Whooping cough booster faces axe

The Federal Government may axe the whooping cough vaccine booster for first year high school students as it pulls plans for an Australian Schools Vaccination Register.

An immunisation expert group has been asked to review the pertussis vaccine schedule, including the need for a booster currently being administered to children in secondary school.

The Government has announced that the Australian Technical Advisory Group on Immunisation (ATAGI) has been asked to “provide advice on the clinical place and effectiveness of the pertussis vaccine schedule, including the pertussis booster currently given in the first year of high school”.

Currently, it is recommended that infants receive a dose of the diphtheria-tetanus-acellular vaccine at two, four and six months of age, with further boosters at 18 months and four years. An additional booster is given between 12 and 17 years.

The review comes at a time when the number of whooping cough cases is in decline – about 16,000 cases have been notified so far this year, well down from the 22,500 infections reported in 2015.

But the decline has come not long after the country’s largest-ever recorded outbreak of the disease, between 2008 and 2012, including 38,732 notified cases in 2011 alone.

The National Centre for Immunisation Research and Surveillance said whooping cough was a “challenging” disease to control because immunity waned over time, and epidemics occurred every three to four years.

The Centre said declining immunity was a factor in the last major outbreak, during which 4408 people were hospitalised, including 1832 babies. Between 2006 and 2012, 11 died from pertussis, all but one of them infants less than six months of age.

The review of the pertussis vaccination schedule coincides with the decision not to proceed with the creation of the Australian Schools Vaccination Register.

The Health Department said it had discontinued the tender process for the creation of the Register following advice about the review of the pertussis booster vaccine for secondary school students and the end, in 2018, of the catch-up varicella vaccination program for adolescents.

The Register was announced in the 2015-16 Budget as part of the No Jab No Pay policy, and was portrayed as vital in helping to controlling infectious disease outbreaks by identifying areas where vaccination coverage was low.

But Health Minister Sussan Ley said it had now been “put on hold…pending further advice from independent medical experts on the vaccination needs of adolescents”.

The Health Department said it was possible that the Schools Register would only hold data on the human papilloma virus (HPV) if the pertussis booster for adolescents was axed and once the varicella catch-up vaccination program ends.

The Health Department said it was now looking at alternatives to the Schools Register, including the inclusion of such data in the whole-of-life Australian Immunisation Register which began operations on 30 September.

It is also in discussions with the Victorian Cytology Service about continuing the HPV Register in 2017.

Commonwealth Chief Medical Officer Professor Brendan Murphy was keen to assure that these changes would have “no impact on the health of adolescents because the full range of vaccination services are being delivered to the community, and will continue to do so”.

The move to axe the Register has coincided with the release of Government figures showing that almost 200,000 children have had their vaccinations brought up-to-date following the introduction of the No Jab No Pay reforms.

The figures, reported in the Sunday Herald Sun, show that since the reforms were introduced on 1 January, 86,562 families, including 102,993 children, have been denied childcare payments, and $38 million of Family Tax Benefit A benefits have been suspended. Parents of 8896 children are still not meeting vaccination requirements.

But 183,000 children have had their vaccinations brought up-to-date as a result of the program, under which parents face losing Family Tax Benefit A and childcare payments if they let their child’s immunity slip.

Adrian Rollins

Penny pinching threatens chronic care reform

The Federal Government’s landmark Health Care Homes reform is at risk of collapse because of a lack of funding, the AMA has warned.

Health Minister Sussan Ley has announced that $100 million will be provided to support the phase one trial of the reform, involving 65,000 patients and 200 medical practices in 10 regions across the country.

Under the Government’s plans, practices will receive monthly bundled payments worth an average $1795 a year to manage patients with chronic and complex health conditions. Payments will vary from $591 for chronically ill patients who can largely self-manage their condition to $1267 for those who need more intensive care and $1795 for those with the most complex health demands.

The allocations mean that patients on the lowest level of subsidy will be funded for just 16 visits to the doctor a year, rising to 48 visits a year for those deemed of highest need.

Controversially, such patients would only be eligible for five extra Medicare-subsidised visits to the doctor for health issues that lie outside their chronic illness – a major change from the current system under which patients have uncapped access to GP care.

A spokesperson for Ms Ley told Fairfax that five-visit cap was only an “indicative figure for modelling and planning purposes”, and said no patient would have their access to Medicare restricted or capped.

Ms Ley said Health Care Homes allowed for team-based, integrated care and would provide increased flexibility and coordination of services to tailor treatment to individual need.

But the details of the trial have reinforced suspicions that the Government is undertaking Health Care Homes primarily as a cost cutting exercise, and the AMA voiced concerns that if the reform was not adequately funded it could founder.

“The modelling is concerning and potentially leaves the whole program at risk of falling over because of being underfunded from the beginning,” AMA Vice President Dr Tony Bartone told News Corporation.

Dr Bartone, a GP, is the AMA’s representative on the Government’s Health Care Home Implementation Advisory Group, which last met on 30 September.

He said that, if appropriately funded, Health Care Homes could support GPs to keep patients healthier and out of hospital, but added the Government needed the goodwill of general practitioners if its trial was to succeed.

“That goodwill will evaporate significantly if there is not the appropriate funding,” he warned.

Earlier this year, AMA President Dr Michael Gannon warned that appropriate funding would be a “critical test” of the success or otherwise of the reform.

“BEACH data shows that GPs are managing more chronic disease. But they are under substantial financial pressure due to the Medicare freeze and a range of other funding cuts,” Dr Gannon said.

“GPs cannot afford to deliver enhanced care to patients with no extra support. If the funding model is not right, GPs will not engage with the trial and the model will struggle to succeed.”

Adrian Rollins

Australians shedding their hard drinking image

Drinks sales are forecast to decline as growing numbers of Australians cut back on their consumption or quit altogether, in a sign that higher excises and lock-out laws are helping to curb the nation’s drinking problem.

Industry analyst IBISWorld expects per capita alcohol consumption, which has already dropped to a 50-year low, will continue to decline until at least the middle of the next decade as people heed health messages and respond to higher prices, drink-driving laws and other measures by reducing their intake.

The analyst predicts that by 2024 consumption will drop to 8.54 litres per person, a fall of almost 20 per cent from the start of this decade.

“We’re seeing increasing health consciousness among the under 30s, while at the other end of the market people are also drinking less,” IBISWorld senior analyst Andrew Ledovshkik told The Australian Financial Review.

The analysis echoes the findings of an Australian Institute of Health and Welfare report showing that consumption is declining, with 22 per cent reporting they had abstained from drinking in 2013 (up from 17 per cent in 2004), and the proportion who have never had a full drink reaching 14 per cent.

Even rates of risky drinking are declining.

The AIHW reported an 11 per cent drop in the rate of Australians drinking at risky levels on a single occasion (from 2950 to 2640 per 10,000 people), and 13 per cent drop who indulge in risky drinking over a lifetime, from 2080 to 1820 per 10,000.

The declines have paralleled changes to the cost and availability of alcohol.

The excise on beer and spirits is indexed twice a year and for some beverages has reached $81.21 per litre of alcohol. Wine is treated differently and is subject to a so-called equalisation tax currently set at 29 per cent of its wholesale value. Public health advocates are critical of the arrangement and argue that alcohol should be taxed at a minimum unit price that applies regardless of the beverage.

Several State governments, most notably New South Wales and Queensland, have also acted to restrict outlet trading hours and impose lock-outs in response to alcohol-fuelled assaults and murders.

The Institute said the results suggested that strategies including increasing the price of alcohol, restricting trading hours and reducing the density of outlets “can have positive outcomes in reducing the overall consumption levels of alcohol”.

Aside from making alcohol more expensive and difficult to get, there are signs that younger people are less inclined to drink to the same extent as older generations.

In the United States, a survey of 67,000 youths and adults conducted by the Abuse and Mental Health Services Administration found that just 9.6 per cent of adolescents aged between 12 and 17 years reported drinking alcohol in 2015, down from 17.6 per cent in 2002.

The question is whether others drugs are being used as a substitute for alcohol.

In the US, there has been a slight drop in heroin use, but prescription drug use and abuse is high. It is estimated that about 19 million Americans aged 12 years or older misused prescription drugs, mainly painkillers, in the previous year.

In Australia, about 3.3 per cent of those 14 years or older have used analgesics for non-medical purposes in the previous 12 months, 10 per cent have used cannabis, 2.1 per cent have used cocaine and methamphetamine, 2.5 per cent have used ecstasy, 1.3 per cent have used hallucinogens and 0.1 per cent have used heroin.

But even with the decline in its consumption, alcohol remains a major health problem. It was the leading cause of disease burden for the under 45s in 2011, and alcohol use disorders accounted for 1.5 per cent of the total burden of disease that year.

Adrian Rollins

[Perspectives] Picturing health: challenges for Syrian refugees in Turkey

Although about 2·7 million refugees from Syria are registered in Turkey, most do not live in official refugee camps. The Turkish Government is working with UNHCR and other partners on a response, but many refugees find themselves in compromised conditions.

Upsurge in doctors under billing scrutiny

A doctor has been ordered to repay Medicare rebates worth almost $1.14 million as part of an upsurge in cases of over-billing being investigated by health authorities.

The Professional Services Review has reported a near doubling of the number of cases referred to it by the Health Department as the conduct of medical practitioners, particularly in the preparation of chronic disease management plans and those working in large practices, comes under increased scrutiny.

In its 2015-16 annual report, the PSR said it had received 80 referrals from the Department, a 29 per cent jump from the previous year and an 82 per cent surge from 2013-14.

Of 49 investigations completed last year, 24 resulted in no further action being taken, while 18 were resolved with a negotiated agreement including the repayment of $1.63 million and the partial disqualification of 12 practitioners.

But in seven instances doctors were reprimanded and ordered to repay Medicare benefits worth between $48,380 and $1.138 million. In one instance, a doctor was disqualified from practising for three months.

In all, doctors were ordered to reimburse Medicare almost $4.6 million.

While the vast majority of the 85,000 practitioners providing Medicare reimbursed services are considered to be doing the right thing, the PSR reported several instances of high billing, including a GP who provided 20,000 services in a single year, as well as almost 600 GP Management Plans, 400 Team Care Arrangements and more than 1000 item 2713 mental health services – each of which has a minimum 20-minute time requirement.

A chronic problem

The agency, which is asked to investigate cases that the Health Department cannot resolve or explain, said the use of Chronic Disease Management (CDM) and Health Assessment items was of particular concern.

“Many practitioners who provide high numbers of these services use computer-generated templates; a plan may have minimal content specific to the patient for whom the plan has been prepared,” it said. “Plans sometimes have very generic health advice of the most minimal nature, and sometimes irrelevant to any condition listed in the patient’s clinical record.”

The PSR said that in other instances some GPs were preparing GP Management Plans every 12 months, and reviewing them every three months, without even consulting the patient.

“In some cases, there was little evidence that patients were aware that they had a GP Management Plan, and the precise regularity of reviews every three months…appeared contrived to maximise income rather than being based on clinical assessment.”

A matter of size

The PSR raised concern about the operation of larger medical practices where GPs are engaged as independent contractors who pay the operator a service fee. It said that under current arrangements individual practitioners were held solely accountable for inappropriate billing and the reimbursement of rebates – practice owners retained their share of Medicare rebates.

Local knowledge

The agency warned that overseas-trained doctors were more susceptible to breaching Medicare rules than their local counterparts, accounting for almost 54 per cent of cases referred to it last financial year.

In one instance, it found an “older English graduate…engaged in particularly egregious use” of CDM items, claiming the MBS items 721 and 723 more than 400 times in 12 months, at $240 a time.

Three other international medical graduates were found to have breached the so-called 80/20 rule, which meant they billed 80 or more GP attendance items on 20 or more days in the year. Typically, this would mean providing between 17,000 and 20,000 services attracting a gross rebate of between $800,000 and $1 million.

In all, five practitioners were investigated by the PSR for breaching the 80/20 rule, while a further 15 were identified to have provided more the 60 attendances on more than 100 days.

In mitigation, many explained that they worked very long hours, they knew their patients well so could serve them quickly, that the practice was under-staffed or that they were unaware of the 80/20 rule.

Round-the-clock

The PSR flagged that while some doctors were billing CDM items inappropriately, others had come under suspicion over their provision of urgent after-hours care.

It said that although those referred for investigation had generally satisfied the definition of providing after-hours care, their interpretation of what constituted the need for urgent care was dubious.

“Examination of clinical records has shown that some practitioners have billed these items for medical conditions such as an uncomplicated rash, reissuing prescriptions for…regular medication and for routine completion of medication charts in residential aged care facilities,” the PSR said, adding that the difference in fee between urgent and non-urgent after-hours MBS items was substantial enough to have a significant financial impact on Medicare.

The agency warned that the Government’s review of the MBS and Medicare compliance measures was likely to include ways to use the billing system to “better detect and define possible inappropriate practice”.

The Federal Government has begun work on upgrading the Medicare payments system, inviting private sector upgrade proposals, though it has insisted the system and the information it collects will remain completely in public hands.

Latest news

[Correspondence] Hunger strike and health system reformation in Nepal

Dr Govinda KC, a senior orthopaedic surgeon and a professor at Tribhuvan University Teaching Hospital, is staging a series of hunger strikes to reform medical education and the health system in Nepal. At every attempt, the government has promised to fulfil his demands, yet never gone through with its promises, and the media report that the unwillingness of government has generated his eight hunger strikes.1,2

[Correspondence] Use of personal information in medical research in Japan

In Japan, the revised Act on Personal Information Protection was approved in September, 2015, and is scheduled to be put into effect in April, 2017.1 Under this revision, medical history, in addition to race, beliefs, and social status, was newly designated as sensitive personal information. Academic research has been excluded from the application of the Act on Personal Information Protection since before the revision.2 However, the government guidelines to which clinical research other than clinical trials for new drug approval,3 to which the Pharmaceutical Affairs Act applies, must include the same items as the Act on Personal Information Protection.

[Perspectives] Histories of medical lobbying

The lobbying of government ministers by medical professionals is a live issue. Health professionals around the world have been active in the pursuit of legislative change. In the UK, the AllTrials campaign continues to exert pressure on parliamentarians to force greater transparency in the publication of clinical trial results. This year doctors in Australia refused to discharge child refugees from hospital into detention centres deemed harmful to their health. The lobbying of medical humanitarians such as Médecins sans Frontières in France effected a change in the law there, in 1998, that allowed undocumented immigrants with life-threatening conditions to remain in the country for medical treatment.

Family doctors need help to tackle domestic violence

Family doctors are more likely than police to see the results of family and domestic violence, and have a key role to play in early intervention and treatment, the AMA says in an updated Position Statement.

AMA President, Dr Michael Gannon, said the trusted role of the family doctor gave GPs a clear insight into the damage caused by the violence.

“Two women are killed nearly every week in Australia due to family and domestic violence,” Dr Gannon said.

“The health effects of family and domestic violence in both the immediate victims and their families are devastating, and it is not only women who are the victims.

“Women experiencing domestic violence will share their experiences with their GPs more often than with any other professional group, and the health impacts persist long after the violence ceases.”

Women who have experienced domestic or family violence have higher levels of mental and physical disorders, higher rates of suicide attempts, and are more likely to have an impaired quality of life than other women.

“Children who grow up witnessing and experiencing domestic violence can also be profoundly affected.”

The AMA is committed to providing important information and guidance to empower doctors, particularly GPs, to provide better support for victims.

The release of the revised and updated Position Statement on Family and Domestic Violence 2016 this week coincided with a major meeting of Commonwealth, State, and Territory ministers at the COAG National Summit on Reducing Violence Against Women and their Children.

It calls on all Australian governments to properly fund and resource specialised family and domestic violence support services, including housing and crisis accommodation.

“Family violence affects people of all genders, sexualities, ages, socio-economic background, and cultures,” Dr Gannon said.

“And we are now also seeing increasing instances of elder abuse, with grandmothers and grandfathers, many frail and vulnerable, being subjected to violence from family members.

“Men can be victims. Women can be perpetrators. But it is clear that the overwhelming majority of people who experience such violence are women.”

Stamping out family and domestic violence requires commitment and coordination from governments; support services; the related professions, especially medical, health and legal; neighbourhoods; and families – backed by adequate funding.

The Women’s Electoral Lobby (WEL) backed the AMA’s call for funding, saying it was disappointing that crisis services for women and children escaping violence were not on the agenda for the COAG Summit in Brisbane.

“The Summit plans to hold roundtable discussions on such topics as ‘using behavioural insights to reduce domestic violence’ and ‘innovative uses of technology’, as well as important discussions on the Family Court, Indigenous insights and experiences, and the effects of domestic violence on children, but there is nothing on the agenda about crisis services, including women’s refuges,” WEL said in a statement.

“WEL calls on the COAG Summit to include support for long-term, secure Commonwealth-State funding for women’s crisis services in its deliberation and follow-up actions.”

Latest news

Big pathology to get massive windfall at expense of patients, doctors

The AMA has warned that Federal Government proposals to cap pathology collection centre rents will likely drive up patient out-of-pocket costs and could force some medical practices out of business.

In a strongly worded letter, AMA President Dr Michael Gannon has appealed to the Small Business and Family Enterpirse Ombudsman, Kate Carnell, to intervene and help try to convince the Government to drop its plan.

Dr Gannon said the proposal, announced during the Federal election, to change provisions in the Health Insurance Act would allow the two major pathology companies that dominate the market to unilaterally cut the rents they paid to medical practices for co-located collection centres (ACCs), delivering a big financial blow to small business already reeling under the effects of the Medicare rebate freeze.

“The proposed changes fundamentally alter the intent of the existing law…by imposing a blunt cap on the commercial rents that GPs and other specialists can receive for co-located ACCs,” the AMA President said. “It delivers two major listed companies with an unwarranted and unfair advantage…estimated to save [them] between $100 million and $150 million per annum.”

Dr Gannon said the rapid increase in ACC rents since they were deregulated in 2010 had been driven by competition for market share between the two big pathology companies, and the Government itself had attested to the fact that there was no evidence of a link between the pathology referrals made by doctors and ACC rents.

He warned that the Government’s proposed changes would have “a big impact” on medical practices.

“Medical practices are [already] feeling the impact of the current MBS indexation freeze, and policy changes like this will simply have a further negative impact on their cash flow and on practice viability,” he said. “For those practices that have used this source of rental income to help keep them viable during the current extended freeze, it may it may mean higher costs to patients or simply selling their business.”

Many, the AMA President said, had made decisions about hiring staff and purchasing equipment based on anticipated revenue streams from ACC rents, and the policy would put their finances under strain.

Dr Gannon said it was unlikely the Government comprehended the full impact of the “poorly targeted” policy when announcing it, including the massive windfall it would deliver to the big pathology providers and the hefty financial blow it would deliver to many medical practices.

Adrian Rollins