more_vertCity health commissioners look to the federal government for support, but increasingly feel they are working at cross purposes. Ted Alcorn reports.
Preference: Government and politics
Canada looks to end over-the-counter codeine
The Canadian federal government is proposing to introduce a prescription for codeine-containing drugs that are currently freely available over the counter.
The change is currently in a consultation process, and is a policy outcome of an Opioid Conference and Summit coordinated by the Canadian Health Minister late last year. Canadians have until November 8, 2017 to comment on the changes.
Canada faces a serious and growing opioid crisis. The Canadian Minister of Health, Jane Philpott believes the response needs to be “comprehensive, collaborative, compassionate and evidence-based”.
The Canadian Health Department says about 600 million low-dose codeine tablets, or about 20 for every person in the country, were sold across Canada in 2015. It notes that more than 500 people entered addiction treatment centres in Ontario alone between 2007 and 2015, with non-prescription codeine as their only problem substance.
Dr Theresa Tam, Canada’s Chief Public Health Officer, believes this is a major public health crisis.
“Tragically, in 2016, there were more than 2,800 apparent opioid-related deaths in Canada, which is greater than the number of Canadians who died at the height of the HIV epidemic in 1995,” Dr Tam said.
The opioid crisis is putting increasing pressure on the country’s health care systems with approximately 16 Canadians a day hospitalised due to poisoning, according to the Canadian Institute of Health Information (CIHI).
“It’s a dramatic increase,” says Michael Gaucher, director of Pharmaceuticals and Health Workforce Information Services at CIHI.
“The rate of hospitalisations over the past few years is very troubling and points to the deepening of the opioid crisis across Canada.”
The Canadian Health Department says the proposed changes to Canada’s regulations to require all codeine products to be sold by prescription would be in line with those already in place in many countries, including Belgium, Czech Republic, Finland, France, Greece, Iceland, India, Italy, Norway, Russia and Sweden.
The proposal was published in the Canada Gazette and is open to a 60-day comment period, after which time the government will decide whether to pass a regulation implementing the change.
Canada is close to the world leader in codeine consumption – its use is several times higher than in most other Western countries, with only Iceland reporting a bigger habit per capita.
MEREDITH HORNE
PHI reforms in right direction, but more work needed
The AMA has welcomed the Government’s reforms to private health insurance as a “start in the right direction”, but says much more needs to be done to make the sector more transparent and affordable.
On October 13, the Federal Government announced a raft of changes to the private health insurance (PHI) sector, following lengthy consultation and an ongoing consumer backlash against the industry.
The changes include encouraging younger Australians to take up PHI by allowing insurers to discount premiums up to two per cent for each year as an adult before turning 30, to a maximum of 10 per cent. This will be phased out by the time they turn 40.
Regional patients will benefit from policies that will for the first time include travel and accommodation subsidies for some hospital services.
A hierarchy of Gold, Silver, Bronze and Basic policy categories will be introduced to help consumers compare what is on offer.
But even policies under the Basic classification will provide mental health services, which are not currently covered under many policies.
Existing policy holders will be able to upgrade their cover in order to access in-hospital mental health services without having to endure a waiting period. And insurers will not be allowed to limit the number of in-hospital mental health sessions a patient can access.
Insurers will be able to keep premiums down by offering higher excess levels.
From April 2019, unproven therapies such as Pilates, yoga, homeopathy, aromatherapy, iridology and herbalism (among others) will not attract rebates.
A prosthetics deal between the Government and manufacturers aims to reduce the cost to private insurers for the devices, and subsequently pass on savings to consumers.
In announcing the changes, Health Minister Greg Hunt said reform in the sector would continue, with the Private Health Ministerial Advisory Committee still examining issues such as risk equalisation.
“And we will work with the medical profession on options to improve the transparency of medical out-of-pocket costs,” Mr Hunt said.
“The Turnbull Government is committed to private health insurance and we’re committed to supporting the more than 13 million Australians that have taken out cover.
“We are investing around $6 billion every year in the private health insurance rebate to help keep premiums affordable.”
The Opposition, however, has described the reforms as “too little, too late” and criticised the Government for not addressing the so-called “junk policies” that are hardly worth the paper they are written on.
Shadow Health Minister Catherine King said junk policies should be banned.
“The fact that the Government has broken its election promise and retained junk policies remains concerning to me,” Ms King said.
Consumer group CHOICE has also criticised the failure to ban junk policies.
AMA President Dr Michael Gannon said the announced changes to PHI would not solve the problem of a perceived lack of value in the services provided by the PHI sector.
Health fund membership has been falling by 10,000 a month, as premiums increase an annual average of 5.6 per cent.
Dr Gannon said Australia needs a strong and viable private health sector to maintain the reputation of the Australian health system as one of the world’s best.
But the reforms will need the genuine commitment and cooperation from all stakeholders to deliver real value and quality to policyholders.
“The framework for positive reform of the private health insurance industry is now in place,” Dr Gannon said.
“The challenge now is to clearly define and describe the insurance products on offer so that families and individuals – many of whom are facing considerable cost-of-living and housing affordability pressures – have the confidence that their investment in private health delivers the cover they are promised and expect when they are sick or injured.”
Dr Gannon welcomed the decision to introduce Gold, Silver, and Bronze categories for PHI policies and that standard clinical definitions will be applied.
“Importantly, the changes will provide better coverage for mental health services and for people in rural and regional Australia,” he said.
“The AMA advocated strongly for standard clinical definitions on behalf of our patients. What we need to see now is meaningful and consistent levels of cover in each category.
“While we had called for the banning of so-called junk policies, we will watch closely to ensure that any junk policies that remain on the market are clearly described so that people know exactly what they are buying and are not subject to unexpected shocks of non-coverage for certain events or conditions.
“Basic cannot mean worthless.
“We will continue to call out any misleading products in our yearly report card.
“Other areas that will need further investigation include the fine detail of the new prostheses arrangements, how and at what level pregnancy will be covered, and the review of low value care for things like mental health and rehabilitation.
“We welcome the removal of coverage for a range of natural therapies such as homeopathy, iridology, kinesiology, naturopathy, and reflexology, which the Chief Medical Officer has rightly declared as lacking evidence or efficacy.”
Dr Gannon said the AMA has concerns about the possible direction of ongoing work on out-of-pocket costs and the review of privately insured patients being treated in public hospitals.
“We will be pushing for the expert committee considering out-of-pocket costs to broaden its review beyond doctors’ fees.
“Doctors’ fees are not the problem – 95 per cent of services in Australia are currently provided at a no-gap or a known gap of less than $500,” he said.
“The out-of-pockets committee must instead focus on the issues that leave patients with less support such as the caveats, carve-outs, and exclusions; hospital costs; and inconsistent and tricky product definitions.
“We will of course support efforts to rein in unacceptably high fees in the small number of cases where they occur.
“And we will be vigilant on any moves to deny private patients access to care in a public hospital. This is a critical and complex area that needs careful consideration. It is especially critical if the Government is going to promote basic and public hospital only cover.”
Dr Gannon told ABC Radio that the changes were “perhaps” a start in the right direction, but that ongoing work was required.
“The one thing the Minister is up against, one thing that future Governments will be up against is the inevitable increase in the cost of health care,” he said.
“Health CPI runs at four, five, six per cent per year. We’re interested in some of the one-off savings that the Minister is going to be able to achieve, but it’s going to require ongoing work.
“The different players in the industry, the hospitals, the doctors, the insurers, need to continue to try and work with Minister Hunt on savings in the system. He’s come up with some good ideas here.
“So, for example, he has managed to negotiate some savings with the people who manufacture prostheses. That’s how he intends to deliver on cheaper hip replacements.
“But he’s got cost control when it comes to doctors’ fees. They’ve been in many ways frozen for nearly five years now. That’s not the problem in the system. The biggest problem in the affordability of private health insurance is the amount that’s going into the pockets of the for-profit insurers.
“Now I’ve spoken to the Minister about this. The genie is not going back in the bottle…
“There are too many tricks in the current system, too many carve-outs, and too many caveats. Too many people who find out they’re not covered for the first time when they’re actually sick.
“We went to the Minister and said we want to get rid of junk policies. We’re not overly excited about the idea of maintaining Basic, but he came back to us and other stakeholders and said ‘look we need to do something about affordability’. So I think, at least for now, we’re stuck with Basic.
“But as long as people know what they’re getting, as long as there’s no tricks on clinical definitions. People shouldn’t need to be six months into a medical degree to know what they’re actually covered for.”
CHRIS JOHNSON
Productivity Commission recommends big changes to health system
Australians are living longer than people in most other developed countries, but they are also spending longer periods in ill health.
That is one finding of the Productivity Commission’s five-year review, released in October and titled Shifting the Dial.
It also found that most Australians have great confidence in the health care they receive.
The report has recommended, however, a dramatic adjustment to the nation’s health system, with reforms that could save more $140 billion over 20 years.
Poor communication between healthcare professionals – GPs and public hospitals in particular – has contributed to problematic issues faced by patients, the report finds.
And it suggests supervised vending machines could replace community pharmacy roles in dispensing medicines in some locations.
“Australians are living longer, with less disability than ever before. Australia outranks most other highly developed economies in health outcomes,” the report states.
“It has the third greatest life expectancy at birth among OECD countries in 2015 at 82.8 years and a high absolute number of years spent in good health (though a lower than expected number given our life expectancy)…
“Indeed, Australia has one of the highest obesity rates in the world, and it appears to be still rising. And while Australians have high life expectancy, they also have the highest number of years spent in ill-health compared with other OECD countries.”
According to the review, the overwhelming share of Australians had confidence they would receive quality and safe medical care, effective medication and the best medical technology if they were seriously ill.
Australia is faring comparatively well by international benchmarks in certain areas of preventative health — most notably in reducing rates of smoking and transport accident deaths.
“On face value, the cost effectiveness of Australia’s health system also appears relatively high compared with other OECD countries, with Australia spending less on health than many countries for comparable or better outcomes in life expectancy,” it states.
Yet Productivity Commission chairman Peter Harris described a “non-existent communication” between different parts of the health system that has led to many problems.
He has recommended to the Federal Government that it undertake a significant overhaul of how the sector functions.
“A simple indicator of service integration is the proportion of a hospital’s patients whose GPs are provided with a discharge summary within 24 hours of discharge,” his report states.
“Currently, Australia’s performance appears poor. Less than 20 per cent of Australian GPs were always told when a patient was seen in an emergency department compared with 68 per cent in the Netherlands, 56 per cent in New Zealand and 49 per cent in the United Kingdom.
“Clinicians, patients and researchers operate under a veil of ignorance posed by inadequate information flows and haphazard data collection. Private health insurance sits uneasily with a system of public insurance, with their respective roles weakly defined.
“The imperative is therefore better coordination of the system, giving a greater weight to the role of public health, and acceptance of people themselves as partners in their own health management.”
GPs are the clinicians that Australians most frequently see and are highly trusted, the report states.
It says all Australian governments should re-configure the healthcare system around the principles of patient-centred care, and implement changes within a five-year timeframe.
Australian governments are urged to cooperate to remove the current “messy, partial and duplicated presentation of information and data” and provide easy access to healthcare data for providers, researchers and consumers.
And the review recommends the Federal Government end community pharmacy as the vehicle for dispensing medicines and move towards a model that anticipates automatic dispensing in a majority of locations.
This would be supervised by a suitably qualified person. In clinical settings, pharmacists should play a new remunerated collaborative role with other primary health professionals where there is evidence of the cost-effectiveness of this approach.
An alcohol tax system that removes the current concessional treatment of high-alcohol, low-value products, primarily cheap cask and fortified wines, should also be embraced.
The uptake of technologies that could lower costs and increase convenience and quality has often been slow, the review found.
“Telehealth is still in its infancy, and restrictions in payment models frustrate its diffusion,” it states.
“More generally, the adoption of eHealth has had a protracted and troubled history in Australia that is only now beginning to be resolved. The old chestnuts — the anti-competitive regulation of the professions and the incongruities presented by retail pharmacy regulations have proved resistant to repeated calls for reform.”
The imperative for policy action is justified on many counts, according to the review. It says such action will produce better health outcomes and wellbeing, provide more voice to and choice for patients, and result in greater efficiency.
“Wasteful expenditure means that resources are being used in the wrong places to no or little effect on health outcomes,” the report says.
In launching the Productivity Commission’s findings, Federal Treasurer Scott Morrison said the review would make governments and the health sector consider the effectiveness of the health system.
“Improving the health of Australians is not just about enhancing our quality of life; it’s an economic growth strategy,” Mr Morrison said.
“Healthy and happy people are naturally more productive people.”
The full report can be found at: https://www.pc.gov.au/inquiries/completed/productivity-review/report
CHRIS JOHNSON
Minister digs in over codeine, pharmacy lobby backs down
Federal Health Minister Greg Hunt is standing firm on the up-scheduling of codeine products, despite a push against the independent ruling of the Therapeutic Goods Administration (TGA).
Objections to the decision to ban over-the-counter codeine has come not only from the pharmacy lobby but also from some of Mr Hunt’s Cabinet colleagues as well as some State Governments.
From February next year, all codeine-based products will become prescription-only, much to the chagrin of the Pharmacy Guild of Australia, which has been lobbying hard for exemptions.
But the Guild has backed down and appears to have reversed its position.
The Minister told a recent health conference that the Guild had finally accepted the up-scheduling in full.
“So they’re not the only ones that can be strong,” he said.
“On this, they have now come around and made it absolutely clear that they will work with us and support the up-scheduling.”
In a subsequent media statement, the Minister said the Government would provide $1 million to ensure health practitioners and consumers were properly informed about the changes.
“From 1 February next year, medicines containing codeine will no longer be available over-the-counter and will instead require a prescription from a doctor,” Mr Hunt said.
“I have listened carefully to calls from State Health Ministers, consumer and medical groups for more support and this funding announced today will ensure health professionals and consumers have the information they need.
“Moving codeine to script-only was the unanimous recommendation of the Advisory Committee on Medicines Scheduling, which is made up of Chief Pharmacists and Chief Health Officers in States and Territories.
“The Advisory Committee on Medicines Scheduling made two separate recommendations to reschedule codeine in August 2015 and March 2016. The Advisory Committee on the Safety of Medicines also made the same recommendation in March 2016.
“The Therapeutic Goods Administration implemented this advice and on 20 December 2016 announced that over-the-counter medicines containing codeine will become prescription only from1 February, 2018.
“The final implementation of this scheduling is a matter for each State and Territory as to whether they adopt the decision in their own jurisdiction. Medical authorities have, however, advised these changes will save lives and protect lives.
“Over-the-counter codeine products have been estimated to be a factor in nearly 100 deaths each year, with evidence that three in four pain-killer misusers had misused an over-the-counter codeine product in the last 12 months.”
The changes are also in-line with international practice, with at least 26 countries only allowing prescription access to codeine based products.
These include the United States, United Kingdom, Japan, Germany, France, Italy, Spain, Sweden, Austria, Belgium, Hong Kong, Iceland, India, the Maldives, Romania, Russia, and the United Arab Emirates, Croatia, the Czech Republic, Finland, Greece, Hungary, Luxembourg, Netherlands, Portugal and Slovakia.
The Guild has not confirmed it has reversed its position but has issued a media statement, along with the Pharmaceutical Society of Australia, saying the changes signal a shift in the pain management category for community pharmacy. The statement says they must plan for and manage the change and ensure pharmacy assistants are prepared for it.
AMA President Dr Michael Gannon said groups seeking to circumvent the TGA’s decision were putting self-interest ahead of patient welfare.
“The health community – including pharmacy – must quickly implement the changes necessary to switch to prescription-only codeine in February next year,” Dr Gannon said.
Dr Gannon recently met again with the TGA to discuss codeine harm. They also discussed cannabis supply where clinically indicated, e-cigarettes, euthanasia drugs, and medicine shortages.
CHRIS JOHNSON
First ever National Rural Health Commissioner appointed
The AMA has congratulated Professor Paul Worley on his appointment to the new position of National Rural Health Commissioner.
Welcoming the appointment, AMA President Dr Michael Gannon said Professor Worley was a highly respected member of the profession who has made a substantial contribution to rural health over many years.
“Professor Worley has a big job ahead of him, and he will have the full support of the AMA and other groups with a commitment to improving access to quality health services in rural, regional, and remote Australia,” Dr Gannon said.
“The long-awaited appointment of a National Rural Health Commissioner had the potential to boost the profile of rural health issues in Government decision-making and health policy development.
“The Rural Health Commissioner will also lead the establishment of a Rural Generalist Pathway, which could boost the much-needed recruitment and retention of skilled practitioners in rural areas.
“The AMA is uniquely positioned to provide Professor Worley with advice on rural health policy.
“We have an extensive rural membership, including medical students, doctors-in-training, career medical officers, GPs, and other specialists.
“The AMA has also established the AMA Council of Rural Doctors (AMACRD) to ensure our rural members have a strong say in our policy and advocacy.
“We are excited at the prospect of working with Professor Worley, and look forward to meeting with him as soon as he settles into the new role.”
Professor Worley was formerly Dean of Medicine at Flinders University. He is a past President of the Rural Doctors Association of SA, a previous national Vice President of the Australian College of Rural and Remote Medicine (ACRRM), and he is a current Council Member of AMA (SA).
In announcing the new role, Assistant Health Minister David Gillespie said he was looking forward to working collaboratively with Professor Worley to progress regional and rural health reform.
“Professor Worley will be a determined, effective and passionate advocate for strengthening rural health outcomes across Australia,” Dr Gillespie said.
CHRIS JOHNSON
Invitation from AMA President to participate in aged care survey
The Australian Medical Association invites you to participate in a brief online survey to help inform AMA policy and lobbying in the area of medical services for older Australians.
Australia is experiencing an ageing population with more complex medical conditions than before. In 2016, there were 3.7 million people aged over 65 in Australia, and this is expected to rise to 8.7 million by 2056. The prevalence of Dementia, a leading cause of death in Australia, is predicted to increase to 900,000 by 2050 (298,000 in 2011).
Currently, Australia’s aged care system is failing this older population. This has become increasingly evident over the past year, with multiple stories of negligence highlighted in the media. In particular, the serious neglect in patient care at the Oakden Older Person’s Mental Health Service has sparked both an independent review and a Senate inquiry into the quality of the whole aged care system.
If nothing changes, Australia’s ageing population will see a system diving further into inadequacy, putting the lives of our patients, and families, at risk.
This is why the AMA will continue, and increase, our advocacy in aged care. Part of this advocacy will also involve updating our position statements to reflect the current climate.
This is where we need your help. As members, this aged care survey gives you an opportunity to comment on your experiences with aged care, and better inform our advocacy strategy, our position statements and our submissions. In developing our future advocacy resources, we want to focus our efforts on ensuring that medical practitioners who provide medical care to older Australians are supported, and their needs are highlighted to government.
Similar surveys were undertaken by the AMA in 2008, 2012, and 2015.
In 2015, the AMA Aged Care Survey revealed the major reasons affecting the provision of medical care in the aged care sector were the lack of availability of suitably trained and experienced nurses, and MBS rebates not properly compensating for the time spent away from surgery.
The results from this 2017 survey will be compared to these earlier surveys to identify trends and measure some of the changes over the past nine years.
The survey takes approximately 15 minutes to complete. Your individual response will not be identifiable, however overall survey results will be published. I urge you to please take the time to complete this very important survey.
Click the following link to begin. Please complete the survey only once.
https://www.surveymonkey.com/r/amaagedcaresurvey2017
The survey closes on Monday 27 November 2017.
Dr Michael Gannon
AMA President
AMA won’t support a default position on advertising for all S3 medicines
The AMA supports the proposed changes to the Therapeutic Goods Advertising Code but cannot support a default position which provides for all S3 medicines to be advertised unless considered unsuitable.
In a submission to the Government’s consultation process in October, the AMA expressed its support for the TGA’s proposals for updating and strengthening the Code’s standards, guidelines and sanctions.
The AMA considers that updating definitions of prohibited and restricted representations and introducing new restricted representations is timely, particularly in the light of new diagnostic techniques such as direct-to-consumer genetic testing.
But it has recommended there be a review of advertising compliance two years after implementation, to assess whether the new Code works effectively.
“The AMA has already argued in previous submissions that it considers there is little benefit in relaxing the regulation of S3 medicines advertising,” the submission states.
“Direct-to-consumer advertising of medicines may increase use, but not necessarily effective or rational use in line with quality use of medicines principles.
“While advertising may potentially increase awareness of certain health conditions and medicines, its primary purpose is to increase demand and sales for the advertiser’s product.”
The AMA cannot offer its support to changes to the S3 advertising framework without being convinced that there will be appropriate, robust and enforceable controls on how it happens.
The proposals in the consultation paper are fine as far as they go, but not sufficient for the AMA to make an informed judgement.
The consultation paper notes that other stakeholders have also stated that their support is dependent on the specific requirements placed on S3 medicines advertising.
“How will advertising be controlled to prevent advertising designed to persuade rather than inform consumers? How will content be managed to ensure that information is balanced and objective to support patients to make an informed choice?” the AMA’s submission asks.
“The consultation paper indicates the TGA is planning to move to a default position where all S3 medicines may be advertised, unless considered unsuitable. It appears that the TGA is already committed to moving down this path without sufficiently detailed consideration or public articulation of how S3 medicine advertising would be restricted, controlled and monitored.”
The only ‘stricter’ controls offered in the paper are two mandatory statements reflecting pharmacist oversight, with the promise of ‘more specific requirements around statements [being] consulted upon at the time of public consultation on the draft advertising code’. This does not provide sufficient assurance to the AMA.
The submission recommends that the TGA should not commit itself to adopting a position of advertising all S3 medicines as the default without detailed proposals being developed and examined.
The timing of this process should not be determined by some arbitrary deadline for completing new legislation and/or an updated Code. The AMA notes that in the consultation paper ‘next steps’ section, the TGA expects the new Code to be in force before, or at the same time as, other proposed changes to the advertising framework come into effect.
CHRIS JOHNSON
[Comment] Child mortality: the challenge for India and the world
Earlier this year, one of us took part in a policy dialogue about child health in Bangladesh. On being presented with evidence of increasing mortality among children younger than 5 years in parts of Bangladesh, a senior government official rightly enquired whether or not disaggregated (regional) cause of death data had been collected that could help explain this deviation from the national trend and guide responses. Sadly, our answer was “no”. That is exactly the kind of data gap that the work by the Million Death Study Collaborators1 published in The Lancet was designed to address.
[Editorial] The next phase for adolescent health: from talk to action
Close to 1000 delegates from more than 65 countries are expected in New Delhi, India, on Oct 27–29, for the 11th World Congress of the International Association for Adolescent Health—a doubling of participants compared with the last conference 4 years ago. In addition, many more representatives are from low-income and middle-income countries (LMICs), and 125 youth delegates are attending, as are many more UN agencies and international non-governmental organisations, who have discovered adolescents as an important new group to focus on.