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Preference: Government and politics

Patchy vaccination coverage leaves some at risk

Vaccination rates in some areas are so low that they are vulnerable to the spread of potentially dangerous diseases such as measles and whopping cough.

A report detailing child vaccination rates nationwide has found that although almost 91 per cent of children were fully vaccinated in 2014-15, in more than 100 postcodes less than 85 per cent were fully immunised, including just 73.3 per cent in the Brunswick Heads area on the New South Wales north coast.

The National Health Performance Authority report indicates that the country has a considerable way to go to achieve the target set by the Commonwealth, State and Territory chief health and medical officers for 95 per cent of all children to be fully vaccinated, though there were some encouraging signs of progress.

The NHPA found immunisation rates among one-year-old Indigenous children increased significantly in 14 per cent of geographical areas, and there was a big 8 percentage point jump in the rate outback South Australia.

The report also revealed improvements in Surfer’s Paradise, and the eastern suburbs of Sydney.

The findings were released against the backdrop of concerted efforts nationwide to boost immunisation rates, most notably through the Federal Government’s No Jab, No Pay laws, which deny family tax supplements and childcare benefits and rebates to parents who refuse to have their children vaccinated.

There have been anecdotal reports of surge in vaccinations before the commencement of the school year as the new rules loomed, but public health expert Julie Leask warned the causes of low vaccination rates were complex, and it was too early to assess the effectiveness of the No Jab, No Pay laws.

In her Human Factors blog (https://julieleask.wordpress.com/), Ms Leask, a social scientist at Sydney University’s School of Public Health, said a significant percentage of the 84,571 children reported as not fully vaccinated were in fact up-to-date but there were errors in recording their status on the Australian Childhood Immunisation Register.

In other instances, parents were unaware of vaccination requirements, or encountered problems in arranging for the immunisation of their children.

Ms Leask said that without further research, it was impossible to know how many children were being denied immunisation because their parents objected to it.

She said there were encouraging accounts of some parents who were previously objectors arranging for their children to be vaccinated – including some who were “angry and resentful, feeling coerced into making the decision because they cannot afford to miss the payments”.

But Ms Leask aired concerns about the implementation of the No Jab, No Pay laws.

She said Primary Health Networks and providers including GPs, nurses and Aboriginal health workers were being forced to work “very hard to implement a complex policy in a very short timeframe,” with often inadequate resources.

Providers were in many cases being overwhelmed by demand and had not been provided with additional assistance, and were being denied access to the ACIR and so could not update patient details.

The importance of high rates of vaccination have been underlined by warnings that the world remains “significantly off-track” targets to eliminate measles, and that communities with immunisation rates below 90 per cent were at risk of fast-spreading outbreaks.

The Gavi Vaccine Alliance said that although the number of deaths from malaria worldwide had fallen substantially in the past decade, the disease still claimed 114,900 lives in 2014 – most of them children younger than five years.

Gavi said it had developed a new approach to support periodic, data-driven measles and rubella campaigns in addition to action to tackle outbreaks.

“Measles is a key indicator of the strength of a country’s immunisation systems and, all too often, it ends up being the canary in the coalmine,” Gavi Chief Executive Dr Seth Berkley said. “Where we see measles outbreaks, we can be almost certain that coverage of other vaccines is also low.”

Adrian Rollins

A 3-year study of high-cost users of health care [Research]

Background:

Characterizing high-cost users of health care resources is essential for the development of appropriate interventions to improve the management of these patients. We sought to determine the concentration of health care spending, characterize demographic characteristics and clinical diagnoses of high-cost users and examine the consistency of their health care consumption over time.

Methods:

We conducted a retrospective analysis of all residents of Ontario, Canada, who were eligible for publicly funded health care between 2009 and 2011. We estimated the total attributable government health care spending for every individual in all health care sectors.

Results:

More than $30 billion in annual health expenditures, representing 75% of total government health care spending, was attributed to individual costs. One-third of high-cost users (individuals with the highest 5% of costs) in 2009 remained in this category in the subsequent 2 years. Most spending among high-cost users was for institutional care, in contrast to lower-cost users, among whom spending was predominantly for ambulatory care services. Costs were far more concentrated among children than among older adults. The most common reasons for hospital admissions among high-cost users were chronic diseases, infections, acute events and palliative care.

Interpretation:

Although high health care costs were concentrated in a small minority of the population, these related to a diverse set of patient health care needs and were incurred in a wide array of health care settings. Improving the sustainability of the health care system through better management of high-cost users will require different tactics for different high-cost populations.

AMA in the News – 23 February 2016

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

AMA attacks health insurers’ clawback, Adelaide Advertiser, 5 February 2015
Private health insurance customers could finally see a slowdown in the rate of premium rises, amid criticism of insurers for scaling back members’ entitlements. AMA President Professor Brian Owler accused some insurers of scaling back members’ coverage.

Sticking up for all children, Northern Territory News, 8 February 2016
The AMA wants all children who fall behind on their vaccination program to be allowed to catch up for free, calling for further Federal Government funding to boost immunisation rates. AMA President Professor Brian Owler said Government claims that health spending was unsustainable were not backed by evidence.

Medicare plan risks privacy, Adelaide Advertiser, 12 February 2016
A private company would know whether a patient had an abortion, herpes or was getting mental health treatment if the Government proceeds with a plan to privatise Medicare and medicine payments. The AMA is calling on the Government to change the system so a patient’s Medicare rebate could be assigned directly to the doctor.

Anti-vax nuts crack at last, The Sunday Telegraph, 14 Februay 2016
Almost 260 extra children are being immunised every week as even the most hardened anti-vaccine fanatics change their view. AMA President Professor Brian Owler said people are starting to realise the anti-vaccination lobby does not hold weight, and some of the policies are starting to take effect.

Indigenous health vital, The Herald Sun, 18 February 2016
AMA President Professor Brian Owler, in Alice Springs visiting health groups and clinics, said the Closing the Gap report, released last week, indicated that health had fallen off the radar.

Bulk-billing on the rise despite mooted cuts, The Australian, 19 February 2016
Bulk billing rates have continued to rise despite health groups warning patients will be left out-of-pocket because of a Federal Government freeze on Medicare rebates. AMA President Professor Brian Owler said the plan to remove the bulk billing incentive from pathology services was a sign the co-payment had risen from the grave.

Radio

Professor Brian Owler, 666 ABC Canberra, 8 February 2015
AMA President Professor Brian Owler discussed the AMA’s Pre-Budget Submission. Professor Owler criticised the Federal Government for telling basic ‘untruths’ about health spending.

Dr Brian Morton, 2GB Sydney, 9 February 2016
AMA Chair of General Practice Dr Brian Morton discussed homeopathy. Dr Morton said he was concerned that people who chose homoeopathy might put their health at risk. 

Professor Brian Owler, ABC News Radio, 11 February 2015
AMA President Professor Brian Owler talked about health spending and the MBS Review. 

Professor Brian Owler, ABC South East NSW, 15 February 2016
AMA President Professor Brian Owler discussed hydrocephalus. Professor Owler said shunt registry for hydrocephalus could be used as a quality assurance tool in order to decrease blockages and infections which affect morbidity and increase costs to the health system. 

Television

Professor Brian Owler, ABC News 24, 28 December 2015
Landmark legislation will be introduced into Parliament to legalise medicinal cannabis. AMA President Professor Brian Owler said medicinal cannabis should be regulated in the same way as other narcotics.

Professor Brian Owler, CNN, 16 February 2016
AMA President Professor Brian Owler slammed Government policy on asylum seekers. Professor Owler said doctors who work with asylum seeker children face an incredible ethical dilemma, because they cannot allow children to be discharged into an unsafe environment.

Professor Brian Owler, SBS Sydney, 17 February 2016
Prime Minister Malcolm Turnbull said there would be no change to Australia’s border protection policies despite an offer from New Zealand Prime Minister John Key to take in children headed for offshore detention. AMA President Professor Brian Owler said this was a complex issue, but the issue facing the AMA is to ensure the health care of asylum seekers and getting children out of detention.

Pathologists on the warpath

Pathology and diagnostic imaging providers have vowed to flex their political muscle as part of an election-year campaign to force the Federal Government to dump controversial cuts to bulk billing incentives.

In a stark warning to Government MPs, pathology and diagnostic imaging groups have vowed to mount a vigorous campaign over last December’s decision to save $650 million by axing the bulk billing incentive for pathology services and reducing it for diagnostic scans.

Emphasising their political impact, industry leaders said there were about 5000 pathology collection centres around the country that were used regularly by millions of Australians.

Sonic Healthcare Chief Executive Colin Goldschmidt told Fairfax Media that his company alone had around 2000 collection centres.

“We reach something like 1 million to 2 million patients per month through those collection centres,” Mr Goldschmidt said. “We have access to a lot of people.”

The Government’s cuts have particularly angered pathology providers, who have not had an increase in the Medicare rebate for their services in 17 years.

Primary Health Care Chief Executive Peter Gregg said the decision was “ludicrous” because it would force providers to begin charging a co-payment, which would in turn deter some patients – including those with chronic conditions such as diabetes – from being tested as regularly, resulting in more serious and expensive health problems later on.

Related: Pathology services ‘cost Aust too much’

Mr Gregg told The Australian pathology services could not absorb any more Government cuts without changing their business model, and said Primary, which operates 71 medical centres, more than 2000 collection centres and 168 radiology clinics, had begun trials of co-payments for some pathology and diagnostic imaging tests to gauge their effect on demand.

Mr Goldschmidt said Sonic currently bulk billed 98 per cent of its services and, although it had not yet moved to introduce more co-payments, “we are tending in that direction”.

But both executives insisted their preferred option was to block the bulk billing incentive cuts altogether.

The change was announced by the Government in its Mid Year Economic and Fiscal Outlook. Health Minister Sussan Ley argued the incentive, worth between $1.40 and $3.40, had done little to boost bulk billing rates, and had instead served to plump up the bottom line of providers like Primary and Sonic.

She said the companies could comfortably absorb the cut.

Related: Graham Jones: Pathology power

But AMA President Professor Brian Owler said the Government’s real intent was to introduce a co-payment “by stealth” by forcing pathology and diagnostic imaging providers charge out-of-pocket expenses for their services.

“It’s very clear that to be viable, that if these bulk billing incentives are taken away, then of course they’re going to have to pass those fees onto patients,” Professor Owler said. “That’s what this strategy is all about. It’s about the Government saying ‘no, we’re not paying any more; we’re going to make the provider charge you a fee’.”

The AMA President said the likely fee providers would have to charge would be considerably more than the incentive, because providers would have to introduce and operate billing systems, chase up bad debts, make provisions for losses and other additional tasks.

“They’ve got to actually introduce a whole new system to enable this to work, so of course they’re going to start to charge more. They’re not going to charge one of three dollars; it’s going to be much more than that,” he said.

Adding to the pressure on Government MPs, the ACTU has revealed it will mount a campaign involving doorknocking and targeted advertising in Coalition marginal seats.

The campaign has been triggered by the cuts to bulk billing incentives and the Government’s plan to outsource the Medicare payments system to the private sector.

Adrian Rollins

Latest news:

 

Govt funding goes begging because of bungling

The Health Department has been accused of bungling a multi-million dollar program intended to boost GP training in rural areas.

AMA President Professor Brian Owler has taken the Department to task over revelations that fewer than 50 Rural and Regional Teaching Infrastructure Grants have been awarded, despite funding for double that number.

In its 2014-15 Annual Report, the Department advised that just 10 of 100 grants provided for by the Government in that year had been approved. Professor Owler said that since then a further 38 had been awarded, and negotiations on another “20 or so” were underway.

But the AMA President said this still fell well short of expected targets. In its 2014-15 Budget, the Government committed $52.5 million over three years to fund at least 175 grants worth up to $300,000 each.

There are ongoing concerns about the difficulty of recruiting and retaining doctors to practise in country areas, and the grant program was established to help rural clinics to expand their facilities to accommodate medical students and supervising GPs.

Professor Owler said the program’s underperformance was particularly disappointing given the Government’s crackdown on spending in most areas of health.

“Many health services and programs and organisations are struggling as the Government puts the Budget bottom line ahead of improving health outcomes,” he said. “So it’s a surprise to find an area of health where funding targets are not being met or, to put it another way, precious allocated health funding is not being spent.”

The AMA President said the implementation of the program had been flawed – it took the Department four months to invite applications, and set a deadline during the 2014-15 Christmas-New Year holiday period.

“Give the Department’s extensive experience with infrastructure grants, this should have been a straightforward exercise. Clearly it has bungled the process,” Professor Owler said. “This ineptitude has wasted a rare opportunity to enable more medical students and GP registrars to experience and develop an interest in rural practice, and give patients better access to health services in their community.”

He said that what made it all the more galling was that this had occurred at a time when the Government was slashing GP funding.

The episode also showed the destructive effect of health spending cuts.

Professor Owler said the financial uncertainty created by Government policies such as the Medicare rebate freeze and the MBS Review had made general practices increasingly risk averse.

In order to qualify, practices have to commit to matching the grant provided by the Government, and the AMA President said many were reluctant to make the investment in the current environment.

He said it was unsurprising that, given the lacklustre response, the Government was reconsidering its approach to infrastructure grant funding.

Adrian Rollins

Films the next tobacco frontier

The World Health Organisation has called for a ratings system for films that show people smoking amid warnings that screen portrayals are luring millions of young people into the deadly habit.

While a major review has found evidence that smoking bans have delivered significant health benefits for non-smokers, the WHO is urging governments to do more to deter adolescents from trying tobacco.

Though the WHO Framework Convention on Tobacco Control, which came into effect in 2005, binds signatories to ban tobacco advertising, promotion and sponsorship, The Lancet said earlier this month that that films and television shows remain a potent way circumventing such restrictions by exposing young people to images of smoking.

Hollywood is yet to kick the tobacco habit – 44 per cent of all films it made in 2014 portrayed smoking, including 36 per cent of films rated suitable for young people.

The Lancet cited calculations by the US Centers for Disease Control and Prevention that seeing on-screen smoking would encourage more than 6 million youngsters to take up the habit in 2014 alone.

Though smoking rates among young people in Australia are low by international standards – just 3 per cent of 12- to 15-year-olds smoke, rising to 10 per cent of 16- to 17-year-olds – the WHO’s call is seen as a way to further undermine the appeal of tobacco among young people, which was a major goal of the country’s world-leading plain package legislation.

This comes against the backdrop of the rise of e-cigarettes and concerns they provide a pathway to smoking for young people.

A US study of young people who had never smoked traditional cigarettes found that almost 70 per cent who used e-cigarettes progressed to traditional smokes, compared with 19 per cent of those who had not.

Of some comfort in this regard are figures showing sales growth of e-cigarettes is slowing.

After expanding at a triple-digit pace in the past five years, sales growth in the US is expected to slow to 57 per cent this year and 34 per cent in 2017.

The latest evidence for the success of tobacco control measures has come from a group of Irish researchers who investigated the effect of smoking bans on health.

The study, published by the Cochrane Library, identified 33 observational studies showing evidence of a significant reduction in heart disease following the introduction of smoke-free workplaces and other public spaces.

The researchers found the greatest reduction in admissions for heart disease following the introduction of smoking bans was for non-smokers.

Adrian Rollins

Profit spike bears down on premiums

The nation’s largest health insurer has reported a surge in profits, strengthening the Federal Government’s hand in pushing for more modest premium increases.

Medibank Private’s controversial drive to offload responsibility for complications including hospital-acquired infections on to private hospitals and patients has helped deliver the insurer a 58 per cent jump in net profit to $227.6 million in the six months to December.

The report of the profit spike, which has also been underpinned by crackdown on benefit payouts, came days after the fund complained it was under pressure from an increase in the range and frequency of member claims. The complaint was made in a bid to manage expectations about the size of any reduction in premiums for the coming year.

Health Minister Sussan Ley has asked health funds to resubmit their planned premium increases. Under current arrangements, each year health insurers are required to obtain Government approval for their premium hikes, which have averaged above 6 per cent in recent years.

Last month, Medibank Private flagged that it would resubmit its 2016, and on 11 February rival HBF announced it would seek a lower premium increase than the 5.96 per cent rise it first asked for.

The insurer, which had initially been critical of Ms Ley’s call, said the Government’s subsequent push to overhaul Prostheses List and reduce the cost of medical devices provided in private hospitals had been crucial.

“The Minister is now showing that she understands the need to relieve pressures on health funds and their members rather than simply demand that funds lower premiums,” HBF Managing Director Rob Bransby told the West Australian. “We expect the change in prostheses pricing to deliver savings of millions of dollars to HBF and, ultimately, our members.”

Ms Ley said HBF’s announcement was an “encouraging sign” for consumers, and hoped it would encourage other insurers to follow suit.

“The Government is serious about working with the private health sector to deliver a better deal for consumers, and there are real opportunities to deliver real reform,” the Minister said, adding that the insurers were holding $5.1 billion in excess capital.

Industry analysts said Medibank’s profit growth would make it difficult for the fund to fight against lower premium increases, and one anticipates a rise of just 2 per cent from 1 April.

Adrian Rollins

Cheaper hips path to lower premiums

Private health funds are under pressure to pass any savings from reform of prosthetic pricing on to consumers through more modest premium increases.

As part of her push to improve the value of private health cover, Health Minister Sussan Ley has appointed experienced health administrator Professor Lloyd Samson to lead a working group examining the way medical implants and devices are priced.

The Industry Working Group on Prostheses, which includes a representative from the AMA, will look at current arrangements under which the cost of around 9000 prostheses and implants used in the private health system is set, resulting in prices that are often double or more of those paid in the public sector.

Ms Ley said the pricing process meant the same pacemaker delivered through the private system cost $26,000 – twice as much as if it was provided through a public hospital.

“It doesn’t matter whether it’s the hospital or the insurer purchasing these devices, the cost will always ultimately fall to the consumer, and I want to take unnecessary pressure off premiums,” the Minister said.

Under the current system, the price of a prosthesis is set and can only be under-cut if a rival device has more than 25 per cent of the market.

The prostheses working group has been asked to look at ways to make the purchase of devices more competitive and efficient, and to ensure that the benefits of this are passed on to consumers.

Private health funds have long complained about the prices they are required to pay for prostheses, and estimate that up to $800 million a year could be saved by bringing prices more in to line with those paid in the public system.

The industry’s peak group, Private Healthcare Australia, said insurers spent $1.9 billion on prostheses last financial year – 14 per cent of total payouts.

The group said private patients in Australia paid far more for medical devices than those in comparable countries such as France, Japan and Italy, and much more than it cost the public sector.

“This is an unfair cost burden on private patients which the Government can address immediately,” PHA Chief Executive Dr Rachel David said, arguing for a system of reference pricing benchmarked against local and international charges.

But the Medical Technology Association of Australia (MTAA), which represents prostheses firms, said the price of medical devices had not changed in five years, and the growing payout reflected increased use of prostheses rather than a jump in cost.

The MTAA has accused insurers of attacking prosthesis prices to divert attention away from their premium increases, and warned the deregulation of the Prostheses List would “lead to an Americanisation of the health system, transferring too much power to private health fund accountants and away from treating clinicians”.

“The last thing a patient needs is to have their private health insurance company…determining which pacemaker their specialist can use to treat them, based simply on cost,” MTAA Chief Executive Susanne Tegen said. “That’s not what Australians expect from their health system.”

The Government’s review has also come under fire from smaller device manufacturers concerned that it will increase the market dominance of the big firms by allowing them to bundle overpriced routine products with devices only they can supply.

Changes to the pricing arrangement may also be resisted by some private hospital groups, which earn significant revenue from the supply and use of prosthetics.

The prosthesis review is taking place amid a broader assessment of the private health insurance system initiated by Ms Ley because of mounting consumer dissatisfaction with the value of private cover.

Ms Ley has asked health funds to resubmit plans for premium increases this year, based on their full financial position, rather than simply a tally of claims and benefits paid.

“Consumers have made it clear they don’t believe they’re getting value for money,” the Minister said.

Ms Ley said that claims and benefits constituted only part of the picture, “when we know insurers are holding an additional $5.1 billion capital in their pockets. The question I am asking insurers is: do they have some capacity to use this excess capital to deliver premium relief for their customers this year?”

The Samson review has been directed to report to the Minister in August.

Adrian Rollins

Hospital funding crisis ‘not our problem’, says Commonwealth

The Commonwealth is on a collision course with the states over health spending after Treasurer Scott Morrison declared the second tier of government was on its own despite a looming $35 billion funding gap.

As the nation’s treasurers prepare to meet next month, Mr Morrison has told his State and Territory counterparts that there would be no extra funding from the Commonwealth.

“We all have to manage our budgets,” he told the National Press Club. “Asking for buckets of money doesn’t solve your expenditure problem.”

Several states have been pushing for tax reform, including a bigger slice of the Commonwealth’s tax take, because of a looming shortfall in funding for hospitals and schools.

Changes unveiled in the 2014-15 Budget that are due to come into effect next year are expected to strip $57 billion from public hospital funding revenue over 10 years, creating what AMA President Professor Brian Owler said was “funding black hole” that would have dire consequences for patients.

“Public hospital funding is about to become the single biggest challenge facing State and Territory finances,” Professor Owler said. “Without sufficient funding to increase capacity, public hospitals will never meet the targets set by governments, and patients will wait longer for treatment.”

The AMA’s annual Public Hospital Report Card showed that performance improvements have stalled and, in some instances, are going into reverse, as hospitals struggle with inadequate funding.

Almost a third of Emergency Department patients categorised as urgent are waiting more than 30 minutes for treatment, and elective surgery patients are, on average, waiting six days longer than they were a decade ago.

There had been hopes that Federal, State and Territory leaders would agree on tax changes at a meeting to discuss reform of the Federation next month that would put health funding on a firmer financial footing.

But the likelihood of the meeting appears to be rapidly receding after Prime Minister Malcolm Turnbull ruled out any changes to the GST, which was at the centre of reform plans advanced by several states, including South Australia and New South Wales.

Instead, the Commonwealth appears determined to divest itself as much as possible of responsibility for health funding.

Mr Turnbull said the Federal Government did not want to increase the total tax take “in net terms”, and challenged the states to find their own sources of extra funds for health.

Papers prepared for the Council of Australian Governments meeting in December indicated that the Commonwealth and the states faced a combined health funding gap of $35 billion by 2030, and suggested closing it would require both spending restraint and an increase in tax revenue.