The Australian Greens have committed to a multi-billion dollar boost to Medicare and hospital funding as part of a drive to increase investment in health.
Greens leader Senator Richard Di Natale told the AMA National Conference that his party would not only match Labor’s $2.4 billion promise to ditch the Medicare rebate freeze but would provide an extra $4 billion to restore Commonwealth funding for public hospitals, including providing 50 per cent of growth funding.
Senator Di Natale said the policies reflected the Greens’ commitment to universal and equitable access to health care, and an end to what he said was the Government’s “shameless exercise in cost shifting”.
Though opinion polls indicate the Greens stand no chance of forming government in their own right, they show that the election contest is finely balanced, opening the possibility the Greens could play a crucial balance of power role in forming the next government – making their views on health policy potentially significant.
In his speech, Senator Di Natale lambasted the Coalition’s cuts to health spending and detailed plans to increase Commonwealth support for hospitals, GPs, allied health workers and health services for Indigenous Australians and other disadvantaged patients.
“We should never be fooled, by those who see health as a cost more than an investment, into believing that cuts to the heart of the health system are a necessity,” he said, arguing that Australia’s spending on health was around the average among developed economies.
Senator Di Natale said that while it was important to ensure health funds were spent effectively, health expenditure would increase.
“As exciting new treatments become available and our country’s demographics change, we will need to spend more on health care to enjoy a better quality of life,” he said. “That, we believe, is a clear and legitimate choice for a wealthy nation to make. Spending more on health care is not unsustainable or irresponsible – it is a key priority and an investment we are luck to make.”
On the highly controversial topic of assisted dying, Senator Di Natale said the Greens believed patients should have “access to voluntary euthanasia and physician care for dying with dignity”.
The Greens leader said policies on Indigenous health, drug and alcohol treatment services and preventive health would be detailed later in the election campaign.
Former AMA President Professor Brian Owler has lashed the Coalition over its conduct of health policy in the past two years, accusing it of allowing short-term budgetary measures to triumph over long-term policy vision.
In a typically forthright speech in his last address to the AMA National Conference as AMA President, Professor Owler said decisions to extend the Medicare rebate freeze, slash public hospital funding and try to impose a GP co-payment had been driven by a focus on savings without regard for their impact on patients and health system.
“As confirmed by [Health Minister Sussan Ley] herself…the health portfolio is not run by the Minister for Health. It is run by Treasury and Finance,” he said.
Professor Owler said the history of the last two years had shown that the Government had a problem when it came to health policy, “but the problems are not the making of the AMA [or] of an outspoken AMA President”.
“The failures of this Government are of their own making – a failure to consult with genuine intent, a failure to listen.”
The former President detailed how the Government set a combative tone for the relationship early on.
“In my first meeting as AMA President, I met with the Health Minister, Peter Dutton, who delivered an ultimatum: ‘As I see it,’ he said, ‘the AMA can either support the Government’s co-payment plans or you can be on the outside’.”
Professor Owler said it was an easy choice: “I was not going to sell out our members, and I certainly wasn’t going to abandon our patients”.
He told the conference how the Government responded after asking the AMA to develop an alternative to its co-payment policy.
“We dutifully did this. We worked hard, we kept it in confidence, and we delivered it to the Minster,” he said. “In return, the Minister ignored the plan and [described it] as a ‘cash grab by greedy doctors’. So much for working closely with Minister Dutton.”
Professor Owler said the Medicare rebate freeze was affecting the viability of medical practices, was punishing patients and was “not sensible policy. It affects the whole system”.
He said it was pleasing that, as a result of intense AMA lobbying, Labor had committed end the freeze, and said it was not too late for the Government to follow suit.
In his speech, Professor Owler took aim at private health insurers, who he said wanted to introduce US-style managed care.
He said the medical profession needed to be “endlessly vigilant” to the threat.
“We must never let private health insurers undermine our health care system, whether it be by interfering with the doctor-patient relationship or by disturbing equity of access in general practice,” he said. “Australians are…relying on you to defend against the actions of insurers, for whom the interests of shareholders come first, and patients are a distant second.”
Professor Owler acknowledged that some AMA members had been made “anxious” by the Association’s statements on asylum seeker policy.
But he said that with the AMA’s influence also came a “responsibility to speak up when governments overstep the mark – that is what happened with Australia’s approach to asylum seekers”.
The former President also highlighted AMA advocacy on Indigenous health and public health, including on family and domestic violence, road safety, alcohol, climate change, immunisation and physical activity.
I was greatly humbled and honoured to be elected as President of the AMA at last month’s National Conference in Canberra.
It is an exciting and challenging time to assume such an important position – in the midst of a close, hard-fought federal election campaign, with health at the top of the agenda. I want to make sure that it stays there.
I am talking to all sides of politics about the issues that matter to you and your patients. Getting rid of the Medicare rebate freeze and increasing funding for public hospitals are top priorities.
The rebate freeze is unfair and it is wrong. We know that it is pushing many practices to breaking point. Some are being forced to introduce patient charges for the first time, others are having to increase their fees. Either way, patients lose out and health suffers.
It is bad policy because it causes people to think twice before seeing their doctor. It will mean more people turning up at hospital – the expensive end of the health system.
Hospitals are already under enough pressure. All levels of government need to realise that an ageing population and epidemics like obesity and drug use are pushing demand up.
We need to break the idea that health is a cost. It is an investment in the future of our community. Without good health, you cannot have a healthy society or, for that matter, a productive economy. Spending on health is not just another budget line to be cut or held down.
I will criticise the Government when they deserve it. I will speak up fearlessly when they produce bad policy.
But I want such criticisms to be the start of the conversation, not the end. I want to engage constructively with all sides of the political debate, and to find better ways forward.
I want to invigorate a conversation on the medical workforce. We need more training positions, not more medical students – and certainly, not more medical schools. The workforce we train should meet the needs of the community it is there to serve. We can do better for rural Australia.
The AMA has a long history of advocating for the sick, the vulnerable and the voiceless. That will continue under my leadership. I have committed myself to continuing the AMA’s work in closing the gap between Indigenous and non-Indigenous health outcomes. I want to do more on mental health. I will hold the Government to account on the health care of asylum seekers.
I congratulate Dr Tony Bartone on his election as AMA Vice President. He is a much valued colleague and friend. I look forward to working closely with him in the next two years to advance the interests of patients and AMA members.
I pay tribute to the tireless work of my predecessor, Professor Brian Owler, and former AMA Vice President Dr Stephen Parnis, in advocating on behalf of patients and our community.
I look forward to the next two years as AMA President with great energy and enthusiasm.
In his Offline, Richard Horton (March 12, p 1041)1 summarised comments from a forum on the role of non-governmental organisations (NGOs) in global health. The Offline echoed a prevalent systematic bias in the treatment of NGOs. NGOs are diverse and dynamic entities that are responsive to social, cultural, and political trends, with varying missions, foci, technical acumen, religious affiliation, experience, and quality assurance standards. The one-size-fits-all label of NGO is outdated. To tackle serious problems, we need to evolve our language, and be both more specific and more systemic.
The UK Government fails to monitor and appropriately report independent research commissioned to inform policy, according to a report published on June 22 by Sense about Science, a charitable trust that aims to make sense of scientific claims in public discussion. The UK Government spends £2·5 billion each year on research, but only four out of 24 government departments maintain a database of commissioned research, leading to fears of “ghost” research that is created and paid for, but unrecorded, unpublished, and therefore unfindable and uninformative.
Health is shaping up to be one of the major election issues, with proposed changes to Medicare rebates and the Pharmaceutical Benefits Scheme (PBS) potentially costing patients more to receive health care.
Our new research shows that, by the end of June 2020, an average full-time GP will have lost A$109,000 in total income due to the freeze since July 2015.
By July 2019, this GP would need to charge their general patients an A$11.40 co-payment per consultation to make up for their lost income (relative to 2014-15).
Our modelling also shows the Coalition’s proposed increase to the PBS co-payment will most affect pensioners.
What is the ‘freeze’?
When GPs bulk-bill their patients, they directly charge the government for the service provided. What GPs are paid for each consultation depends on the Medicare Benefits Schedule (MBS) item charged, with longer and more complex consultations earning them more. A “standard” consultation rebate is A$37.05, while a “long” consultation rebate is A$71.70.
Traditionally, the amount for each item increases year to year to account for the increased cost of care. This is called indexation. Since July 2014, the government has paused or “frozen” this indexation. The government initially planned this freeze to last until 2017-18.
At the time, we modelled the effect of this initial freeze. We found that by 2017-18, a bulk-billing GP would have a relative income loss of 7.1% (5.8%-8.5%) compared with their 2014-15 level of Medicare income.
We concluded that if GPs wished to keep bulk-billing their concessional patients (those with a government health care card), they would need to charge their non-concessional patients an A$8.43 (A$6.71-A$10.16) co-payment for each consultation to make up this loss.
Using the same assumptions we used in our previous modelling, we found that by 2019-20, a bulk-billing GP will have had a relative Medicare income loss of 11.6% compared to their 2014-15 income level (assuming a CPI of 2.5% a year).
However, CPI has been lower than earlier projected. The CPI projections in the federal budget were 1.25% in 2015-16, 2.0% in 2016-17 and 2.25% in 2017-18. Using these figures and assuming CPI of 2.25% per year in 2018-20, we estimate a relative income loss of 9.4%.
For an “average” GP (who bills 5,050 consultations a year), this 9.4% income loss will equate to approximately A$26,300 in 2019-20 alone. For an average full-time GP (7,680 consultations a year, assuming 160 consultations per 40-hour week, 48 weeks a year) the loss of relative income will be A$40,000 in 2019-20.
By June 30 2020, a full-time GP will have lost a total of A$109,000 since 2014-15 due to the freeze.
What does this mean for patients?
The 9.4% reduction in income may force GPs who bulk-bill to cover their loss by charging general patients (who make up 45.6% of encounters) a co-payment. This co-payment would need to be A$11.40 to maintain 2014-15 levels of income.
Our estimates are conservative as they would be the minimum charge needed to make up for the GP’s lost income. We did not account for:
administrative costs in implementing new billing systems
increased bad debt from patients who are charged, but never pay
the previous freeze of fees
lost income when a GP chooses to bulk-bill general patients facing financial hardship.
It’s therefore likely that GPs who opt to charge a co-payment will charge more than our estimates. Further, after abandoning bulk-billing, some GPs may take the opportunity to charge more than required to merely recoup their rebate loss.
A poll by Australian Doctor, a newspaper for GPs, found that over the next 12 months, almost one-third of the responding GPs said they would charge A$35 or more. More than half the sample said they would charge their general patients A$25 or more for a standard consultation.
In 2013, the Australian Medical Association (AMA) recommended a fee of A$73 for a standard GP consultation. That equates to a co-payment of over A$35 if GPs chose to charge this amount, and even this would only be at 2013 AMA rates.
The freeze is likely to have a greater impact on practices that serve socioeconomically disadvantaged people, as the practices would have to absorb the reduction in gross income, which may not be viable.
Labor’s alternative
Isn’t Labor proposing to reverse the freeze?
Well, yes and no. Labor announced it will reintroduce indexation from January 1, 2017. This means the freeze will remain until then.
Prime Minister Malcom Turnbull has dismissed the potential impact of Labor’s proposed increase, saying:
If the indexation were to be restored from 1 July, the increase in the benefit paid to doctors would be around 60 cents. 60 cents. And by 2019-20, it would be A$2.50.
This is true only if you are talking about the rebate for a single “Level B” item (which is below the average rebate per consultation) and if indexation was set at only 1.65% a year, well below the CPI projections in the 2016 federal budget.
A more accurate estimate would be to use the average rebate claimed per consultation (A$50) and use the CPI projections in the budget. This would mean an average increase per consultation of A$1 in 2016-17 and A$4.50 in 2019-20.
Compared with continuing the freeze, the indexation would mean an additional A$34,700 in earnings in 2019-20 alone for an average full-time GP and an additional A$84,400 combined to 2020.
Changes to the cost of medication
The government subsidises the cost of important medications through the PBS. General patients currently pay a maximum of A$38.30 for a PBS-subsided medication and concessional patients pay a maximum of A$6.20. These thresholds are indexed yearly, usually in line with CPI.
In the 2014 federal budget, the Coalition proposed that these co-payments increase by A$5.00 and A$0.80 respectively – additional to the regular indexation. So far, this proposal has been blocked in the Senate, but associated savings are included in the May 2016 budget.
While it would seem that the A$0.80 increase for concessional patients is small, our modelling from 2014 shows this increase would be larger in dollar terms for concessional patients. Nearly all medications prescribed for concessional patients face this increase, whereas only a fraction of medications prescribed to general patients cost more than the current threshold, so far fewer medications would incur an additional cost.
An average 45- to 64-year-old would pay an additional A$12.99 a year if they were a general patient and A$16.59 if a concessional patient.
The patients most impacted by the PBS co-payment increase will be aged pensioners, who on average would see their co-payment for medications increase by A$29.65 a year.
These estimates are conservative as they only include the number of instances where a script is written and do not include any repeats scripts provided on these occasions.
Child marriage is common in Nepal but the government hopes a new, multipronged strategy can end the practice by 2030. Sophie Cousins reports from Kathmandu, Nepal.
Ban Ki-moon’s final flagship initiative for his tenure as UN Secretary-General, the World Humanitarian Summit, was held in Istanbul, Turkey, last week (May 23–24). The meeting, the first of its kind, was marred in controversy before it started, with Médecins Sans Frontières boycotting the event because it did not believe that it would address the weaknesses in humanitarian action and emergency response. Other non-governmental organisations (NGOs) were sceptical too. Were they right?
New AMA President Dr Michael Gannon has declared that the Medicare rebate freeze is “unfair…and wrong”, and must be scrapped.
In his first public statement following his election at the AMA National Conference, Dr Gannon reaffirmed the peak medical organisation’s commitment to overturning the freeze, which he warned could force some doctors to abandon bulk billing and begin charging patients up to $25 a visit.
“GPs are at breaking point. They can’t take too many more cuts,” he said. “I would not be surprised if those practices that move away from bulk billing, and decide to invest in the infrastructure required to collect the fees, turn around and collect something like a fee between $15 and $25”.
The Federal Government’s decision to extend the current freeze on Medicare rebates an extra two years to 2020 has provoked outrage among GPs and the broader medical profession. The AMA has mounted a nationwide campaign against the policy, which is also the target of television ads by the Royal Australian College of General Practitioners that warn patients the freeze means “you will pay more”.
Dr Gannon has assumed the presidency in a highly politically-charged environment, with the nation embroiled in one of the longest Federal Election campaigns in decades. Opinion polls have the two major parties locked in a close contest.
THe Western Australian obstetrician has held discussions with Health Minster Sussan Ley, Shadow Minister Catherine King and Greens leader Richard Di Natale, and promised to “pursue a consultative style [to] try and find constructive ways forward”.
He said there was an opportunity to improve the AMA’s relationship with Ms Ley, and said the AMA should “always try and be constructive when it criticises policy of governments or opposition to come up with alternatives”.
Dr Gannon warned that, “when you criticise Government on any area of policy you need to realise that there might be a cost in that area or in other areas of your agenda”.
But he said the Medicare rebate freeze had to go, and reiterated the AMA’s support for Labor’s policy to end the freeze. Both Labor and the Greens have promised $2.4 billion to reinstate rebate indexation from 1 January next year.
Dr Gannon called for the Coalition to “change tack” on the freeze.
“Unravelling the freeze is so important,” he said, adding that such a move should be the start of a broader discussion about improved support for general practice.
“Successive governments have under-invested in quality general practice. That is the cornerstone of the health system,” he said. “High quality primary care reduces the need for more expensive hospital admissions. Unravelling the freeze is not a solution to the underfunding of general practice. We need to do so much better.”
The AMA President also attacked Commonwealth cuts to public hospital funding.
“I don’t think that there’s room to cut hospital funding; in fact, quite the opposite,” Dr Gannon said.
While the AMA needed to be “responsible” in calling for greater health funding, he lamented that both the Federal and State tiers of government had failed to comprehend the rise in hospital costs stemming from the ageing population and health epidemics like obesity and drug use.
But Dr Gannon said his advocacy would not be limited to general practice and hospital, and the AMA’s “very strong” platform on social issues would continue under his leadership.
He said he was committed to “continuing the AMA’s long history in trying to close the gap between Indigenous and non-Indigenous Australians”, and also made particular mention of mental health and “speaking up for people who can’t speak for themselves”.
Doctors “must speak up” on the health care of asylum seekers, new AMA President Dr Michael Gannon has said.
Indicating the Government would continue to come under pressure over the treatment of asylum seekers and refugees being held in detention, the WA obstetrician said the issue was “core business” for the AMA.
“Asylum seekers and refugees, ethically and under law, are entitled to the ethical protections of the Australian Government, Australian law, the Australian people,” he said. “That means that doctors must speak up. That is a core ethical principle of medical care, that you speak up when patients are not being treated well.”
But he clarified that any comments he made regarding asylum seekers would be confined to issues affecting their health: “If you ever hear me talking about it, I’ll be talking about the health of asylum seekers, I won’t be making any comments about broader policy”.
Dr Gannon said the AMA needed to be “smart” and recognise that when it raises politically contentious issues, “there are risks to other elements of [its] agenda”.
“The AMA must always be fearless in speaking up on social issues, even if there is a cost. But we need to be smart, and recognise that there can be a cost to the relationship,” he said.
“I would love to build a more constructive relationship with the Turnbull Government if they’re re-elected, but we will speak up fearlessly when they produce bad policy. If they produce policies that aren’t good for the health of Australians, then we will criticise them.”
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