Private health insurance – its role in the Australian health system

Women with private health cover are overwhelmingly choosing to use the public health system for their second baby, Medibank Private chief medical officer Linda Swan told delegates at the AMA National Conference.

In a policy session on the role of private health insurance in the Australian health care system, Dr Swan said expenditure and claims were exceeding patients’ willingness to use their private cover.

“People are very clearly telling us that affordability is their No.1 issue,” Dr Swan said.

Rising health care costs could not continue unless Governments and consumers were willing to pay more, or the expense of care could be reduced, she said.

Earlier that day, News Corp national health reporter Sue Dunlevy told the conference that she had been “forced” by the Government to take out private health insurance but was “determined not to use it” because of excessive out-of-pocket expenses.

“There’s something crooked at the heart of the private health insurance industry in this country,” Ms Dunlevy said.

But Professor John Horvath, the strategic medical advisor at Ramsay Health Care, had a more positive view of the future.

“Australia has an excellent health care system producing world-leading outcomes for patients,” Professor Horvath said.

“Australia spends around 9 per cent of GDP on health care, of which 30 per cent is from private sources. This is lower than the OECD average, yet our life expectancy and outcomes are among the highest in the OECD.”

Professor Horvath said the ongoing increase in demand for health care, and rising costs, meant payers – including governments – and consumers would continue to push for more value from their health care spend.

He said benchmarked performance reporting and clinician engagement, not “stick” approached like financial penalties, would drive real improvements in quality, while digital technology would improve patient outcomes and enable hospitals to extend their care beyond hospital walls.

“This is all good news for patients,” he said.

Ramsay has begun measuring and benchmarking with the International Consortium on Health Outcomes Measurement (ICHOM) to allow global comparison of specific medical conditions.

It is measuring outcomes in six specific areas:

Low back pain,
Hip and knee osteoarthritis,
Cataract surgery,
Coronary artery disease,
Depression and anxiety, and
Prostate cancer.

The measurements will take in readmission rates, returns to theatre, infection rates, falls, hand hygiene, pressure injuries, medication safety, and patient experience.

Ramsay is also adding new measures including quality of life following treatment, survival, and disease control.

It is also about to commence a trial of the Vanderbilt Program, to assess its effectiveness in managing poorly behaved Visiting Medical Officers who undermine a culture of safety and quality.

The Vanderbilt Program looks at behaviours such as not following a surgical checklist, not washing hands, and bullying of staff – all of which can lead to consequences such as surgical complications, high rates of infections or errors, lawsuits, and loss of staff.

The program is based on the principal of having a conversation with a physician around their behaviour and building up to authority conversations with clearly defined consequences.

Opinions from the floor were mixed. Some doctors said that the combination of more complex patients, procedures and medications would inevitably lead to higher expenditures.

Others said that in most industries, new technologies drive costs down, but in health care they increase costs.

Maria Hawthorne

Medibank actions ‘unconscionable’: ACCC

The consumer watchdog is taking the nation’s largest health insurer to court alleging it engaged in misleading and unconscionable conduct after it reduced benefits without informing policyholders.

In damning accusations that reflect widespread public discontent over the conduct of private health funds, the Australian Competition and Consumer Commission has launched legal action against Medibank Private claiming it deliberately withheld information about a cut in benefits for in-hospital radiology and pathology services to make money and avoid hurting its image ahead of its public float.

“We think these are very serious allegations, and we think the behaviour we’re alleging should change right across the industry,” ACCC Chairman Rod Sims told The Australian.

In a strongly-worded statement, the ACCC claimed Medibank made a calculated decision to keep communications about the change “contained and reactive” for fear that if it was disclosed members might leave the fund, and the bad publicity could damage its reputation and “have a negative impact on its planned initial public offering of securities”.

The issue arose when, in September 2014, Medibank terminated and phased out agreements with pathology and radiology providers to pay the gap for in-hospital services. As a result, the ACCC said, policyholders were left with average out-of-pocket expenses of $151 for pathology services, and $83 for radiology services.

The ACCC alleges Medibank failed to give members with advance notice of the changes despite previously committing to do so, and that representations it made that members would not face out-of-pocket expenses for in-hospital pathology and pathology services were, from 1 September 2014, false and misleading.

“Consumers are entitled to expect that they will be informed in advance of important changes to their private health insurance cover, as these changes can have significant financial consequences at a time when consumers may be vulnerable,” Mr Sims said. “Private health insurers must ensure their disclosure practices comply with the Australian Consumer Law.”

Medibank has rejected the ACCC’s allegations.

“Medibank take sits obligations under the Australian Consumer Law seriously, and has appropriate processes in place to ensure compliance,” a spokesman for the health fund said. “We have been working cooperatively with the ACCC throughout its investigation.”

AMA President Dr Michael Gannon welcomed the ACCC’s action.

Dr Gannon said the AMA has long been highly critical of the actions of insurers making changes to their health cover without informing policy holders, and it was pleasing to see that at least one was now being held to account.

“It has become a distressingly common experience for patients to think they are covered for the cost of medical treatment, only to find that they are lumbered with unexpected out-of-pocket costs,” Dr Gannon said.

“It is completely unacceptable for insurers to make changes to the cover they provide without informing policyholders, and it is very important that this type of behaviour is now being called out.”

The ACCC’s action follows the release earlier this year of the AMA Private Health Insurance Report Card, which showed that many policies offered by health insurers were no better than junk, while others did not provide the cover expected.

The AMA’s analysis of the 40,000 policies offered by the nation’s 33 private health funds has found that Medibank Private, NIB, HCF, HBF, which together account for more than 55 per cent of the health insurance market, are marketing products that, because of multiple exclusions, provide barely more cover than Medicare or, in many instances, provide no additional entitlement at all.

The ACCC last year launched a report highly critical of the quality and accuracy of information provided by the health funds, which the watchdog said served to confuse consumers about what they were covered for and hampered their ability to make informed choices.

Health Minister Sussan Ley has commissioned a review of the private health insurance industry amid widespread discontent about rising premiums and shrinking cover, and the Coalition has promised that if it is re-elected it will institute a rating system for health cover and “weed out” junk policies by mandating a minimum level of cover.

Dr Gannon said it was time insurers were held accountable for their actions, which often caused great financial and emotional distress for patients caught unaware by surprise out-of-pocket expenses.

“Policyholders need to know exactly what they are covered for and are entitled to, rather than being hit with shock bills when they are ill or at their most vulnerable,” he said.

The AMA Private Health Insurance Report Card 2016 is at ama-private-health-insurance-report-card-2016

Adrian Rollins

[Correspondence] Breastfeeding in the 21st century

The breastfeeding Series papers by Cesar Victora and colleagues1 and Nigel Rollins and colleagues2 are a notable contribution to the maternal and child nutrition field. Both papers comment that the World Health Assembly’s target aiming to increase the rate of exclusive breastfeeding globally in the first 6 months up to 50% by 2025 is achievable, if not unambitious.3 However, the flaws of the target indicator itself were not addressed.

[Perspectives] Utopia, health, and happiness

The anniversaries keep on coming—the death of William Shakespeare this year, Martin Luther’s Theses next, the defeat of Napoleon last year. One that might get lost in the crowd is the first publication of Utopia. It was in Leuven in Belgium, in 1516, that an ambitious lawyer called Thomas More published a little book, at once playful and provocative, that outlined the society and culture of an imaginary people called the Utopians.

[Correspondence] Stillbirth in China

The global stillbirth rate is estimated to be 18·4%. A goal of reaching a rate of 12% by 2030 has been proposed by Joy Lawn and colleagues1 in the Lancet Series Ending preventable stillbirths. The stillbirth rate in China has reduced by 4–6% in the past 15 years (2000–15). However, the number of stillbirths in China in 2015 remains high and ranked in the top fifth of the world.1,2 The mean stillbirth rate analysed from six tertiary hospitals in our network3 is even higher than the global rate and has increased from 26·29% in 2010 to 41·90% in 2015 (table).

Hospitals, doctors in gun sights

The AMA has joined international calls for combatants to respect the neutrality of health workers and medical facilities amid widespread outrage at an attack on a Syrian hospital that has reportedly left at least 55 dead and 60 injured.

AMA Vice President Dr Stephen Parnis said it was “unacceptable” that health professionals and facilities were being targeted in armed conflicts in many parts of the world, most recently in Syria.

“It is unacceptable that health personnel and facilities are ever regarded as legitimate targets,” Dr Parnis said. “It is the duty of the international health community to speak out and protect the non-discriminatory provision of health care to all those in need.”

The AMA Vice President was commenting following a recent spate of deadly attacks on hospitals and clinics in strife-torn parts of the world, including Syria and Afghanistan, in which hundreds of patients, doctors, nurses and other health workers have been killed and injured.

In one of the most recent incidents, Syrian Government forces were blamed for killing at least 55 people and injuring 60 late last month after launching an air strike on the al-Quds Hospital in Aleppo.

Several doctors and nurses were among those killed in the attack on the hospital, including one of the city’s few remaining paediatricians, Dr Mohammed Wassim Maaz.

A spokeswoman for Medicins Sans Frontieres (MSF) which, along with the International Committee of the Red Cross (ICRC), has been supporting the hospital, told The Guardian that 95 per cent of doctors from opposition-held parts of Aleppo had fled or been killed, leaving fewer than 80 doctors to care for around 250,000 still living in the war-torn city.

The al-Quds Hospital is the latest in a string of attacks on medical facilities. According to media reports at least seven MSF-supported hospitals and clinics have been bombed since the beginning of the year, and the US Government has punished 16 military officers over a deadly airstrike on a MSF hospital in the Afghan city of Kunduz last year in which 42 people, including 13 doctors, nurses and other health workers, were killed.

In a report on the incident released late last month, the Pentagon blamed a chain of human errors and failures of procedures and equipment for the attack, but rejected accusations from MSF that it amounted to a war crime.

MSF is furious that the hospital was bombed despite the fact all combatants had been notified of its location, and that the attack continued despite repeated calls from the medical charity to the US military alerting it to the fact it was bombing a medical facility.

The military personnel involved, including a general, will not face criminal charges and will instead receive a range of “administrative actions” including suspension, letters of reprimand and removal from command.

The ICRC, the World Health Organisation and the World Medical Association have in recent years been sounding increasingly loud warnings about the incidence of attacks on health workers and medical facilities.

Late last year they issued a joint call for 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 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 2014.

Disturbingly, while many incidents involved health workers and facilities caught in cross-fire or being hit in indiscriminate attacks, the ICRC has also identified numerous incidents where they have been deliberately targeted.

Governments attending the 32^nd International Conference of the Red Cross and Red Crescent last December reaffirmed 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, and the ICRC is also working with non-state combatant groups to raise awareness of laws and conventions around the protection of patients, health workers and medical facilities.

Adrian Rollins

Rural internet as useful as a blunt chainsaw

As a long time rural internet user, I was shocked when going online in Hong Kong last December.

No time was wasted watching an arrow endlessly circling, nor were there long pauses where one is forced to consider taking up smoking or knitting to pass the time while switching between screens. Just click, and the next screen is there faster than one can blink.

The internet is a big part of our lives, and essential to our provision of health care. It enables us to learn from the most current resources, explore treatment options, watch demonstrations of procedures and attend live discussions with experts. It permits our patients to receive specialist care online, and is the backbone for the My Health Record.

Soon, it will lessen the burden of obtaining authority prescription – online authorisation is around the corner after much AMA lobbying to minimise the time currently wasted.

While I never expect those of us outside the big cities to be provided with a service matching speeds provided to inner city residents, we should at least get a half decent service and costs per gigabyte similar to city users – not 20 times more expensive, as recently outlined in The Land.

I have a mate who gets up at 2am to post his online billing to NSW Health. Their system is one from the Dark Ages, designed to save their accounting department time and money with no realisation that with tortoise speed rural internet it is a pain in the derrière for all those using it.

Assumptions are made that we have oodles of time to waste in rural Australia, when the reverse is true.

We want to spend more time on fun and families, not online with clunky unfriendly software battling to overcome a very slow internet system.

Having to get up at 2am to get a speedy connection is just cruelty.

So we have a double whammy – poor internet speeds that waste our time, and higher costs per GB for the lousy service we get.

Currently, consumer protection laws give some protection for fixed line phone users. But there is none for mobile and internet users in rural locations.

The Government has admitted change is needed, and is seeking the Productivity Commission’s direction on reforms. This cannot come too soon.

So, next time you find poor connectivity is annoying the hell out of you don’t waste the moment. Get online to your local Federal Member and express your frustrations.

Just as a blunt chainsaw wastes fuel and time, lousy internet connectivity at high cost lessens our output as rural doctors.

Driving fatigue

Doctors are very well acquainted with what it’s like to work long hours under pressure.

The experience begins in the undergraduate years with what seems like a Herculean effort to keep passing all of those exams.

By my second year as a medical student, I didn’t even sneeze when the anatomy lecturer said that we could be examined on anything at all from the 820 pages of Gardner, Gray and O’Rahilly’s textbook – that is, except for anything about teeth.

Looking for some respite, I quickly flicked through the pages to find that Chapter 61’s description of teeth was only eight pages long, leaving another 812 pages to memorize.

On my first day as a resident in a hospital with 300 beds I was rostered to do the 4pm to midnight shift in Casualty, with the last two hours in the hospital on my own.

That was until a phone call just before midnight to tell me that the night RMO had called in sick and that I’d need to work on my own until 8am.

Fast forward to life as a hospital registrar with the once-a-week 8am to 5pm (the next day) shift.

Or worse still, the monthly 8am Friday until 5pm Monday mix of on-duty and on-call.

The words “proximate” and “remote” don’t quite convey how gruelling the work was.

Of course, there was no possibility of complaining about the hours worked. The threat of not having a position in the following year would silence any complainers.

You are most vulnerable to fatigue when you don’t get enough sleep, you work at night, are awake for long periods of time, or some combination of the above.

But my experiences pale in comparison to the hours involved in some forms of surgery.

One well-known neurosurgeon recently found his gown dripping with saline and blood after a 14-hour operation.

He commented, “Oh my God, it looks like I wet myself”, only to then find himself the subject of an AHPRA investigation when his off-the-cuff comment was taken literally.

Thankfully, heavy vehicle drivers can attend to calls of nature in a more timely fashion, compliments of the Heavy Vehicle National Law (2012).

After 5¼ hours of work they can take a 15 minute break or, if they choose to keep working, they must have a 30 minute break after 7½ hours or at least a one hour break after 10 hours.

They also must have a full seven hours of rest every 24 hours, and can’t work for longer than a total of 12 hours in that period.

There are heavy penalties for not taking the stipulated rest breaks, and all of this is recorded in a National Driver Work Diary for verification.

That is, of course, everywhere in Australia except for Western Australia and the Northern Territory, where they presumably don’t drive long distances.

Oh, by the way, any hours spent waiting to be loaded and not resting in a bed are all counted as work hours.

The fatigue-regulated heavy vehicles that this legislation applies to includes any truck with a gross vehicle mass (GVM) over 12 tonnes and buses over 4.5 tonnes with a seating capacity of more than 12 adults (including the driver).

There are very good reasons for preventing fatigue on the road, as truck drivers are more than 12 times as likely to be killed on the job compared with the average worker.

This easily makes road freight transport Australia’s most dangerous job. It carries a 50 per cent greater risk than farming, which is our next most dangerous occupation.

The community expects that pilots and truck drivers are taking enough breaks to ensure they are performing well and are not fatigued.

Undoubtedly, fatigue management practices have improved in medical workplaces, but as I recall it, this change has always lagged behind other industries, which is just not good enough.

[Perspectives] Emotion, error, and judgment

Physicians who pick up Ian McEwan’s The Children Act may be intrigued by its focus on legal cases involving medicine and ethics, but the book is really a character study of High Court judge Fiona Maye. She is a specialist in family law who is bound by the UK’s Children Act to hold the welfare of children as her paramount concern. Like many physicians, Fiona grapples with the emotional difficulties of a job that requires making decisions about the lives of others.