Health Department admits truth on bulk billing

Federal Government claims that bulk billing rates are at a record high have been undermined by the Health Department’s admission that less than two-thirds of patients have all their GP visits bulk billed.

In an answer to a question on notice on 2 December, the Department confirmed that just 64.7 per cent of patients had all of their GP visits bulk billed in 2015-16 and almost 20 per cent were left out-of-pocket up to half the time they saw their family doctor.

The results, as first reported by Medical Observer, belie claims by Health Minister Sussan Ley that bulk billing remains at record high levels.

Last month the Minister seized on official figures showing that 85.4 per cent of GP services were bulk billed in the September quarter, up almost 1 percentage point from a year earlier, as evidence of the Government’s investment in Medicare.

But the figure is a measure of the number of services bulk billed, as opposed to the number of doctor visits, which many consider to be a more meaningful indicator of patient costs and access to care.

The AMA has warned that the Government’s Medicare rebate freeze is putting medical practices under intense financial pressure, forcing them to cut back on bulk billing or abandon it all together, increasing costs for their patients and driving concerns that people who are ill will increasingly put off seeing their doctor, putting their health at risk and increasing the cost of treatment when they eventually seek care.

These concerns have been leant weight by a separate answer to a question on notice in which the Department confirmed the average patient contribution jumped 5.4 per cent in inflated-adjusted terms in 2015-16, the biggest increase in three years.

In the past decade, Government figures show, patient out-of-pocket costs have grown by an average 5.6 per cent a year in real terms, and AMA President Dr Michael Gannon said they were now above the average among advanced economies.

In the September quarter alone, out-of-pocket costs surged 4.5 per cent to reach an average of $34.61.

Dr Gannon said this showed that the Medicare rebate was falling increasingly behind the real cost of providing health care, and underlined the inadequacy of the Government’s investment in primary health care.

The Government has frozen Medicare rebates until 2020, but is coming under mounting pressure from doctors and patients to scrap the measure and substantially boost its contribution to the cost of care.

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Hep C cure’s $1bn price tag

The Federal Government has spent almost $1 billion on drugs in the first four months of its campaign to eliminate hepatitis C, reinforcing estimates that it will ultimately cost taxpayers $3 billion to cure chronic sufferers.

Figures compiled by Australian Prescriber show that since the hepatitis C treatments sofosbuvir and ledipasvir were listed on the Pharmaceutical Benefits Schedule in March, the Government has paid out $942.8 million on 43,900 prescriptions for the drugs, at an average cost of almost $21,500 per script.

Sofosbuvir has been hailed as a “game-changing” medicine that can cure hepatitis C in as little as 12 weeks, but the cost for most individuals is prohibitive – $110,000 for a course of treatment.

But following its listing on the PBS, chronic hepatitis C sufferers can get for as little as $6.20 a prescription.

Health Minister Sussan Ley has linked the subsidisation of the hepatitis C treatments to $650 million in savings from the controversial axing of bulk billing incentives for pathology and diagnostic imaging services.

“These two new hepatitis C medicines have come on to the market and rocketed into the number one position on the list of top drugs by cost to the Government,” Australian Prescriber medical editor Dr John Dowden said. “They were only approved in March, and in the four months to June have cost the Government almost $1 billion for 43,000 prescriptions.”

While the hepatitis C treatments grabbed the crown as the most costly drugs for 2015-16, the most common medicines prescribed were statins and proton pump inhibitors.

Altogether, more than 14 million prescriptions where issued for the statins atorvastatin and rosuvastatin last financial year, while almost 6.9 million were written for the proton pump inhibitor esomeprazole.

The next most commonly prescribed drug was the painkiller paracetamol (5.05 million prescriptions), followed by the reflux medication pantoprazole (4.7 million), the blood pressure drug perindopril (4.05 million) and the diabetes medicine metformin (3.57 million).

While hepatitis C treatments have grabbed a big slice of the Commonwealth’s medicine’s budget, other expensive treatments for leukaemia, multiple sclerosis, arthritis and eye disease are also grabbing a hefty share.

The anti-inflammatory biologic adalimunab, a drug used to treat rheumatic and psoriatic arthritis, Crohn’s disease and chronic psoriasis, has been supplanted at the top of the expenditure table by ledipasvir and sofosbuvir, but still cost the taxpayer almost $334 million last financial year.

Top 10 drugs by cost

Medicine	Cost (A$)
Sofosbuvir and ledipasvir	570 730 056
Sofosbuvir	372 094 623
Adalimunab	335 857 859
Ranibizumab	241 256 012
Aflibercept	231 194 036
Esomeprazole	170 554 177
Etanercept	166 538 773
Trastuzumab	157 134 211
Fluticasone & Salmeterol	148 878 399
Insulin Glargine	146 202 125

Source: Australian Prescriber

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[Editorial] Recognising the Rohingya people

Fresh violence against the Rohingya people of Myanmar has drawn international attention to their plight. Since early October, 30 000 Rohingya have fled their homes to Bangladesh to escape an army crackdown in response to the killing of nine police officers. In a Review published online on Dec 1, Syed M Mahmood and colleagues detail the long and complex history that has led to the health and human rights crisis affecting the Rohingya people, who have been stripped of citizenship by the Myanmar Government.

[Correspondence] Transgender health in India and Pakistan

Sam Winter and colleagues (July 23, p 318 and p 390)1,2 reported a much neglected health issue of transgender people, who have been officially recognised as a third gender citizen registration category in Nepal, Pakistan, India, and Bangladesh, since 2010. Locally known as hijras (hijra), this civil recognition is profound for their social rights because it translates into confirmed allocation into government and education quotas. Despite the legal recognition, access to quality health care is alarmingly scarce compared with their cisgender counterparts.

AMA, Govt hold talks on ‘more balanced’ approach to pathology rents

AMA President Dr Michael Gannon met with Health Minister Sussan Ley in Canberra on 24 November to discuss the Government’s proposal to change the definition of market value for pathology collection centre leases.

Dr Gannon told the Minister that the AMA was prepared to work with the Government to try and come up with a more balanced policy approach that genuinely targeted inappropriate rental arrangements and did not interfere with legitimate commercial arrangements.

The AMA President also highlighted that the Government’s proposed changes had significant implications for existing leases that had been entered into freely, and on the basis of which financial commitments have been made by practices.

The discussion followed a meeting of the AMA Federal Council which reiterated its support for prohibited practices laws, but recommended significant changes to the Government’s election policy.

The Federal Council stressed the need for a more a targeted approach that focused on inducements to refer, consistent with the original intent of the prohibited practices laws, and that pathology referrals should be solely based on the quality of services, as opposed to commercial relationships.

Federal Council resolved to support the right of medical practices to negotiate collection centre leases freely with pathology providers, provided rents were not linked to a stream of referrals and that any new definition of market value must not adversely affect those medical practices that were acting ethically when entering into leasing arrangements.

The Council stated that reasonable transition arrangements would need to accompany any changes, and the Government would need to develop an appropriate educational strategy to ensure requesters and providers were aware of their obligations under existing prohibited practices laws and ensure that these and any future laws were properly administered and enforced.

Responding to allegations of sham leasing arrangements, Federal Council agreed that the Government needed to work with stakeholders to establish whether these could be sustained and, if so, develop measures to address them with urgency.

The AMA Federal Council also expressed its disappointment in successive Federal Governments for their failure to adequately fund patient access to medical care, including the prolonged freeze on Medicare rebate indexation, which increasingly threatened the viability of pathology, general practice and other specialist services.

During his meeting with the Minister, Dr Gannon welcomed her advice that the Government would not proceed with its planned 1 January 2017 commencement date, and the Minister’s commitment to allowing more time for consultation with general practice and pathology practice over the definition of market value and what transition arrangements might be needed. In this regard, the Minister stated that the Department of Health would be expected to work closely with the AMA as it developed further advice to Government.

Worrying MBS changes could be more than skin deep

The AMA has voiced strong concerns about significant changes the Federal Government has made to the Medicare Benefit Schedule without the input of clinicians.

As part of the Government’s 2016 Budget repair plans, the Health Department has used the outcomes of a recent Skin Services review to implement a number of changes to the MBS, including axing 48 skin service items and replacing them with 28 new items recommended by the Medical Services Advisory Committee (MSAC).

Separate to this, an internal decision was made by the Department, without consultation, to reclassify a number of items into a new “banding”. These changes effect the clinical setting in which services can be delivered in order to be still eligible for private health insurance rebates.

Though the development of new MBS skin item numbers arose from constructive engagement between the Department and medical profession stakeholders, there was no discussion of the banding of items under the Private Health Insurance Act.

It is not surprising then that, in absence of advice from the medical profession, the changes to banding classification are now having a deleterious effect on patient care.

The banding classification disadvantages patients, in particular children and patients with complex medical needs who may require these procedures to be carried out in the hospital setting. Under the new banding classifications, these items are no longer indicated for hospital stay unless a written certification is carried out, which is still no guarantee of complete insurance coverage.

The harm caused by these changes has been magnified by the Department’s decision to announce them just days before they were due to come into effect on 1 November, seriously undermining informed financial consent. In many cases, patients had already been scheduled for procedures, including the excision of malignant melanomas which, after 1 November, were no longer automatically eligible for private health coverage when carried out in a private hospital setting.

In some instances, MBS rebates have also been reduced, resulting in many patients now being potentially out-of-pocket.

These changes, and the manner in which they were undertaken, do not instil confidence in the current MBS Taskforce reviews, which follow a similar process.

Alarm bells are ringing because it seems that clinical input is not being taken into account when the final policy decisions are made.

Hopefully this past process will not be replicated in the future MBS Taskforce Review work, as it would drive a wedge between the Government, doctors and their patients by undermining the collaborative decision making required to deliver an efficient and sustainable health system.

The AMA has consistently sought that MBS clinical committees and working groups conduct a complete review. To that end, the Government needs to address how they will accurately link clinician recommendations to implementation throughout the MBS Taskforce reviews – in each and every tranche.

AMA President Dr Michael Gannon has already written to the Minister for Health calling for a rollback of the problematic banding determinations relating to skin items, while also reinforcing the need for transparency and collaboration with medical profession before further substantive changes to the MBS are made.

The AMA’s support for the MBS Taskforce reviews continues to be contingent upon our concerns, and those of our colleagues, being addressed.

The AMA is urging members, together with the medical colleges, associations and societies to keep the Government accountable by highlighting the key principles considered necessary to enable complete reviews. This includes:

seeking reassurance that the reviews will not have unintended consequences for patients;
being vigilant in shaping the clinical narrative and review framework to ensure the reviews do no negatively impact clinician scope of practice;
engaging clinical committees and working groups in translating their findings to policy design; and
supporting the clinicians who are directly involved in the review.

The AMA will continue to influence the MBS reviews through meetings with the Minister, in public commentary, and in more direct engagement with the Health Department.

A forum of the AMA and the colleges, associations and societies is planned for the first quarter of 2017 to provide stakeholders with an update and policy direction regarding the MBS reviews.

Eliisa Fok, AMA Policy Officer

[Perspectives] Deborah L Birx: on a mission to end the HIV/AIDS epidemic

Ambassador Deborah Birx is the US Global AIDS Coordinator and in charge of the US President’s Emergency Plan for AIDS Relief (PEPFAR) and the US Government’s engagement with the Global Fund. She is also the US Special Representative for Global Health Diplomacy and aligns the government’s diplomacy with foreign assistance programmes on global health issues. Speaking to her on the day after the US elections, she was upbeat about PEPFAR’s future. “We are very lucky to have an incredible programme that has bipartisan support now and from the beginning.

[World Report] Government purge continues in Turkey after failed coup

Scientists and medical professionals are among those being detained or dismissed from their jobs by the Turkish Government after the failed coup attempt. Sharmila Devi reports.

[Perspectives] Bending the rules

“All human life is there—joy, pain, honour, dishonour, revenge, temptation, self-destructive ambition.” You might imagine, especially in the light of current events, that playwright Jonathan Maitland is talking about politics. But the subject of his new play Deny Deny Deny is sport—a topic that, while common enough at the movies, is seldom tackled on stage.

A sugary drinks tax could recoup some of the costs of obesity while preventing it

Obesity is a major public health problem In Australia. More than one in four adults are now classified as obese, up from one in ten in the early 1980s. And about 7% of children are obese, up from less than 2% in the 1980s.

Obesity not only affects an individual’s health and wellbeing, it imposes enormous costs on the community, through higher taxes to fund extra government spending on health and welfare and from forgone tax revenue because obese people are more likely to be unemployed.

In our new Grattan Institute report, A sugary drinks tax: recovering the community costs of obesity, we estimate community or “third party” costs of obesity were about A$5.3 billion in 2014/15.

We propose the government put a tax on sugar-sweetened beverages to recoup some of the third-party costs of obesity and reduce obesity rates. Such a tax would ensure the producers and consumers of those drinks start paying closer to the full costs of this consumption – including costs that to date have been passed on to other taxpayers. There is the added benefit of raising revenue that could be spent on obesity-prevention programs.

The scope of our proposed tax is on non-alcoholic, water-based beverages with added sugar. This includes soft drinks, flavoured mineral waters, fruit drinks, energy drinks, flavoured waters and iced teas.

While a sugary drinks tax is not a “silver bullet” solution to the obesity epidemic (that requires numerous policies and behaviour changes at an individual and population-wide level), it would help.

Why focus on sugary drinks?

Sugar-sweetened beverages are high in sugar and most contain no valuable nutrients, unlike some other processed foods such as chocolate. Most Australians, especially younger people, consume too much sugar already.

People often drink excessive amounts of sugary drinks because the body does not send appropriate “full” signals from calories consumed in liquid form. Sugar-sweetened beverages can induce hunger, and soft drink consumption at a young age can create a life-long preference for sweet foods and drinks.

We estimate, based on US evidence, about 10% of Australia’s obesity problem is due to these sugar-filled drinks.

Many countries have implemented or announced the introduction of a sugar-sweetened beverages tax including the United Kingdom, France, South Africa and parts of the United States. The overseas experience is tax reduces consumption of sugary drinks, with people mainly switching to water or diet/low-sugar alternatives.

There is strong public support in Australia for a sugar-sweetened beverages tax if the funds raised are put towards obesity prevention programs, such as making healthier food cheaper. Public health authorities, including the World Health Organisation and the Australian Medical Association, as well as advocates such as the Obesity Policy Coalition, support the introduction of a sugar-sweetened beverages tax.

What the tax would look like

We advocate taxing the sugar contained within sugar-sweetened beverages, rather than levying a tax based on the price of these drinks, because: a sugar content tax encourages manufacturers to reduce the sugar content of their drinks, it encourages consumers to buy drinks with less sugar, each gram of sugar is taxed consistently, and it deters bulk buying.

The tax should be levied on manufacturers or importers of sugar-sweetened beverages, and overseas evidence suggests it will be passed on in full to consumers.

We estimate a tax of A$0.40 per 100 grams of sugar in sugary drinks, about A$0.80 for a two-litre bottle of soft drink, will raise about A$400-$500 million per year. This will reduce consumption of sugar-sweetened beverages by about 15%, or about 10 litres per person on average. Recent Australian modelling suggests a tax could reduce obesity prevalence by about 2%.

Low-income earners consume more sugar-sweetened beverages than the rest of the population, so they will on average pay slightly more tax. But the tax burden per person is small – and consumers can also easily avoid the tax by switching to drinks such as water or artificially sweetened beverages.

People on low incomes are generally more responsive to price rises and are therefore more likely to switch to non-taxed (and healthier) beverages, so the tax may be less regressive than predicted. Although a sugar-sweetened beverages tax may be regressive in monetary terms, the greatest health benefits will flow through to low-income people due to their greater reduction in consumption and higher current rates of obesity.

The revenue could also be spent on obesity programs that benefit the disadvantaged, reducing the regressivity of the tax.

While the beverage and sugar industries are strongly opposed to any tax on sugar, their concerns are overblown. Most of the artificially sweetened drinks and waters, which will not be subject to the tax, are owned by the major beverage companies.

A sugar-sweetened beverages tax will reduce domestic demand for Australian sugar by around 50,000 tonnes, which is only about 1% of all the sugar produced in Australia. And while there may be some transition costs, this sugar could instead be sold overseas (as 80% of Australia’s sugar production already is).

A tax on sugary drinks is a public health reform whose time has come.

Stephen Duckett, Director, Health Program, Grattan Institute and Trent Wiltshire, Associate, Grattan Institute

This article was originally published on The Conversation. Read the original article

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