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Preference: Government and politics
Turnbull’s hospital pass
Prime Minister Malcolm Turnbull has indicated financial relief for the nation’s beleaguered public hospitals will depend on finding additional sources of revenue, delivering a blow to hopes of averting a multi-billion dollar funding crisis set to hit the system from next year.
Mr Turnbull told a meeting of the AMA Federal Council that hospital funding was “a big issue”, and he fuelled speculation of a pre-election spending boost after revealing he was “in discussions” with premiers and chief ministers on the matter.
But the Prime Minister gave no sign his Government was contemplating a major change in the policy course set by the Coalition in 2014 when it announced funding changes that would rip $57 billion out of the public hospital system between 2017 and 2025.
Instead, he reinforced the need for more effective health spending, signalling there would be no let-up in the pressure on doctors, nurses and other health professionals to deliver greater efficiencies.
“Hospital funding is a big issue,” Mr Turnbull said. “It is something I am in discussions with chief ministers and state premiers [about], and we have COAG before not very long, where we will seek to take that issue forward.”
“[But], the big issue is where additional funding will come from.”
Several premiers, most notably Mike Baird in NSW and Jay Weatherill in South Australia, had proposed an increase in the GST – partially offset by other tax changes – to increase the health budget, but the Prime Minister reiterated his Government would not contemplate an increase in tax revenue.
“We have to recognise that Australians already pay high taxes,” Mr Turnbull said. “This is not a low-tax country, so getting better value [for health spending] is vital.”
Instead, while praising advances in the quality and effectiveness of health care, he exhorted health service providers to greater efficiency.
The Prime Minister said rising health expenditure was “often seen as an admission of failure, [but] the reality is that we are getting a lot more for it”, in terms of longer and healthier lives.
However, funding constraints meant that “the pressure is to get better and more effective outcomes” for the same outlay.
Q&A at AMA House
Following one-on-one talks with AMA President Professor Brian Owler, Mr Turnbull was joined by Health Minister Sussan Ley in meeting with AMA Federal Councillors, who grilled the pair on significant aspects of Federal Government health policy including public hospital funding, the Medicare rebate freeze, pathology and diagnostic imaging bulk billing incentives, medical workforce training and emergency department performance targets.
Several AMA Federal Councillors including Dr Tim Greenaway, Dr Saxon Smith and Dr David Mountain challenged the PM and Health Minister on the scale of the Federal Government’s cuts to hospital funding, pointing out the sharp growth in demand for hospital services occurring around the country.
Mr Turnbull questioned why there was a sharp rise in the number of patients showing up at hospital emergency departments, speculating that some of it may be due to a failure in primary care.
But Dr Mountain and Dr Smith explained that as people lived longer, they developed multiple health problems that could compound one another and quickly escalate, requiring expensive and complex emergency care.
Questioned on the Medicare rebate freeze, Ms Ley said on-going Budget deficits meant the Government was not in a position to restore rebate indexation, and was instead examining new models of primary care arising out of the recent review.
Addressing the cut to bulk billing incentives, the Health Minister said it was “not healthy” that the pathology sector was dominated by two providers, and said the major issue raised by pathologists she consulted with was not the incentive cut, but rents charged to co-locate with medical practices.
Ms Ley added that bulk billing incentives for concession card radiology patients had not been touched, supporting their access to care.
On medical training, Ms Ley said she was concerned to find ways to get more “generalist” practitioners into rural areas. The Minister said she did not believe in using Medicare provider numbers and other methods to bond doctors to work in particular areas, but the problem of luring more doctors into rural practice was one that “we do have to collectively solve”.
The Minister said the Government understood concerns around the establishment of a third medical school in Perth, but expressed doubts that the decision could be “unravelled”.
Adrian Rollins
Shine a light on murky insurance deals: AMA
Health insurance premiums are being inflated by commissions and many consumers are being lured into unnecessarily switching cover because of murky arrangements between health funds and insurance comparison websites, the AMA has warned.
Releasing its inaugural Private Health Insurance Report Card, the nation’s peak medical organisation has urged greater Government scrutiny of health insurance industry practices which is says may be distorting the market and undermining the value of private health insurance cover.
As consumer anger over looming premium price hikes builds, the AMA has developed the Report Card to help consumers understand how the market operates and enable them to make better informed choices regarding their health cover.
Launching the Report Card, AMA President Professor Brian Owler said it was common for patients coming to hospital for surgery shocked to discover they were not covered, forcing them to cancel or defer treatment or facing unexpected out-of-pocket costs.
“The AMA wants every person who has private health insurance to know what their policy covers them for, and to review it every year to make sure it continues to meet their needs,” Professor Owler said.
The Report Card addresses two of the biggest gripes of policyholders – gaps and shortcomings in cover, and out-of-pocket fees.
It sets out the level of cover each of the nation’s 35 insurers provides and it details differences in the benefits paid by eight funds for 22 common procedures, including birth, hip and knee replacement, cataract surgery, coronary bypass, vasectomy, haemorrhoid treatment and breast biopsy.
The AMA said there were four main levels of cover, from top private hospital through to public hospital-only policies that President Owler said were junk and should be banned.
He said often policies had misleading names that implied they would provide a much higher level of cover than they actually did, creating the risk that consumers would be caught out when they were most in need.
“There are a lot of policies on offer that provide public hospital-only cover. These are better known as ‘junk’ policies, because they do not support patient choice of doctor or timing for health services or procedures,” Professor Owler said. “It is the AMA’s view that junk policies should be banned outright.”
Even where a treatment is covered by insurance, patients may still be left with out-of-pocket expenses if the benefit paid by the insurer falls short.
For privately insured patients, Medicare pays 75 per cent of the MBS fee, and health funds 25 per cent or more. The bulk of services are provided by doctors with no gap, when Medicare and the health fund between them cover the full total cost of treatment. Sometimes, there is a ‘known gap’, where practitioners charge a fee a set amount above the benefit.
But the Report Card shows that the benefits paid by insurers vary considerably, and the AMA “strongly recommends” that patients seek an estimate from their doctor, including the cost of any implant, and then talk with their insurer prior to treatment.
The AMA has released its Report Card amid concerns that premium increases set to come into effect from 1 April will spur thousands to consider downgrading their cover.
Earlier this month, Health Minster Sussan Ley claimed a victory of sorts after convincing 20 of the nation’s 35 private health funds to lower planned premium increases, a move she said had saved consumers $125 million.
But the average 5.59 per cent increase is virtually treble the inflation rate, and is expected to feed consumer dissatisfaction with the value of private health insurance.
Professor Owler said it was important that consumers were fully informed and aware about the consequences of taking out cheaper cover, which would usually entail more restrictions and exclusions, as well as higher excess.
He said it was particularly worrying that people looking to hold their premium costs down would be duped into taking out junk policies.
“If people have one of the junk policies, the AMA urges them to consider carefully what cover they really need,” the AMA President said.
In addition to the quality of cover on offer, the AMA has raised concerns about the operations of websites that compare health insurance policies.
Professor Owler said these ‘free’ comparator sites earned often exorbitant commissions from insurers, either a fixed percentage of a premium or a fixed fee per sale, which could act as an incentive to get consumers to switch policies.
Either way, the fees could make up a sizeable proportion of the total insurance premium, he said, urging a greater level of transparency and Government scrutiny.
The Australian Competition and Consumer Commission last year issued a report highly critical of the quality and accuracy of information provided by the health funds.
Echoing AMA concerns, the watchdog warned that comparator websites often included only a selection of insurers or policies on offer, and added “they may have commercial relationships with, or receive financial inducements from, listed businesses”.
Ms Ley has launched a review into the private health insurance industry to examine regulation of the sector, including the setting of premiums, as well as other issues including the industry’s push into primary health care; a possible relaxation of community rating principles; and a proposal to replace health insurance rebates with Medicare-style payments for hospital care.
Adrian Rollins
United effort needed to close health gap
Genuine collaboration across the political divide is needed if good intentions about close the gap on Indigenous health is to result in tangible improvements, AMA President Professor Brian Owler has said.
Professor Owler said that although there had been welcome progress on some measures of Indigenous wellbeing, a multipronged approach involving all levels of government and their agencies was vital if significant and enduring advances were to be achieved.
“As a nation, we have changed the way we talk about Aboriginal and Torres Strait Islander health and, as a nation, we can now take the next step to close the health and life expectancy gap,” the AMA President said in a statement to mark National Close the Gap Day.
“A genuine partnership between governments, across the political spectrum, would be a catalyst to achieving significant and much-needed health and lifestyle improvements for all Indigenous Australians.”
Government figures show smoking rates among Indigenous people are coming down, and the nation is on track to halve the mortality rate for Aboriginal and Torres Strait Islander children by 2018.
But Professor Owler said they continued to suffer from a high incidence of treatable and preventable conditions including type 2 diabetes, rheumatic heart disease, kidney disease and scabies.
Furthermore, Indigenous people were much more likely to have undiagnosed and untreated chronic conditions, and to suffer several problems simultaneously.
Combined, these factors have meant that Indigenous people are, on average, dying 10 years earlier than other Australians.
The Federal Government led by Tony Abbott turned the policy focus on to school attendance and employment, but Professor Owler said good health was fundamental to improvement in other areas and should be a priority.
“We have seen encouraging improvements in some areas of Aboriginal and Torres Strait Islander health and wellbeing over recent years, but we need to see consistency of positive outcomes across the country and across the major health indicators,” he said. “Much more needs to be done to close health inequality gap between Indigenous and non- Indigenous people [and] health should be a foundation that underpins improvements in other measures.”
The AMA has been a long-standing supporter of the Close the Gap campaign, and Professor Owler said National Close the Gap Day was an important reminder for all Australians to act to improve Indigenous health equality.
“It is inexcusable that Australia, one of the world’s wealthiest nations, can allow three per cent of its citizens to have poorer health and die younger than the rest of the population,” he said. “Closing the gap is everybody’s business.”
Adrian Rollins
[World Report] Experts sceptical about Nigeria’s free health-care plans
Nigeria’s Government has promised to provide health coverage to millions of citizens. But experts are not convinced that it will happen based on the country’s track record. Andrew Green reports.
When not doing something may be the best choice
X-rays for sprained ankles, antibiotics for ear infections and colds and colonoscopies to screen for bowel cancer are among more than 60 tests, treatments and procedures medical experts say should be avoided because they are wasteful and unnecessarily risky.
Fourteen specialist colleges, societies and associations have taken the lead in identifying 61 tests and procedures that should no longer be used because they expose patients to harm, undermine the effectiveness of lifesaving antibiotics and are a poor use of scarce health dollars.
The list, compiled under the Choosing Wisely initiative of NPS Medicinewise, includes many practices and treatments often considered routine and uncontroversial, but which evidence shows achieve little and are potentially harmful.
An area of particular focus is the use of antibiotics, amid fears that they are being overused, fostering bacterial resistance and the rise of superbugs impervious to known medicines.
In changes that could improve patient outcomes and potentially save millions of dollars, doctors and parents are being urged to make much more careful use of antibiotics, including in the treatment of middle ear infections in children, and in the treatment of colds and other upper respiratory tract infections.
The Royal Australian College of General Practitioners (RACGP) has recommended against the initial use of antibiotics for children aged between two and 12 years with a middle ear infection, where a review is possible in the following 24 to 48 hours.
AMA President Professor Brian Owler said it was important advice that would avert unnecessary treatment while helping to preserve the effectiveness of antibiotics.
“In the case of an ear infection, if there is a chance of review in 24 to 48 hours and the ear looks red, just come back and have a review rather than going straight to antibiotics, so that we try and reduce this over-prescribing of antibiotics,” Professor Owler told Channel Nine’s Today show.
The AMA President said it was advice aimed not only at doctors, but also parents and patients.
“Part of the problem here is not just to educate doctors in terms of when antibiotic prescribing is or isn’t called for, it is also to educate parents and patients themselves so that we don’t prescribe too many antibiotics, because we know if we do that we are likely to see more resistant infections. That’s going to mean that people’s infections are going to be much harder to treat in the future,” he said.
Two Bond University academics, Professor of Clinical Epidemiology Tammy Hoffmann and Professor of Public Health Chris Del Mar said the Choosing Wisely initiative was important not because of the money that could be saved, but because of a change in a approach that it represented.
They wrote in The Conversation that clinicians were guilty of doing too much rather than too little, and Choosing Wisely helped to signal “a very important departure from normal business for clinicians – thinking about not doing things”.
“The premise behind Choosing Wisely is not about cost-cutting. It is one of the few existing processes for dealing with the one-way ratchet caused by more treatments and tests being generated every year, all of which increases the amount of things that can – but not necessarily should – be provided to patients,” they wrote.
Other therapies that have come under question include chest x-rays, one of the test most commonly ordered by GPs.
The RACGP has advised that GPs should no longer, as a matter of routine, order chest x-rays for patients with acute uncomplicated bronchitis.
The Royal Australasian College of Surgeons, meanwhile, has recommended against CT scans for suspected appendicitis without first considering an ultrasound, the Australian Physiotherapy Association has advised that there is “no advantage from routine imaging of non-specific low back pain”, and the Australian and New Zealand Society of Palliative Medicine has advised against the use of stomach feed tubes for patients with advanced dementia.
Professor Owler said the initiative demonstrated that doctors were keen to get rid of wasteful and potentially harmful practices, and supported efforts to improve the effectiveness of health spending.
He said doctors took seriously their responsibility as stewards of the health care system, and were constantly reviewing their practices and the evidence to ensure patients received the best possible care.
His comments were echoed by Australasian College of Dermatologists President Associate Professor Chris Baker, who said that one of the challenges of modern medicine was to determine which of the multiplicity of tests and treatments available were of benefit to patients.
A/Professor Baker said his College had identified several instances where the use of antibiotics was unnecessary and could help undermine their effectiveness, including in the treatment of acne vulgaris, epidermal cysts and redness and swelling of both lower legs.
The Choosing Wisely campaign is running in parallel with, but is unrelated to, a Federal Government taskforce review of the Medicare Benefits Schedule, which was set up last year and is not expected to complete its work until 2017.
The goal of updating the MBS to reflect modern clinical practice has been backed by the AMA, but there are concerns that the Government wants to use it primarily as a cost-cutting exercise that will be quick to de-list old treatments but slow to add new ones.
Adrian Rollins
[Comment] Offline: Uncivil society
What can be bad about non-governmental organisations (NGOs)? They are essential voices in a discordant global health conversation often dominated by risk-averse multilaterals, corrupt governments, and neo-colonial donors. NGOs democratise global health by rebalancing the dialogue towards those who have little or no voice. They advocate for issues too sensitive for others to mention. They are instruments for accountability. And increasingly, they deliver services that weak governments simply cannot provide.
Claims of sub-standard chronic care ‘blatantly wrong’
The AMA has hit back at “blatantly wrong” claims that GPs are failing to adequately care for patients with chronic illnesses.
AMA Council of General Practice Chair Dr Brian Morton said that although there was “no doubt” management of chronic disease could be improved, a Grattan Institute study accusing GPs of serial shortcomings in their care of patients with chronic illnesses including diabetes, asthma, heart disease and mental illness, was flawed.
Using data drawn from 162 medical practices using the Medical Director patient management system, the report, Chronic failure in primary care, claims that just 15 per cent of diabetic patients had their blood glucose, weight and blood pressure checked every year, less than 30 per cent with high blood pressure had it adequately managed and two-thirds of patients with a mental illness missed out on care.
But Dr Morton strongly disputed the findings, which he said did not stand up to scrutiny.
For instance, he said, the proportion of Australians admitted to hospital with uncontrolled diabetes was 7.5 per 100,000 – one of the lowest rates among rich countries and well below the United Kingdom (23.9 per 100,000).
Related: Grattan primary care report right, says GP
The Grattan Institute report itself admitted the paucity of data available to assess the effectiveness of the primary health system in managing complex and chronic disease, which Dr Morton said meant its analysis and conclusions must be treated with caution.
The report’s author, Professor Hal Swerrison, used the findings of the report to argue that the Government was getting a poor return on the $1 billion a year it provided to GPs to prepare chronic disease plans and conduct health assessments.
To rectify this, Professor Swerrison recommended that Medicare rebates be frozen at current levels and funds currently provided through the Practice Incentives Program, Service Incentive Payments and other sources to support chronic disease management be instead combined into an annual $40,000 payment to practices based on achieving performance targets and health outcomes.
A similar model was considered in the Primary Health Care Advisory Group report presented to Health Minister Sussan Ley late last year, as well as a blended model of fee-for-service and so-called capitation payments. The Minister is yet to formally respond to the report.
In its submission to the Primary Health Care Advisory Group, the AMA expressed support for a blended payment model and reform of Medicare chronic disease items to strengthen the role of a patient’s GP, cut red tape, streamline access to allied health care and reward longitudinal care.
Dr Morton said any changes to the model of care needed to be carefully considered and tested before being introduced, and a much more urgent priority was to lift the freeze on Medicare rebates.
“The burden of complex and chronic disease in this country continues to grow, and the Government needs to take a long-term view if it is to tackle this problem effectively,” he said. “The Government needs to invest significantly in general practice, [including] immediately lifting the current freeze on the indexation of Medicare rebates.”
He said the Grattan Institute report also highlighted the need for much better primary health care data: “There is very little data as to what actually works in Australia in the primary care space. Yes, we need data, and we need to collect it.”
Related: Meeting end-of-life care needs for people with chronic disease: palliative care is not enough
The AMA has proposed a PIP incentive payment to support quality improvement, “informed by better data collection”.
Last month, pharmacists outlined the scope of their ambitions for involvement in the provision of health services, particularly chronic care.
Pharmacy Guild of Australia Executive Director David Quilty told a parliamentary inquiry into chronic disease prevention and management that pharmacies could play an “enhanced role” in a number of areas including: transitional care, continued dispensing and prescription renewal, treatment of minor ailments, vaccination, medicine adherence, point of care testing, risk assessments, early intervention, broader diabetes management, treatment of patients through biologics, asthma support, improved after-hours access to primary health care, illicit drug use and the use of pharmacies as rural health hubs, with a strong focus on triage services.
While the AMA has highlighted the risk to patients of allowing pharmacists to administer vaccines, conduct health tests and provide other services outside their scope of expertise, it has proposed the introduction of non-dispensing pharmacists in general practices as a way to help improve medication management, particularly for the chronically ill.
Adrian Rollins
A vision for GPs
The training that aspiring GPs receive should be responsive to local health care needs and include greater prevocational rotation opportunities in areas such as paediatrics, obstetrics and anaesthetics, the AMA has said.
Setting out its vision for GP training, the peak medical organisation said that although the current system was world-class, it needed to evolve and improve to make sure it produced practitioners well placed to meet future health care needs.
The AMA said the training system needed to develop a workforce that met individual and community needs, served the most disadvantaged, and achieved health equity.
To do this, GP registrars needed to be trained to the point where they could safely undertake independent practice and viewed professional development and lifelong learning as essential to high quality practice.
AMA President Professor Brian Owler said general practice was the cornerstone of the health system, and the Vision Statement set out what the AMA considered to be core values and priorities of high quality GP training.
“GPs are the first port of call when Australians feel unwell or want health advice, and directly manage 90 per cent of the medical problems they are presented with,” Professor Owler said.
Evidence indicates that most people have a usual general practice or practitioner, and Professor Owler said GPs were a very cost effective part of the health system, accounting for just 7 per cent of total health spending.
The AMA has developed the Vision Statement for General Practice Training 2016 to guide its advocacy on improvements to GP training, and as a way to promote general practice as a career.
There are currently around 4500 registrars undertaking GP training, and there are concerns that not enough medical graduates are opting for a career in general practice.
Professor Owler said that, by highlighting the professional and personal rewards of general practice, the Vision Statement would encourage more to consider it as a career.
The GP workforce is ageing, and is unevenly distributed around the country, providing uneven access to care.
While the big cities have a relatively high concentration of GPs, there is often a shortage in rural areas, and bonded programs and other Government attempts to redress this have met with only limited success.
The AMA has proposed that there be much greater investment in GP training opportunities in regional and rural areas.
The AMA Vision Statement for General Practice Training 2016 is at ama-vision-statement-general-practice-training-2016
Adrian Rollins
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
Focus on health wins, Northern Territory News, 20 February 2015
AMA President Professor Brian Owler visited health facilities in Alice Springs, as well as the Indigenous communities of Utopia, Ampilatwatja, and Kintore. Professor Owler said Indigenous health gains might be slow, but it is important successes are not lost in a sea of depressing statistics.
Angry medicos urge action over plight of detainees, Sydney Morning Herald, 22 February 2016
AMA President Professor Brian Owler has savaged the Department of Immigration and Border Protection for what he says has been its intimidation of doctors who speak out about the plight of asylum seekers.
Row stymies e-health rollout, AFR Weekend, 27 February 2016
Pharmacists and doctors are feuding over the Federal Government’s struggling electronic My Health Record system. AMA President Professor Brian Owler said the organisation backed e-health records as a way of controlling health costs, but the Government had failed to ask medical specialists what they needed to make My Health Record work.
Hangover cure no miracle as clinic closes, Sun Herald, 28 February 2016
NSW health authorities have launched an investigation into a national chain of hydration clinics after a Sydney woman was hospitalised following an intravenous vitamin infusion sold as a miracle hangover cure. AMA Vice President Dr Stephen Parnis has accused those behind the IV infusion trend of bringing the medical profession into disrepute.
Patients to feel pain as cuts bite, Adelaide Advertiser, 11 March 2016
Across Australia, public hospitals will lose more than a $1 billion in federal funding next year. AMA President Professor Brian Owler said as hospital capacity shrinks, doctors won’t be able to get their patients into hospital or keep them there to receive the critical care they require.
AMA warns of hospital funding crisis as cuts bite, Sydney Morning Herald, 11 March 2016
Hospitals are limiting surgery hours and forcing patients to wait longer for elective procedures as an economic disaster looms. AMA president Brian Owler said patients with life-threatening conditions such as cancer would wait longer for surgery, while emergency departments would struggle to treat half their sickest patients within 30 minutes.
Porn turning kids into predators, The Australian, 29 February 2016
Online pornography is turning children into copycat sexual predators, doctors and child abuse experts warned. AMA Vice President Dr Stephen Parnis said the internet was exposing children to sexually explicit content that taught sex was about use and abuse.
Radio
Professor Brian Owler, Radio National, 22 February 2016
AMA President Professor Brian Owler discussed calling for the immediate removal of infants and children from immigration detention centres, and for all asylum seekers to have access to quality health care.
Dr Stephen Parnis, 2HD Newcastle, 22 February 2016
AMA Vice President Dr Stephen Parnis discussed Turnbull Government plans for asylum seeker Baby Asha and her family to be returned to Nauru once medical and legal process are complete. Dr Parnis said doctors were in an untenable situation in treating patients with serious physical and mental health issues, particularly the children, who were under threat of return to conditions that will only exacerbate their health problems.
Dr Stephen Parnis, 5AA Adelaide, 28 February 2016
AMA Vice President Dr Stephen Parnis talked about hangover clinics. He said clinics which claim to cure hangovers through intravenous infusions have no benefit and could put lives at risk.
Professor Brian Owler, 2UE Sydney, 11 March 2015
AMA President Professor Brian Owler talked about public hospital funding. Professor Owler said Australia has one of the best health care systems in the world, but it relies on having adequate funding.
Television
Professor Brian Owler, ABC Melbourne, 21 February 2016
Federal Immigration Minister, Peter Dutton, says that asylum seeker baby Asha and her family will moved to community detention, and not immediately sent to Nauru. The AMA reiterated its call for all children to be immediately released from detention
Dr Stephen Parnis, ABC Melbourne, 2 February 2016
A new report warns that Australia isn’t properly prepared for health problems triggered by an increase in heat waves over the next 40 years. AMA Vice President Dr Stephen Parnis said hundreds of people could die every year if nothing is done to tackle climate change.
Dr Stephen Parnis, Channel 10, 8 March 2015
An official submission to the Government proposes increasing the tax on alcohol. AMA Vice President Dr Stephen Parnis is supportive of increasing the price.
Professor Brian Owler, Prime 7, 10 March 2016
AMA President Professor Brian Owler warns regional communities they will be worst hit when the Federal Government’s hospital cuts take effect from next year. AMA urges the Government to prioritise health when it lays down the budget in May.
Professor Brian Owler, Sky News, 10 March 2016
AMA President Professor Brian Owler talks about the No Jab, No Pay laws coming into force on March 18, when parents who don’t ensure their child’s immunisation is up-to-date stand to lose childcare benefits.