Government rethinks kick in the guts for patients

Patients have been saved from being left with huge unexpected out-of-pocket expenses after the AMA intervened to secure a delay in major changes to Medicare benefits for abdominal surgery.

The AMA acted after the Health Department, in a letter sent to AMA President Professor Brian Owler on 17 December, gave just 14 days’ notice of significant amendments to Medicare items for lipectomy services, which involve the removal of large flaps of skin left hanging from the gut following rapid weight loss.

Increasingly, lipectomies have been performed on people who have lost significant weight following lap band surgery or other medical interventions.

A review of Medicare Benefits Schedule items for lipectomy services conducted in 2013 found a large increase in the number of claims made in the previous decade. Most of the procedures were carried out on women between 35 and 54 years of age.

In its letter to Professor Owler, the Department said that the review had found little strong evidence regarding the effectiveness, safety and quality of lipectomies.

“But [the review] concluded that patients with a major abdominal apron following massive weight loss due to bariatric surgery or other weight loss measures were the most likely patient population for clinically relevant lipectomy, with personal hygiene and ulceration as the main clinical issues,” the Department said.

In April, the Medical Services Advisory Committee, which oversees the listing of services on the MBS, supported changes to Medicare items for lipectomies recommended by an expert working group.

But the Government did not act on this advice until deciding to implement the changes as part of its Mid Year Economic and Fiscal Outlook deliberations, and it announced they were to come into effect from 1 January 2016.

In her letter to Professor Owler, Health Department Assistant Secretary Natasha Ryan admitted that the rapid implementation of the changes meant there was little time to give doctors and patients notice. But she argued the nature of the changes meant they were likely to cause “only minimal inconvenience”.

But the AMA told the Department patients already booked in for a lipectomy, particularly those undergoing the procedure in January, were likely to be left badly out-of-pocket as a result of the extremely tight timeframe.

“There may be cases where patients are booked for services in January, who will now not be eligible for Medicare rebates and, therefore, private health insurance rebates,” the AMA warned. “Without proper notice to the relevant medical practitioners, the Department may be exposing some individuals to having to pay the full costs of treatment, [including both] the medical and hospital costs”.

The AMA said the period of notice given by the Department was “unacceptable”, and urged for a delay.

It said there was no material reason why the changes had to be implemented so quickly, and the decision showed “a lack of insight by the Department in how the health system works and how changes need to be planned for.

Following strong representations from the AMA, the Department has announced that the changes will be deferred until 1 April 2016.

Adrian Rollins

‘Get kids out of detention’

The Australian Medical Association has released its revised Position Statement on the Health Care of Asylum Seekers.

The statement reaffirmed a long-held believe that all asylum seeker children should be moved out of immigration detention.

AMA President Professor Brian Owler said they acknowledge the Government has significantly reduced the numbers of children in detention but more can be done.

“Detention has severe adverse effects on the health of all asylum seekers, but the harms in children are more serious.

“Some of the children have spent half their lives in detention, which is inhumane and totally unacceptable.

“These children are suffering extreme physical and mental health issues, including severe anxiety and depression.

“Many of these conditions will stay with them throughout their lives,” Professor Owler said.

According to the latest Immigration Detention and Community Statistics Summary, as at 30 November 2015, there were 104 children held in immigration detention facilities within the Australian mainland, 70 children held in detention in Nauru, and 331 children in community detention.

The position statement also confirmed the AMA position that those who are seeking or have been granted asylum should have the right to appropriate medical care.

“Refugees and asylum seekers living in the community should have access to Medicare and the Pharmaceutical Benefits Scheme, state welfare and employment support, and appropriate settlement services,” Professor Owler said.

Other recommendations include:

There should be a maximum time that an asylum seeker can spend in detention
Those in detention should have access to appropriate specialist services
Anyone who has been in detention should be able to access their medical records after their release or deportation
Doctors treating asylum seekers who are transferred should be able to provide appropriate handover of relevant documents.
Doctors shouldn’t be obliged to artificially feed a hunger striker

Visit the AMA’s site to read their position statement.

Latest news:

Ley tries to stymie opposition with hep C link

Health Minister Sussan Ley has attempted to stifle opposition to controversial pathology and diagnostic imaging bulk billing incentive cuts by linking the changes to plans to eradicate hepatitis C within a generation.

The Health Minister said a $1 billion initiative to publicly subsidise access to breakthrough hepatitis C drugs had been “fully accounted for” in the mid-year Budget update unveiled on 15 December, but had not been announced at the time to enable confidential price negotiations with the drug companies to be finalised.

Ms Ley confirmed to the Adelaide Advertiser that axing and winding back bulk billing incentive payments for pathology and diagnostic imaging tests – collectively expected to save $650 million over four years – would help fund the subsidy for hepatitis C drugs.

“This demonstrates that the Government is prepared to make the tough decisions to prioritise where we should put our health dollar in Australia,” the Minister said.

By linking the two measures, Ms Ley will make it harder for political opponents of the bulk billing incentive cuts to block the measures in the Senate, where many previous health measures have foundered – most recently proposed changes to the Medicare safety net.

But, while he was “really pleased” hepatitis C patients would get access to potentially life-saving drugs, AMA President Professor Brian Owler warned the Minister she would be “on dangerous ground” if she sought to trade the interests of one group of patients against those of another.

Shadow Health Minister Catherine King told the Adelaide Advertiser that, while she welcomed the decision to list hepatitis C treatments on the PBS, it was “an absurd proposition” to make patients with cancer, diabetes and other serious health conditions pay for the treatment of other seriously ill people.

Professor Owler has criticised the bulk billing cuts, warning that they amounted to a “co-payment by stealth” because they would force pathology companies to begin charging patients a fee.

One of the nation’s largest providers, Sonic Healthcare, has already warned that patients could be charged $20 for a blood test.

Professor Owler said such a co-payment would hit chronically ill patients in need of frequent pathology tests particularly hard, and would discourage many from having diagnostic tests, increasing the risk of more serious health problems later in life.

But Ms Ley has vowed to confront providers over any plans to introduce a co-payment, claiming such a move was “not appropriate”.

She has argued that competitive pressures in the pathology industry meant that companies should absorb the cut, rather than passing it on to patients.

But the pathology market is dominated by two major providers, and the fact that they are contemplating introducing a co-payment suggests the Government’s analysis of the dynamics of the market is flawed.

But the Minister appears confident that she has the upper hand in the politics of the debate, particularly given her move to link the bulk billing incentive cuts to the hepatitis C announcement.

“I have every expectation that Labor will pass these savings, as they make perfect sense – and, particularly, in the context of an announcement like [the hepatitis C initiative],” she told the Australian Financial Review.

Under the measure, the Government will list four new frontline drugs for the treatment and cure of hepatitis C, including sofosbuvir with ledipasvir (Harvoni), sofosbuvir (Sovaldi), daclatasvir (Daklinza), and ribavirin (Ibavyr), on the Pharmaceutical Benefits Scheme from March next year.

The move is expected to benefit around 233,000 people currently infected with the blood-borne virus that attacks the liver causing serious illness, including cirrhosis and cancer. Around 10,000 people are diagnosed with the disease each year, and it responsible for about 700 deaths annually.

The Government’s decision came eight months after the Pharmaceutical Benefits Advisory Committee recommended that sofosbuvir be listed on the PBS because of “high clinical need”.

This overturned advice from the PBAC a year earlier, in which it recommended against listing the drug because it was likely to have “a high financial impact on the health budget”.

In recommending the drug’s listing, the PBAC warned it was likely to cost taxpayers $3 billion over five years to put 62,000 chronic hepatitis C patients through a course of treatment – three times the Government’s current budgeting.

Though sofosbuvir has been hailed as a “game-changing” medicine that can cure hepatitis C in as little as 12 weeks, its prohibitive price – a course of treatment can cost more than $110,000 – has meant that until now it has been out of the financial reach of most sufferers.

Listing on the PBS means a prescription will cost as little as $37.70 for general patients and $6.10 for concession card holders.

Ms Ley said the combination therapies listed on the PBS had a 90 per cent success rate, and caused fewer side effects than current treatments. She said in most cases patients will only need to take the drug as a pill.

The fact that the Government has budgeted just $1 billion for the measure suggests either that it has managed to negotiate a significant discount with the drug companies, or will eventually need to allocate more money to the effort.

Adrian Rollins

[Correspondence] India—small progress in health care, decline in rural service

It was disheartening to see that the Indian Health Authority’s plan to increase resources in the three-tier health system during 2005–15 remains only a promise.1 India is a predominantly rural country, with 70–80% of the population living in villages. Poverty and illiteracy are rampant, and most patients rely on government hospitals for health care.

‘Why does this Government have it in for sick people?’

AMA President Professor Brian Owler has accused the Federal Government of ‘having it in’ for the ill over its plan to scrap bulk billing incentives for pathology services and downgrade them for diagnostic imaging.

As Health Minister Sussan Ley admitted some patients “may be worse off” as a result of the changes announced in the Mid Year Economic and Fiscal Outlook, Professor Owler warned they would increase expenses for patients and amounted to a “co-payment by stealth”.

“I really don’t understand why this Government has it in for sick people,” he told Channel Nine.

The AMA President said the Government’s decision to save around $300 million by axing bulk billing incentives for pathology services would force many providers, who haven’t had their Medicare rebate indexed for 17 years, to introduce a charge for patients.

“That is why it is a co-payment by stealth,” Professor Owler told ABC radio. “It’s about forcing providers to actually pass on those costs to their patients.

“So, while Tony Abbott might have said that the co-payments plans was dead, buried and cremated, it seems to have made a miraculous recovery and it’s reaching out from beyond the grave – or, at least, components of it are.”

Treasurer Scott Morrison has denied the claim, and Health Minister Sussan Ley said competition in the pathology industry would ensure increased costs were absorbed by providers rather than being passed on to patients.

In an interview on ABC radio she initially claimed there were 5000 providers operating in a “highly corporatised and highly competitive” environment.

She later clarified her comments, admitting that there were 5000 collection centres rather than individual operators, and most were owned by “two very large corporate entities and they’re doing very nicely.”

Ms Ley said the charging practices of providers was a commercial decision and “we can’t dictate what they charge patients”.

But Professor Owler said it was “completely ridiculous” for the Government to pretend its cuts would not result in charges for patients.

“You can’t take out what is essentially over $300 million from pathology and not expect that there’s going to be some sort of effect on patients,” he said. “Without that money being supplied to those providers, of course they’re going to have to charge the patients and so you’re going to see more patients with more out of pocket expenditure.

“And that is the plan of this Government – to pass more expense on to the pockets of the patients, and that is going to affect the sick and the most vulnerable in our community.”

In addition to axing and downgrading bulk billing for pathology and diagnostic imaging services, the Government expects a further $595 million will be saved by “streamlining” health workforce funding, including dumping several programs including the Clinical Training Fund (which was originally intended to fund up to 12,000 clinical training places across a range of disciplines), the Rural Health Continuing Education Program, the Aged Care Education and Training Initiative and the Aged Care Vocational Education and Training professional development program.

The Federal Government is also tapping the aged care sector for significant savings. It plans to cut more than $480 million by improving the compliance of aged care providers and making revisions to the Aged Care Funding Instrument Complex Health Care Domain.

The Government also expects to realise $146 million in savings from improving the efficiency of health programs, and plans to extract $78 million from the Independent Hospital Pricing Authority and $104 million from the National Health Performance Authority.

A further $31 million will be withdrawn from public hospital funding over the next four years.

Professor Owler said the health sector needed more detail and explanation from the Government regarding the MYEFO cuts.

“All up, MYEFO has delivered another significant hit to the health budget with services and programs cut, and more costs being shifted on to patients,” he said.

The health savings have been announced as part of measures to help improve the Budget, which has been rocked by a plunge in revenues caused by soft economic activity and falling commodity prices.

Since May, the Budget deficit has swelled by more than $2 billion to $37.4 billion, and is expected to be $26 billion bigger than anticipated over the next four years. Mr Morrison has targeted social services and health to deliver the bulk of spending cuts needed to put the Budget on the path to a surplus, which has been pushed back to 2020-21.

But the tenuous nature of this goal has been underlined by the fact that the Government is relying on savings measures that have little prospect of being implemented to help achieve the surplus.

In particular, proposed changes to the Medicare Safety Net worth $267 million were withdrawn by Ms Ley earlier this month after failing to garner sufficient support in the Senate, but still included in the Budget.

While the Government targeted health for major cuts, it did announce some initiatives welcomed by the AMA, including $131 million to expand the Rural Health Multidisciplinary Training Program and establish grants for private healthcare providers to support undergraduate medical places, and a further $93.8 million to develop an integrated prevocational medical training pathway in rural and regional areas – a measure the AMA has long been advocating for.

The Government has also introduced new MBS items for sexual health and addiction medicine services.

Adrian Rollins

[Comment] The road to universal health coverage in India

In this issue Vikram Patel and colleagues1 report on the need for health coverage for all in India. The Government of India had set up a High Level Expert Group to suggest a road map for achieving universal health coverage (UHC) in India. The blueprint outlined an entitlement-based national health system, with an emphasis on substantial strengthening of the public health system and a radical approach to health financing.2,3

[Comment] Health insurance, assurance, and empowerment in India

In this issue of The Lancet, Vikram Patel and colleagues1 present a balance sheet of universal health coverage (UHC) policy in India. They describe progress and the failures, identify seven challenges, and call for a “restructuring of India’s health-care system” to implement UHC. Their analysis is evidence-based and the prescription reiterates the 2011 recommendations of the High Level Expert Group appointed by the Government of India.2 But UHC in India faces four questions.

Big profits, inefficiencies driving health premiums up

Private health insurers are hitting consumers with unjustified premium increases and overly complex insurance products in their pursuit of big profits, according to a leading industry analyst.

As the Federal Government undertakes a review of the sector amid mounting complaints about the value of health insurance, Credit Suisse analyst Andrew Adams has released a scathing critique of the industry in which he argues funds are not operating efficiently, have deviated away from their core principles, and have set profit and capital targets that are unjustifiably high.

Health funds are coming under increased scrutiny over their strategy of pursuing relentless above-inflation premium increases while downgrading the quality of the cover they offer.

Health Minister Sussan Ley has launched a review of the sector after it was revealed policies covering 500,000 people had been downgraded last financial year despite surging industry profits and premium revenue.

Ms Ley said the confluence of factors suggested there was “something wrong” with the way the industry was regulated.

But AMA President Professor Brian Owler said insurers, driven by the pursuit of profit, were downgrading the cover of policyholders – often without their knowledge or full understanding – leaving many without the insurance they thought they had paid for.

At the same time as they are downgrading the cover they offer, insurers – led by Medibank Private – are looking to force private hospitals to accept responsibility for a greater share of treatments arising from medical complications.

Medibank has just struck a deal with large hospital operator Healthscope which, it is claimed, is aimed at “reducing hospital-acquired complications and avoidable readmissions”.

Professor Owler said that although every effort needed to be made to reduce complications and avoidable readmissions, insurers should not be using the pursuit of quality improvements as an excuse for cost-cutting.

“What we don’t want is punitive measures that punish patients and interfere in what would otherwise be routine clinical cases in order to save money,” he said.

There are also concerns the industry is seeking to undermine community rating, the principle under which all policyholders pay the same premium for a given policy, regardless of age, health or claims history.

It has been suggested that insurers be allowed to offer discounts for those with healthier lifestyles, such as non-smokers and the physically active, though Medibank chief George Savvides told The Australian such an approach was not financially feasible.

Instead, he suggested no-claim bonuses for those who stayed healthy and a reward for long-term members.

But such measures would discriminate against those who, through no fault of their own, became sick, and would increase the deterrent for people to seek care – potentially leading to more serious and costly ailments later on.

Like Professor Owler, Mr Adams is concerned that patients are being made to pay for pursuit of profits by insurers.

Official figures show the industry recorded a $1.1 billion after-tax profit in 2014-15, and premium revenue surged by 7.3 per cent.

In his analysis, reported in The Australian, Mr Adams pointed out that the industry delivered a 17.5 per cent return on equity – by comparison, for the major banks it is around 9.5 per cent – and held double the capital considered to be adequate.

He calculated that reducing the return on equity to 12.5 per cent could enable the industry to reduce its premium increases to just 2.5 per cent over the next three years, compared with the 7 per cent it is seeking next year alone.

Mr Adams questioned why such a heavily regulated and subsidised industry was being allowed to generate such high profits, argued the case for premium increases needed to be re-examined : “In our view, regulated price increases need to also take into account prior year performance and capital position, which could justify a period of below-inflation premium increases”.

In addition to these concerns, Mr Adams said the recent proliferation of health policies – more than 20,000 different types are on offer – had increased costs and inefficiencies in the industry, and suggested there would be some “quick and easy gains to be made by going back to basics”.

“Restricting the level of policy selection to a small number of simplified and homogenous products and reducing the excess returns being generated by the insurers themselves, will significantly assist the affordability and simplicity of private health insurance in the market,” he said.

Adrian Rollins

Health neglected in climate talks

More than half of governments around the world are yet to develop national plans to protect their citizens from the health effects of climate change despite increasing warnings it will cause more extreme weather, spread disease and put pressure on food and water supplies.

As leaders from around the world attending the United Nations Climate Change Conference in Paris reaffirmed their commitment to provide $139 billion a year by 2020 to the UN’s Green Climate Fund and other climate initiatives, an international survey of 35 countries, including Australia, has found a general lack of focus and urgency around the looming threat of climate change to health, with most governments doing little work on likely effects and how to mitigate them.

The survey results underline calls from the AMA, the World Medical Association and other national medical organisations for the health effects of climate change to be made a priority.

AMA President Professor Brian Owler said that while much of the Paris talks were about carbon emission targets, there should be equal emphasis on equipping health systems to cope with the extra burden of problems created by climate change.

“Climate change will dramatically alter the patterns and rate of spread of diseases, rainfall distribution, availability of drinking water and drought,” Professor Owler said. “The incidence of conditions such as malaria, diarrhoea and cardio-respiratory problems is likely to rise.”

The AMA President’s comments came as a survey coordinated by the World Federation of Public Health Associations (WFPHA) found almost 80 per cent of governments are yet to comprehensively assess the threat climate change poses to the health of their citizens, two-thirds had done little to identify vulnerable populations and infrastructure or examine their capacity to cope, and less than half had developed a national plan.

The result underlines the importance of repeated AMA calls for the Federal Government to do much more to prepare for the effects of climate change, which Professor Owler said were “inevitable”.

Earlier this year the AMA released an updated Position Statement on Climate Change and Human Health that warned of multiple risks including increasingly frequent and severe extreme weather events, deleterious effects on food production, increased pressure on scarce water resources, the displacement of people and an increase in health threats such as vector-borne diseases and climate-related illnesses.

“There are already significant health and social effects of climate change and extreme weather events, and these effects will worsen over time if we do not take action now,” Professor Owler said.

“Nations must start now to plan and prepare. If we do not get policies in place now, we will be doing the next generation a great disservice.

“It would be intergenerational theft of the worst kind — we would be robbing our kids of their future.”

In May, the AMA and the Australian Academy of Science jointly launched the Climate change challenges to health: Risks and opportunities report that detailed the likely health effects of climate change and called for the establishment of a National Centre of Disease Control to provide a national and coordinated approach to threat.

The WFPHA said the results of its survey should serve as a wake-up call for governments to do much more.

“The specifics of these responses provide insight into the lack of focus of national governments around the world on climate and health,” the Federation said.

Disturbingly, the survey found that Australia was one of the laggards in addressing the health effects of climate change, having done little to assess vulnerabilities and long-term impacts, develop an early warning system or adaptation responses, and yet to establish a health surveillance plan.

On many of these measures, the nation was lagging behind countries like the United States, Sweden, Taiwan, New Zealand and even Russia and China.

Climate and Health Alliance Executive Director Fiona Armstrong, who helped coordinate the survey, said the results showed the Federal Government needed to place far greater emphasis on human health in its approach to climate change.

“As a wealthy country…whose population is particularly vulnerable to the health impacts of climate change, it is very disappointing to see this lack of leadership from policymakers in Australia,” Ms Armstrong said.

Public Health Association of Australia Chief Executive Officer Mike Moore said the increasing number and ferocity of bushfires and storms underlined the urgent need for action.

“It is time to ensure that health-related climate issues are part of our national planning and budgeting if we are to pre-empt many avoidable illnesses and injuries,” Mr Moore said.

Read the AMA’s Position Statement on Climate Change and Human Health.

Adrian Rollins

Deadly attacks raise fears of breakdown in rules of war

Picture credit: IgorGolovniov / Shutterstock.com

Governments and armed groups are being pressured to ensure the safety of patients and health workers in conflict zones amid a spate of high-profile attacks that have left dozens dead and injured.

The World Medical Association, the International Committee of the Red Cross, the World Health Organisation and several other peak health groups have jointly called on national governments and non-state combatants to adhere to international laws regarding the neutrality of medical staff and health facilities, and ensuring this commitment is reflected in armed forces training and rules of engagement.

The call follows an admission by the US military that a deadly attack on a Medecins Sans Frontieres (MSF) hospital in Kunduz in which 30 people were killed – including 13 staff and 10 patients – was a tragic mistake.

“This was a tragic and avoidable accident caused primarily by human error,” the US’s top commander in Afghanistan, General John Campbell, said, adding that the error was “compounded by systems and procedural failures”.

Though the location of the MSF hospital was widely known, a series of technical and operational errors led the crew of the US gunship that launched the devastating attack to mistake the hospital for the headquarters of the Afghan security service, which had been briefly seized by the Taliban.

The strike co-ordinates for the security building took the aircraft to an open field, so the aircrew decided to launch the attack on the nearest building that matched the description they had been given, which turned out to be the MSF hospital. The aircrew, and the operational command in Kabul, did not check the co-ordinates of the planned target against a “no-strikes” list.

MSF International President Dr Joanne Liu said the incident showed the deadly consequences of any ambiguity about how international humanitarian law applied to medical work in war.

“We need a clear commitment that the act of providing medical care will never make us a target. We need to know whether the rules of law still apply,” Dr Liu said.

The Kunduz attack has added to the urgency for action to be taken to ensure the safety of medical staff and hospitals in combat zones.

The International Committee of the Red Cross (ICRC), through its Health Care in Danger project, recorded 2398 attacks on health workers, facilities and ambulances in just 11 countries between January 2012 and the end of last year.

Policy and Political Affairs Officer for the ICRC’s Australian mission, Natalya Wells, said such attacks were not new, and were virtually a daily occurrence.

Ms Wells often health workers were caught in the cross-fire, particularly as a result of indiscriminate attacks in urban areas.

But she said that on occasion they were also being deliberately targeted, underlining the need for all combatants to respect the Geneva Conventions.
Ms Wells said that through the Health Care in Danger project, the ICRC was working with governments, armed forces and non-state combatants to improve awareness of, and respect for, laws and conventions around the protection of patients, health workers and medical facilities, particularly in conflict zones.

As part of the effort, governments attending the 32^nd International Conference of the Red Cross and Red Crescent between 8 and 10 December were expected to back a resolution reaffirming their commitment to international humanitarian law and a prohibition on attacks on the wounded and sick as well as health care workers, hospitals and ambulances.

In addition, Ms Wells said the ICRC had held meetings with 30 non-state combatant groups from four continents about international humanitarian law and the rules of armed conflict.

The discussions have included incorporating knowledge of these conventions into their training, backed by sanctions for any breaches.

Promisingly, Ms Wells said that so far “one or two” non-state armed groups, though not signatories to the Geneva Conventions, have discussed creating a similar code of conduct for their forces.

Adrian Rollins