mental and behavioural disorders	140	10.14%	32 000	9.58%	43 000	9.49%	3 > 3
Cardiovascular disease^*	94	6.81%	25 000	7.41%	30 000	6.70%	4 > 4
Depression (excluding postnatal depression)	94	6.81%	24 000	7.06%	28 000	6.33%	5 > 6
Injury/accident	78	5.65%	20 000	6.02%	29 000	6.44%	6 > 5
Diseases of the nervous system	79	5.72%	20 000	5.76%	26 000	5.86%	7 > 7
Other diseases of the musculoskeletal system and connective tissue	74	5.36%	16 000	4.76%	24 000	5.30%	8 > 8
Cancer	50	3.62%	15 000	4.29%	20 000	4.39%	10 > 10
Diabetes	46	3.33%	14 000	4.15%	22 000	4.95%	11 > 9
Asthma	34	2.46%	8000	2.50%	12 000	2.66%	12 > 13
Chronic obstructive pulmonary disease	22	1.59%	8000	2.22%	14 000	3.01%	13 > 12
Diseases of the digestive system	22	1.59%	4000	1.30%	8000	1.76%	14 > 14
Diseases of the ear and mastoid process	23	1.67%	4000	1.25%	6000	1.42%	15 > 15
Diseases of the eye and adnexa	18	1.30%	4000	1.06%	5000	1.10%	16 > 16
Other diseases of the respiratory system^†	9	0.65%	2000	0.60%	3000	0.77%	17 > 17
Other endocrine/nutritional and metabolic disorders	5	0.36%	1000	0.36%	2000	0.42%	18 > 19
Diseases of the genitourinary system	6	0.43%	1000	0.32%	2000	0.43%	19 > 18
Deafness/hearing loss, noise-induced	2	0.14%	342	0.10%	322	0.07%	20 > 20
All other conditions	71	5.14%	16 000	4.73%	19 000	4.22%	9 > 11
Not in the labour force due to ill health	1381	—	339 000	—	449 000	—	—

*Cardiovascular disease includes ischaemic heart diseases, stroke, high cholesterol level, hypertension (high blood pressure) and other diseases of the circulatory system. †Other diseases of the respiratory system include bronchitis/bronchiolitis, respiratory allergies (excluding allergic asthma) and emphysema.

Box 3 –
Contribution of main drivers to growth in productive life years lost and labour force participation between 2010 and 2030

Driver	Employed full-time		Employed part-time		Productive life years lost due to chronic conditions
Driver	With a chronic condition	Without a chronic condition	With a chronic condition	Without a chronic condition	Productive life years lost due to chronic conditions

Population growth (total)	81.97%	94.00%	63.21%	70.43%	89.18%
Growth due to population ageing (a component of total population growth)	-0.92%	-3.32%	1.23%	-3.32%	3.97%
Chronic disease trends	1.78%	-4.31%	0.53%	-2.73%	8.28%
Labour force trends	10.42%	8.39%	26.45%	26.78%	NA
Interaction effects	5.83%	1.92%	9.81%	5.52%	2.54%

NA = not applicable.

Box 4 –
Loss of GDP arising from lost productive life years caused by chronic ill health in Australians aged 45–64 years, 2010–2030 (expressed in $, billions)

2010	2015	2020	2025	2030

37.79	44.51	50.54	56.39	63.73

GDP = gross domestic product.

Financing options to sustain Medicare: are we committed to universalism?

Policies addressing health care financing should reinforce Australia’s commitment to the principle of universalism

The United Nations-initiated Sustainable Development Solutions Network (SSDN) has recently proposed the inclusion of universal health coverage (UHC) as a priority of the 2015–2030 Sustainable Development Goals to alleviate global poverty.1 Australia has established itself over a number of decades as a member of an elite group of mainly high-income countries that have been declared to have achieved UHC. Since 1975, through the social-national insurance programs, Medibank (1975–1981) and Medicare (since 1984), universal access based on need for medical services and pharmaceuticals has been the bedrock of Australian health policy. One therefore wonders whether the current SSDN discussions are relevant to Australia?

In addressing this question, UHC should be viewed as part of a continuum of levels of financial protection, in which population coverage, the type of services covered and levels of reimbursement are, in practice, never fully comprehensive.2 In Australia, the lack of coverage for dental services is a case in point, where, in an ostensibly universal health system, there has been long-term persistence of health inequities resulting from a lack of access to dental services, resulting in significant disadvantage, particularly in rural, low-income and Indigenous populations.3 Ultimately, UHC is never perfectly attained and the extent of financial protection it affords a population is something that can be eroded over time. It would be a mistake to view UHC as a one-off and irreversible achievement.

The trade-off between the need to secure the financial sustainability of the health system and that of maintaining fairness and universal access to services is inevitable. Cost-saving strategies have predictably gained centre stage, and discussion has consequently turned to areas where government funding can be cut. This was shown by the recent debate about proposals in the 2014 Federal Budget to introduce a $7 general practitioner copayment. However, two main problems have not been properly acknowledged in these discussions:

1. The already high level of reliance by government on out-of-pocket costs and the burden experienced by individuals and households with chronic and long-term conditions

According to the SSDN, at least 5% of gross domestic product (GDP) should be spent on health care to achieve UHC1 — a target that Australia meets comfortably. In the financial year 2011–12, it spent 9.5% of its GDP on health, slightly above the average for Organisation for Economic Co-operation and Development countries.4 However, the share of health expenditure paid by Australians in the form of out-of-pocket costs has risen steadily over the past decade; it is currently 17%.4 This is higher than for most other high-income countries and is proving to have a profound effect on regular users of the health care system, such as those with chronic illnesses and the elderly.5,6 Research in Australia has shown that many in these groups are incurring debilitating levels of out-of-pocket costs and, as a consequence, they experience economic hardship and impaired quality of life.6 Further, such costs have proven to be a barrier to optimal care, leading, for instance, to non-adherence to medication.5

The SSDN stresses that UHC financing options that reduce out-of-pocket spending should be promoted to ensure equality of access to necessary health care across the entire population.1 The significant opposition and eventual retraction of the $7 GP copayment proposal seemed to show the limit to which the Australian public can accept a greater burden of costs being shifted to patients. Nevertheless, this is not the end of the story, as legislation to increase pharmaceutical copayments is awaiting Senate consideration, and the freeze on Medicare rebates to GPs remains in place.7

2. The high and increasing amount of funding allocated to private health insurance subsidies

During the financial year 2014–15, the Australian government paid just over $5.9 billion for the private health insurance rebate delivered through the tax system or directly to private health insurance funds.8 This figure has been increasing steadily over many years, rising from $1.4 billion in 1999–2000.9

The rationale for government support for the private health insurance system is that it reduces pressure on the public sector by encouraging those who are able to afford private health cover to take responsibility for insuring for the cost of such treatment. Indeed, the amount of additional funding injected into the health system by the private insurance net of government subsidies during the financial year 2013–14 was about $11.2 billion — a 2 for 1 multiplier of the public subsidy given to the industry.10

A feature of Australia’s private health insurance system is that community rating is mandated by regulation. This means that private health insurers are unable to adjust premium levels according to the individual risk profile of a policyholder, and so are unable to explicitly discriminate through their pricing against high-risk individuals who are likely to be regular claimants on their policies (eg, people with chronic conditions). This regulatory constraint enables some degree of equity in access to private insurance. However, the requirement to set premiums on the basis of average community risk rather than individual risk exposes private health insurers to the problem of adverse selection in which they attract a predominance of high-risk individuals; ie, in this scenario, bad risks drive out the good risks.11 Government support through subsidies of health insurance premiums and tax rebates for individuals with health insurance coverage can therefore be seen as a charge to the community for ensuring the sustainability of a private health insurance industry that is faced with a regulatory requirement to community rate.

The financial burden of providing support to Australia’s private health insurance industry is likely to grow in the foreseeable future. In the 2015 Budget, the federal government asserted an ongoing commitment to this rebate, and its cost is estimated to increase to around $7 billion over the next 3 years.8 Research has shown that government support for private health insurance bears significant opportunity cost — eliminating the private health insurance rebate in Australia could lead to public sector savings that far exceed those predicted by increasing out-of-pocket primary health care costs for the patient.9 As the subsidies overwhelmingly benefit the wealthier households, redeploying some of these resources to relieve the pressure on individuals caused by increasing user charges would be a progressive measure.

It is against this background that one should view with caution recent interest in an expanded role for private health insurance in primary care. Reports of activity in this area show this role to be potentially akin to America’s managed care programs that encompass priority and expedited appointments and fee-free care for policyholders.12 Moreover, the 2014 National Commission of Audit has suggested making private health insurance for basic health services compulsory for higher income earners to make Medicare more sustainable.13

As outlined in the SSDN report,1 there are many ways a country can mobilise money to meet the financial pressure associated with increased health care demands, apart from user fees and private health insurance (Box). Some solutions are less controversial to implement, such as improving spending efficiency in primary health care through the Choosing Wisely campaign.14

Maintaining the health of UHC in Australia requires regular check-ups, and the current global discussion of UHC provides an opportunity to reflect on the direction that we are taking. In its most recent assessment, the federal government asserted that a strong, sustainable Medicare requires well-off patients contributing more to the cost of their health care than those less well-off.15 It seems that the current direction in which we have been looking to finance our growing health care needs in Australia is at odds with this mission, and more generally with global initiatives to establish and sustain UHC.

The fundamental reason for establishing Medicare in Australia was to provide equal access to affordable health care for anybody in need. With increasing pressures on public finances, and current policies that increase the role of private health insurance and patient contributions to the financing of health care, it is time to take a step back and to reinforce our commitment as a nation to the principle of universalism.

Financing universal health coverage (adapted from the Sustainable Development Solutions Network report)1

Raising revenue through taxation

Revise tax policy to prefer taxes that potentially improve public health; eg, reducing fossil fuel subsidies, taxing harmful emissions to improve air quality
Reforming legislation on tax havens, corporate tax rates and financial transparency of multinational corporations

Make spending more efficient

Invest in cost-effective preventive care
Reduce the use of services and treatments that offer little or no benefit by implementing Health Technology Appraisal programs and routine assessments of value in practice
Reassess purchasing plans and provider payments; link payments to value in practice and institute globally set budget caps
Task shifting to non-physician health workers, and increased used of information technology in hard-to-reach locations

Special collection on Indigenous health

August 9 marked the United Nations International Day of the World’s Indigenous Peoples. This year’s theme was “Ensuring Indigenous peoples’ health and wellbeing”.

To mark this occasion, the National Health and Medical Research Council (NHMRC), Canadian Institutes of Health Research (CIHR) and Health Research Council of New Zealand (HRC) came together with the Cochrane Collaboration to publish a series of special collections of the Cochrane Library (http://www.cochranelibrary.com) on Indigenous health. This initiative is the latest to emerge from a 2002 tripartite agreement between NHMRC and our sister agencies in Canada and New Zealand (https://www.nhmrc.gov.au/_files_nhmrc/file/your_health/indigenous/tripartite_letter_of_intent_for_web_121127.pdf) in which we cemented our commitment to working together to reduce the gap in health outcomes between our non-Indigenous and Indigenous peoples.

The Special Collection focuses on three topics, each of which involves a significant health burden for Aboriginal and Torres Strait Islander peoples: prevention of suicide, foetal alcohol spectrum disorder, and diabetes. The collection was compiled to engender greater awareness of disparities in health outcomes for Indigenous peoples globally, and to raise awareness of the need for better and more relevant research in each of these areas. For example, in the case of suicide prevention, most Cochrane reviews evaluate pharmacological interventions. None have evaluated non-drug interventions alone or community-based interventions. None of the Cochrane reviews of drugs appear to have involved studies in Indigenous populations.

If conducted well, and if they address relevant questions, systematic reviews have the potential to make significant improvements to health and health care — particularly if they are used as the basis for clinical practice, or public health guidelines and health policy. We hope that this collection will provide food for thought for producers and users of health and medical research.

Stronger general practice key to Primary Health Care reform

The AMA Submission to the Government’s Primary Health Care Review highlights the robustness of the Australian health system, particularly the crucial role of general practice, and stresses the need to build on the proven track record of general practice with significant new investment.

AMA President, Professor Brian Owler, said this week that the Review must focus on strengthening the parts of the system that deliver quality, accessible and affordable care to the community, most notably general practice.

Professor Owler cautioned the Primary Health Care Advisory Group’s (PHCAG) against change for change’s sake and pursing reforms of which there is only very limited evidence about any significant positive impact.

“The AMA has put forward to the PHCAG a measured, workable plan to improve access to care for patients, particularly those with chronic disease,” Professor Owler said.

This includes practical reform of existing MBS Chronic Disease items, funding directed to general practice to support pro-active models of care coordination and incentives to support quality improvement.

For the Review to have genuine credibility, the Government must change its reform language – it must start talking about primary care reform as an investment, not a cost or a saving to the Budget bottom line.

“There is no doubt that extra investment in general practice will deliver long term savings to the Government, and improve the sustainability of the health system.

“The Government needs to take a long term view and make this investment now, in the knowledge of savings in later years, better patient outcomes, and less pressure on our hospital system.

“Significant new investment in general practice and the urgent need to lift the current freeze on the indexation of Medicare patient rebates must be priorities for the Review, or they will be priority issues for voters at the next election,” Professor Owler said.

“The Government has raised the expectations of the community, as well as stakeholders, and it must now deliver the significant real new investment needed to achieve genuine reform that benefits patients and communities.”

AMA Submission to the Primary Health Care Review

This post was first published on GP Network News.

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Suburbs with higher diabetes rates have more access to takeaway food, alcohol

When looking at rising type 2 diabetes rates, we need to also look the availability of fresh food in the local geographical area, experts say.

In a perspective published in today’s Medical Journal of Australia, research has found that people living in western Sydney have a higher access to takeaway and alcohol shops than those living in Sydney’s north shore.

There are also much higher rates of Type 2 diabetes rates in western Sydney, particularly around the suburbs of Mount Druitt and Blacktown.

Dr Thomas Astell-Burt, Director of Public Health Sciences at Western Sydney University, and Dr Xiaoqi Feng, Senior Lecturer in Epidemiology at the University of Wollongong calculated the number of greengrocers, supermarkets, takeaway shops and alcohol outlets within 15–20 minutes’ walk from a person’s home.

“About 28% (868/3148) of neighbourhoods in the west had at least [a 3:1] ratio of takeaway shops to greengrocers and supermarkets, in comparison to 20% (546/2744) in the north,” they report.

“The equivalent results for alcohol outlets were 12% (365/3148) in the west and 5% (131/2744) in the north.”

They said in Sydney’s west, the availability of fresh produce within a reasonable walking distance was limited.

These preliminary findings are from the Mapping food Environments in Australian Localities (MEAL) Project, which was initiated in 2014 to explore geographical inequities in food environment in metropolitan Sydney.

The researchers say the findings indicate that more needs to be done to help people struggling with Type 2 diabetes.

“We have to invest in multisectoral change for which the health benefits may only be realised in the long term,” they write.

Read the full perspective in the Medical Journal of Australia.

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Surgeons apologise for extreme culture of bullying

The Royal Australasian College of Surgeons has apologised for discrimination, bullying and sexual harassment by surgeons.

The apology comes after a draft report and recommendations were released by an Expert Advisory Group (EAG), commissioned by RACS in response to reports of bullying behaviour in the surgical field.

The report found there is culture of bullying that is considered a ‘rite of passage’ within the College with the intent to prepare trainees for surgery.

Although the report admits that not all surgeons behave ‘badly’, there are individuals or groups who wield power and are repeat offenders. There is a lack of accountability structures in place which results in a major stumbling block for change.

“The EAG Report has identified that many of those affected have not felt they could trust the College to complain,” RACS President, Professor David Watters said in a video message.

“These behaviours have been too long tolerated and have compromised the personal and professional lives of many in the health workforce,” he said.

The report found that 49% of Fellows, Trainees and International Medical Graduates (IMGs) report being subjected to discrimination, bullying or sexual harassment. It also found that 71% of hospitals reported discrimination, bullying or sexual harassment in their hospital in the last five years, with bullying the most frequently reported issue.

EAG Chair, Hon. Rob Knowles AO said: “We have been shocked by what we have heard. The time for action has come.”

Woman told to ‘get tubes tied’

The report found that minority groups, particularly trainees and women, were the main targets of bullying.

Women were subjected to sexual harassment including demands for sexual intercourse and were not considered suitable for surgery by many of the bullies. Survey respondents reported discrimination for pregnancy and for asking surgeons for part time hours or time off to care for sick children.

The report noted comments from survey recipients such as:

“I was told I would only be considered for a job if I had my tubes tied.”

“I was expected to provide sexual favours in his consulting rooms in return for tutorship.”

“I felt sure I was marked down because I didn’t respond to my supervisor’s sexual advances.”

Racial discrimination was a recurrent theme, the EAG reports, with active measures to exclude surgeons from practice in Australia. Survey respondents reported incidents of abuse such as:“They want you out of the country or they want you dead.”

“I still fear that he could ruin my reputation and destroy my life”

The report talked about the fear encountered by surgeons, even in participating in the survey itself. Most of the fear was about career loss, particularly how much time, effort and expense had gone into their career thus far. One respondent wrote: “Reputation is everything…public hospital appointments depend on reputation.”

Respondents felt that power and lack of accountability had led to the issues that exist today. They felt that there was a lack of accountability from top surgeons as well as a lack of accountability and action from hospital administrators.

“There is a hierarchical system which is often dictated by senior consultants behaving in a chauvinistic manner, which I believe has been handed down over time. The acceptance/tolerance of appalling behaviours in the past has no doubt enabled the tradition of bullying/narcissism to continue,” a survey respondent wrote.

Report recommendations

The report has five key recommendations, which include undertaking a review of process in relation to complaints, provide avenues of support including mentoring programs and contact officers.

They say the college should provide for greater measures of accountability, develop training and awareness programs to help lead and influence and continue to review their structures for more inclusive practice.

Professor David Watters says the college fully accepts the recommendations and will publish an Action Plan by the end of November that addresses the issues raised.

“All Fellows, Trainees and International Medical Graduates (IMGs) will need to champion and model the high standards of behaviour we expect of others,” he said. “There is no place for discrimination, bullying or sexual harassment in surgical practice, surgical training or the health sector more broadly,” Professor Watters said.

Read the full report on the RACS website.

The Draft Report is now open for comment about errors of fact or suggestions for action that will strengthen the EAG’s recommendations. Comment can be emailed to eag@surgeons.org by 18 September 2015, before the EAG finalises its recommendations to the College on 21 September 2015.

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Profession united in approach to MBS Reviews

The AMA last month convened a high-level Roundtable of the medical colleges, associations, and societies to discuss the profession’s involvement in, and response to, the Government Reviews of items on the Medicare Benefits Schedule (MBS).

The meeting was attended by over 70 people, representing 53 organisations.

Professor Bruce Robinson, Chair of the MBS Review Taskforce, made a presentation to the meeting and responded to questions from the floor.

Following the meeting, AMA President Professor Brian Owler wrote to Health Minister Sussan Ley to inform her that the profession would be united in its response to the Reviews, and outlined some of the major concerns arising from the meeting.

Here is the text of that letter …

I am writing to you to set out broad concerns with the Medicare Benefits Schedule (MBS) Reviews: the broadened scope that will impact long standing arrangements; the composition of the review working groups; and that new items are out of scope.

The AMA is concerned that the Reviews will be undertaken in the absence of an overarching vision and specific direction for the Australian healthcare system to guide the final outcomes.

In addition, as there are no specific and quantifiable aims, other than delivering better patient outcomes, there is a risk that the scope of the reviews will extend into dangerous territory, whereby the fundamental structure of our healthcare system will be interfered with.

The latter was highlighted in Professor Bruce Robinson’s presentation to a forum of the medical colleges, specialist associations, and societies convened by the AMA on 19 August 2015 to discuss the medical profession’s involvement in the MBS Reviews. Professor Robinson made a presentation to the group and very generously answered all of the participants’ questions.

We learnt that the Reviews will now also consist of groups to review “macro issues and rules”, and that this will consider issues such as referral arrangements and the potential removal of surgical assistance fees. We heard that patients find it inconvenient to visit their GP for a referral to a specialist. Given that the referral arrangements are the most fundamental feature of our healthcare system, providing the gateway to clinically necessary tertiary care, it is incredible that such a change might be contemplated in an environment where Government wants to reduce expenditure.

In addition, the surgical assistance fees support the very basis of vocational training in Australia. Removal of them will have a significant impact on the training opportunities and therefore the future medical workforce. It is equally incredible that a change to these arrangements is being contemplated.

On both these issues it is not clear what the objective is, and therefore why they would even be on the table for review.

The 70 participants representing 53 medical organisations at the AMA forum were extremely vexed by this latest turn of events.

Working groups

The profession is very concerned that the working groups will not comprise a representative from the relevant specialist college, association or society. While working group members will be able to “confer with colleagues”, it is more appropriate for professional organisations to be formally included in the working groups. We believe this is critical to professional buy‑in to the outcomes of the Reviews, as well as continuity of the professions’ participation in the ongoing maintenance and management of the MBS into the future.

Further, there are potential problems with the members of the in-scope speciality discipline comprising less than 50% of the working group numbers, with decisions to be made using a >60% majority. The equation has the potential to arrive at incorrect outcomes because the members of the speciality discipline with the knowledge and expertise will be in the minority. We appreciate the need to transparently manage conflicts of interest, but this should not be at the expense of arriving at sensible outcomes in the decision making process.

New items

The medical profession supports an MBS that facilitates patient access to evidence based modern medical procedures and practice. This cannot occur if the review process is limited to removing obsolete and infrequently used items, and working groups are not able to consider and recommend the inclusion of new items on the MBS. While there is scope to update items, this may not always be the best way to bring the MBS up to date, and the objectives of the Reviews will be only partly achieved.

In many cases, completely new items for procedures that have evolved in the 20+ years since they were first included on the MBS will be the only sensible outcome. If this is not resolved, the Reviews could thwart patient access to services that have been provided for several years even though they are not explicitly catered for in existing items. If the rapid review questions are appropriately framed, these services should be substantiated by the relevant literature.

There must be capacity to include new items on the MBS as a result of the reviews, which does not involve a full health technology assessment and consideration by the Medical Services Advisory Committee.

Professor Brian OwlerAMA President

Based on discussions at the MBS Roundtable, the AMA compiled the following list of issues for medical colleges, associations and societies to consider and discuss in preparing for the Reviews.

1. Identify how the MBS should be changed to reflect current practice

Identify current practice for specific services.
Describe those services and the clinical circumstances for which they are intended.
Identify how the MBS currently covers those procedures.
Determine what is needed for the MBS to properly reflect current practice.
Identify services that are new due to ‘evolution’ and therefore require an update to the item descriptor compared to ‘novel’ services where there is new technology used.
Identify the time period in which the ‘novel’ service/s was introduced in your practice.
Identify items that can be deleted and the reasons for deleting them.
Frame the questions that will form the literature review.
Determine what data you need to demonstrate/inform the changes.

2. Identify the key participants

Identify who of your colleagues is best placed to represent you.
Identify the craft groups that also provide the services.
Identify the craft groups that do not provide the services, but whose clinical practice might be affected.
Anticipate how they might respond.

3. Identify other issues

Are there quality considerations?
Are there compliance issues?
What are the likely impact on business structures of the changes and what transition is needed?

4. Guiding principles for participating in the reviews

Ensure services support best practice, provides value for public expenditure and supports quality, safe and effective care that is appropriate to the patient’s needs and circumstances.
Avoid limiting services to specific specialties, expertise, scope of practice, credentialing, and/or endorsement arrangements. If there are safety and quality issues, consider how these can be best dealt with i.e. medical registration and/or hospital credentialing arrangements.
Accept the MBS rebates are inadequate. The reviews are not the vehicle to address inadequate rebates, and certainty not at the expense of another specialty group.
Share information about the reviews to ensure consistent outcomes and clinician participation throughout the review process.

The MBS Review Taskforce is seeking nominations from clinicians to participate in clinical committees and working groups. The Taskforce is seeking people who have sound clinical knowledge and experience, are committed to interpreting evidence and research, and are interested in furthering the objectives of the Review. Nominations can be made to MBSReviews@health.gov.au providing the name, position, clinical expertise, and email contact.

Information about the reviews can be found at

http://www.health.gov.au/internet/main/publishing.nsf/Content/healthiermedicare

John Flannery

Medibank saga remains unpreventable

The full page ads last week in some capital city papers may have heralded ‘peace in our time’ in the dispute between Medibank Private and Calvary Health, but the big insurer’s approach to safety and quality in our hospitals is still in question by hospitals, doctors, and patients.

While Medibank and Calvary may have finally signed a contract, the detail of the belated agreement remains top secret.

While the AMA agrees that any commercial details should remain private, it is in the public interest that any agreement over Medibank’s draconian list of 165 preventable events should be disclosed.

Calvary CEO, Mark Doran, told Adelaide radio that Medibank Private had agreed to engage with the Australian Commission on Safety and Quality in Health Care on what they believe are preventable events, and that they will act on the call for an independent clinical review process. But that’s about all we get to know at this stage.

AMA Vice President Dr Stephen Parnis said that Medibank’s ‘trust us, we’ll do the right thing by you’ response is not good enough.

“I’m a doctor and I don’t say that sort of thing to patients anymore,” Dr Parnis said.

“I’ve got to give them the specifics. And I think Calvary and Medibank Private need to do the same here.

“We’d like to understand exactly what the arrangements are with regard to that long list of 165 complications, which Medibank was erroneously calling mistakes, to understand what is going on with those as a result of this new agreement.

“The concern, of course, is that if you’re insured it’s the detail that tells you what you’re covered for and what you’re not covered for.

“The treating doctors need to understand what their patients will be covered for so that they can treat them in the appropriate setting.

“Up to now it’s been hardball by Medibank.

“The AMA rarely intervenes in these sorts of disputes but, because it has such wide-reaching implications for the health system, both private and public, we have regarded this as essential that, one, it gets sorted out, and, two, that it is done in a transparent way.

“It is positive that the Commission for Safety and Quality in Health Care is now involved.

“The Commission does things the right way when these complications are being assessed to try and reduce risk, rather than what was happening with Medibank saying these are not complications, they’re mistakes, and if they occur we’re not funding them or we’re dramatically reducing our funding.

“So we need more detail here because it doesn’t just affect Calvary and it doesn’t just affect Medibank Private. Every other player in the health system is watching on here.

“If this sets a good precedent, wonderful. If it doesn’t, then it’s going to have repercussions for everyone.”

John Flannery

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Information regarding payments under the previous GP Rural Incentives Program

On 1 July the GP Rural Incentives Programme (GPRIP) moved to the new classification system, the Modified Monash Model, which entailed the introduction of new eligibility criteria for doctors and new payment levels.

The AMA recently sought advice from the Department of Health regarding the Department’s process for issuing final payments under the previous GP Rural Incentives Program, which ceased on 30 June 2015.

The Department advised that those doctors that completed 4 active quarters at the end of June 2015 will receive their payments as normal from August 2015. Those doctors that have more than 1 but less than 4 active quarters at 30 June 2015 will receive a final pro-rata payment in November 2015.

To enable the payment of service provision under 12 months, the Department of Health and the Department of Human Services are making significant changes to the current payment system model. The Department has advised that these changes have caused the delay in the dates when payments were expected to occur.

As of 1 July 2015, assessment of payments under GPRIP will be based on the new criteria. The first payments under the new arrangements will occur from June 2016 to eligible medical practitioners who have completed the required number of active quarters.

For more information visit the Department’s Rural and Regional Health Australia website.