Bulk billing falls back, patient costs rise

The GP bulk billing rate has fallen back and patient out-of-pocket costs have jumped in what could be an early sign that the Federal Government’s Medicare rebate freeze is forcing general practices to increase patient charges to stay financially viable.

Repeated AMA warnings that medical practices were being driven by the rebate freeze to reduce or abandon bulk billing and hike patient charges have been leant weight by Health Department figures showing the bulk billing rate fell from 85.9 to 85.4 per cent in the September quarter while out-of-pocket costs surged 4.5 per cent to reach an average of $34.61.

While the AMA urged caution in reading too much into one quarter’s figures, the results could be the first confirmation of fears that Government policy is pushing up the cost of seeing a GP, including for vulnerable patients, such as those with chronic illness or on welfare.

“We know that the patient rebate is in many cases inadequate to maintain quality medical practice,” AMA President Dr Michael Gannon said.

In their search for ways to stay afloat, practices appear not only to be cutting back on bulk billing but also looking to charge non-bulk billed patients more.

Government figures show the average patient contribution increased at more than six times the pace of inflation in the September quarter, a heavy financial blow to households already stretched by near-stagnant wage growth, fuelling fears that patients will increasingly defer or forego seeing a doctor.

While decrying the “obsession” of both sides of politics in using the bulk billing rate as a measure of the quality of health care people receive, Dr Gannon said the Medicare figures nonetheless highlighted the importance of the Medicare rebate in funding primary health services, and the consequences when it failed to keep pace with the cost of providing care.

“The statistics show that Australians pay above-average out-of-pocket expenses, which is a sign that patient rebates are inadequate in funding our health system,” he said.

But Health Minister Sussan Ley claimed the latest Medicare data showed GP bulk billing rates remained at record high levels.

Seizing on figures showing the bulk billing rate in the September quarter was almost 1 percentage point higher than the same period last year (84.6 per cent), Ms Ley said the result was an affirmation of the Government’s policies.

“These ongoing increase in bulk billing rates are underpinned by our record investment in Medicare, which is increasing by $4 billion over the next four years,” the Minister said.

But Shadow Health Minister Catherine King said the quarterly result belied the Minister’s claims.

“This is the evidence Malcolm Turnbull didn’t want revealed – bulk billing is dropping and he knows it,” Ms King told reporters. “Australians are already seeing the impact of his six-year Medicare freeze every time they go to the doctor with more and more patients having to pay out of their own pocket.

“On the day before the election Malcolm Turnbull promised that no Australian would pay more to visit the doctor – this was a complete and utter lie.

“The Government needs to pull their head out of the sand and admit that their health policies are hurting Australians.”

AMA President Dr Michael Gannon has directly lobbied Prime Minister Malcolm Turnbull to immediately end the rebate freeze, warning that the increasing financial squeeze on medical practices was forcing many to cut bulk billing and increase patient charges in order to remain financially viable.

Medicare rebates have been frozen since 2014, and under current plans will not be indexed until at least 2020.

Ms Ley has talked down hopes that the policy could be reversed soon, arguing the Government cannot afford to recommence indexation until its finances improve.

The Government is due to release its Budget update next month, but the Parliamentary Budget Office has reported a further deterioration in the Government’s finances, projecting that the deficit will balloon to $105.1 billion by 2018-19 – an $8.9 billion blow out from the Budget.

The latest Medicare statistics show the bulk billing rate for the September quarter ranged from a high of 88.7 per cent in New South Wales to a low of 60.3 per cent in the Australian Capital Territory.

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E-cigs a gateway to smoking for young: study

The AMA’s call for a cautious, evidence-based approach to the use of e-cigarettes has been underlined by research that ‘vaping’ can lead to heavy smoking among young users.

As debate rages over the effectiveness of e-cigarettes as an aid in avoiding or giving up smoking, a study published in the Journal of the American Medical Association has cast doubt on the idea that they can divert people from the deadly habit.

The longitudinal study involving 3084 public high school students in Los Angeles County found a “positive association” between the use of e-cigarettes and subsequent smoking, particularly when those taking up the vaping habit were non-smokers.

“In this study of adolescents,” the researchers said, “vaping more frequently was associated with a higher risk of more frequent and heavy smoking six months later.”

Furthermore, the positive association between baseline vaping and follow-up smoking frequency was stronger among baseline non-smokers than infrequent or frequent smokers, the research found.

The findings follow a United States Centers for Disease Control and Prevention investigation that found a large number of non-smoking middle and high school students had used an e-cigarette, and were twice as likely as those who hadn’t to report that they intended to start smoking tobacco cigarettes.

The findings back AMA concerns that e-cigarettes are undermining tobacco control efforts and should be subject to the same restrictions as on cigarettes, including a ban on sales to children and adolescents, and tight restrictions on their marketing and promotion.

In a Position Statement released late last year, the Association warned that many e-cigarettes were being marketed to appeal to young people, including through the use of flavourings, and voiced fears that they could act as a gateway for young people to progress to become smokers – a concern borne out by the JAMA study.

The AMA said the evidence that using e-cigarettes helped people to give up smoking was “mixed and low-level”, and the risk they posed meant governments should take a precautionary approach.

“Currently, there is no medical reason to start using an e-cigarette,” the Association said. “There are legitimate concerns that e-cigarettes normalise the act of smoking. This has the potential to undermine the significant efforts that have been dedicated to reducing the appeal of cigarettes to children, young people and the wider population.

“In fact, using an e-cigarette may significantly delay the decision to quit smoking,” the AMA warned, adding that the longer-term health implications of inhaling e-cigarette vapours produced by illegally imported and unregulated solutions were unclear.

The best approach, it said, was restrict their promotion and ban sales to young people until further evidence as to their safety and efficacy was available.

The AMA’s Position Statement, Tobacco Smoking and E-Cigarettes – 2015, can be downloaded at: position-statement/tobacco-smoking-and-e-cigarettes-2015

Adrian Rollins

GPs targeted in national plan to curb antibiotic resistance

GPs will be targeted over their antibiotic prescription practices as part of a national strategy to tackle the threat from rising antibiotic resistance.

Less than 10 days after researchers sounded the alarm over the arrival in Australia of a superbug capable of overcoming the last line of defence against salmonella infection, the Federal Government has detailed its plans to implement the National Antibiotic Resistance Strategy.

Health Minister Sussan Ley said the inaugural plan, covering the period 2015-19, had as one of its main targets reduced recourse to antibiotics by GPs.

“A particular focus will be Australia’s high use of antibiotics in general practice, which is 20 per cent above the OECD average,” Ms Ley said. “Bringing prescribing rates down is critical, as high antibiotic use is the number one driver of the increasing resistance to antimicrobials.”

Despite this focus Ms Ley, who launched the strategy in conjunction with Agriculture Minister and Deputy Prime Minister Barnaby Joyce, said the plan encompassed a broad “one health” approach which recognised the inextricable links between human, animal and ecosystem health.

“[This means] that combating resistance to antimicrobials requires action in all sectors where antimicrobials are used,” the Health Minister said.

The plan calls for, among other things, better support for doctors and vets in educating patients about the need for care in antibiotic use; the implementation of effective stewardship practices among health professionals; improved national surveillance of antibiotic use; better infection control measures; and intensified research efforts.

The plan has been developed amid mounting international alarm regarding the threat posed by antibiotic resistance. A recent British Government report warned the world was on track to a future in which even common infections and medical procedures could become potentially deadly because of the risk of infection.

The UK report estimated that antimicrobial resistance could kill 10 million a year by 2050, and cost the world a cumulative USD$100 trillion in reduced economic output without effective action to slow the rate of drug resistance.

The threat to Australia has escalated following the discovery by Murdoch University researchers of a strain of the Salmonella bug that is resistant to carbapenems, the drug used as the last line of defence against such infections.

The superbug was discovered in a pet cat admitted to Concord Veterinary Hospital in New South Wales with an upper respiratory tract infection that subsequently developed into a gut infection.

A sample of the infection sent to a team of researchers at the Concord Hospital identified a strain of Salmonella never before seen in the country. It was found to be carrying the highly resistant IMP-4 gene.

A further three animals at the veterinary clinics were also found to be infected with the superbug. The outbreak has been contained.

Dr Abraham said the identification and containment of the bacteria was “an example of Australia’s One Health capabilities, where animal and human health specialists work together to prevent the spread of infection”.

Adrian Rollins

States to feel heat on doctor shopping

The states are under pressure to detail how they will act on doctor shopping when they report on progress in implementing a national real-time prescription monitoring system at a meeting of the country’s health ministers next month.

More than three years after the Commonwealth, states and territories agreed on a framework for tracking the dispensing of controlled drugs including painkillers and tranquilisers, frustration is mounting that a reporting system is yet to be enacted.

Attempting to inject fresh momentum, Federal Health Minister Sussan Ley last month secured a commitment from the states and territories to report on their progress in implementing the scheme to an Australian Health Ministers’ Advisory Council meeting scheduled for December.

At last month’s COAG Health Council meeting, the State and Territory ministers agreed to “further progress a national real-time prescription monitoring system that alerts doctors and pharmacists to people who are abusing prescription drugs by doctor or pharmacy shopping”.

The importance of the issue has been underlined by figures showing in 2013 almost 5 per cent of Australians admitted to misusing pharmaceuticals, up from 4.2 per cent in 2010.

Painkillers are the most commonly abused medication. Among adults, 3.3 per cent admitted using them for non-medical purposes, and of these half were using prescribed analgesics.

The scale of the problem is large. The number of opioid prescriptions subsidised through the Pharmaceutical Benefits Scheme jumped from 2.4 million to 7 million in the 15 years to 2007, and between 1997 and 2012 the supply of oxycodone increased 22-fold and fentanyl, 46-fold.

Abuse of such drugs has become the most common cause for people seeking drug and alcohol treatment. A Victorian drug and alcohol counselling service has reported that it receives almost three times as many calls regarding prescription opioids as it does heroin.

Seeking to crack down on doctor and pharmacy shopping, the Federal Government in 2012 finalised the Electronic Recording and Reporting of Controlled Drugs System.

But so far, only Tasmania has rolled it out in their State.

Adrian Rollins

The medical profession is under attack: WMA

The physical safety and professional autonomy of doctors around the world is under attack from governments, armed groups and individuals, hampering their work and putting the health of patients at serious risk, according to incoming World Medical Association President Dr Ketan Desai.

Speaking following a spate of deadly attacks on hospitals and medical centres in war-torn Syria, Yemen and Afghanistan, Dr Desai told the WMA annual assembly in Taiwan that increasingly the Geneva Convention was being “practised more in breach than observance, invariably ending up in flagrant violation of human rights”.

UN Secretary-General Ban Ki-moon has condemned the sustained bombing of medical facilities in the besieged Syrian city of Aleppo as war crimes, amid claims that 95 per cent of pre-war medical personnel in the city have fled since the conflict began.

In Yemen, Saudi-led forces have been accused of targeting several health facilities, including a strike on a Medicins Sans Frontieres hospital in which 11 died and 19 were injured.

Dr Desai praised the dedication of doctors and health professionals working in these countries, and said they deserved protection: “To a physician, a patient is neither a friend nor an enemy. They legitimately need protection from violence while at work, whether in war or civil conflict situations”.

Doctors also risked physical attack outside war zones.

The WMA President, who was elected to the post after serving as President of the Medical Council of India, said medical practitioners working in many parts of the world, particularly in Asia, were being assaulted, and hospitals and clinics ransacked and damaged, by angry patients and their families.

In addition to these physical threats, Dr Desai said that in countries as diverse as Turkey, India and the United Kingdom, governments were attempting to encroach on the independence and autonomy of the medical professional, to the detriment of patients.

“Regulation of clinical practice, framing evidence-based standard treatment guidelines, defining and checking professional malpractice and medical education all need vital professional independence and a democratic system based on meaningful participative decision-making,” he said. “In many countries there are continued political attempts to undo or marginalise autonomy and self-governance of the medical profession, including mauling and trampling on the trinity of professional autonomy, clinical independence and self-governance.”

Dr Desai said the WMA was alert to these threats and would continue to fight government efforts to make the medical profession subservient.

But he said part of this involved ensuring the medical profession acted with honesty and integrity, something that was at risk in many countries because physicians were prescribing and referring patients based on pecuniary self-interest or kickbacks.

In other developments, the WMA General Assembly:

approved ethical guidelines on the collection and use of identifiable health data (the Declaration of Taipei);
demanded an immediate and impartial inquiry into the bombing of hospitals in Aleppo;
urged national medical associations and other health groups to divest fossil fuel stocks;
called for greater focus on care of the elderly; and
said doctors must be prepared to intervene to protect girls from undergoing female genital mutilation.

Adrian Rollins

[Comment] Offline: A barometer for trust in China

The Chinese Academy of Medical Sciences celebrated its 60th anniversary last week. 60 is commonly symbolised by a diamond. The word diamond (Greek, adamas) means “unbreakable” and “unconquerable”. Fitting. Because thanks to the organisation of health care in China, the Chinese public has been the beneficiary of some remarkable successes. Indeed, “health” has increasingly been emphasised in government manifestos since 1954, according to research presented at the second Lancet–Chinese Academy of Medical Sciences Health Summit held in Beijing this week.

Getting difficult to call Australia home

Disillusioned National Health Service doctors have been warned that they may find it difficult to get work in Australia.

Dr John Zorbas, Chair of the AMA Council of Doctors in Training, told the Financial Times that Australia’s long-standing reliance on overseas trained doctors to fill gaps in the medical workforce was waning.

Dr Zorbas said the although international medical graduates (IMGs) from around the world, including the United Kingdom, had made a “critical” contribution to the medical workforce in the last 15 years, demand was easing as an increasing number of locally trained doctors were graduating.

“IMGs looking to come to Australia need to know that job opportunities are limited, often confined to short-term roles or areas of medical workforce shortage like rural locations,” he said.

In the past 12 years the number of medical school graduates has more than doubled from 1500 to 3700 a year, creating intense pressure for advanced specialist training places.

As a result, the Government is considering removing a number of specialties from the Skilled Occupations List used to assess applications for permanent residency, including general practitioners, anaesthetists, intensive care specialists, gastroenterologists and obstetricians.

“We do not expect that this will have a big impact as there will still be other visa options available,” Dr Zorbas said. “However, it is the first sign that we are overcoming medical workforce shortages and are less reliant on international recruitment.”

He said data showed overall doctor numbers in Australia were “in balance”, even though they were not evenly distributed by location or specialty.

Adrian Rollins

Cancer register bill passes with amendments

The new National Cancer Screening Register will begin in May 2017 after legislation passed federal Parliament – with amendments after the AMA and other groups raised concerns about privacy.

The new Register will replace eight separate State and Territory cervical cancer screening registers and the paper-based national bowel cancer screening system, allowing more timely and efficient notification and follow-up.

“Cervical and bowel cancers are largely preventable with regular screenings,” Health Minister Sussan Ley said.

“The Australian Government remains committed to saving lives through more efficient screening processes and co-ordination, and the new national register is an important part of this process.”

The draft Bill was amended to strengthen the privacy provisions in the Bill. The contractor will be forced to notify the Australian Information Commissioner and Health Department Secretary of any breaches of data.

The changes came after the AMA, the Australian Information Commissioner, and other health groups raised concerns about the potential for privacy breaches, and called for highly rigorous and ethical safeguards.

Related: Cancer registry privacy fears

The AMA also criticised the lack of transparency around the process for awarding the contract to Telstra Health.

“The awarding of such a contract to an entity that has hitherto had no direct role in establishing or operating a register of this kind sets a challenging and potentially troublesome precedent,” the AMA submission to the Senate inquiry into the legislation said.

“The AMA therefore would welcome a detailed explanation and assurance from the Department of Health, as well as independent privacy and data experts, that the entity awarded the contract has the capacity to deliver it as contracted, and that every assurance can be given as to how sensitive health and medical data will be stored, how any potential breaches will be addressed, and what arrangements are to be put in place to manage the transition of nine separate cancer screening registers into a single National Cancer Screening Register.

“Given the potential commercial value of the data contained in the register, the AMA would be more comfortable with it being operated by government, a tertiary institution, or not-for-profit entity that has little interest in how the data in the register might otherwise be used.

“This would go a long way to allaying concerns about the secondary use of data for commercial reasons.”

Labor also criticised the Government’s decision to sign the contract with Telstra before legislation had been presented to parliament.

“Labor has said from the outset that we support the National Cancer Screening Register, but given the volume of sensitive health information at hand, it is critical to get it right,” Labor health spokeswoman Catherine King said.

“The passing of this legislation does not lessen the fact that Australians are still owed a clear explanation about why, only days before calling the election, the Turnbull Government rushed to sign a contract with Telstra.”

Labor tried but failed to amend the bill further to mandate that the Register be run only by a Government agency or a not-for-profit body, to ensure consumers are notified of data breaches, and to impose more severe penalties for data breaches.

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UK’s ‘stunning own goal’ could feed doctor exodus

The British Government has been accused of a “stunning own goal” over its muddled plan to make the country self-sufficient in doctors by the middle of the next decade.

Just days before Prime Minister Theresa May told senior National Health Service officials there would not be any more money for public health services when the Government issues a financial update this month, Health Secretary Jeremy Hunt announced an extra 1500 home-grown doctors would be trained each year from 2018 in order to reduce the nation’s reliance on international medical graduates.

Under the plan, which the Government said would cost £100 million (A$160 million) in its first two years, doctors would be fined £220,000 (A$352,000) if they left the NHS before completing a minimum four years of service.

The goal is to make the country self-sufficient in doctors by 2025.

Mr Hunt outlined the plan as a response to concerns that a shortage of medical practitioners is contributing to overwork and poor morale among NHS doctors.

Ms May also portrayed it as a way to reduce the country’s reliance on practitioners from overseas to help fill workforce gaps – an issue with heightened implications given the UK’s decision to cut ties with the European Union.

But, coming against the backdrop of a bitter dispute over the Government’s attempts to impose new work contracts on junior doctors, the policy has been criticised by some as ham-fisted and ill-conceived.

Harrison Carter, co-Chair of the British Medical Association’s medical students committee, told The Lancet the initiative was poorly directed and failed to address the underlying problems afflicting the UK’s medical workforce.

“It’s a stunning own goal by the Secretary of State [for Health],” Mr Carter said. “[The Government] needs to deal with the underlying issues causing doctors to walk away from the NHS.”

A recent survey of 420 British doctors who have graduated in the past decade found that 42 per cent planned to practise overseas, because their experience of work was worse than they had expected. A further 16 per cent said they had “taken a break” from their medical career.

The results have underlined concerns that the bruising industrial battle over work contracts, which involved unprecedented strikes, has created significant ill-will and disillusionment among junior doctors, encouraging many to look elsewhere to develop their careers.

Dr John Zorbas, Chair of the AMA Council of Doctors in Training, told the Financial Times that there was strong interest among young UK doctors about working in Australia.

“When I speak to my overseas trained colleagues already working here, interest from UK doctors in training about working in Australia is high,” Dr Zorbas said. The AMA has written to the UK Government about the [NHS] dispute, which is no doubt impacting on the morale of doctor sin training in the UK. Unfortunately, it appears the Government’s agenda is more about an attack on working conditions than improving the quality of care for patients.”

Mr Carter said Mr Hunt’s plan to create extra training places and impose a four-year service requirement was no solution.

“This is not the way to address the crisis in morale in the profession,” he said. “What they will be faced with is doctors who are disillusioned, with low morale, and who will be bound to their job, not because of desire but because of an obligation.”

His concerns have been echoed by Royal College of Physicians Registrar, Andrew Goddard, who told The Lancet that although the extra training places was welcome, an extra 1500 graduates a year was not enough.

There is also dismay at the way the Government has sold its policy, particularly remarks by the Prime Minister regarding overseas trained doctors.

In an interview following the announcement, Ms May should doctors from overseas would stay “in the interim period until the further number of British doctors are able to be trained and come on board”.

While the PM later clarified her comments to say that overseas trained doctors did not have to leave, senior figures in the profession said the remarks were damaging.

“I think it is really dangerous to start thinking that all overseas doctors are about to go home,” Medical Schools Council Chief Executive Katie Petty-Saphon told The Lancet. “We really appreciate the work of overseas doctors…and the NHS would fall over without them. They are welcome here and they need to stay here.”

Mr Carter said the Prime Minister’s comment betrayed confused thinking within Government over the push to self-sufficiency in doctors.

He said if the goal was to train local doctors to take over roles currently filled by overseas trained practitioners as well as meeting the growing need for health care, the Government would need to train many more than just 1500 extra a year.

“There is no way that by 2025, with the 1500 who will come in [from] 2018, we will be anywhere near being self-sufficient,” Ms Petty-Saphon said.

Adrian Rollins

Mental health groups urged to boycott new plan

A prominent mental health advocate has blasted the Government’s draft Fifth National Mental Health Plan as “rubbish”, and called on mental health groups to boycott the consultation process.

The plan was released for consultation on 20 October, with Health Minister Sussan Ley describing it as “an important document” that was “focused on actions that will genuinely make a difference for consumers and carers”.

“The Fifth Plan contains seven priority areas, which have been identified for action in close collaboration with the mental health sector,” Ms Ley said in a statement.

But Professor John Mendoza, the former head of the Mental Health Council of Australia, said the plan would simply continue funding late-term intervention at the expense of prevention and early intervention.

Professor Mendoza called on colleagues at an international mental health conference in Brisbane that the consultation process should be boycotted.

“The plan does not reflect the Prime Minister’s commitment at the election ‘to leave no stone unturned when it comes to mental health’,” Professor Mendoza told The Australian, adding that the plan was “mealy-mouthed rubbish” designed by bureaucrats with no institutional knowledge.

“The plan does not take us one step further in relation to the Government’s announcements last November when it responded to the National Mental Health Commission report and it strongly endorsed the national commission’s recommendations.”

Professor Mendoza said that Prime Minister Malcolm Turnbull had used the words “we need to really embrace innovation, we have to focus on the mental wealth of the nation”.

“And he was stating that because it was clear to him that the economic drag on Australia now, through its focus on acute, late-intervention services rather than early intervention and prevention, means that we have hundreds of thousands of Australians who are unable to participate in work, who are unable to complete education, who are unable to sustain and maintain relationships, because they simply can’t get access to the care they need,” Professor Mendoza said.

“The Commission said this isn’t good enough, we need fundamental reform. And the Government said that was what it was going to do.

“Now, the Fifth Plan that’s been released for consultation does nothing of the sort.

“It pays no attention to the Government’s reform agenda, and it certainly doesn’t marry up with what either the Queensland and NSW Governments [are doing] – two different sides of politics, both of them have articulated clear plans.

“This national plan is completely devoid of any specific actions, any measures, any targets.”

The seven priority areas are:

Integrated regional planning and service delivery;
Coordinated treatment and support for people with severe and complex mental illness;
Suicide prevention;
Aboriginal and Torres Strait Islander mental health and suicide prevention;
Physical health of people living with mental health issues;
Stigma and discrimination reduction; and
Safety and quality in mental health care.

The Department of Health and Mental Health Australia will hold consultation meetings in all capital cities, as well as Townsville and Alice Springs, in November and December.

The final plan will be considered by the Australian Health Ministers’ Advisory Council and the COAG Health Ministers’ Council early next year.

Maria Hawthorne