more_vertAccess to high-quality surgical treatment is an indispensable part of a well-functioning health-care system, and as the Amsterdam Declaration on Essential Surgical Care1 has recently emphasised, there are important shortfalls in surgical service in many parts of the world. In recognition of this fact, the Chinese government has made notable recent efforts to standardise surgical training programmes, as part of the National Health and Family Planning Commission’s (NHFPC) complete set of model residency training programmes.
Preference: Government and politics
[Editorial] WHO’s war on sugar
On Oct 11, World Obesity Day, WHO upped the ante in its fight against sugar. First, it called for governments to introduce subsidies for fruits and vegetables and taxation of unhealthy foods, with a particular target on sugary drinks. The new WHO recommendations are based on global expert opinion and 11 systematic reviews of the effectiveness of fiscal interventions for improving diets and preventing non-communicable diseases (NCDs). The second move saw the removal of sales and provision of sugary drinks from WHO headquarters, including at official functions.
[Correspondence] Instability adversely affects HIV care in Haiti
Fragile states are characterised by the intersection of weak governments and weak health systems. Since the 2010 earthquake, Haiti has been in a prolonged period of political upheaval, public health crises, and natural disaster.1 A public health worker strike beginning in Port-au-Prince in March, 2016, spread throughout the country and ended only recently. We report the effects the strike has had on care since April, 2016, at two public hospitals (table): Hôpital St Michel in Jacmel and Hôpital St Antoine in Jérémie.
Ley ‘expects’ health funds to pass on prostheses price cuts
Health Minister Sussan Ley has raised expectations of a slowdown in the growth of private health insurance premiums after announcing a multimillion dollar cut in the cost of common medical implants.
As insurers finalise their proposed premium increases for 2017, Ms Ley has approved changes in the pricing of 2440 prostheses including pacemakers, intraocular lens’ and artificial hips and knees that she said would save health funds $86 million in the first year and $394 million over five years.
The Minister is pressuring insurers to pass on the savings to their members in lower premiums.
“I expect that every dollar of the $86 million finds its way to the bottom line to reduce the cost of next year’s premium,” she told reporters. “I expect if insurers take $86 million out of the cost they pay the hospital that will immediately transfer to lower premium increases for patients and consumers.”
But the Minister refused to specify by how much she expected premiums to fall, and demurred when asked to detail what processes were in place to ensure insurers passed the cuts on to policyholders.
Her reluctance was seized upon by Labor. Shadow Health Minister Catherine King said that while steps to improve health insurance affordability were welcome, “there is no guarantee whatsoever that these cuts will be passed on to consumers”.
But in evidence to a Senate Estimates hearing, senior Health Department officials said the move would put downward pressure on premiums and expected it would result in “a lesser increase than there would otherwise have been”.
Earlier this year Ms Ley initiated a review of the way the Government sets the price of prostheses amid complaints by insurers that they were being charged grossly inflated prices compared with those billed to public hospitals.
Health funds claimed that up to $800 million could be saved by bringing prostheses costs in private hospitals in line with those paid in the public sector. For example, a public hospital in WA is charged $1200 for a coronary stent that costs $3450 in the private system.
The claimed savings have been disputed by private hospitals and medical device manufacturers, and the Medical Technology Association of Australia told The Australian the cuts announced by the Minister would result in job losses, increased out-of-pocket expenses for patients and cost shifting to other parts of the private health sector.
Ms Ley, under pressure over mounting patient disaffection with the relentless rise of insurance premiums – which have been growing by around 6 per cent a year – has prioritised reform of the Prostheses List as a way to rein in the cost of private health cover and slow the drift of policyholders to cheaper but much less comprehensive policies riddled with multiple exclusions.
In February, she appointed Professor Lloyd Sansom to head a working group looking at medical device pricing, including the operation of the Prostheses List, which was created in 1985 to set out the maximum benefit insurers should pay for medical implants and devices.
Since 2001, there have been a number of regulatory reforms that have resulted in a significant increase in prices.
The Australian has reported that the cuts announced by the Minister are based on advice from the Sansom review, which highlighted how the regulated prices of cardiac devices, intraocular lens systems, hips and knees were “significantly higher, in many cases, than market prices based on available domestic and international data”.
“These categories are considered appropriate for initial consideration for benefit reduction because they have large volumes and benefits paid, with relatively high levels of competition among prostheses sponsors,” it said.
The AMA said it supported a “robust and transparent process” for prosthetic pricing, and backed the use of price referencing in review charges on Prostheses List.
But it urged the Government to make sure that any changes did not have the unintended consequence of reducing the range of prostheses available to privately insured patients.
The Association said it would be vigilant in ensuring that Government reforms and health fund initiatives did not encroach on the freedom of medical practitioners to make decisions in the best interests of their patients.
It called for Prostheses List reforms that emphasised the importance of clinician choice, reduce prices and were devised taking into account possible implications for the cost of rehabilitation.
Adrian Rollins
Whistleblower doctors exempt from jail threat
Doctors will no longer be threatened with imprisonment for speaking out about conditions in immigration detention after the Federal Government amended its controversial Australian Border Force Act.
Immigration Department Secretary Michael Pezzullo has confirmed that provisions of the Act have been changed so that secrecy and disclosure rules that threaten whistleblowers with up to two years’ imprisonment no longer apply to health professionals including doctors, nurses, psychologists, pharmacists and dentists.
The backdown follows outcry by the AMA and many other medical groups and individuals against the Act’s secrecy provisions, including the launch of a High Court challenge by the group Doctors for Refugees and the Fitzroy Legal Service.
Doctors for Refugees President Dr Barri Phatafod told the Guardian the decision was a “huge win for doctors and recognition that our code of ethics is paramount”.
The provisions make it a criminal offence for those contracted to provide services to the Department of Immigration and Border Protection to record or disclose information obtained in the course of their work. The penalty is up to two years’ imprisonment.
The operation of immigration detention centres, especially those located offshore on Nauru and Manus Island, has been surrounded by controversy amid claims of assault, self-harm, child abuse and substandard living conditions and medical services.
Groups including Amnesty International have condemned the detention regime, claiming it is causing enormous harm to the wellbeing of asylum seekers and refugees, particularly children.
The AMA has for several years called for the establishment of an independent medical panel empowered to investigate and report on detention centre conditions directly to Parliament.
Doctors have protested that the secrecy provisions in the ABF Act conflict with their ethical duties and their obligations under the Medical Board of Australia’s Code of Conduct, most particularly their paramount obligation to the health of their patients.
These concerns have been magnified by a number of cases in which, it is claimed, authorities have sought to intervene in or override clinical advice on the transfer of detainees in need of medical attention, including the death of Omid Masoumali, who was medically evacuated to Australia from Nauru more than 24 hours after setting himself alight.
The Government denied the intention of the law was to prevent doctors from speaking up on behalf of their patients, and earlier this year Immigration Minister Peter Dutton said he thought it unlikely that health practitioners would be prosecuted under the Act.
But it was revealed that Dr Peter Young, who oversaw the mental health care of detainees for three years, was the subject of Australian Federal Police investigation, including access to his electronic communications and at its most recent National Conference, the AMA passed an urgency motion asking the Federal Council to “look into the matter” of AFP surveillance of doctors.
Dr Young told the Guardian the Government made the amendment because it wanted to avoid legal scrutiny of its policy.
“It’s a big backdown from the Government, and they’ve made it because they didn’t want to go to court, they knew they were going to lose, and they didn’t want their planning and policies discoverable in an open court. That’s what it’s about,” he said.
Adrian Rollins
Health costs rise as rebate freeze bites
Patients face higher out-of-pocket costs as the medical profession struggles under pressure from the Federal Government’s Medicare rebate freeze.
As a result of the Government’s freeze, the gap between the Medicare rebate and the fee the AMA recommends GPs charge for a standard consultation will increase to $40.95 from 1 November, up from $38.95, continuing the steady devaluation of Medicare’s contribution to the cost of care.
The increase comes on top of the effects of the Medicare rebate freeze, which is forcing an increasing number of medical practices to abandon or reduce bulk billing and begin charging patients in order to remain financially viable.
Adding to the financial squeeze, the Government is considering changes that would cut the rents practices receive for co-located pathology collection centres that the AMA estimates would rip up to $150 million from general practice every year.
Under the changes recommended by the AMA, the fee for a standard Level B GP consultation will increase by $2 to $78, while the Medicare rebate remains fixed at just $37.05.
AMA Vice President Dr Tony Bartone said doctors had kept medical fee increases to a minimum, but Medicare indexation lagged well behind the cost of providing medical care.
“The MBS simply has not kept pace with the complexity or cost of providing high quality medical services,” Dr Bartone said.
The rise is roughly in line with Reserve Bank of Australia forecasts for underlying inflation, currently at 1.5 per cent, to rise anywhere up to 2.5 per cent by the middle of next year, and reflects steady increases in medical practice costs.
Staff wages, rent and utility charges have all increased, as have professional indemnity insurance premiums, continuing professional education costs and accreditation fees.
While practice running costs are rising, the Government’s contribution to the cost of care through Medicare has been frozen for more than two years, and in many cases far longer.
The Medicare rebate for GP services has not been indexed since mid-2014, while the last rebate increase for most other services was in November 2012. In the case of pathology and diagnostic imaging the rebate freeze is even longer, going back more than 15 years.
Dr Bartone said the rebate freeze was pushing up patient out-of-pocket costs.
“Many patients will pay more to see their doctor because of the Medicare freeze,” he said. “The freeze is an enormous burden on hardworking GPs. Practices cannot continue absorbing the increasing costs of providing quality care year after year. It is inevitable that many GPs will need to review their decision to bulk bill some of their patients.”
The AMA is pressing the Government to reverse the rebate freeze, and AMA President Dr Michael Gannon has declared he would be “gobsmacked” if it was still in place by the time of the next Federal election, due in 2019.
But Health Minister Sussan Ley has played down hopes that indexation will soon be reinstated, warning that there will not be a change of policy “any earlier than our financial circumstances permit”.
The Government is trying to curb the Budget deficit and rein in ballooning debt.
As part of its strategy, it is increasingly pushing the cost of health care directly onto patients.
Australian Institute of Health and Welfare figures show the Commonwealth’s share of the nation’s health bill slipped down to 41 per cent in 2014-15, while patients’ share has increased to almost 18 per cent, and Australians now pay some of the highest out-of-pocket costs for health care among Organisation for Economic Co-operation and Development countries.
The cost of health
How AMA recommended fees compare with the frozen Medicare rebates
|
Medical Service |
AMA Fee (2015) |
AMA Fee (2016) |
MBS Schedule Fee (2016) |
|
Level B GP consult (MBS item 23) |
$76.00 |
$78.00 |
$37.05 |
|
Level B OMP consult (MBS item 53) |
$76.00 |
$78.00 |
$21.00 |
|
Blood test for diabetes (MBS item 66542) |
$48.00 |
$49.00 |
$18.95 |
|
CT scan of the spine (MBS item 56219) |
$990.00 |
$1,055.00 |
$326.20 |
|
Specialist – initial attendance (MBS item 104) |
$166.00 |
$170.00 |
$85.55 |
|
Consultant Physician – initial attendance (MBS item 110) |
$315.00 |
$325.00 |
$150.90 |
|
Psychiatrist attendance (MBS item 306) |
$350.00 |
$355.00 |
$183.65 |
Adrian Rollins
‘Obsolete’ Medicare system to be replaced
The Federal Government has commenced work on replacing the ageing Medicare, health and aged care payments system in a move welcomed by the AMA.
Health Minister Sussan Ley and Human Services Minister Alan Tudge have announced that the process of identifying a new system to supplant the current 30-year-old structure has commenced.
“Australia’s existing health and aged care payments system is 30 years old and is now obsolete,” the Ministers said. “A process has commenced to identify solutions for this new payments system, which will be based on existing commercial technology.”
But, seeking to prevent a repeat of Labor’s damaging election campaign claim that such a move amounted to the privatisation of Medicare, the Ministers insisted the Government would retain ownership and control.
“The new system will support the Australian Government continuing to own, operate and deliver Medicare, PBS, aged care and related veterans’ payments into the future,” they said.
AMA President Dr Michael Gannon said the Government’s move amounted to a modernisation rather than privatisation.
“The AMA made it very clear during the election campaign that replacing the backroom payment system for Medicare does not equate to the privatisation of Medicare,” Dr Gannon said. “The current payment system is 30 years old. It is clunky and inefficient. Its many faults create inefficiency and inconvenience for doctors and patients.”
The AMA President said medical practices had taken on much of the work of processing Medicare payments on behalf of the Government, costing them considerable time and effort.
The Government has promised to consult “extensively” with health providers and stakeholders in determining the final design of the new system.
Dr Gannon said such consultation was vital.
“It is critical the AMA is closely involved in the design of the new system to ensure it meets the needs of doctors and patients,” he said, adding that medical practices must be properly supported to incorporate and implement the new system for the benefit of patients.
Consultations on the new system are due to be finalised in January 2017.
Adrian Rollins
[World Report] Scepticism over the UK’s plan to train more British doctors
Experts have questioned the feasibility, details, and funding of the UK Government’s plans to boost the numbers of home-grown doctors during the next decade. Dara Mohammadi reports.
[Comment] Healthy cities in China: a Lancet Commission
The year 2016 marks the 30th anniversary of the concept of healthy cities, which has been promoted by WHO since 1986.1 The movement started in Europe as a way to put health high on the political, social, and economic agendas of cities. It represents a mindset shift from a health-care system centred on disease treatment to one that combines treatment, prevention, promotion of health policy, and a transferral of responsibility from health professionals to the entire society, with an emphasis on the role of local governments.
[Comment] Pursuing excellence in graduate medical education in China
Unquestionably, one of China’s primary challenges in health-care reform is improving the quality of clinical services.1 Patients who seek quality of care bypass poorly staffed primary care facilities for long waits in congested hospitals. Unsatisfactory quality of care is a major source of conflict between patients and doctors. Health inequity in China is due less to a shortage of health-care workers and more to abundant yet poorly educated service providers, especially in rural areas. That is why seven Chinese Government ministries in 2013 jointly launched the Standardized Residency Training (SRT) programme, which consists of 3 years of residency training after 5 years of medical school.