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Preference: Government and politics

Health must be focus whoever wins Government: Gannon

The tight Federal election result was “compelling evidence” that voters want a strong Medicare and health system that supports general practice and public hospitals, AMA President Dr Michael Gannon said.

As the outcome of the election remains in the balance two days after voting day, Dr Gannon said the clear message from the poll was that health policy was a vote changer.

“The exit polls confirmed what the AMA had been hearing from its members in the lead-up to the election: people want confidence that they can see their doctor or get to a hospital when they or their loved ones need health advice or care,” Dr Gannon said.

The Turnbull-led Coalition is facing the very real prospect of minority government, having to negotiate deals with independent and minority party MPs if it is to return to office.

The latest tally from the Australian Electoral Commission gives the Coalition 67 seats, Labor 71 seats, two to the Nick Xenophon Team, one each to the Greens and Katter’s Australian Party and two independents. The Commission reports that six seats remain too close to call.

Health issues figured prominently in the campaign. The AMA campaigned strongly on lifting the Medicare rebate freeze, funding public hospitals, and reversing cuts to pathology and diagnostic imaging bulk billing incentives – all issues seized on by Labor and the Greens in their own campaigns.

The Coalition also found itself on the back foot over accusations by Labor – discredited by Dr Gannon – that it had a secret plan to privatise Medicare.

During the campaign, the AMA President rubbished Labor’s attempts to portray the possible outsourcing of the Medicare payments system as amounting to its privatisation, but said the Coalition’s refusal to change key policies allowed the Opposition to spread such misinformation.

He said that, rather than scare campaigns, voters were swayed by the genuine concerns expressed by their family doctors.

“We believe that people who voted because of health policy were influenced by credible information from trusted doctors and other health professionals who campaigned against the Medicare freeze,” Dr Gannon said. “Grassroots doctors across the country shared their concerns with their patients. Local family doctors had genuine fears about the livelihoods of their practices.”

It is expected to be days, or maybe even weeks, before the final result of the election is known, but Dr Gannon said the AMA stood ready to work cooperatively with whoever formed Government.

Either way, he said, health needed to be at the centre of the national policy agenda.

“The election result is compelling evidence that people want a strong Medicare and a health system that promotes quality primary care, supports general practice, and properly funds public hospitals,” Dr Gannon said.

Adrian Rollins

Watchdog stays hand on codeine

The medicines watchdog has held off on making a final determination on its controversial proposal to axe over-the-counter sales of the common painkiller codeine.

Therapeutic Goods Administration has revealed that at its March scheduling meeting it deferred finalising its position on the re-classification of codeine following an interim decision late last year to make the painkiller a prescription-only medicine.

The delay follows an outpouring of concern by patients and consumer groups worried that taking codeine off the shelves would make it much harder for people to manage chronic pain and force some to pursue unsafe alternatives.

Following an interim proposal in October last year to end over-the-counter (OTC) access to the drug and reclassify it as a schedule 4 poison, the TGA received 127 submissions, including 113 opposing the move and just 14 in support.

In response, the watchdog said it would hold off on making a final determination until at least March, and any implementation would not occur before 2017.

In a submission to the TGA during its first round of consultations, the AMA did not come to a definitive position on the proposal.

While accepting that codeine dependence was “a real concern” and acknowledging the serious side effects caused by excessive consumption, the AMA voiced reservations that re-scheduling the drug would necessarily solve these problems.

It said there could be an argument to restrict access to higher dose and compound codeine preparations, and noted inconsistencies in current regulations that allowed over-the-counter sales of Panadeine Extra, while Panadeine Forte (one tablet of which is equivalent to two Panadeine Extra pills) was only available by prescription.

“Up-scheduling in isolation is unlikely to address the problems of misuse,” the AMA said, arguing that any such move needed to be accompanied by better education about safe and effective pain management options.

But in its interim decision, the TGA indicated it was persuaded by concerns about the potential harm caused by inappropriate use of codeine and the availability of effective alternatives, paracetamol and ibuprofen.

The TGA said OTC codeine was intended to help manage acute, self-limiting pain, but instead people were using it to help treat chronic pain, potentially creating dependence and toxicity.

In addition, it said, at least 10 per cent of the population were “ultra-rapid metabolisers” of the drug, making codeine potentially deadly at even normal doses.

Its concerns have been echoed by Professor Stephan Schug, Director of Pain Medicine at Royal Perth Hospital, who said codeine was a poor painkiller, had become a drug of dependence for many who were taking it at dangerous levels, and was not as effective as other, safer, alternatives.

Professor Schug said he had seen patients who were taking up to 80 tablets of codeine combined with paracetamol or ibuprofen a day, raising the risk of fatal paracetamol and ibuprofen toxicity.

“Dependence on opioid analgesics is a significant concern in Australia, and OTC codeine contributes to this by providing unmonitored access to a drug which in the body is metabolised to morphine,” Professor Schug said.

He said the number of overdose deaths related to codeine had jumped from 3.5 to 8.7 per million between 2000 and 2009.

Professor Schug said scheduling codeine would not reduce access to effective pain relief. He said adding low doses of codeine to paracetamol and ibuprofen did little to enhance their effectiveness, while combining paracetamol and ibuprofen instead provided significantly better and safer pain relief.

“As a practising clinician, I can tell you that under the current arrangements, the easy and widespread availability of these codeine-containing medicines is not limited or monitored at all well,” he said.

The AMA has repeated its call for a national Electronic Recording and Reporting of Controlled Drugs system to provide doctors and pharmacist with real-time information on the prescription of medicines prone to misuse and harm.

The peak medical association has also suggested that pharmacies be required to record codeine sales in the same way as they do for pseudoephedrine.

The AMA warned that making codeine prescription only would also likely increase Medicare and PBS costs for the Government.

Adrian Rollins

World told to get ready for plain packaging

Australia has received a big filip in its fight to protect its tobacco plain packaging laws after the World Health Organisation launched an international campaign declaring that all governments had to “get ready” plain packaging.

Since it introduced the world’s first plain packaging laws in 2012, Australia has been playing virtually a lone hand in a global battle with major tobacco companies determined to have the laws overturned.

So far, Britain, Ireland and France have joined Australia in passing plain packaging legislation, and both, Canada and New Zealand have announced plans to introduce plain packaging legislation.

Tobacco companies have failed in successive bids to have the laws overturned by national courts and international tribunals.

The latest setback came last month when the highest court of the European Union ruled in favour of regulations that give its member states the option of implementing plain packaging for tobacco products.

This followed the acceptance of the Permanent Court of Arbitration sitting in Singapore of Australia’s argument that it did not have jurisdiction to hear a claim by Philip Morris Asia that the legislation breached trademark protection laws.

The WHO used World No Tobacco Day to join the fight, launching its “Get ready for Plain Packaging” campaign for more effective health warnings on tobacco products around the globe.

The WHO said tobacco packaging was a form of advertising and promotion, often misled consumers and served to hide the deadly reality of tobacco use.

Plain packaging requires tobacco products be sold without marketing gimmicks and with clearly displayed health warnings. Australia was the first country in the world to introduce the legislation. Introduced in 2012, research has indicated that Australia has seen a reduction of 100,000 fewer smokers as a direct result from the plain packaging legislation.

The AMA has been a loud supporter of plain packaging legislation. Past AMA President Dr Andrew Pesce was alongside Federal Health Minister Nicola Roxon as she released the world-first draft Bill and the proposed design for the plain packaging packs.

The WHO said that plain packaging built upon other measures as part of a comprehensive multi-sectoral approach to tobacco control. For more information about the campaign, visit http://www.who.int/campaigns/no-tobacco-day/2016/en/

Kirsty Waterford

 

Committee backs AMA on primary care

A parliamentary committee has called on the Federal Government to consider reforms to the Medicare Benefits Schedule to help GPs better manage chronic disease in patients.

The House of Representatives Standing Committee on Health handed down its report on Chronic Disease Prevention and Management in Primary Health Care last month, noting that the groundwork for improvements to the primary health care system already existed.

“It is clear, however, that this cannot occur without cooperation, coordination, evaluation and adequate data and records to support Primary Health Networks in fulfilling their important role as coordinators of care,” the committee said.

“Performance measurements, expansion of chronic disease items, improved referral and rebate claiming processes and encouraging private health insurers to manage their members in cooperation with the primary health care system is a clear goal.”

The AMA made a submission to the inquiry in August last year, noting that primary health care was critical to providing quality, effective and empowering health care for people with chronic disease.

“With more than half of all potentially preventable hospital admissions due to chronic conditions, costing more than $1.3 billion a year, there are significant benefits in ensuring access to timely, clinically necessary and well-coordinated health care,” the AMA said.

The AMA called for reform of the MBS to restructure specific chronic disease management (CDM) items to cut red tape and reflect modern clinical practice.

It also called for formal engagement protocols between Primary Health Networks (PHNs) and Local Hospital Networks (LHNs) to work together on areas such as transitioning patients out of hospitals and into aged care.

It recognised that there was scope for private health insurers to explore the potential for greater engagement with general practice, but urged caution on expanding their role into a managed care model.

The Committee picked up many of the AMA’s recommendations.

It recommended the Government investigate expanding the number of allied health treatments that can attract an MBS rebate within a year, on the proviso that the patient has the relevant General Practitioner Management Plan and Team Care Arrangements in place.

It also recommended that the Government examine reforms to the MBS to allow for a practitioner to claim a rebate for a chronic disease management consultation and a general consultation benefit, for the same person on the same day.

It recommended considering expanding the Practice Incentives Program to include programs for breast, bowel and skin cancer screening, as well as the Integrated Health Check developed by the National Vascular Disease Prevention Alliance.

“Preventive health promotion as well as expanded health checks will help to provide the awareness and early detection required to help combat these diseases,” the committee said.

“The Health Care Home trials which are expected to commence in 2017 will help to improve this outcome, and with appropriate funding, privacy considerations, capture and consolidation of data, and a focus on research and improvement, the cooperative care goals required to improve chronic disease primary care can become a reality.”

Maria Hawthorne

[Editorial] Syria: a health crisis too great to ignore

Last week, the Independent International Commission of Inquiry on the Syrian Arab Republic gave an evidence update to the 32nd session of the UN Human Rights Council in Geneva, Switzerland. It reported that the Syrian Government was conducting daily air strikes in the country amid indiscriminate attacks by militant groups, including ISIS. Paulo Pinheiro, chair of the Commission, said that schools, hospitals, mosques, and water stations “are all being turned into rubble” and tens of thousands of people were trapped between front lines and international borders.

Global emergency call on yellow fever outbreak

The World Health Organisation has been urged to take emergency action over a rapidly spreading yellow fever epidemic that has so far infected more than 2000 people in Africa and Asia.

Health experts at Georgetown University’s Institute for National and Global Health Law, writing in the Journal of the American Medical Association, have warned that “quick and effective action” is needed to halt the spread of the disease, which has already killed more than 250 people in Angola and has appeared in Congo, Kenya and China.

The experts, Dr Daniel Lucey and Professor Lawrence Gostin, said that shortages in the supply of the yellow fever vaccine raised the risk of a “health security crisis” if the disease spreads through Africa and reaches Asia (which has never experienced a yellow fever epidemic) or the Americas (where the mosquito that can transmit yellow fever is endemic).

“The WHO should urgently convene an emergency committee to mobilise funds, coordinate an international response, and spearhead a surge in vaccine production,” they said.

Dr Lucey and Professor Gostin said delays in the international community’s response to the 2014 Ebola outbreak that eventually infected 28,646 people and claimed 11,323 lives should serve as a salutary lesson of the costs of a tardy response.

“Prior delays by the WHO in convening emergency committees for the Ebola virus, and possibly the ongoing Zika epidemic, cost lives and should not be repeated,” they said. “Acting proactively to address the evolving yellow fever epidemic is imperative.”

Yellow fever kills around 30,000 people a year, mostly in Africa, and the latest outbreak has added impetus to mass vaccination programs. More than 7 million Angolans have been immunised against yellow fever, and in May the Democratic Republic of Congo Government announced plans to vaccinate 2 million of its citizens.

Dr Lucey and Professor Gostin warned that these mass immunisation campaigns “could be a tipping point in exhausting global vaccine supplies”.

Medical experts have already advised that just one-fifth of normal vaccine dose be administered to avert the risk of an acute shortage if the disease spreads, but Dr Lucey and Professor Gostin said it was time for the WHO to step in.

They said the world health body should invoke procedures similar to those used during the Ebola epidemic to safeguard vaccine supplies.

“Stewardship of scarce vaccine supplies is essential, but requires the WHO’s Director-General to declare a public health emergency of international concern,” they wrote. “[But] it is only by convening an emergency committee that the Director-General could declare a public health emergency of international concern.

“Given the world’s vital health security interest, the WHO’s Director-General should use [the procedures] to authorise a reduced vaccine dose to control the epidemic in Angola.”

Dr Lucey and Professor Gostin said the yellow fever outbreak, combined with the experiences of the Ebola and Zika epidemics, showed that the WHO needed to have a standing emergency meeting that met regularly, rather than having to be formed each time a serious global health threat arose.

“The complexities and apparent increased frequency of emerging infectious disease threats, and the catastrophic consequences of delays in the international response, make it no longer tenable to place the sole responsibility and authority with the WHO’s Director-General to convene currently ad hoc emergency committees,” they said.

Adrian Rollins

Election FactCheck: Has the Coalition invested an average of $5 billion more per year into Medicare than Labor did?

And for the record, despite Labor’s scare campaigns, the Coalition is investing an average of $5 billion more per year into Medicare than Labor did. – The Liberal Party of Australia’s Medium page, June 19, 2016.

The Liberal Party has said that it is investing $5 billion more per year on average into Medicare than Labor did.

Is that right?

Checking the source

We asked the Liberal Party to provide the sources of the statement but we did not receive a reply before publication. However, we can test this against the available data that tracks Medicare expenditure.

The meaning of ‘Medicare’

One major uncertainty in the claim is that there are different definitions of what constitutes Medicare.

The two major areas we are focusing on as representing Medicare expenditure are the Medicare Benefits Schedule (MBS) and the Pharmaceutical Benefits Schedule (PBS). The MBS covers expenditure on medical services, and includes things like professional attendances, diagnostics and therapeutic procedures, while the PBS pays for drugs. The government budgetary definition of Medicare spending is only for the MBS. However, we believe the PBS is likely to be contained within the Liberal Party figure of $5 billion.

One area we are assuming is not included is state spending on public hospitals; if we were to include this, it may increase the difference in total spending between the two periods.

Below, the term PBS refers to both the PBS and the Repatriation Pharmaceutical Benefits Schedule (RPBS), which provides for certain classes of Department of Veterans’ Affairs beneficiaries.

Tracking annual spending on the MBS, PBS and RPBS

We therefore take the statement by the Liberal Party to mean that the sum of MBS, PBS and RPBS expenditure has increased by an annual average of $5 billion – but note the uncertainty in the definition.

The Department of Human Services provides month by month figures on government expenditure for the MBS, PBS and RPBS.

Aggregate figures for this are shown below by quarter since January 2008 until the most recent complete quarter (ending March 2016). The transition point between the second Rudd government and the Abbott one is marked approximately on the graph with the vertical blue line.

Election FactCheck: Has the Coalition invested an average of $5 billion more per year into Medicare than Labor did? - Featured Image

Aggregate PBS/MBS/RPBS expenditure by quarter (2008 Q1-2016 Q1)
Author provided

Medicare spending under Labor

Labor was in power between December 3, 2007, and September 18, 2013. To approximate this period, we used data from January 1, 2008 to September 30, 2013 to represent Medicare expenditure under the Labor government. (We used January 1 rather than the December 1 as some data sources report quarterly data, and January 1 lines up with this.)

Over the period of the Labor government, total PBS/RPBS spending was $46.577 billion, and total MBS spending was $93.931 billion. This comes to $140.508 billion, which on an annual basis (based on a figure of 5.75 years to represent the period Labor was in power), is an average spend of $24.436 billion per year.

Medicare spending under the Coalition

For the period between October 2013 and May 2016 (representing the period when the Coalition has been in power), total spending under the MBS was $54.448 billion, and total PBS/RPBS spending was $26.713 billion.

This totals $81.161 billion over two years and eight months, or $30.435 billion per year.

So, using our definition of what constitutes Medicare, the difference between the average annual Medicare spend under Labor and the average annual Medicare spend under the Coalition is about $5.999 billion per year.

Using these data, the claim made by the Coalition is true.

Context matters

However, it is not clear whether this increase in spending represents either an increase in spending per person, or an increase in service delivery. All we know so far is that the total dollar amount is bigger.

The Australian population has increased between the two time periods, meaning the per capita Medicare expenditure will not have increased at quite the same impressive-sounding rate as the raw figure of an average of $6 billion per year.

The second factor to consider is the rising cost of health care.

After adjusting for inflation and population growth, the average extra Medicare expenditure will be more modest than that indicated by the raw figures. And health costs are rising faster than inflation.

In other words, more Australians than before are accessing Medicare and most unit costs are likely to have, on average, risen.

Verdict

Without knowing the source for the Liberal Party’s claim, it was difficult to know what its “average of $5 billion more per year” claim was based on.

Assuming the claim refers to the sum of MBS, PBS and RPBS spending, the Liberal Party is correct.

Using our definition of what constitutes Medicare spending, the difference between the average annual Medicare spend under Labor and the average annual Medicare spend under the Coalition is about $6 billion per year.

However, care must always be taken drawing conclusions from the raw dollar amounts, since they do not take into account changing population size and inflation. – Richard Norman and Rachael Moorin

Review

The authors have valiantly attempted to fulfil a tricky brief because of the ambiguity of the claim. It is a sign of Australia’s complex health care system when we can’t even be precise about what constitutes Medicare funding.

As noted by the authors, there are different definitions of what constitutes Medicare. Here, the authors have assumed it means spending on the MBS and PBS/RPBS. On this basis they compare average annual MBS/PBS funding during the Gillard/Rudd era with funding during the Abbott/Turnbull era. The authors find that the Liberal Party has underestimated the additional annual spent by around $1 billion.

However, if we restrict the claim to Medicare spending only (excluding PBS/RBS spending), the average annual difference between the Abbott/Turnbull and Gillard/Rudd era is $4.13 billion – which implies that the claim is exaggerated by about 21%.

Under a broader definition of Australian government health spending, Budget Outcomes data reveals totals of $62.012 billion (2011-12), $61.302 billion (2012-13), $63.983 billion (2013-14) and $65.696 billion (2014-15). Under this definition, and comparing the last two years of the Gillard/Rudd era with the first two years of Abbott era, the increase in annual health funding is substantially less than $5 billion.

This brings us to the futility of the claim itself. I agree with the authors that the claim needs be considered in the context of population growth and price increases. After taking these two factors into account, expenditure has increased by a modest amount. While funding health care is an important issue, the claim made by the Liberal Party says nothing about whether the additional funding is delivering greater access to better health care. – Kees Van Gool

The ConversationRichard Norman, Senior Research Fellow in Health Economics, Curtin University and Rachael Moorin, Associate Professor, Health Policy & Management | School of Public Health, Curtin University

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

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Simple processing and clever apps? Don’t hold your breath for a user-friendly Medicare IT system

The privatisation of Australia’s Medicare organisation has become a hot issue in this election with the Labor party accusing the Liberals of wanting to privatise Medicare.

The Liberal Government earlier this year earmarked A$5 million to fund consultants to review the digital payment services of Medicare. This was with a view to cutting costs on Medicare’s processing of A$50 billion in annual claims.

The “digital payments services taskforce”, which promised to examine how Medicare’s systems could be modernised, no longer seems to be running.

Prime Minister Malcolm Turnbull has also stated there are no plans to proceed with a privatisation of Medicare’s payment systems.

It is misleading to talk about Medicare’s payment system as if it was a single system that could be easily outsourced to a private company. Medicare’s IT systems are the product of an evolution of government policy that dictates who is to be paid for health service encounters and under what circumstances.

The payments service is further complicated by the fact it has to interface with thousands of different providers and millions of end users.

Medicare processes medical expense claims for potentially every encounter between an eligible Australian and a health professional or organisation. There are a series of rules that govern what can be claimed and whether the organisation, health professional or individual is responsible for making the claim.

Some of these payment claims are handled through software provided by any one of dozens of different vendors. These software companies have all gone through a process whereby their systems are certified to interface with those of Medicare’s.

Medicare also manages the issuing of cards, identifiers and runs a “public key infrastructure” which provides health professionals with cryptographic signatures that can be used in conjunction with the payments system.

From Medicare’s perspective, its major goal is to provide a reliable service so the entire system processes payments correctly and with an acceptable timeframe. The secondary role would be to provide a digital interface to its customers, especially the general public.

Medicare has certainly been very slow to fulfil this latter role. Its moves in this direction have missed the mark when compared to the slick and user-friendly apps most modern tech companies are now providing.

However, this is also true of some of the private companies that were put forward as possible providers of Medicare’s payment system. Companies such as Telstra and Australia Post are not that far behind Medicare in terms of the technology they have provided their own customers.

The problem all companies face, especially those that aren’t technology companies, is their internal IT is usually underfunded. It is also often set with expectations of reliability and security that run counter to being able to innovate and move quickly. Often, the technology produced by these departments is a reflection of how the companies do business, so clunky mobile apps reflect the same lumbering processes.

Changing culture in these departments is very difficult because new leaders have to make do with staff who have become “acculturated” to a specific way of doing things are done. They can therefore be reluctant to change their practice through fear of change or lack of ability.

When a system is as complex as Medicare’s, it is extremely expensive to rebuild. It is not possible to simply “retrofit” an off-the-shelf product from another company.

IBM’s attempts to redevelop Queensland’s payroll system, for example, were plagued with delays and budget blow-outs, resulting in a system that didn’t work very well. In large part this was caused by the complexity of the system’s arcane rules and a lack of real understanding of these rules by the people interfacing with IBM and others.

Attempts to privatise Medicare’s systems would be met with similar challenges.

IT is often a reflection of the underlying company business models and processes, so improvements to IT systems cannot happen unless there is a change to the underlying processes they implement.

Medicare has a much greater challenge. Not only are business processes an issue, the politics that drove these policies and processes would need to change. Given the politics of Medicare as a public good, it is very difficult to disassociate tackling any part of that service from being seen to be challenging Medicare’s role in public life.

As a result, it is unlikely very much will change to any significant extent in Medicare’s IT services, even if there was a technological way forward and a team of people, internal or otherwise, to implement them.

The ConversationDavid Glance, Director of UWA Centre for Software Practice, University of Western Australia. This article was originally published on The Conversation. Read the original article. 

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