more_vertWe welcomed The Lancet’s Editorial (May 5, p 1750)1 about the release of the seventh US Centers for Disease Control and Prevention (CDC) Autism Developmental Disabilities Monitoring Network (ADDM) report.2 This report is based on surveillance of health and education records of samples of more than 300 000 children aged 8 years from 11 US states since 2000. The latest CDC report for 2014 documents a further increase in the prevalence of autism spectrum disorder, from 14·4 per 1000 children in 2012, to 16·8 per 1000 in 2014.
Preference: Education
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Exams rigged against female applicants in Japan
One of Japan’s leading medical schools has been automatically reducing the entrance exam scores of female applicants by 20 per cent for at least 12 years to graduate more male doctors, an independent inquiry has found.
The case has been examined in a report in the British Medical Journal (BMJ).
According to the BMJ, Tokyo Medical University’s acting president, Keisuke Miyazawa, admitted to the exam rigging at a press conference on 7 August after the release of a damning report by external lawyers.
“For those people whom we have caused tremendous hardship, especially female candidates whom we have hurt, we will do everything we can,” he said.
Miyazawa said that the school was considering options including financial compensation and retroactive admission of some women who would have passed without the automatic deduction. He said that he had not known of the score manipulation.
Tetsuo Yukioka, the school’s executive regent and chair of its diversity promotion panel, stood beside him.
Both men spent much of the press conference with their heads bowed in an attitude of shame.
“Society is changing rapidly and we need to respond to that, and any organisation that fails to utilise women will grow weak,” Yukioka said. “I guess that thinking had not been absorbed.”
Kenji Nakai, a lawyer who led the inquiry, said that the rigging had been ordered by the former chair of the board of regents, Masahiko Usui, 77, with the approval of the former president, Mamoru Suzuki, 69.
Both men resigned last month amid allegations that they had inflated the exam score of the son of Futoshi Sato, a health ministry official, in return for increased research funding. Usui, Suzuki, and Sato have all since been charged with bribery.
As well as discriminating against women, the school secretly penalised men who had failed the entry test more than twice before. The school had far more applicants than places – only one in 11 men and one in 33 women who tried for a place succeeded in 2018 – so multiple attempts were common.
A computer algorithm automatically deducted 20 per cent from the score of everyone taking the first multiple choice segment of the entrance exam.
Men taking the test for the first or second time were then re-awarded 20 per cent, men taking it for the third time were given back 10 per cent, and men taking it for the fourth time – plus all women – were given back 0 per cent.
The investigators also found 18 instances of applicants’ scores being inflated in return for donations to the school or bribes to its officials. In one case, a student’s mark had been raised by 49 per cent in return for a donation to the school.
Investigators examined records dating back to only 2006 so that they could report their findings earlier, said Nakai.
The principal motive for the discrimination, he said, was the perception that female doctors are more likely to quit the profession young to have children, exacerbating a doctor shortage.
Because medical graduates in Japan typically work in hospitals affiliated to their medical school, this would be a problem for the institution itself, not just for society at large.
‘Profound sexism’ among the school’s leadership also played a role, said Nakai.
The revelations have released a torrent of online criticism, much of it under the hashtag, “It’s okay to be angry about sexism”.
Female doctors in Japan have complained that staying in the profession is almost impossible after having children because childcare services are lacking and because women are expected to perform all household tasks while also working the extremely long hours demanded of male doctors.
The number of Japanese children waiting for kindergarten places this year rose to 55 000. The health ministry, which is also responsible for welfare programs, has announced plans to add 320,000 childcare places by 2021.
Suspicion is now widespread in Japan that exam rigging against women is not limited to one medical school. The education minister, Yoshimasa Hayashi, said yesterday that he plans to examine entrance procedures at schools around the country.
He will also decide what action to take against Tokyo Medical University after studying the report, he said.
Coalition’s own goal on health policy
Scott Morrison is the new Prime Minister, Peter Dutton’s ambitions have been put on hold (for now), Malcolm Turnbull will leave politics, and it is highly unlikely that Greg Hunt will be back as Health Minister (having run as Deputy to Peter Dutton).
Over the coming hours, days, and weeks, there will be resignations, recriminations, a new front bench, and a new direction for the Coalition Government under Scott Morrison.
But through the murkiness of the Government’s leadership crisis this week one thing is starkly clear – the Coalition has scored a massive own goal on health policy with a Federal election just months away.
To continue the football analogy, the Government has gone into a penalty shootout to decide the World Cup final without a goalkeeper.
Come election day, Labor could well have free shots at goal on public hospital funding, private health insurance, the MBS review, primary care reform, and prevention – just for starters. And that is before Mediscare Mark 2 kicks in.
Yes, Labor is well prepared to repeat the tactics of 2016 to undermine the Coalition’s credibility on health. And the polls provide further ammunition.
With Greg Hunt’s resignation ahead of the leadership spill, the Government lost its third Health Minister since its election win in 2013.
After the co-payment disaster under Peter Dutton and the loss of Sussan Ley after her promising start in the key but complex health portfolio, things were looking pretty good for the Government and the sector with Greg Hunt at the helm.
Minister Hunt had won the trust and confidence of the profession, and had quickly developed a solid knowledge across the breadth and depth of health policy and the major players in the sector.
He was also a master at the PR side of health – lots of new drug announcements, photo ops with kids in hospitals, and a Ministerial office with an open door for advocates, lobbyists, and campaigners, including successive AMA Presidents.
He oversaw the gradual lifting of the Medicare freeze.
He was managing the MBS Review and the PHI Review with end dates in sight for reporting and implementing outcomes.
There was even talk of the Coalition matching Labor’s promise on public hospital funding.
He was fixing the My Health Record legislation to give greater confidence on security and confidentiality – and pledging a big education campaign to convince the Australian people to stay opted-in.
And he was working with the AMA and others to develop a bold new vision for general practice and primary care.
Greg Hunt was across his brief and had strong and friendly working relationships with most of the major health sector players.
The failed Health Care Homes trial and the botched launch of the My Health Record opt-out phase are negatives, however.
Now he is gone, and with him a lot of the hope that genuine meaningful health reform was within reach.
With the Federal election due in the first half of 2019 – but now possibly much earlier – the Coalition must go back to square one to rebuild its health policy credentials.
Sure, the bureaucratic machinery will continue behind the scenes with the various reviews, but there is no longer a credible messenger or an experienced tactician to craft the strategic political health messages that are needed to win votes in the limited time available.
With no obvious strong candidate on the horizon to take over Health, there is an outside chance that new PM Scott Morrison might try to make peace with the warring factions and keep Hunt in the portfolio. We will see.
You need a good spinner to be a winner. It is indeed an own goal.
Shared Responsibility
BY DR RICHARD KIDD, CHAIR, AMA COUNCIL OF GENERAL PRACTICE
New amendments to the Health Insurance Act 1973, strengthening the Government’s debt recovery powers and seeking to tackle the role of corporate entities in billing under Medicare, have recently been passed by Parliament.
Practitioners may have a debt to the Commonwealth raised against them due to receipt of incorrectly, inappropriately, or fraudulently claimed Medicare benefits. However, according to the Government, a large proportion of these debts has proven difficult to collect. New powers will allow the Department of Human Services to off set a portion of future bulk billed claims against debts. If the practitioner doesn’t bulk bill, the new arrangements will allow garnisheeing of other funds owed to them.
So, more than ever, it is in practitioners’ interests to get their claiming right from the outset.
The problem, as many of you have no doubt found, is trying to get clarity when you are unsure of how to interpret an item or an applicable rule. The Department of Human Services ‘ask MBS’ email for billing enquiries was supposed to provide this. However, the answers are often very unclear or non-committal.
What you are likely to get today, at best, is the regurgitation of either the item descriptor, rules, or legislation back in response to a query. At worst, you will get a misinterpretation and advice that is contrary to the rules. The incorrect advice recently provided to a GP Registrar that GPs could not claim a consultation when providing a vaccination, where the vaccine is funded under the National Immunisation Program, is a prime example.
This is not good enough and must be addressed! The AMA Council of General Practice recently made this point to the head of compliance at the Department of Health. If the Department hopes to increase compliance through education, it needs to have on staff medical advisers who understand the legislative requirements and have experience in their application. The Department of Health should also consider bringing ‘ask MBS’ within its realm of responsibility.
The other legislative change, which will take effect on 1 July 2019, is provision for a Shared Debt Recovery Scheme. To date, all the liability for a Medicare debt has been with the individual practitioner, except in cases where another party has engaged in fraud. The new change provides that, where contractual or other arrangements exist between a practitioner and an employer or corporate entity, both may be held responsible for the repayment of the debt.
What the percentage split of the liability between the employing/ contracting organisation and the individual practitioner is, is still to be finalised. Although it is likely it will be similar to the average of current billing splits. Both sides will have the opportunity, where a shared debt determination is made, to make a case for a review of assigned liability.
The objective of this measure is for a fairer assignment of liability and to facilitate greater billing assurance from a practice level as well as from the practitioner level. This is a proposal that the AMA strongly supported as part of improving debt recovery arrangements.
We are still to see how these new compliance arrangements will play out in practice. Most GPs seek to do the right thing, and the AMA be watching the implementation of these measures with interest to ensure its fairness and appropriate application
[Editorial] Half measures on children’s mental health
In December, 2017, the UK Department of Health and Social Care and the Department for Education released Transforming Children and Young People’s Mental Health Provision, a green paper proposing changes to the way that mental health services are provided to children. The proposal calls for an additional 8000 staff in Child and Adolescent Mental Health Services (CAMHS), which account for 0·7% of the National Health Service’s (NHS’s) £125 billion budget, to create new Mental Health Support Teams in schools.
[Perspectives] George F Gao: head of China CDC signals a more global outlook
Had the state bureaucracy been allowed to determine the career path of George F Gao (Gao Fu), the current Director-General of the Chinese Center for Disease Control and Prevention (China CDC) might now have been working not as one of his country’s leading scientists but as a vet practising in Shanxi province near the border with Inner Mongolia. This was where Gao was born in 1961. In the China of that era, personal choice in education was not a priority; Gao was allocated a place to study veterinary medicine at Shanxi Agricultural University.
Two decades of community service
Family Doctor Week
Australian Capital Territory – Dr Rashmi Sharma OAM
About 20 years ago, Dr Rashmi Sharma opened a medical practice in the southern suburbs of Canberra with her sister Divya.
Today, the Isabella Plains Medical Centre is a thriving practice and Dr Sharma is a recipient of the Order of Australia Medal.
She is a Clinical Associate Professor at the Australian National University’s Medical School, the head of education for GP Synergy, sits on numerous Government committees and, as a Practice Principal at Isabella Plains Medical Centre, regards herself as a portfolio GP.
“I think the joy of general practice is the privilege of joining with some of your patients through their lives with them,” Dr Sharma said.
“Of the all the caps I wear, general practice is the one thing I enjoy the most. Sitting in a little consultation room with a patient is very satisfying. It keeps me grounded
“I have been in this practice about two decades – I started it with my sister who is also a GP. I have seen patients grow up and start families.
“I bumped into a patient on the street the other day and I hadn’t seen them for some years, yet I remembered the condition of their child. We have patients for life.
“And we are not just looking after patients, we are looking after the community. We have been looking after the southern parts of Canberra for two decades. We have second and third generation patients.”
As the head of education at for GP Synergy, Dr Sharma has had to spend considerable periods in New South Wales, looking after about 200 registrars the provider is training.
In recent times, she relocated to Northern New South Wales where she grew up. But that has not stopped her work in Canberra.
“I couldn’t give up my practice in Canberra. I only do general practice in Canberra,” she said.
“So, I kind of fly-in fly-out, but so much of my medical work is in Canberra.
“Some days I might see 30 patients in the clinic. We have a lot of nurses too who do a great job. We started this clinic and went from four doctors to 17 doctors, and from no nurses to seven nurses. We feel very proud of what we have been able to do for this community.”
CHRIS JOHNSON
Your patients’ health in their hands
Information for AMA Members from the Australian Digital Health Agency about My Health Record.
By Professor Meredith Makeham
Australians are being offered an important choice over the next three months about how they want to interact with their health information.
By the end of 2018, all Australians will have a My Health Record created for them, unless they choose not to have one.
The decision, importantly, is theirs to make after considering the benefits of having immediate online access to their health and care data, and being able to share it with their clinicians.
They will have access to information such as their medicines and allergies, hospital and GP summaries, investigation reports and advance care plans which could not only save their life in an emergency but also help their clinicians find vital information more quickly so that they can make safer health care decisions.
Trusted health care providers – GPs, specialists, pharmacists and others – are likely to find their patients want to talk to them about their decision. The My Health Record system is here to support better, safer care – not to replace current clinical record keeping systems or professional communication. Neither will it replace the patient-doctor relationship and clinical judgement. It is simply a secure online repository of health data and information that wouldn’t be accessible otherwise.
The data flows into the record from securely connected clinical information systems in hospitals, general practices, pharmacies, specialists’ rooms, and pathology and radiology providers. It also provides access to Medicare Benefits Schedule (MBS) and Pharmaceutical Benefits Scheme (PBS) data, the Australian Immunisation register and the Australian Organ Donor registry.
People understandably want reassurance that the Australian Digital Health Agency (the Agency) holds the privacy and security of their health information as its first priority. The system’s security has not been breached in its six years of operation. There is no complacency however – My Health Record system security operates to the highest standards, working with the Australian Cyber Security Centre and others. It is under constant surveillance and threat testing.
The legislated privacy controls are world-leading and easily accessed on the consumer portal. They include features such as a record access control – similar to a PIN – that a person can apply to their entire record so it can’t be viewed unless shared with their clinician. In an emergency, the legislation allows a clinician to ‘break glass’ and see vital medicines and allergy information. However, all instances of this are audited and people can choose to receive a text or email informing them if this happens.
The steps required for a healthcare practitioner to view a My Health Record require a number of security authentications to take place. For a provider to access the My Health Record via their clinical information system, they must be a registered health care provider – for example, registered with the Australian Health Practitioner Regulation Agency. They must also have a valid provider identifier and work in an organisation with a valid organisational identifier.
Software must be conformant, with a secure and encrypted connection to the My Health Record system. In addition, the patient must have a record on the provider’s clinical information system as a patient of the practice.
The Agency has not and will not release documents without a court/coronial or similar order. No documents have been released in the past six years and no other Government agencies have direct access to the My Health Record system.
We know 230,000 hospital admissions occur every year as a result of medication misadventure, costing the Australian taxpayer $1.2 billion annually. Many of these could be avoided if people and their clinicians had better access to vital medicines and allergy information.
The ‘Medicines View’ is a recent addition to My Health Record. It provides a consolidated summary of the most recent medicines information from notes entered by GPs, hospitals, pharmacies and consumers.
Over the past 12 months, the system has enriched its clinical content. Public and private pathology and imaging providers are now connecting and a vast increase in connected pharmacy systems as well as hospitals has occurred. This will accelerate the realisation of benefits as clinicians find they can access a more comprehensive source of information within the My Health Record system.
This month, a national communication plan was launched to ensure Australians are well informed when making their decision. Almost 20,000 My Health Record education kits were distributed to GPs, community pharmacies, aboriginal health services, post offices and public and private hospitals.
Our role as health care providers is to be our patients’ advocate, to support them in making the decisions and choices that will lead to better health outcomes and ensure that they have access to safe and effective care. My Health Record isn’t here to solve all of our problems, but it is an important step forward in our ability to deliver a safer and better-connected healthcare system.
Clinical Professor Meredith Makeham is Chief Medical Adviser of the Australian Digital Health Agency.
Senate Seeking Action on Stillbirths in Australia
Labor Senator Kristina Keneally has wasted no time since joining the Senate earlier this year, in driving the establishment of a Senate Inquiry into Stillbirth Research and Education.
Six babies a day in Australia are stillborn. One in 135 births in Australia will be a stillbirth.
Senator Keneally told the Senate that rate of stillbirths in Australia have not shifted for two decades, a tragedy that is also personal. Senator Keneally’s daughter, Caroline was stillborn in 1998.
“Stillbirth is an often overlooked, under-investigated and ignored public health issue,” she said when recommending the Inquiry to the Senate.
“It has significant economic impact. Surely we, as a country, can do better than this. There are things that we know that we’re not telling parents that could help them prevent stillbirth, and there are things we could know better with better data collection and more coordinated and better funded research.”
The Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) welcomed the Senate Inquiry, adding: “A large proportion of stillbirths are unexplained and the causes need to be further explored.”
RANZCOG also said in its submission, it believed the areas in which there are substantial opportunities for improvement in outcome are with the detection and management of fetal growth restriction (FGR) and avoidance of intrapartum hypoxic death – together contributing about 8 per cent of all stillbirths.
The Royal Australasian College of Physicians (RACP) told the Senate Inquiry it believed: “Stillbirth is a tragic complication of pregnancy which often remains poorly understood within the health profession and the wider community. This impacts awareness and education as well as training and research.”
RACP encouraged the Committee to explore a range of options for reducing stillbirth rates in Australia, and improving care where stillbirths occur, including undertaking an Audit of current data and collection methodologies, and mandate annual reporting to a single agency with responsibility for stillbirth oversight. It also believes it is important for States and Territories to mandate the use of the Perinatal Society of Australia and New Zealand (PSANZ) guidelines and fund Medical Practitioner Education around them at least twice per year.
RACP also said organisations providing support groups following pregnancy loss should have their programs evaluated and, where proven effective, fully funded, to make them universally available. Also in the RACP submission was a view that current stillbirth research funding should be reviewed, and funds allocated to research that addressed specific stillbirth priority areas.
Sands, an Australian miscarriage, stillbirth and neonatal death charity, used the Inquiry to advocate for improved training in bereavement care for all health professionals.
The Stillbirth Foundation’s primary recommendation was a National Action Plan for Stillbirth be developed and implemented, in a process which involves key stakeholders such as medical practitioners, midwives and nurses, health bureaucrats, families who have experienced stillbirth and representative groups.
The Stillbirth Foundation’s chief executive Victoria Bowring said a strategic and well-considered policy approach from Federal Government was “long overdue”.
She added that an action plan would be a coherent policy roadmap to set out priorities, establish measured targets and the necessary funding behind it.
“Too often we see inconsistent medical care, a lack of awareness in the community, not enough coordination and investment in research and poor data collection and management,” she said.
“We have seen a similar approach recently with the national action plan for endometriosis being developed by the Federal Government, and a similar model could work for stillbirth.”
The Committee is due to report back with its recommendations when the Parliament resumes in early 2019.
Details of the Senate Inquiry into Stillbirth Research and Education, including submissions can be found at: www.aph.gov.au/Parliamentary_Business/Committees/Senate/Stillbirth_Research_and_Education/Stillbirth
MEREDITH HORNE
Is oral health the unspoken determinant?
BY AMA PRESIDENT DR TONY BARTONE
According to the Australian Institute of Health and Welfare’s (AIHW) report Australia’s Health 2012, most people will experience oral health issues at some point in their life. In fact, oral diseases are recurrently among the most frequently reported health problems by Australians.
Considered a disease of affluence up until the late 20th century, poor oral health outcomes have now become an indicator of disadvantage, highlighting a lack of access to preventative services. Insufficient access to, high cost of, or long waiting periods for dental services; and low oral care education, have all been associated with patients not seeking dental care when it is needed. Of course, non-fluoridised water supplies also has a role in explaining the prevalence.
However, more recently, it is the modifiable risk factors like poor nutrition, smoking, substance use, stress, and poor oral hygiene that are considered to have the greatest impacts on periodontal diseases.
Dental conditions frequently rank in the top 10 potentially preventable acute condition hospital admissions for Aboriginal and Torres Strait Islander people and were the third leading cause of all preventable hospitalisations in 2013-14, with 63,000 admissions.
Like most other health conditions, Aboriginal and Torres Strait Islander people have poorer oral health outcomes. While Indigenous people currently have most of the same oral health risk factors as non-Indigenous people, they are less likely to have the same access to preventative measures, leading to marked disparities in oral health between Indigenous people and other Australians.
While the majority of oral health concerns are often considered inconsequential, such as avoiding certain foods, or cosmetic with people embarrassed about their physical appearance, there is a significant body of evidence which suggests that oral health may be the undiscussed determinant of health.
More than two decades ago, population-based studies identified possible links between oral health status and chronic diseases such as cardiovascular disease (CVD), diabetes, respiratory diseases, stroke, and kidney diseases, as well as pre-term low birthweight. And the relationship appears to lie with inflammation.
It is clear more research is needed to determine the exact links (if any), between periodontal disease and chronic disease condition, however, the growing body of evidence links poor oral health to major chronic illnesses.
The Government has made numerous financial commitments to improving access to dental services, however, oral health data will continue to demonstrate that without equitable access to dental services, Australians, and particularly Aboriginal and Torres Strait Islander people, will continue to suffer poorer oral health outcomes, and potentially poorer health outcomes, as a result.
The AMA supports improved Doctor/Dentist collaborations if such partnerships could lead to increased early identification of both chronic disease and oral health conditions, particularly for Aboriginal and Torres Strait Islander peoples, for whom oral health services are less frequently accessed.
Dental Health Week is 6-12 August 2018.