Public Hospital Doctors gearing up for a productive meeting

DR ROD McRAE, CHAIR, AMA COUNCIL OF PUBLIC HOSPITAL DOCTORS

As part of our busy schedule, the Council of Public Hospital Doctors will be meeting on 20 April. As always, there are many issues to discuss and we can’t cover them all, but a couple of the more topical ones we’ll be looking at are:

Private patients in public hospitals

Whilst private health insurance is a topic unto itself, patients can be lawfully treated privately in a public hospital by a doctor who has private practice privileges as a workplace employment condition. They may be admitted through the ED, referred from a GP’s or a specialist’s rooms, or be eligible for third party payments.

In March, the Independent Hospital Pricing Authority released its report: Private Patient Public Hospital Service Utilisation.

Key findings of the report include:

the number of separations in public hospitals funded by private health insurance has almost doubled from 451,591 in 2008–09 to 814,702 in 2014–15 (i.e. an average increase of 10.3 per cent per annum);

there is considerable variation in the proportion of public hospital separations funded by private health insurance between jurisdictions from 2007–08 to 2014–15 with QLD (an 8.1 per cent increase) and TAS (a 5.1 per cent increase) experiencing larger growth; and

a number of practices have developed encouraging patients in public hospitals “to elect” to use their private health insurance if it happens they possess it, including job descriptions for private patient liaison officers, and websites promoting the savings to the public hospital from patients electing to be treated as private patients.

The report concludes that there is sufficient evidence that the national Activity Based Funding model has not been a significant driver in the upward trend in privately funded public hospital separations.

It’s an interesting trend and we’ll be looking at this issue with a view to developing a position on it, as it now appears such patient elections are a major revenue line for all public hospitals.

Public/Private Partnerships in Hospitals

This is another growing issue, with a chequered history and many implications for public hospital doctors.

Public-private partnerships are gaining some traction in Australia, with recent developments such as Sydney’s new Northern Beaches Hospital developed under such arrangements.

Public/private partnerships can have a variety of forms, including:

a private company takes responsibility for both building a hospital and providing maintenance on the building for a 20 – 50 year period. The jurisdictional government saves paying the full capital costs up front and it reduces the immediate debt burden on the State’s balance sheet; and

private-sector management takes responsibility for all aspects of service provision in the hospital, including clinical care.

The stated benefit is usually that private management will more thoroughly drive efficiency because of the desire to generate its profits.

A main issue for both the AMA and ASMOF is that of identifying the employer, which has profound industrial implications, including accountability of government as an employer, the award under which staff will work, and the transferability of entitlements from previous State Government employment.

Public-private partnerships are typically long-term, with complex contractual arrangements setting out the responsibilities of the parties. They have regularly attracted criticism from Auditors General in several States. Some have been returned to public control, code for being a failure.

Facts we know are that this is a growing phenomenon, and it doesn’t always work. We will be taking a careful look at both the industrial implications but also the clinical care implications, of these partnerships and discussing how they have affected, and are likely to affect, public hospital doctors all around the country.

I look forward to engaging with as many public hospital doctors as possible on these and other important issues as they arise. I also look forward to seeing as many of you as possible at National Conference in Melbourne in May.

Health COAG meets

The Federal and State and Territory Health Ministers met in Melbourne recently at the Council of Australian Governments (COAG) Health Council to discuss a range of national health issues.

The meeting was chaired by the Victorian Health Minister Jill Hennessy and welcomed New Zealand Health Minister Dr Jonathan Coleman as a participant.

The Ministers considered a draft of the Health Practitioner Regulation National Law Amendment Bill 2017.

Once enacted, the Bill will make a number of important reforms to the operation of the National Registration and Accreditation Scheme and the powers of National Boards and the Australian Health Practitioner Regulation Agency. The Bill responds to recommendations arising from the Independent Review of the National Scheme undertaken in 2014–15.

All Health Ministers also endorsed a revitalised agenda to streamline the conduct of clinical trials in Australia. Clinical trials are an important driver in improving health outcomes through access to new drugs, devices and treatment.

Under this directive, all Governments have agreed to redesign trial operating systems around central coordinating units that will make it easier to conduct and participate in safe, high quality clinical trials. The Commonwealth has committed funding of $7 million over four years to support jurisdictional clinical trial reform.

The Ministers noted that timely negotiation of expiring National Partnership Agreements (NPA) was important for each jurisdictions’ planning and delivery of services. They agreed to continue a cooperative dialogue to progress discussions about a range of expiring funding arrangements to ensure current care and timely preventative services can continue to be delivered to the community.

Medical research at Commonwealth and State levels; re-exposure prophylaxis for the prevention of HIV; meningococcal W; ear disease and hearing loss in Aboriginal and Torres Strait Islander children; digital health, childhood obesity, the implementation of the Health Care Homes program; end of life care; and the medicinal cannabis were all also discussed at the Health COAG.

In addition, the Ministers agreed that the Fifth National Mental Health Plan will re-emphasise its objective of suicide prevention and will therefore become the Fifth National Mental Health and Suicide Prevention Plan.

They also agreed to a national opt-out model for long-term participation arrangements in the My Health Record system.

Chris Johnson

World first “brain training” could help smokers quit for good

Simple computer-based exercises which train smokers’ brains to improve their impulse control are being trialled at Deakin University’s School of Psychology.

It’s hoped the world-first Inhibitory Smoking Training (INST) program could help smokers give up for good.

Lead researcher, Associate Professor Petra Staiger, said tobacco remained the leading preventable cause of illness and death worldwide, killing approximately six million people every year.

“Despite the wide range of treatments designed to help people quit smoking, the vast majority relapse within six months,” Associate Professor Staiger said.

Deakin University cognitive neurosciences expert Dr Melissa Hayden, who is also on the INST team, says research suggests difficulties overcoming addiction may be partly due to an impaired ability to control automatic impulses.

“Recent advances in neuroscience have highlighted that one way to address this difficulty is by retraining people’s brains to improve their impulse control,” Dr Hayden said.

The INST trial is a collaboration with Dr Natalia Lawrence in the UK where the training technique has already enjoyed success helping people decrease the amount of unhealthy food they eat, leading to long-term (six months) weight loss.

The training has also helped people significantly reduce their alcohol consumption and Associate Professor Staiger said the method could have significant benefits over other quit programs.

“For a start, it’s cost effective. Australians have highlighted that the financial costs associated with smoking are the number one reason they want to quit,” she said.

“That means there’s a need for smoking treatments to not only be effective, but also cost-effective if they are going to facilitate quitting for good.

“If it works, this computer brain training task has the potential to reduce the global prevalence of smoking at no cost to the consumer.”

Associate Professor Staiger said the program was also time-efficient, taking only “10 to 15 minutes per day for two weeks”.

“Plus with brain training there are no negative side-effects. Quitting aids like patches or gum can sometimes have adverse side-effects which negatively impact their uptake and long-term adherence, but there are none of those issues here.”

Researchers with the INST team are still looking for participants to take part in the world-first trial.

“We’re looking for smokers who wish to quit, aged between 18 and 60, living in the Melbourne metropolitan area and who smoke at least 10 cigarettes daily on average,” Associate Professor Staiger said.

“It’s a very simple program and you’ll only need access to a computer and internet for a two-week period.”

To find out more about the trial, contact the INST team at: inst@deakin.edu.au

Odette Visser

Trump can’t get rid of Obamacare

United States President Donald Trump has suffered a humiliating defeat, with his failure to eradicate his predecessor’s health laws.

Before even a single vote could be cast to repeal President Barak Obama’s Affordable Care Act, otherwise known as Obamacare, Republican House Speaker Paul Ryan pulled the Bill.

There was not enough support in Congress for the repeal Bill to get up.

“We were very close,” President Trump said in the Oval Office after the Bill was pulled. “It was a very, very tight margin.”

But in reality, the decision to delay the vote (probably indefinitely) his highly embarrassing for Mr Trump, who made trashing Obamacare a key policy platform of his campaign.

He has blamed his Bill’s failure on the Democrats, saying: “We had no Democratic support.” But there was not even enough support from within his own party.

The President’s credibility and authority are now severely dented, but so too is that of Speaker Ryan, who was defied by his own conference and had to pull the Bill in order to avert a crushing defeat.

Mr Ryan has indicated that the Bill might never resurface.

“We came up short,” he told reporters. “We are going to be living with Obamacare for the foreseeable future.”

However, the President subsequently tweeted: “Obamacare will explode and we will all get together and piece together a great health care plan for THE PEOPLE. Do not worry!”

House Minority Leader Nancy Pelosi, who was herself the Speaker who helped President Obama pass the Affordable Care Act, described the Republicans’ defeat as “great day for our country” and a “victory for the American people”.

“Let’s just for a moment breathe a sigh of relief for the American people,” she said.

Senate Minority Leader Chuck Schumer was even more forthright in his criticism of the President.

“In my life, I have never seen an administration as incompetent as the one occupying the White House today,” he said.

“Today we’ve learned they can’t count votes and they can’t close a deal. So much for the art of the deal.”

The American Medical Association has also opposed the House Republicans’ plan to replace the federal health care law enacted by the Obama administration.

Chris Johnson

[Editorial] What has Europe ever done for health?

March 25, 2017, marks the 60th anniversary of the signing of the Treaties of Rome—two treaties that gave birth to the European Economic Community (EEC) and to the European Atomic Energy Community (EURATOM). The treaty establishing the EEC affirmed in its preamble that signatory states were “determined to lay the foundations of an ever closer union among the peoples of Europe”. Security, solidarity, and freedom are protected in the Charter of Fundamental Rights of the European Union (EU). The 1992 Maastricht Treaty placed the health mandate of the EU centre stage and although delivery of health care remains a national competence, EU law governs many areas, such as medicines regulation.

[Editorial] Syria suffers as the world watches

March 1 5, 2017, marks the sixth anniversary of the civil war in Syria, a conflict perhaps unprecedented in its apparently shameless disregard for international law. The world has stood by in horror, watching the death toll rise and the humanitarian and refugee crises spread their indelible stain on the world map and human history. The Syrian conflict has been marked on the one hand by immense suffering and on the other by a stunning lack of adequate condemnation or action from governments, international agencies, or the medical community.

Treat addiction as health issue, not crime – experts

Australian governments are continuing to ignore the recommendations of the Ice Taskforce to treat ice addiction as a health and social issue, rather than a criminal justice problem, two prominent drug law reform advocates say.

Dr Matthew Frei, the clinical director of Turning Point, and Dr Alex Wodak from St Vincent’s Hospital’s Alcohol and Drug Service, say that the prevailing theme of the Ice Taskforce report was an emphasis on drug treatment over law enforcement, but governments had failed to act.

“Governments continue to define the issue as primarily a criminal justice problem, use pejorative terms when referring to people who use drugs, and generously support law enforcement measures while parsimoniously funding health and social interventions,” they wrote in the Medical Journal of Australia.

“Australian Commonwealth, State and Territory governments allocated about two-thirds of drug spending to law enforcement and only 9 per cent for prevention, 21 per cent for drug treatment, and 2 per cent to harm reduction over the 2009-10 financial year.

“After decades of this approach, Australia’s illicit drug market is expanding. Not only are illicit drugs easy to obtain, but prices have fallen and many newly identified psychoactive drugs have appeared, often more dangerous than older drugs.

“Over recent decades, drug-related deaths, disease, crime, corruption and violence appear to have increased.

“Vast sums spent on criminal justice measures have only succeeded in making a bad problem much worse.”

Ice, or crystalline methylamphetamine, now dominates the market, compared with less potent powder forms of the drug.

“While the Ice Taskforce acknowledgment of the role of treatment is positive, it follows years of parsimonious funding for drug treatment that has left Australia with an inflexible, poor quality system with limited capacity,” Dr Frei and Dr Wodak wrote.

“This would not be considered acceptable anywhere else in the health sector.”

However, there were some promising signs.

“An encouraging aspect of the Taskforce recommendations was the provision of Medicare item numbers for the relatively new discipline of addiction medicine,” they said.

“This was implemented in November 2016, ending many years of struggle for this important specialty.

“[This] will help addiction medicine recruit new trainees, and build a specialist alcohol and other drug sector.”

Maria Hawthorne

AMA, Govt hold talks on ‘more balanced’ approach to pathology rents

AMA President Dr Michael Gannon met with Health Minister Sussan Ley in Canberra on 24 November to discuss the Government’s proposal to change the definition of market value for pathology collection centre leases.

Dr Gannon told the Minister that the AMA was prepared to work with the Government to try and come up with a more balanced policy approach that genuinely targeted inappropriate rental arrangements and did not interfere with legitimate commercial arrangements.

The AMA President also highlighted that the Government’s proposed changes had significant implications for existing leases that had been entered into freely, and on the basis of which financial commitments have been made by practices.

The discussion followed a meeting of the AMA Federal Council which reiterated its support for prohibited practices laws, but recommended significant changes to the Government’s election policy.

The Federal Council stressed the need for a more a targeted approach that focused on inducements to refer, consistent with the original intent of the prohibited practices laws, and that pathology referrals should be solely based on the quality of services, as opposed to commercial relationships.

Federal Council resolved to support the right of medical practices to negotiate collection centre leases freely with pathology providers, provided rents were not linked to a stream of referrals and that any new definition of market value must not adversely affect those medical practices that were acting ethically when entering into leasing arrangements.

The Council stated that reasonable transition arrangements would need to accompany any changes, and the Government would need to develop an appropriate educational strategy to ensure requesters and providers were aware of their obligations under existing prohibited practices laws and ensure that these and any future laws were properly administered and enforced.

Responding to allegations of sham leasing arrangements, Federal Council agreed that the Government needed to work with stakeholders to establish whether these could be sustained and, if so, develop measures to address them with urgency.

The AMA Federal Council also expressed its disappointment in successive Federal Governments for their failure to adequately fund patient access to medical care, including the prolonged freeze on Medicare rebate indexation, which increasingly threatened the viability of pathology, general practice and other specialist services.

During his meeting with the Minister, Dr Gannon welcomed her advice that the Government would not proceed with its planned 1 January 2017 commencement date, and the Minister’s commitment to allowing more time for consultation with general practice and pathology practice over the definition of market value and what transition arrangements might be needed. In this regard, the Minister stated that the Department of Health would be expected to work closely with the AMA as it developed further advice to Government.

AMA policy on euthanasia and physician assisted suicide – an update

The issue of euthanasia remains very much to the fore in current media, and attempts to introduce euthanasia laws continue in several states.

In South Australia, a new voluntary euthanasia Bill is currently being considered by Parliament and will be voted on as soon as this month. Pro-euthanasia MPs in Tasmania and Western Australia have indicated they will introduce legislation in the near future. The Victorian Government is due to respond by year’s end to a report on the Inquiry into End of Life Choices in Australia, which recommends the development of a legislative framework for assisted dying.

In the midst of this, the AMA’s review of its own policy on euthanasia and physician assisted suicide continues to progress. The Federal Council held a special policy session on the issue at its meeting in August, where it considered information gained from a very wide-ranging and deliberate process of member consultation, including:

the results of an AMA member survey on euthanasia and physician assisted suicide;
issues raised through this year’s AMA National Conference Q&A session on assisted dying;
member responses to the current AMA policy (undertaken last year through Australian Medicine); and
relevant background information on euthanasia and physician assisted suicide, including national and international legislative initiatives and professional and community attitudes.

At its August meeting, Federal Council recognised the diversity of member views on euthanasia and physician assisted suicide and agreed that there was a need to consult further with State and Territory AMA offices on whether the AMA’s current policy opposing doctor involvement in euthanasia and/or physician assisted suicide should be amended.

There were, however, several issues highlighted at the meeting over which there was no dispute:

access to adequate palliative care and end of life care remains inadequate throughout the country;
regardless of the final policy position, there must be appropriate funding of palliative care and greater clarity regarding legislative protections for doctors providing good end of life care for their patients; and
irrespective of whether or not euthanasia and/or physician assisted suicide become legal in Australia, it is imperative that the medical profession articulates the message that end of life care is a central responsibility of doctors, and that we will always care for patients and the broader community.

The members of Federal Council are acutely aware that this issue is sensitive and controversial, and that any decision will have potential political ramifications and consequences for health care. It is an issue on which some members have very strong views, many of which have been expressed as heart-felt and compelling arguments during the current consultation process.

However, because this is a debate about something that is very much at the core of what it is to be a doctor – that is, whether doctors should be involved in actions with a specific intention to end life – there are times when those with opposing views maybe forget the need to genuinely listen to each other. This is unfortunate when it occurs, because what has become very clear during the consultation process is that all members, whatever their views, have shown a deep dedication to the care of their patients and the welfare of the community as a whole.

So, the Federal Council’s mission is to be respectful of the views of all members, and to be understanding of the passion of those with opposing views, while seeking to find a position which is sensible and justifiable, but also reflects the unbreakable responsibility of doctors to always care for their patients.

Federal Council will continue its deliberations on a euthanasia and physician assisted suicide policy position at its upcoming meeting in November. We will keep members informed of the progress of this issue.

Govt’s dodgy deal with big pathology ‘not the answer’: Gannon

AMA President Dr Michael Gannon has told pathologists that capping pathology collection centre rents is “simply not the answer” to the challenge the sector faces from almost 20 years of frozen Medicare rebates.

In a message to AMA pathologist members, Dr Gannon said the surprise deal struck between the Federal Government and Pathology Australia during the Federal election to impose a rent ceiling was a “poorly targeted” policy that would deliver a massive windfall for the big pathology companies at the expense of medical practices, and did nothing for individual pathologists.

“The Government’s proposal goes too far, interfering with legitimate commercial arrangements that have been entered into by willing parties,” he said. “It will unfairly damage medical practices that have made business decisions based on projected rental streams, including investment in infrastructure and staffing.”

The AMA President said there was no guarantee from Pathology Australia, whose biggest member is Sonic Healthcare (which holds 43 per cent of the market), that any money pathology companies saved by cutting their collection centre rents would be re-invested in pathology services or the pathology workforce.

Instead, the rents deal controversy was overshadowing important issues such as the impact of the near 20-year rebate freeze for pathology services and the need for a much more sustainable funding base, he said.

In striking his deal with Pathology Australia, Prime Minister Malcolm Turnbull blindsided groups including the AMA and the Royal College of Pathologists of Australasia, who had been involved in discussions with the Government earlier this year on ways to improve transparency and strengthen compliance within the existing regulatory framework governing pathology collection centre (ACC) rents.

ACC rents have risen strongly since their deregulation in 2010, and there have been fears of a nexus between leases and the number of pathology tests a practice orders.

But the Health Department has reported in several different forums that it has not detected any such link, and told a roundtable meeting of stakeholders attended by the AMA on 27 April that it had found no evidence that rents were substantially above market value.

Instead, rents are being driven higher by intense competition for market share. Consolidation in the industry has intensified since deregulation, and the two big pathology companies, Sonic and Primary Health Care, between them now hold about 77 per cent of the market – a 12 per cent increase in five years.

Instead of addressing issues around the structure of the industry and how that was affecting competition and rents, Dr Gannon said the Government’s unilateral move to cap rents was simply a “knee jerk reaction” to head-off a politically damaging campaign.

The Government struck the deal in the early days of the Federal election in order to get Pathology Australia to drop its threat to axe the bulk billing of pathology services following the abolition of the pathology bulk billing incentive.

The terms of the agreement were laid out in a Senate Estimates hearing last month by Health Department Deputy Secretary Andrew Stuart, who said the “nature of the deal between the Government and Pathology Australia is to work to bring rents down to a more reasonable level and, at the same time or in some relationship to that, to continue with the Government’s proposal to remove the bulk billing incentive”.

Government Minister Senator Fiona Nash told the Estimates hearing the Coalition had received assurances from the pathology industry that “it is going to keep the bulk billing levels at its rates [and] we are taking it in good faith that that is exactly what they meant, and we expect they will do that”.

Dr Gannon said that in rushing to strike its deal with Pathology Australia, the Government had failed to take into account the consequences for GPs.

The Government’s plan went well beyond the intent of existing laws and gave pathology providers an unfair advantage in commercial negotiations with medical practices, he warned.

His concerns were borne out by the testimony of Mr Stuart, who admitted that the Department had not modelled the likely effect of the pathology rents cap on general practices, particularly when combined with the Medicare rebate freeze.

The senior health official, who made pointed reference to the fact the deal was “a Government negotiation, not a departmental negotiation”, said details of the arrangement, especially regarding its implementation, were still being finalised.

Significantly, the deal leaves the contentious issue of what should be defined as ‘market value’ unresolved – something admitted by Health Department First Assistant Secretary Maria Jolly in her testimony to the Senate committee.

She said how the new arrangement would be introduced was also yet to be determined, including how existing leases would be treated, and how the new deal would relate to the current regime governing prohibited practices.

Adrian Rollins