[Comment] Unresolved issues in Canada’s law on physician-assisted dying

On Feb 6, 2015, a landmark decision by the Supreme Court of Canada declared Criminal Code proscriptions against physicians assisting in the death of patients in violation of the Canadian Charter of Rights and Freedoms. Implementation was suspended for 12 months.1 With the change of government in late 2015 an extension was granted. After considerable wrangling between the House of Commons and the Senate Bill C-14 was passed on June 17, 2016, making medical assistance in dying legal in Canada.2 The ruling granted the right to assistance in dying to all competent adults with a “grievous and irremediable condition”.

Blocking overseas practitioners won’t solve rural doctor shortage

The nation needs to do more to encourage medical practitioners to work in under-served rural areas rather than simply seek to choke off the supply of overseas-trained doctors by tightening visa rules, AMA President Dr Michael Gannon has said.

Responding to a report in The Australian that the Health Department wants to axe visas for imported doctors to make room for a growing number of domestic medical graduates, Dr Gannon said the real issue was to improve the attractiveness of rural practice for doctors, regardless of where they come from.

A surge in the number of medical graduates in recent years has eased fears of a doctor shortage, leading some to argue the country no longer needs to rely on the recruitment of doctors from overseas to plug gaps in the medical workforce.

But, while acknowledging the big jump in medical graduates had altered the landscape, Dr Gannon said the Health Department’s proposal to remove 41 health jobs from the Skilled Occupations List was misdirected.

Related: Rural doctors want support

Dr Gannon said for several decades overseas-trained doctors had been a valued part of the health system, helping ameliorate the effects of a long period of under-investment in medical training.

He said it was important that those with special skills or talent continued to have the opportunity to work in Australia.

Instead of blocking doctors from overseas, the focus should be on addressing the misallocation that sees most doctors, whether locally trained or from overseas, congregating in practices in the major cities rather than moving into rural areas where they were most needed, Dr Gannon told ABC radio.

“We just have to look at a system which is not delivering on its stated intention, which is to get doctors where they’re really needed,” the AMA President said. “What we’ve seen now is that we’ve got a reasonable oversupply of GPs and other specialists in inner-metropolitan Australia, and I think what we need to work harder on is investing in incentives to get doctors to work in rural areas.”

Dr Gannon said country practice was a “very, very rewarding professional career”, and evidence showed that junior doctors given opportunities to train in rural areas were far more likely to work there.

The AMA has urged increased Commonwealth investment in rural training, and late last year the Government announced the establishment of a $93.8 million Integrated Rural Training Pipeline to improve the retention of postgraduate prevocational doctors in country areas.

Dr Gannon said that while the funding was welcome, it did not come close to replacing the Prevocational General Practice Placements Program (PGPPP) scrapped in the 2014 Budget, and much more effort was needed, particularly to encourage more procedural GPs to set up in the bush.

The AMA has proposed a Community Residency Program which would allow doctors in training to undertake rotations of up to 13 weeks to give them a good experience of life as a rural GP and to enhance their clinical experience.

“The abolition of the PGPPP has left general practice in a position where it is the only major medical specialty unable to offer doctors in training a structured prevocational training experience before they make a career choice,” Dr Gannon said.

“The Community Residency Program would provide them with opportunities to undertake important general practice prevocational training in an effort to encourage more young doctors to choose a career in general practice.”

The AMA President said it would complement the Government’s plan to establish a National Rural Generalist Pathway as a way to address rural workforce issues.

Adrian Rollins

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[Comment] The perils and possibilities of the private health sector

Few issues provoke as much disagreement, even anger, as the question of the private sector’s role in delivering health care. Supporting a contribution by the private health sector towards achieving the goal of universal health coverage is seen as a betrayal of public welfare by many critics. For those of us brought up with (or trained within) a publicly financed health system (such as the UK’s National Health Service), private provision of health care may be anathema. Very often, we will rail against private providers—the profit they make from the sick, the catastrophic health expenditures they may cause, or the latitude they enjoy to exploit the poor in systems where government regulation is weak or non-existent.

Insurers pick wrong target in war on health costs

AMA President Dr Michael Gannon has accused the major private health funds of “squeezing” patients, doctors and hospitals in pursuit of ever-greater profits.

Hitting back at Medibank Private claims that “market failure” in the health system was driving up the cost of care, particularly some surgical procedures, Dr Gannon denied do doctors were forcing up costs and instead blamed insurers for forcing more of the expense on to patients and providers.

“Insurers are trying to contain costs everywhere, and it’s very difficult for the Government and the industry if the industry is in profit mode,” the AMA President told The Australian. “They are looking to cut costs wherever it is possible and there are reasonable and appropriate ways in which they can do that, and there are other ways which involve squeezing doctors, squeezing hospitals and squeezing patients.”

Dr Gannon said costs were being driven by a mix of factors including the cost of prostheses, rising wages, technological advances, soaring drug prices and an ageing population, which meant that patients were increasingly presenting with a complexity of health problems.

But he said there was little evidence that doctors were responsible for driving up costs.

Dr Gannon said that while international comparisons were important, and it was understandable that Medibank was looking to contain its costs, the fact was that the “vast majority” of operations were provided at no direct cost to the patient.

He said that 86 per cent of operations involved no gap payment, and a further 7 per cent included a known gap of less than $500. Doctor fees typically accounted for between 5 and 7 per cent of the cost of elective surgery in a private hospital.

“So, when we look at the increase in the costs year-on-year in private health care, the doctor’s fee represents a very small part of that. The doctor’s fee is very rarely the issue,” he said.

Medibank Private Executive General Manager Dr Andrew Wilson has used a three-year-old report showing that Australians were paying among the highest costs in the world for cataract surgery and knee and hip replacement as evidence of market failure that was making the nation’s health system internationally uncompetitive.

Dr Wilson said patients were being denied access to the information needed to assess whether or not the prices they were being charged represented good value for money, such linking specialist fees with clinical outcomes.

“While such data undoubtedly exists, it is unavailable to consumers, leaving them with little information to make informed decisions on medical specialists – a classic example of market failure,” the Medibank executive said.

But the same study, the 2013 Comparative Price Report prepared by the International Federation of Health Plans (IFHP), showed for many common procedures such as childbirth, appendectomy and angioplasty, costs in Australia were comparable with those of most other developed economies, and well below those charged in the US.

It found that hospital costs per day in Australia were almost half of those charged in New Zealand and less than a third of the US cost, charges for MRIs and CT scans were moderate by international standards, while the normal delivery of a baby cost on average US$6623, compared with US$8307 in Switzerland and US$10,002 in the US.

Australian Private Hospitals Association Chief Executive Michael Roff accused Medibank of being “in a time warp” in its search for figures to justify Dr Wilson’s claims.

Mr Roff said cost comparisons in 2013 had been distorted by the strength of the Australian dollar against the US currency, and more recent 2015 data showed “Australia is indeed competitive based on the IFHP analysis, and is not the most expensive country by any measure”.

This included figures showing the cost of cataract surgery in Australia was 16 per cent cheaper than in the US last year, and was also lower than in the United Kingdom, he said.

Dr Gannon said all had an interest in ensuring the health system delivered value for money.

“It’s in the interest of all of us to look at good stewardship, reduce complication rates, contain costs where possible, that’s in the interests of everyone because ultimately it’s the taxpayers of Australia that foot these bills,” he said. “The doctor’s fee is a small part of the issue, but we want to work with Government, with insurers, to make sure that Australian taxpayers and, especially those who put their hand in their pocket for private health insurance, get really good value for money.”

Adrian Rollins

[Comment] Sitting on the FENSA: WHO engagement with industry

When decisions are made that will impact on people’s health, who should be represented at the policy-making table? Is it sufficient to rely upon representatives from national governments, or should other stakeholders participate—and if so, to what purpose? To advise? Make decisions? Or as funders? These questions lie at the heart of a governance debate1 that has been rancorously discussed in relation to WHO for some years. In May, 2016, the World Health Assembly (WHA) reached consensus in a resolution known as FENSA (Framework of engagement with non-State actors): “WHO engages with non-State actors….to encourage [them] to…protect and promote public health”, in which non-State actors are “non-governmental organizations [NGOs], private sector entities, philanthropic foundations and academic institutions”.

[Comment] End-of-life care across the world: a global moral failing

The Economist Intelligence Unit (EIU) and its funder, the Lien Foundation, have served humanity well by creating a thoughtful way to grade the availability and quality of care for patients near the end of life across the world; their results expose a dismal situation.1 Modern medicine’s focus on mastering each part of the human body and the diseases that make them malfunction has generated remarkable power to sustain life. But this focus, shared by governments and health-care planners, has neglected the dying and their suffering, as if repressing a shameful secret.

Your Family Doctor: Invaluable to your health

AMA Family Doctor Week, 24 – 30 July 2016

The AMA used this year’s Family Doctor Week to not only celebrate the hard work and dedication of Australia’s 30,000 GPs, but to put the re-elected Coalition Government on notice that changes in health care policy are urgently needed.

The traditional National Press Club address has been moved to August to allow for continued campaigning against the Medicare rebate freeze, cuts to public hospital funding, and cuts to bulk billing incentives for pathology and radiology.

Media outlets around the country, including the national WIN network of regional television stations, picked up on the message that GPs are the most cost-effective sector of the health system and need support.

AMA President, Dr Michael Gannon, said that the personalised care and preventive health advice provided by family doctors helps to keep people out of hospitals, and keep health costs down.

“Australian GPs provide the community with more than 137 million consultations, treat more than 11 million people with chronic disease, and dedicate more than 33 million hours tending to patients each year,” Dr Gannon said.

“Nearly 90 per cent of Australians have a regular GP, and enjoy better health because of that ongoing trusted relationship.”

The AMA used the week to outline a series of proposals for improving the health of Australians while also delivering savings to the Government.

The Pharmacist in General Practice Incentive Program (PGPIP) proposal would integrate non-dispensing pharmacists into GP-led primary care teams, allowing pharmacists to assist with medication management, provide patient education on their medications, and support GP prescribing with advice on medication interactions and newly available medications.

“Evidence shows that the AMA plan would reduce unnecessary hospitalisations from adverse drug events, improve prescribing and use of medicine, and governments would save more than $500 million,” Dr Gannon said.

“When the Government is looking to make significant savings to the Budget bottom line, the AMA’s proposal delivers value without compromising patient care or harming the health sector.”

Independent analysis from Deloitte Access Economics identified that the proposal would deliver $1.56 in savings for every dollar invested in it.

The AMA also stepped up the pressure for more appropriate funding for the Government’s trial of the Health Care Home model of care for patients with chronic disease.

In March, the Government committed $21 million to allow about 65,000 Australians to participate in initial two-year trials in up to 200 medical practices from 1 July 2017. However, the funding is not directed at services for patients.

“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.”

With chronic conditions accounting for approximately 85 per cent of the total burden of disease in Australasia and 83 per cent of premature deaths in Australia, it was vital that Australians could turn to their family doctor for advice, Dr Gannon said.

“The Government uses concerns about the sustainability of the health system to justify funding cuts, but instead of making short-sighted and short-term savings, it should invest in preventing disease in the first place,” he said.

Family doctors in rural and regional communities, in particular, needed more support.

The AMA called on the Government to rethink its approach to prevocational training in general practice, and to revamp and expand its infrastructure grants program for rural and regional practices.

Maria Hawthorne

AMA in the News

Your AMA has been active on policy and in the media on a range of issues crucial to making our health system better. Below is a snapshot of recent media coverage.

Print/Online

Specialists exposed in new website for public to rate doctors, Sydney Morning Herald, 29 July 2016

AMA President Dr Michael Gannon said 86 per cent of doctors already charged the recommended fee. He said that he understood the desire for greater information, but a website owned by health insurers has potential to produce asymmetry in a whole lot more dangerous way than relying on GPs.

Medicare freeze U-turn tipped, The Australian, 26 July 2016

Dr Gannon said he did not expect the rebate freeze, which was introduced by a Labor government and then extended by the Coalition, to be taken to the next election.

Designer babies, Adelaide Advertiser, 25 July 2016

Dr Gannon, who is an obstetrician, said gender selection for family balancing was not an appropriate use of medical science.

Doctors expect Medicare win, West Australia, 22 July 2016

Doctors expect Malcolm Turnbull to surrender over the Medicare rebate freeze, with the AMA saying it would be gobsmacked if the Government took the policy to the next election.

Celebs should know: fame won’t heal what ails you, Sun Herald, 17 July 2016

AMA Vice President Tony Bartone said that an off-the-cuff comment by an ill-informed celebrity can overturn years of public education about good health care.

Medicare hike proposed by AMA, Northern Territory News, 16 July 2016

Dr Gannon said an increase in the Medicare levy should be considered as a way of ending cutbacks to hospital funding.

Ministers warned PM about voter backlash over super, The Australian, 12 July 2016

Dr Gannon said the AMA had warned the Government under both Mr Turnbull and former Prime Minister Tony Abbott that health policies from the 2014 Budget were bad and must change.

Medicare levy rise ‘should be on table’, The Australian, 8 July 2016

Dr Gannon said it was time to have a proper discussion about the sustainability of Medicare, arguing an increase to the 2 per cent levy should be considered.

It’s Medi-crunch, Herald Sun, 7 July 2016

Dr Gannon said the Coalition should end the Medicare rebate freeze, halt price rises for medicines, leave bulk billing incentives in place and boost hospital funding.

Kids off the scale, Herald Sun, 7 July 2016

Dr Gannon said it was time to invest in the future to “reap the benefits in the years to come”. Some parents find it hard to make healthy choices when energy-rich foods are so readily available.

AMA calls for review of Medicare rebate freeze, Canberra Times, 6 July 2016

Dr Gannon said the Medicare rebate freeze had always been bad policy, and the election outcome proved it was bad politics as well.

Turnbull trips on Medicare misstep, Weekend West, 2 July 2016

Dr Gannon said GPs were reporting being at “breaking point”, and some had already changed their billing practices. He warned fees could “easily” rise to $15 a patient, which could cause some to defer seeking care if the Medicare rebate freeze wasn’t abolished.

Radio

Dr Michael Gannon, 702 ABC Sydney, 29 July 2016

Dr Gannon said he had a lot of concerns about a new rate-my-doctor-style website. He questioned the purpose of the website. While he supported the stated aim to reduce bill shock for patients having private medical care, he said the size of the problem isn’t as great as some might assert.

Dr Tony Bartone, Triple J Hack, 28 July 2016

Dr Bartone said catching bi-polar early can give suffers the chance to cope with their disorder better.

Dr Michael Gannon, 6PR Perth, 27 July 2016

Dr Gannon said health professionals alerting national security authorities of a patient’s activities could be breaching client confidentiality. He said one of the reasons that patient confidentiality was so important was that people should feel that they had the ability to seek help if they were sick, including mental illness.

Dr Michael Gannon, 3AW Melbourne, 25 July 2016

Dr Gannon said allowing gender selection for a third child using IVF would open the door for people to have IVF for no reason other than “family balance”.

Dr Michael Gannon, Radio National, 21 July 2016

Dr Gannon said after meeting with Health Minister Sussan Ley that he would be gobsmacked if the Coalition maintained its Medicare rebate freeze to the next election.

Dr Tony Bartone, 5AA Adelaide, 18 July 2016

Dr Bartone said changes to diabetic subsidies only affected type 2 diabetics who were not on insulin, and after the first six months patients could still get access to subsidised strips if a doctor deemed it appropriate to manage their care.

Dr Michael Gannon, 2GB Sydney, 15 July 2016

Dr Gannon said it was disappointing the Coalition didn’t focus on health much during the election campaign.

Dr Michael Gannon, ABC North West WA, 11 July 2016

Dr Gannon discussed the re-election of the Turnbull Government and said the Government needed to unravel the freeze on the Medicare rebate.

Dr Michael Gannon, ABC News Radio, 6 July 2016

Dr Gannon talked about Medicare scare campaign claims and said the Federal Coalition health policy laid fertile ground for the allegations.

Dr Michael Gannon, SYN FM, 5 July 2016

Dr Gannon said the AMA had been calling for a sugar tax for a number of years. Overweight and obesity was the second highest contributor to the burden of disease in Australian. Dr Gannon said a sugar tax alone would not fix the problem, but it should be part of a holistic approach.

Dr Michael Gannon, Radio National, 1 July 2016

With opinion polls showing the Federal election outcome on a knife-edge, Dr Gannon said a six-year freeze on Medicare rebates would invariably mean bulk billing became a thing of the past in many doctor surgeries.

Television

Dr Michael Gannon, Seven News, 21 July 2016

Doctors are pressuring the Government to end its Medicare rebate freeze to avoid another scare campaign at the next election. After talks with the Health Minister, the AMA President Dr Michael Gannon said he would be gobsmacked if a change wasn’t made.

Dr Michael Gannon, Sky News, 6 July 2016
Dr Gannon said Labor’s campaign threat that the Coalition would privatise Medicare was not true, but was part of a scare campaign that worked. He said unravelling the GP freeze would go a long way to assuaging the concerns of the AMA and the medical profession.

Dr Michael Gannon, TEN Eyewitness News, 1 July 2016
Dr Gannon warned that patients could be asked to fork out up to an extra $25 to see their doctor thanks to the Government’s freeze of the GP rebate.

Dr Michael Gannon, ABC News 24, 1 July 2016
Dr Gannon said the AMA was ready to work with whoever was elected but, the AMA was concerned about the freeze on Medicare rebates, as GPs were at breaking point.

Experienced hands hold on to health

Health Minister Sussan Ley and her Opposition counterpart Catherine King have held on to their portfolios following the tight Federal election in which health policy was a key battleground.

In the days following the election there were rumblings in both major parties regarding the performance of their respective health spokeswomen, but both Ms Ley and Ms King were confirmed in their positons when the Coalition and Labor frontbenchers for the new term of Parliament were announced.

AMA President Dr Michael Gannon welcomed the outcome.

“The health sector and patients are very fortunate to have two experienced and consultative operators in Sussan Ley and Catherine King back in charge of health for the Government and Opposition,” Dr Gannon said. “They know the issues, they seek advice from health professionals, and they will be strong voices in the respective parties to ensure Australian voters will be offered positive health policies at the next election.”

While there is stability at the top, there has been a significant change in Ms Ley’s office. She has appointed experienced health bureaucrat and policy adviser Dr Lisa Studdert as her Chief of Staff to replace the recently departed Craig Bosworth.

Dr Studdert was most recently First Assistant Secretary of the Department of Health’s Population Health and Sport Division, and has previously worked in the Therapeutic Goods Administration and as an adviser on public and Indigenous health to former Health Minister Dr Michael Wooldridge.

In a sign that Labor is intent on keeping health and Medicare on the political frontline in the next three years, Opposition Leader Bill Shorten has added “Medicare” to Ms King’s title and has appointed South Australian MP and former national powerlifting champion Tony Zappia as Shadow Assistant Minister for Medicare.

Alert to the threat after Labor’s success in the election campaigning on Medicare, Ms Ley said one of the tasks confronting the Government was “protecting the future of Medicare and ensuring it remains universally accessible to all Australians”.

But, in a taste of things to come, Ms King renewed her attack on the Coalition’s health policy, particularly Medicare.

“The Turnbull Government remains committed to undermining Medicare through its ongoing freeze on GP rebates, and its determination to make further cuts through its attacks on pathology and diagnostic imaging as soon as Parliament resumes,” the Shadow Minister said. “As we did in the last Parliament, Labor will once again resist furiously any attempts to attack bulk billing, increase out-of-pocket costs and undermine the rights of all Australians to access decent, affordable health care.”

Ms Ley will be supported in her portfolio by Western Australian MP Ken Wyatt, who continues in his role as Assistant Minister for Health and Aged Care. Following the promotion of Nationals Senator Fiona Nash to be Minister for Regional Communications, she has been replaced in her rural health role by Dr David Gillespie, who has been appointed Assistant Minister for Rural Health.

On the Labor side, Julie Collins has been appointed Shadow Minister for Ageing and Mental Health, and Senator Helen Polley has been made Shadow Assistant Minister for Ageing.

Health portfolios
Government	Opposition
Minister for Health and Aged Care Sussan Ley	Shadow Minister for Health and Medicare Catherine King
Assistant Minister for Health and Aged Care Ken Wyatt	Shadow Assistant Minister for Medicare Tony Zappia
Assistant Minister for Rural Health Dr David Gillespie	Shadow Minister for Ageing and Mental Health Julie Collins
	Shadow Assistant Minister for Ageing Senator Helen Polley

Adrian Rollins

PM takes direct role in health

Prime Minister Malcolm Turnbull has taken a much more hands-on role in health policy as the Coalition Government seeks to improve its performance in an area that emerged as a major area of political weakness at the Federal election.

Just days after winning the knife-edge 2 July poll, the Prime Minister met with AMA President Dr Michael Gannon, and it has been revealed that late last month he took the unusual step of personally attending the first high-level meeting between Health Minster Sussan Ley and senior Health Department bureaucrats since the election.

In a speech announcing his new Ministry on 18 July, Mr Turnbull revealed he had already met with Dr Gannon and anticipated working closely with doctors over the next three years.

“I am confident we will have a better working relationship with the AMA and its GP membership,” the Prime Minister said.

The Prime Minster followed this up a week later by joining with Ms Ley in meeting Government health officials to discuss the Coalition’s election agenda and plans for health.

The intense focus on health at the highest levels of the Government reflects widespread acceptance in Coalition ranks that it was an area of vulnerability that was ruthlessly exploited by Labor during the election campaign, costing it many votes and bringing it to the brink of a first-term loss.

The importance of health in the election was underlined by an Essential Media report that found health trumped all other policy concerns in the minds of voters, including the economy.

Sixty per cent of voters said health policies were very important in deciding who they voted for at the recent election, with Medicare a close second at 58 per cent. Economic management came third at 53 per cent.

Reflecting this, a majority of voters (55 per cent) said investing in health should be the top priority for Government, compared with 31 per cent for education and 27 per cent who wanted spending cut to reduce the deficit.

Ms Ley, who was accused by some within the Coalition of ‘going missing’ during the election campaign, welcomed the Prime Minister’s interest in her portfolio.

“I am delighted that we have kicked off the current term of Government with a high-level conversation, because of course he is interested in health, as he is in every single area of government,” the Health Minister told ABC radio. “It’s terrific for me to have a Prime Minister so dedicated to the cause and so understanding of the need for a health system that supports all Australians, one that we can both pay for and deliver.”

Reflecting on the tight election result, Mr Turnbull indicated that the Coalition needed to change its approach in health, raising hopes that unpopular decisions like the Medicare rebate freeze and public hospital funding cuts might be revisited, though Ms Ley was non-committal.

“I understand people’s concerns and I am very keen that we take those concerns into account as we move forward. MYEFO [Mid-Year Economic and Fiscal Outlook] is at the end of this year, the Budget is next year, all of these things will play into to usual business of Government.”

Adrian Rollins