Organ donation – should Australia adopt an opt-out system?

Opinion

BY DAVID TARRANT

The statistics paint a stark picture. More than 12,000 Australians suffer each year while they are on transplant waiting lists or dialysis. Six Australians will die in August alone while waiting for an organ transplant, a grim reminder of the limitations of the healthcare system in the face of overwhelming demand and scarce supply.

But is the organ donation system merely indicative of a failure by the Government to enact smart legislation that goes some way to overcoming societal apathy towards registering as an organ donor?

It has become evident that Australia’s current opt-In organ procurement legislation has failed to correct the disparity between the number of people on organ transplant waiting lists and the number of organs available for transplantation. A number of factors have been identified which potentiate this ever-widening gap. Primarily, the aforementioned societal unwillingness to registering as an organ donor, followed by potential donors’ families denying consent when donation is requested, and the reluctance of health care professionals to request that the deceased patient’s organs be donated.

Australia is ranked 20 in the world for organ donation. We are behind countries such as Croatia, Spain, Portugal and Italy. Recent international studies have demonstrated that implementation of an Opt Out system of organ procurement would increase donation rates by 50 per cent.

Spain has been most successful in implementing “soft” opt-out legislation there, sustaining the highest rate of organ donation in the world for the past two decades. Implementation of the Spanish model opt-out legislation in Australia could result in an additional 1,400 Australians receiving a transplant every year. Think about the impact of that on the healthcare system in terms of primary, hospital and allied health care, and the associated effect on patient flow.

Notwithstanding the advantages of an opt-out system for those individuals on organ transplant lists, nevertheless implementation of an opt-out system in Australia requires examination of several ethical issues. Whilst Australian law states that there is no property in a dead body, the potential for a negative impact upon individual autonomy must be considered.

Despite proponents of presumed consent suggesting that implementation of an opt-out system could improve individual autonomy, a number of authors are sceptical of this claim. However, when weighing limits of personal autonomy against the concept of benefits to society in terms of giving back to the community, under a communitarian-based approach, the number of lives that could be saved as a result of the enacting opt-out legislation could be preferable to society.

If implementation of a national “soft” opt-out organ donation legislation is proposed in Australia, enactment of this type of legislation must be prefaced by comprehensive publicity and education programs, focusing on both the general public and health care professionals. In conjunction with these amendments to legislation, Australia should adopt an individual hospital-based approach to organ donation as described under the “Spanish model”.

Australia must act now to implement these changes. People will continue to die until the disparity between organs required and those available for organ transplantation is rectified.

Views expressed in the above Opinion piece are those of the author and do not reflect official policy of the AMA.

David Tarrant is a lawyer and a registered nurse. He completed his Honours thesis on organ donation, which was published in the NSW Operating Theatre Nurses Association Journal, and has also drafted papers on related issues (in collaboration with his colleagues at Carroll & O’Dea Lawyers). Prior to embarking on his legal career, David worked in hospitals in Tamworth, Sydney and London. Following completion of his Graduate Diploma in Clinical Practice, he was awarded the Anne Carrodus Memorial Prize for excellence in clinical practice.

This bondage isn’t right

BY DR JOHN ZORBAS, CHAIR, AMA COUNICL OF DOCTORS IN TRAINING

There’s a key difference between bondage and bonding. One is a contract between two or more parties, requiring informed consent, and designed for the mutual benefit of all involved. The other is a terribly flawed stick that the Australian Government seems intent on bashing medical graduates with, in a poorly informed attempt to provide a rural workforce.

In Australia, we have two medical bonding programs: the Bonded Medical Places (BMP) scheme and the Medical Rural Bonded Scholarship (MRBS). There are several different versions of these schemes, if you count the number of different contracts that now exist since their inception, but they can broadly be summarised as follows. The BMP scheme provides participants with a Commonwealth Supported Place (CSP) in medical school in exchange for a return of service of one to six years in rural and regional Australia. The MRBS scheme provided participants with a CSP in medical school and by the time it was axed a scholarship of $26,310 a year in exchange for six continuous years of work as a specialist in rural and regional Australia. Sounds simple enough, but the more you dig, the more you realise just how bad a deal this is for these future doctors and the patients they’re supposed to be serving.

You see, the first major flaw in this plan is that bonding just doesn’t work. Funnily enough, if you force someone to do something on your terms in an uncertain and inflexible manner, it turns out that people don’t appreciate the experience and they don’t come back. When bonding in medical school was first conjured up, the AMA provided evidence that similar schemes overseas, especially in North America, had failed to provide any form of sustainable medical workforce. More than 13 years have now passed and an exceedingly small number of scheme participants have completed their return of service. In fact, more participants have withdrawn or breached their agreement than those who have completed their return of service. Not exactly a ringing endorsement.

Compare this with the other measures and programs that are supported by the AMA. We know that having a rural background significantly increases your chance of going rural, and we have strongly supported increasing the quota of students from rural backgrounds. We floated the idea of Regional Training Networks in 2014, to help allow those who wanted to work and stay rural obtain fellowship in a more sustainable manner and reduce infrastructure duplication in what is already a resource poor area of medical training. We supported the Prevocational General Practice Placements Program and, following its abolition by the Abbott Government, subsequently developed an alternative proposal for a Community Residency Program (CRP), to enable doctors to have meaningful rural experiences in their pre-vocational years, while they work out exactly what career they want to pursue. And we have long supported an increased rural focus in the Specialist Training Program (STP), allowing registrars to be adequately funded to work in rural areas on progression to fellowship. It’s a suite of measures that encourages positive experiences and supports trainees along their often complicated and difficult path.

But the Government has chosen to focus on draconian bonding schemes. Let’s explore the MRBS for a second, mostly as initially on paper it looks very attractive. You take a 17-year-old undergraduate student and you promise them $26,310 tax free and a place in medical school for a return of service. Sounds reasonable. Except what 17-year-old understands Medicare? Hell, how many healthcare workers and bureaucrats even understand Medicare? Do we adequately explain to them that leaving the scheme will result in a 12-year ban from Medicare, effectively killing their medical career there and then, simply because of a change in their life situation and circumstances? Do we explain to them that as they train to become a rural general practitioner, they will be effectively forbidden from working in the city for short periods of time, preventing them from upskilling in crucial rural skill sets such as emergency medicine, obstetrics and anaesthetics? Do we explain to the orthopaedic trainee that they only have 16 years from the start of medical school to complete their requirements? Caveat emptor is one thing, but conscriptive blackmail is another.

And even if you are one of the few to complete your return of service, just how happy will you be at the end of it all? What doctor, having had to deny themselves the opportunities of personal and professional development at the behest of such an authoritarian scheme, will look kindly on rural Australia? When you take away mastery, autonomy and purpose, you’re left with a bitter, angry human. That’s not the kind of person that rural Australia deserves.

The AMA Council of Doctors in Training is continuing to lobby government to adjust the BMP and MRBS for the good of its participants and the Australian public that it purports to serve. Nobody is arguing that a return of service isn’t owed, but it certainly shouldn’t function like this. If you or someone you know is affected by these schemes, we’d like to hear about it. Please contact me at cdt.chair@ama.com.au and let’s see if we can’t loosen the bureaucratic nipple clamps, just a little bit.

Critical attention given to doctors’ health at COAG

Federal, State and Territory Health Ministers met in Brisbane this month at the COAG Health Council to discuss a range of national health issues.

During broad ranging discussions it was agreed to amend mandatory reporting provisions for treating health practitioners. Doctors should be able to seek treatment for health issues with confidentiality. They also acknowledged that protecting the public from harm is also important.

The resulting COAG communique said: “A nationally consistent approach to mandatory reporting provisions will provide confidence to health practitioner that they can feel able to seek treatment for their own health conditions anywhere in Australia.”

AMA President Dr Michael Gannon commended the decision, saying: “It has been acknowledged that there needs to be a change, that there’s a problem.

“Healthy doctors take better care of their patients.”

Other items discussed by Health Ministers included:

Family violence and primary care

The Health Ministers agreed to seek further advice from Primary Health Networks on existing family violence services, including Commonwealth, State and NGO service providers in their regions, with a view to developing an improved whole-of-system response to the complex needs of clients who disclose family violence.

This is supported by evidence given by Professor Kelsey Hegarty at the Victorian Royal Commission into Violence, when she said: “PHNs and other alliances across the health services sector have a significant role to play in supporting practitioner training about family violence.”

Fifth National Mental Health and Suicide Prevention Plan

Health Ministers endorsed the Fifth National Mental Health and Suicide Prevention Plan 2017-2022 and its Implementation Plan.

Federal Health Minister Greg Hunt said it stood out from previous plans with its focus on eating disorders and suicide prevention, keys areas that had been raised by lobbyists.

“The prevalence and the danger of (eating disorders) is still dramatically understated in Australia,” he said.

“The reality is that this is a silent killer, particularly women can be caught up for years, so there is a mutual determination to make progress.”

The plan will also focus on improving Aboriginal and Torres Strait Islander mental health and suicide prevention, reducing stigma and discrimination, and better coordinating treatment and support programs.

The National Psychosocial Supports Program

The 2017-18 Budget allowed for the establishment of a National Psychosocial Supports Program that aims to provide flexible, targeted services to people with severe mental illness resulting in psychosocial disability who are not eligible for the National Disability Insurance Scheme (NDIS).

The Health Ministers agreed to establish a time-limited working group to progress a National Psychosocial Supports Program to reduce the community mental health service gap, improve mental health outcomes and reduce the inequity in service availability.

National Digital Health Strategy and Australian Digital Health Agency Forward Work Plan 2018–2022

The COAG Health Council gave the green light to the National Digital Health Strategy. Currently, 5 million Australians have a My Health record – this strategy aims, among other things, to expand this non-compulsory offer to all Australians by 2018.

Expanding the public reporting of patient safety and quality measures

Ministers agreed that the Australian Commission on Safety and Quality in Health Care (ACSQHC) would undertake work with other interested jurisdictions to identify options in relation to aligning public reporting standards of quality healthcare and patient safety across public and private hospitals nationally.

The Australian Institute of Health and Welfare last month highlighted the gaps in reporting, and in some areas, the lack of data altogether, saying: “There is no routinely available information on some aspects of quality, such as the continuity and responsiveness of hospital services.”

Health Ministers at the COAG meeting also considered the development of the next iteration of the Implementation Plan for the National Aboriginal and Torres Strait Islander Health Plan 2013–2023; agreed to explore a National Human Biomonitoring Program by undertaking a feasibility assessment; agreed to proceed to Strengthen penalties and prohibition orders under the Health Practitioner Regulation National Law; and sought clarification of roles, responsibilities and relationships for national bodies established under the National Health Reform Agreement.

MEREDITH HORNE

Publically funded contraception set for challenge by the Trump administration

With the politics in the United States still playing out on the Affordable Care Act, the White House has reportedly moved forward with a plan to cut a provision that was introduced to protect women’s reproductive rights.

The Affordable Care Act expanded contraception coverage to about 55 million women with private insurance coverage.

The Trump administration is expected to amend the Federal regulation that requires employers to provide health-insurance plans that offer preventive care and counselling – which the US Department of Health and Human Services has interpreted to include contraception – at no cost.

The expected Presidential executive order will allow any business or organisation to request an exemption on religious or moral grounds.

The Obama administration issued regulations allowing religious employers to opt out of offering contraceptive coverage. However affected employees were then covered directly by their insurers.

Gretchen Borchelt, Vice President for Reproductive Rights and Health at the National Women’s Law Center, has said that hundreds of thousands of women could lose access to their birth control “if this broad-based, appalling, and discriminatory rule is made final”.

Many family planning advocates are concerned that this policy shift will see a result to an increase in abortion rates across the US. Recent research by the Guttmacher Institute suggests that improved contraceptive use, resulting in fewer unintended pregnancies, likely played a larger role than new state abortion restrictions in the decline between 2011 and 2014.

The American Congress of Obstetricians and Gynaecologists has issued a statement that denounces any plan to roll back contraception coverage, saying that any move to decrease access to these services would have a damaging effect on public health.

“Contraception is an integral part of preventive care and a medical necessity for women during approximately 30 years of their lives.

“Since the Affordable Care Act increased access to contraceptives, our Nation has achieved a 30 year low in its unintended pregnancy rate, including among teens.

“Unintended pregnancies can have serious health consequences for women and lead to poor neonatal outcomes,” the statement reads.

MEREDITH HORNE

Attending the House of Delegates meeting of the American Medical Association

BY ANNE TRIMMER AMA SECRETARY GENERAL

The annual meeting of the House of Delegates (HOD) of the American Medical Association (AmMA) is the only event in which all of “organised medicine” in the United States physically comes together at the same time and place.

The program for the annual HOD meeting is immense. There is a mix of open sessions and committee sessions in the lead in the HOD meeting itself. Eight committees meet over the course of two days to work their way through a comprehensive agenda of reports and resolutions that amend existing policy or introduce new policy. The result of the committees’ work is then caucused by the participating representative societies and associations in preparation for debate on the floor of the HOD.

The HOD opens with a formal speech by the President (who completes a one-year term at the close of the HOD meeting) and another by the CEO. The meeting then opens to debate on the reports and resolutions that have come forward from the committees. This takes two days and can continue into a third day of the business isn’t completed.

As an international guest at this year’s meeting in June, I was invited to observe all proceedings and I made the most of the invitation by attending an open forum of the Council on Ethics and Judicial Affairs, two committee meetings, and the HOD meeting.

The conduct of the debate is democracy in action. The Speaker and Deputy Speaker control the debate with great deftness and humour. Speakers line up, as they do at the AMA National Conference, waiting to be recognised to speak.

There were several recurring issues that resonated. The first, and most pressing, was that of access to health care, even more so with legislation introduced by the Trump administration to wind back the Affordable Care Act (ObamaCare) which would have the result that 23 million Americans would lose cover. The legislation (the American Health Care Act or AHCA) is causing deep concern within the AmMA about the likely outcome.

Delegates debated the acceptability of per capita caps under federal Medicaid funding, which are a key element of the AHCA and are being considered for incorporation into the Senate version of the legislation that is still being drafted. The delegates rejected any proposal for caps on the basis that they would weaken States’ ability to respond to enrolment changes, greater care needs or breakthrough treatments.

The tactics of health insurers to deny cover for patients, or to create delays for physicians in trying to secure approval, were raised on many occasions. One of the more interesting debates focused on a resolution for AmMA to advocate for a public option to provide health cover where no insurance cover exists. This aspect of the original ObamaCare legislation was removed as a compromise to get the majority of the legislation through the Congress. AmMA voted to support the inclusion of a public option. The Australian health system was cited in debate as an exemplar of a system where there is public cover but also a right to choose private cover.

The networks established by the insurers are shrinking, often with the result that patients lose the physician they have had all of their lives. The provision of out of network care carries significant cost for patients who are not covered if they need care at a hospital that is not within their insurer’s network. This has an impact on emergency doctors who won’t turn patients away if they present at an out of network emergency department. At times the patient may not even be aware that they are out of network.

The resulting “surprise bills” come about either because the patient has presented out of network or because the cover they have is inadequate for the procedure that is undertaken. Delegates were critical of “outlier” medical colleagues who levied significant bills in these circumstances, attracting the ire of patients and media.

This has led to consideration in several States of a “fair minimum benefit”. However as States have been ratcheting down the benefits paid under Medicare, doctors are concerned that any benefit that is tied to Medicare will be inadequate for the service that is provided. Delegates discussed the potential for an independent database to be used as a reference point for charging (which sounds not dissimilar to the AMA Fees List).

Another example of egregious insurer behavior occurs in emergency departments where the insurer withdraws cover on the basis that the reason for presentation is not an emergency. To overcome this the patient is forced to seek pre-approval.

The issue of physician health was raised on several occasions. The concern is with burnout, exacerbated by the frustrations of dealing with the health insurers in seeking pre-approval for patients, and the electronic health record. Speakers referred to the extensive delays created by the system. Reference was also made to depression and suicide among doctors.

The open session of the Council on Ethics and Judicial Affairs provided a forum for the AmMA to obtain member feedback in the development of a new policy on euthanasia and physician assisted suicide. Among the speakers from the floor were physicians from the five States where it is already legal for doctors to prescribe end of life pharmaceuticals. In California, for example, physicians can choose to opt into the process with 18 per cent currently doing so. The legislation provides multiple safeguards.

Colorado is the most recent State to introduce euthanasia. The State medical society undertook a two year consultation before changing its policy to accommodate the change. In that State a patient must be able to self-administer the medication. However the cost of effective medication can be a barrier to a patient carrying out the euthanasia.

In the State of Oregon where euthanasia has been legal for 20 years, the State medical society has maintained a neutral position.

Notwithstanding that euthanasia is legal in some States, the debate emphasised the need for a better understanding of the role of palliative care and the place of hospice care. Patients at the end of life were often ignorant of the benefits of palliative care.

The address by the outgoing President of the AmMA, Dr Andrew Gurman, highlighted the big issues faced by the AmMA over the previous 12 months. These included the requirements of the health insurers for pre-authorisation of drugs and medical devices before they could be prescribed or utilised in surgery; gun control as a public health issue; the defeat of proposed health fund mergers which would have further reduced access to health care; and physician burnout.

Dr Gurman highlighted what he described as “advocacy at its most basic, human level” when he met with medical trainees who had grown up in the US but now feared deportation under proposed changes announced by the Trump administration.

The Executive Vice President and CEO, Dr James Madara, highlighted that the AmMA recently celebrated its 170^th birthday, having been established in 1847. He identified three strategic areas for current focus in the work of the AmMA:

Practice satisfaction and professional practice;
Medical education; and
Patients with pre-diabetes.

This last point relates to the fact that a staggering 83 per cent of health services in the US are for chronic conditions.

Unsurprisingly an opinion poll released while I was in the US has health as the number one issue for the electorate.

The AmMA’s work on medical education centres on online learning to provide tools and resources to physicians, including the recent release of an online education program on best use of electronic health records. This is part of a project entitled health 2047 (for the 200^th birthday of the establishment of the AmMA) which aims to return to the physician one hour per day of the working week. Many speakers identified that navigating the current EHR system currently consumes up to two days each working week.

The AmMA is also working to protect patients at risk of losing their health cover by expanding meaningful coverage and including safety nets.

Resident mental health is now mandated as part of every residency program.

The contributions from the medical students were among the most compelling. The medical student section put forward a motion calling on the AmMA to be a leader in advocacy on the social determinants of health. The National Academy of Medicine established a framework in 2016 to better understand the social determinants. As several delegates pointed out, without understanding the social context of a patient there may be impacts on the care that is given. Examples provided were a patient living in accommodation with no running water, or with no access to transport to attend a pharmacy to have a prescription filled.

Another significant public health issue that attracted debate is the opioid epidemic in the US which has arisen as a result of the over-prescribing of pain medication.

The organisation

The AmMA’s revenue in 2016 was $323.7 million with a profit of $13.6 million.

The House of Delegates is the supreme policy making body and elects the office-holders, including the President-elect who then becomes President the following year. It also elects the members of the Board of Trustees.

The Board of Trustees is the principal governing body and takes actions based on the policy and directives of the HOD. It exercises broad oversight and guidance with respect to management systems and risk through the oversight of the Executive Vice President (the CEO). It has 21 members who have fiduciary responsibility for the organization and select and evaluate the CEO. The members include a student, a resident, a young physician, and a public member.

The eight Councils are standing, domain based, expert bodies. They are:

Council on Constitution and Bylaws
Council on Ethical and Judicial Affairs
Council on Legislation
Council on Long Range Planning and Development
Council on Medical Education
Council on Medical Service
Council on Science and Public Health
American Medical Political Action Committee.

The Sections and Special Groups represent the constituent groups and provide a channel for outreach and member insights. They are as diverse as the Advisory Committee on LGBT Issues, the International Medical Graduates Section, the Medical Student Section, and the Organised Medical Staff Section.

The HOD draws representation from the State and territorial medical associations (260 delegates) and national medical specialty societies (205 delegates). It has 528 delegates and the same number of alternate delegates. With Past Presidents and observers there are approximately 1200 attendees at the HOD annual meeting.

The rules for participation of a national medical specialty society are complex and are based on the number of its members who are members of the AmMA at the rate of one delegate per 1,000 AmMA members with every eligible national medical specialty entitled to at least one delegate. Similarly every State/territory is entitled to at least one delegate.

In addition delegates represent Federal Services (Air Force, Army, Navy, Department of Veterans Affairs, and the US Public Health Service); AMA Sections; other national societies; and professional interest medical associations.

AmMA represents approximately 25 per cent of American physicians. However as the umbrella body representing the entire profession it is the voice in Washington DC that speaks for all physicians.

Each policy that is put before the HOD has a fiscal note on the likely cost of the proposal if adopted. This is a good discipline in either reducing or refining some resolutions.

Every policy is recorded in PolicyFinder which is an electronic database available online and updated after each meeting of the HOD.

As a final note, every resolution or policy that is put forward is framed as ‘our AMA’ undertaking the specified action. This engenders a sense of ownership and pride in the organisation’s advocacy.

Parliamentarians scrutinise health issues from around Australia

The Australian Senate is continuing its inquiry into the number of women in Australia who have had transvaginal mesh implants, having had to extend the date for submissions has been extended until 30 June 2017. The reporting date is 30 November 2017. The committee will examine the types and incidence of health the Committee plans to hold public hearings at locations around Australia.

The inquiry will scrutinise problems experienced by women who have had this surgery, and the impact this has had on their lives. The committee will also examine the information available to patients and doctors about this surgery; any incentives offered to medical practitioners in relation to the use of transvaginal mesh implants and the role of the Therapeutic Goods Administration’s role in regulating and monitoring the use of transvaginal mesh implants.

The Senate is also responding to the reported incidents in the Makk and McLeay Aged Mental Health Care Service at Oakden in South Australia, by examining the current aged care quality assessment and accreditation framework in the context of these incidents. The reporting date of this inquiry is 18 February 2018.

The House of Representatives is using the committee process to look into the use and Marketing of Electronic Cigarettes and Personal Vaporisers in Australia.

Committee chair Trent Zimmerman MP, said: “In recent years the use of e-cigarettes has grown rapidly and governments have taken very diverse approaches to dealing with their emergence.”

“Internationally e-cigarettes have been regulated either as consumer, tobacco, or medicine products and the Committee will be investigating these different international regulatory approaches,” Mr Zimmerman said.

A House of Representative Committee adopted an inquiry in March this year into how Australia’s federal family law system can better support and protect people affected by family violence. Hearings are currently being conducted around Australia and will hear evidence from those with personal experience at the intersection of family violence and the family law system, including Rosie Batty, 2015 Australian of the Year.

Committee chair Sarah Henderson MP said family violence was an issue which required a response from all sections of the community, and across all levels of government.

“We must ensure that the family law system provides adequate support and protection in cases where family violence has occurred,” Ms Henderson said.

“In carrying out the inquiry, the Committee will consider what has been done so far—and what more can be done—to meet the needs of vulnerable people in family law proceedings.”

Other parliamentary inquiries looking into special health issues include hearing health and wellbeing; delivery of outcomes under the National Disability Strategy 2010-2020 to build inclusive and accessible communities; and value and affordability of private health insurance and out-of-pocket medical costs.

The AMA advocates to the Australian Parliament on many issues and submissions can be found at: advocacy/

MEREDITH HORNE

Trump can’t get his way on health care

US President Donald Trump can’t seem to win a trick when it comes to replacing his predecessor’s universal healthcare system.

His promised repeal of Obamacare is dead in Congress for now after the Senate refused to cooperate with the President.

His own Republicans could not muster enough votes to kick out the healthcare system put in place by President Barack Obama.

They lost the on the floor by one vote – their own Senator John McCain casting his vote against them.

Republicans (and in particular President Trump) were hoping the Arizona Senator would be the saviour of the repeal bill, but instead he joined with two others GOP senators to vote no. If McCain had voted with his party, the repeal bill would have passed.

But his move killed it.

And according to reports coming out of Washington, Senate Republicans have no plans to revive attempts to repeal Obamacare.

Senator McCain is now being treated for an aggressive brain tumour, taking him out of action in the Senate.

But the 50th Senate vote Trump needs to pass his bill still seems out of reach.

The President’s frustration is evident in his continued erratic tweeting – calling his own GOP senators “fools” and “total quitters” if they totally abandon his healthcare plan.

But the Republicans appear unmoved, with a growing number openly saying it is time to move on.

“Until somebody shows us a way to get that elusive 50^th vote, I think it’s over,” South Dakota Senator John Thune is reported to have said.

“Maybe lightning will strike and something will come together but I’m not holding my breath.”

Senator Roy Blunt, a member of the GOP leadership team, has openly said the party should only revisit health care once it can “put some wins on the board” in other areas.

“Tax reform, infrastructure are the kinds of things we ought to be looking at,” he said.

The phrase “move on” is being increasingly bandied around by the Republicans.

But President Trump seems less inclined to give up on his major campaign promise.

The White House appears ready to take other moves to gut the existing healthcare laws.

Trump has used Twitter to suggest he might follow through on his threat to end subsidies to health insurers – effectively throwing the insurance market into chaos.

“If a new HealthCare Bill is not approved quickly, BAILOUTS for Insurance Companies and BAILOUTS for Members of Congress will end very soon!” he Tweeted on July 30.

Denying the cost-sharing subsidies has been under consideration for some time, and has been referred to as “Trump’s nuclear option” that could see insurers lose billions of dollars – potentially sending America’s whole healthcare system into further decline.

But as the Trump administration continues its frantic downward spiral, many around it are suggesting a “nuclear option” might the frustrated President’s way to address a number of controversial issues.

CHRIS JOHNSON

Speak into the microphone please doctor

Patients in the United Kingdom and United States are increasingly taking their smart phones out of their pockets, placing them on doctors’ desks and pressing record during medical consultations.

Even more are secretly recording their visits.

Laws vary according to national and State jurisdictions, but generally in those countries patients have the right to record clinical visits while doctors also have the right to terminate consultations if they don’t want them recorded.

According to a research paper recently published in the American Medical Association’s medical journal JAMA, the growing practice should not necessarily be a concern.

Some health clinics even offer patients recordings of their visits.

“Many clinicians and clinics have concerns about the ownership of recordings and the potential for these to be used as a basis for legal claims or complaints,” the authors noted.

“Administrators and patients are unclear about the law and are concerned that recording clinical encounters might be illegal, especially if done covertly. The law is inconsistent: recording is allowed in certain situations and is illegal in others.”

The research found, however, that for most patients wishing to record consultations, the motivation was reasonable.

“Patients want a recording to listen to again, improve their recall and understanding of medical information, and share the information with family members,” the report says.

“As healthcare continues to make significant strides toward transparency, the next step is to embrace the value of recording clinical encounters.

“The clinician can choose to continue, accepting that the conversation is being recorded, or terminate the visit.

“Using the recording to harm or damage the reputation of the clinician recorded could lead to legal action.”

A survey conducted among the general public in the UK found that 19 of 128 respondents (15 per cent) indicated they had secretly recorded a clinical visit, and 14 of 128 respondents (11 per cent) were aware of someone covertly recording a clinic visit.

A subsequent review identified 33 studies of how patients used recordings of their clinical visits. Across the studies, 72 per cent of patients listened to their recordings and 68 per cent shared them with caregivers.

Patients who recorded their consultations reported greater understanding and recall of medical information.

In parts of the US, clinicians as well as patients report benefits in having sessions recorded. Liability insurers in America even insist that the presence of a recording can protect doctors.

CHRIS JOHNSON

Maxigesic licensing expands to 124 countries

AFT Pharmaceuticals has added to its existing agreements in concluding an alliance with private European pharmaceutical company Amicus SA Switzerland.

The agreement is for licensing of the product line of its patented combination painkiller Maxigesic in three regions: the Baltics (Latvia, Estonia and Lithuania); Central Eastern Europe (Czech Republic, Hungary, Bulgaria, Romania and Slovakia); and most of the Balkans (Croatia, Slovenia, Serbia, Montenegro, Bosnia and Macedonia).

“We had previously disclosed our target to sell Maxigesic in 100 countries in our product disclosure statement,” said AFT chief executive officer Dr Hartley Atkinson.

“This agreement, together with other recent out-licensing agreements, means that Maxigesic is now licensed in 124 countries around the world. Getting these agreements in place shows that we are expanding on our planned pathway to deliver on our sales targets.”

Currently Maxigesic is sold in eight countries, including Australia and New Zealand. AFT has previously informed the market that it anticipates registration and product launches covering existing agreements will occur on a phased basis in these countries according to the following approximate schedule: around one-third in the 2018 financial year, around one-quarter in both the 2019 and 2020 financial years, and the balance in the 2021.

Maxigesic consists of a patented, fixed ratio of ibuprofen for anti-inflammation management and paracetamol (also called acetaminophen) for pain management. Maxigesic products covered by this new agreement will include tablet, sachet, oral liquid, fast-dissolve and dry powder sticks.

Amicus chief executive officer Jean-Michel Lespinasse commented that: “Amicus was honoured to be selected by AFT as its long-term licensing partner across a large central European territory. We are excited to be able to roll-out a novel pain reliever with both an efficacy and safety claim,”

In May, AFT Pharmaceuticals announced an agreement with a French pharmaceutical company to out-license the product line of Maxigesic to France, Monaco, Andorra and some French dependencies.

At that time, French labour laws prohibited AFT from disclosing the name of the French company. In compliance with French law, AFT can now inform the market that the agreement is with the French pharma company Laboratoires Expanscience headquartered in Courbevoie, France.

The New Zealand regulatory agency Medsafe, through its Medicines Classification Committee, is currently also considering a proposal to harmonise New Zealand regulation with Australia by up-scheduling codeine-based painkillers to prescription-only based on the risks of misuse and addition.

CHRIS JOHNSON

Ten tips for medical expert witnesses

Doctors can play an important role as medical expert witnesses in the decision process in Australian courts and tribunals. There’s a limited supply of them, however, which means they are much in demand.

Medical expert witnesses are used in three main types of legal encounter. Firstly, in civil cases where the expert is required to give evidence as to whether another doctor acted in accordance with the accepted standard of care; secondly, in cases where another doctor faces disciplinary action; and lastly in coronial inquests where a medical expert witness is asked to help determine the cause of death and any role a person or institution may have played in it.

It’s important to understand the onus of proof in courts, which can vary considerably from what would be considered scientific proof in the medical world. In civil cases, legal proof is based on the balance of probabilities, while in criminal courts proof must be beyond reasonable doubt.

Expert medical witnesses have important duties in the legal system and it is not up to them to decide whether a doctor or other defendant is “guilty”.

Most states and territories have codes of conduct for expert medical witnesses which is important to read before you write your initial report.

Here are a few tips for doctors who have been offered or are thinking about a role as a medical expert witness:

The role can be time-consuming and it may not be feasible to be doing it in your “spare time”;
Be fully prepared and have your opinion formed before you are called upon to testify;
Develop a clear reasoning for your opinion, but do not hypothesise about what may or may not have happened in any case;
If you have any concerns about your opinion, go through them with the lawyer who engaged you before writing your report;
If something is unclear, you may decide you need to give two different opinions based on two different possible scenarios;
Don’t contradict in court what you have already written in your report;
Be aware of outcome and hindsight biases. These involve judging a decision on the basis of outcomes rather than what led up to the decision in the one case; and in the other, it involves predicting the probability of an adverse event retrospectively;
Be clear on levels of evidence and recognise the differences between a directive, a policy, a standard, a guideline and a position statement;
Don’t fall into the trap of being an advocate for the lawyer who hired you;
Be aware that expert medical witnesses can face disciplinary action for evidence given in court which is seriously flawed.

Source: Avant

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