more_vertAs a character said in Jean Renoir’s 1939 movie The Rules of the Game, “The awful thing about life is this: everybody has their reasons.” Pertinent for our daily interactions with other people, this point is also relevant when we think of politics and international disputes. At a time when diplomacy and peace-making skills are disregarded by some political leaders, it’s refreshing to be reminded that listening to other people made a big difference in a peace process, even in the most unlikely conditions.
Preference: Government and politics
Latest figures released on overseas travel emergencies
Foreign Minister Julie Bishop has urged all Australians who travel overseas to ensure they are fully insured for medical emergencies and sickness when abroad.
In 2016-17, Australia’s consular officers around the world helped more than 12,000 nationals in trouble overseas, in cases that included 1,701 hospitalisations and 1,653 deaths.
There were also 1,642 arrests overseas, 2,546 whereabouts inquiries, 3,081 welfare cases, and 1,090 victims of crime.
More than 10 million departures from Australia were recorded in 2016-17.
“With so many Australians travelling, things can go wrong including robbery, injury, assault and arrest,” Ms Bishop said.
“However, there are limits to the assistance the Government can provide.
“Australians who choose to travel overseas should be as prepared and self-reliant as possible. Appropriate insurance is essential. If you can’t afford travel insurance, you can’t afford to travel.
“Uninsured travellers who are hospitalised overseas or need medical evacuation can face crippling medical bills. Medicare and the Government will not cover those expenses.”
Early in October, the Minister launched the 2016-17 Consular State of Play – a statistical snapshot of consular assistance provided to Australians abroad by the Department of Foreign Affairs and Trade (DFAT).
It showed that Australian residents took 10,039,700 trips during that financial year, having grown about five per cent annually over the past five years.
While only one in one thousand Australians who are overseas at any given time during a year need the Australian Government’s assistance with problems, priority is given to cases involving particularly vulnerable Australians such as children, the mentally impaired, and victims of assault (including sexual assault).
The destinations where Australian travellers have received consular help the most are New Zealand, Indonesia, USA, the UK, Thailand, China, Singapore, Japan, Fiji and India.
The 30-39 year-old age group received the most help (18 per cent of cases), followed by 40-49 year-olds and 50-59 year-olds (17 per cent each), 20-29 year-olds (15 per cent), 60-69 year-olds (12 per cent), and 10-19 year-olds (8 per cent).
Children up to nine years old who received help accounted for eight per cent of cases, while the 70+ age group accounted for five per cent.
According to the 2017 Australian Travel Insurance Behaviour survey (commissioned by DFAT and Understand Insurance and released at the same time as the Consular State of Play), 48 per cent of recent cruise ship travellers bought the wrong kind of insurance for their travel.
“Travellers need to choose the right insurance for their trip. Many travellers mistakenly believe their insurance provides appropriate cover,” Ms Bishop said.
“I urge all Australians planning overseas travel to visit the Smartraveller website for advice and to read the Consular Services Charter, which explains what services the Government can provide if assistance is required while overseas.”
The Consular State of Play 2016-17 can be found at: http://dfat.gov.au/about-us/our-services/consular-services/Pages/consular-state-of-play-2016-17.aspx .
CHRIS JOHNSON
Regulation of autologous cell and tissue products
The Government has decided that changes to regulation should be implemented
[Correspondence] Medical education: what about the barefoot doctors?
Medical education aims to cultivate effective and essential medical human resources for protecting people’s health and the nation’s sustainable development. On July 11, the State Council of China introduced bold plans to deepen the reform and development of medical education, which were summarised in The Lancet (July 22, p 334).1 Facing the increasing needs of health care and medical education, the Chinese Government is struggling to change the current situation and improve educational programmes, financial welfare, career promotion mechanisms, and ethical decision-making.
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 polices.
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
[Comment] Catastrophic medical insurance in China
China’s medical insurance system has changed dramatically in the past two decades. The country’s most established programme, the Urban Employee Basic Medical Insurance, dates back to the mid-1990s and initially covered only 109 million employees of state-owned and collective enterprises.1 In the early 2000s, the Chinese Government established two additional insurance programmes, the New Cooperative Medical Scheme (NCMS) for rural residents and the Urban Resident Medical Insurance (URMI) programme for self-employed and unemployed urban residents.
[Articles] Is late-life dependency increasing or not? A comparison of the Cognitive Function and Ageing Studies (CFAS)
On average older men now spend 2·4 years and women 3·0 years with substantial care needs, and most will live in the community. These findings have considerable implications for families of older people who provide the majority of unpaid care, but the findings also provide valuable new information for governments and care providers planning the resources and funding required for the care of their future ageing populations.
TGA’s independent ruling on codeine is the right one
AMA President Dr Michael Gannon has strongly condemned the Pharmacy Guild of Australia for its “irresponsible and unprincipled lobbying of State and Territory Governments” aimed at undermining the independent Therapeutic Goods Administration (TGA).
The TGA has ruled that codeine will become a prescription-only medicine from February next year.
The AMA has welcomed that decision, saying codeine can be a harmful drug if misused.
But the Guild, which represents pharmacy owners, is against the TGA ruling and has lobbied State and Territory governments, calling for codeine to continue to be available over the counter.
Patient advocacy groups such as the Consumers’ Health Forum and Pain Australia support the decision; other groups publicly supporting the TGA include the Rural Doctors’ Association, the Royal Australian College of Physicians, the Royal Australian College of General Practitioners, and the Australasian Chapter of Addiction Medicine.
State Governments appear to have buckled to the Guild’s strong-arm lobbying.
Dr Gannon said any such move to “get around” the TGA – an independent federal body – would put patients’ health at risk.
“It is essential for public safety that the TGA makes evidence-based decisions about medicines, free from political interference and sectional interests,” Dr Gannon said.
“As doctors, we rely on the independence and expertise of the TGA to ensure Australians have access to safe, effective, and high quality medicines.
“There is compelling evidence to support the decision to make codeine prescription-only. Deaths and illness from codeine use have increased in Australia.
“A 2016 survey showed that 75 per cent of recent painkiller or opioid misusers reported misusing an over-the-counter codeine product in the previous 12 months. Tragically, the survey showed these products were even more likely to be misused by teenagers.
“Under the new arrangements, patients who have short-term pain will still have access to alternative over-the-counter painkillers, which are more effective than low-dose codeine, but without codeine-associated health risks.
“It is better for patients with chronic pain to manage it with doctors’ advice on appropriate medicines and non-medicine treatments. Self-treating long-term with codeine is dangerous.”
When the TGA announced its decision, the AMA warned that some groups would put self-interest ahead of patients’ best interests by using highly-paid lobbyists to influence or coerce State Governments to change, delay, or dilute the impact of the TGA decision.
Dr Gannon said that fear was realised when the Guild announced in early October that it had won support from the NSW Nationals, and then most other State and Territory Governments wrote to the Federal Minister expressing concern about the upscheduling.
The AMA fully supports the independence of the TGA in making decisions about medicines scheduling and will actively support the TGA codeine decision by intensifying its efforts to work with all governments to respect and uphold the evidence-based rulings of the highly-respected independent regulator.
“We will be urging the Pharmacy Guild and others groups who seek to undermine the TGA to reconsider their actions and put the health of Australians first,” Dr Gannon said.
“The AMA supported the independent scientific advice of the TGA – the authority that’s responsible for determining which medications come in, how they come in, and how they’re made available.
“They looked at the science, looked at the increasing understanding of the risks of codeine use, made a determination, and gave that advice to Federal Health Minister Greg Hunt, who agreed, with the full support of the AMA.
“And, we thought, with the support of the Pharmacy Guild, the Pharmaceutical Society, and certainly other medical bodies like the College of GPs, and the College of Physicians.
“Australia would join the situation in roughly 25 other countries that you need a script to get codeine.
“But we have now seen the Guild going out and doing what they’re good at – lobbying politicians hard. They’re very well resourced, but they’re wrong on this.
“The AMA will continue to make the case that the TGA has made the right decision. It’s long overdue. Codeine is a harmful drug. And do you know what? It’s not even that good a painkiller. There are better alternatives.”
The Committee who reached the decision was comprised of medicines experts – including pharmacists.
The Guild claims that it is not seeking to overturn or disregard the TGA decision, yet it has taken every opportunity to criticise the ruling to upschedule codeine to prescription-only.
The Guild alleges it is only wanting a “part reversal” of the decision, but its lobbying suggests otherwise, and has sought to link the decision to upschedule with prescription monitoring.
Dr Gannon said that the Guild was being “a bit too cute” for his liking.
“I’d like to know exactly what they mean by a part reversal,” he said.
“We should be reassuring the public that they can buy more effective and safer over-the-counter medicines at their local pharmacy. Their short-term acute pain will be eased without codeine. Instead, the Guild is claiming that people in rural areas without easy access to GPs will suffer. This is simply not true.”
“People with chronic pain should not be using over-the-counter codeine at all. People with chronic pain can be helped to manage it with doctors’ advice on appropriate medicines and non-medicine treatments. Self-treating with codeine is dangerous.”
Dr Gannon said if codeine was invented next week, it might struggle to get listed. When the harms it causes and its ineffectiveness at low doses are looked at, it might struggle to get on the formulary today.
“At low doses it’s no better than the standalone agents like paracetamol and anti-inflammatory, and at high doses it is increasingly a drug of abuse,” he said.
“So there’s no argument here. I’m not interested in GPs, other specialists, prescribing yet more and more codeine. The more we know about this drug, the more we realise that we should be looking for more effective and safer alternatives.
“I’ve written up codeine prescription for patients for a long time, up until about three or four years ago when I started to become apprised of the evidence. I’ve had to change my practice. That’s true of many, many other doctors and look, that’s what we do in the medical profession: we look to new robust evidence and we change our practice.
“Codeine is a drug that’s found in too many people’s systems. We’ve seen the Victorian Coroner’s report. Too many people are found with codeine in their body at post mortem examinations.
“This is a harmful drug. It’s hurting people, it’s killing people.”
CHRIS JOHNSON
Codeine – the facts
The Theraputic Goods Administration has ruled medicines that contain codeine will no longer be available without prescription from 1 February 2018.
This will include codeine-containing combination analgesics (available under brand names such as Panadeine, Nurofen Plus, Mersyndol and pharmacy generic pain relief products).
Codeine-containing cough, cold, and flu products (available under brand names such as Codral, Demazin and pharmacy generic cough, cold and flu medicines) will also become unavailable as over-the-counter medicines.
High dose codeine (30-120 mg per dose), used for cancer pain, post-operative pain and other acute pain conditions, already requires a prescription.
There are a range of products available that do not require a prescription to help manage pain and will be available post-February 2018.
Most Australians are aware codeine used for pain relief offers very little additional benefit when compared with medicines without codeine.
The decision to re-schedule codeine is consistent with the Australian Government’s commitment to protect public health and safety for all Australians.
Codeine is closely related to morphine and, like morphine, is an opioid. Long-term use of low-dose codeine has been linked to opioid dependence, toxicity and abuse.
Codeine can cause opioid tolerance, dependence, addiction, poisoning and, in high doses, death. Codeine use can be harmful. Tolerance occurs when codeine becomes less effective and so the body needs higher and higher doses to feel the same relief from symptoms.
Severe withdrawal symptoms can result when the medicine is stopped; these include head and muscle aches, mood swings, insomnia, nausea and diarrhoea. Some of these withdrawal symptoms, such as head or muscle aches, mimic the symptoms that low-dose codeine products are often used to treat, leading to people incorrectly continuing to take the medicine longer or in higher doses.
Codeine poisoning contributes to both accidental and intentional deaths in Australia.
Unfortunately in Australia the most common class of drug identified on toxicology reports in drug-induced deaths are opioids, including opiate-based analgesics such as codeine.
The codeine-containing medicines that are currently available over-the-counter are usually combined with either paracetamol or ibuprofen. Regular use of medicines containing codeine, for example for chronic pain, has led to some consumers becoming addicted or tolerant to codeine without realising it.
Taking more than the recommended dose of combination products could result in serious side effects.
Though safe at recommended doses, long-term use of high doses of paracetamol can result in liver damage,
while the most severe adverse effects of long-term ibuprofen use include serious internal bleeding, kidney failure and heart attack.
CHRIS JOHNSON
The AMA fully supports the independence of the TGA
The AMA fully supports the independence of the TGA in making decisions about medicines scheduling.
It is essential for public safety that the TGA makes evidence-based decisions about medicines, free from political interference and sectional interests.
Doctors rely on the independence and expertise of the TGA to ensure Australians have access to safe, effective and high quality medicines.
There is compelling evidence to support the decision to make codeine prescription only:
- Deaths and illness from codeine use have increased in Australia;
- This is despite a rescheduling decision in 2010 shifting many over-the-counter codeine medicines to Schedule 3 (pharmacist only); and
- There is no evidence that low-dose codeine (8mg-15mg/unit) provides any benefit beyond placebo.
To put this change in perspective:
- all other opioid medicines sold in Australia are available only on prescription (S4 or S8); and
- codeine is not available over-the-counter in 13 European countries nor in the US.
Patients who have short-term pain will still have access to alternative over-the-counter painkillers which are more effective than low-dose codeine (i.e. ibuprofen plus paracetamol), without codeine-associated risks.
It is better for patients with chronic pain to manage it with doctors’ advice on appropriate medicines and non-medicine treatments, rather than self-treating long-term with codeine.
It is unlikely doctors will see a large increase in patients. Most people who use codeine take it to relieve short-term pain; they can still buy effective painkillers (ibuprofen plus paracetamol) over the counter.
Doctors may see an increase in visits from patients who have long-term chronic pain. These patients should be helped by doctors to manage their pain with a combination of non-medicine and medicine treatments, rather than self-treating with codeine.
It may be years before State Governments have real time monitoring systems up and running. We can’t allow more unnecessary deaths while governments argue about funding.
The AMA’s Position Statement on Medicines 2014 states that:
(a) The AMA supports the role of the Therapeutic Goods Administration as the regulator of medicines in Australia to ensure that medicines meet appropriate standards for quality, safety and efficacy.
(b) The AMA recommends medicines should only be up or down scheduled where there is strong evidence it is safe to do so, where there is demonstrated patient benefit and safety in dispensing the medication by this method, and where it would not adversely affect appropriate access to medicines.