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Preference: Palliative Care

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Let’s be clear eyed while moving forward on private health insurance

BY ASSOCIATE PROFESSOR JULIAN RAIT, CHAIR, COUNCIL OF PRIVATE SPECIALIST PRACTICE

On October 11, Health Minister Greg Hunt announced the final rules that support the new private health insurance clinical categories and the Gold, Silver, Bronze and Basic classification system. 

CPSP and the AMA have called on these reforms to deliver simplified, better value private health insurance products for consumers. A system that offers more comprehensive coverage, with clear definitions, and less caveats and carve outs. Will the new system deliver total clarity and transparency? Not quite, but it is going to be a lot simpler for consumers than trying to navigate through the current 70,000 policy offerings.

The AMA has always supported, two key aspects of these reforms:

  1. Clarity about what medical conditions are covered in each tier of benefits; and
  2. The use of standard clinical categories across all private health policies. 

The new classification system categorises existing policies into easier to understand tiers. These tiers, in combination with new Private Health Information Statement (which includes mandatory information about what each policy covers), should make it easier for people to compare policies, to shop around and actually see what they are covered for.  

This should enable consumers to know that when they book in for a procedure they are covered now and not have to wait an additional 12 months or try the public system. 

The tiers outline minimum requirements, but they still allow insurers to add additional cover. The legislation clarifies that insurers can move people onto new products, closing old products, but introduces new protections about warning and information for consumers. Additionally, the Minister is on the record stating that “importantly consumers will not be forced to change their policy cover if they are happy with it”. 

There are also some more hidden benefits that will come in with the new system.  

  1. That the system provides full mandatory cover for the medical conditions in each tier; partial cover is not permitted (except in Basic cover and for Psychiatry, Rehabilitation, and Palliative Care – except in Gold cover where there are no exclusions allowed at all); 
  2. The inclusion of gynaecology, breast surgery, cancer treatment, and breast reconstruction in bronze tier products; 
  3. That a clinical category covers the entire episode of hospital care for the investigation or treatment;  
  4. That an episode of hospital treatment covers the miscellaneous services allied to the primary service; and 
  5. Patients with limited cover for psychiatric care can upgrade their cover (once) to access higher benefits for in-hospital treatment without serving a waiting period.  

While these look obvious, they haven’t always been included in policies. From next year they will be. 

The Minister has called for an April 1, 2019 commencement to coincide with the annual announcement of new premiums. However, as with most major changes, not all groups can adapt as quickly as others. So, while the reforms start next year, insurers have a further 12 months to ensure that each of their products is compliant and to move people onto new products if required. This is not ideal, but the transition for the smaller insurers is likely to be very resource intensive. The Minister has stated that his expectation is that the great majority of policies will be ready to go by April 1 next year. He has also stated that these reforms will have an overall neutral to -0.3 per cent impact on premiums compared with current policy settings. 

But we also need to be clear eyed here. This will not solve the wider issue of how to bridge the ongoing premium increases in the 4-5 per cent range, and wages growth at 2 per cent range. That fundamental paradox to a long-term, sustainable private health insurance system remains. These reforms will not address the concerns around private health insurer behavior, nor will they address the variation in rebates. These reforms are about making life a little easier for our patients, and our practices. But the AMA will need the support of all our members going forward – for clearly, the bigger problem is yet to be addressed. 

 

[Editorial] The Astana Declaration: the future of primary health care?

Primary health care is in crisis. It is underdeveloped in many countries, underfunded in others, and facing a severe workforce recruitment and retention challenge. Half the world’s population has no access to the most essential health services. Yet 80–90% of people’s health needs across their lifetime can be provided within a primary health-care framework—from maternity care and disease prevention through vaccination, to management of chronic conditions and palliative care. As populations age, and multimorbidity becomes the norm, the role of primary health-care workers becomes ever more important.

[Perspectives] The deathwife

Kathryn Mannix’s message in With the End in Mind is that “there is little to fear and much to prepare for”. Her book has been lavishly praised by lay readers and was shortlisted for this year’s Wellcome Book Prize. Mannix, who worked as a palliative care doctor for three decades, tells the stories of some of the many patients she has attended as a “deathwife”. She describes a crucial episode in her training, when the first palliative care consultant she worked with teaches her how to talk with dying people.

Private health insurance reforms – moving ahead

In October last year, Health Minister Greg Hunt announced that the Government would embark on a package of reforms aimed at making private health insurance simpler and more affordable for Australians.  

Private health insurance is one of the most complex forms of insurance and the current complexity of product offerings has led many consumers to report that they do not understand what they are covered for. These reforms aim to simplify private health insurance hospital cover by creating easily understood tiers of cover. There will be four tiers of hospital products Gold, Silver, Bronze and Basic. These new private health insurance products will take effect from April 1, 2019.

When announced, the AMA President welcomed the reforms as a long overdue opportunity to bring much-needed transparency, clarity, and affordability to the private health sector. However, the AMA also noted that the challenge ahead was to clearly define and describe the insurance products on offer – to deliver meaningful and consistent levels of cover in each category.

The reform package has built on the work of the Private Health Ministerial Advisory Committee, which was established to examine all aspects of private health insurance and provide government with advice on reforms. This committee met extensively and set up several working groups to look at specific issues. The AMA has been represented continuously throughout this process. An ad hoc group of members has been working to provide the AMA representatives with advice and support.

As part of this process the AMA recently provided a submission to the Health Department concerning the draft standard clinical definitions that support the new private health insurance categories. More recently, the Government has introduced the legislation required to support the package of reforms into parliament. The legislative package has now been referred to a Senate Committee Inquiry, which is expected to report in mid-August.

On Sunday July 15, the Minister announced the Gold, Silver and Bronze categories again without much further information. However, the next day the Health Department released the draft rules (or subordinate legislation/regulations) that will support the package of reforms. 

Under these new rules, the proposed Gold, Silver and Bronze policies will not contain restrictions or carve outs for included clinical treatments (except hospital psychiatric care, rehabilitation and palliative care). According to Government modelling currently about 25 per cent of people with private hospital insurance purchase cover have restrictions applied to a clinical category other than hospital psychiatric care, rehabilitation and palliative care. In the new system, only the new Basic category can have restrictions (outside hospital psychiatric care, rehabilitation and palliative care), and even then, it must be clearly marked as having a restriction.

The AMA Secretariat is now working with the other Colleges, Associations and Societies to provide the Government with comprehensive advice on the proposed rules, including the critical issue of clinical definitions and MBS item coverage under these definitions.

Extract of a letter to members from AMA President Dr Tony Bartone.

More than just writing a script

Family Doctor Week
Western Australia – Dr Simon Torvaldsen

Dr Simon Torvaldsen is Chair of the AMA WA Council of General Practice, and he is also one of the owners of Third Avenue Surgery in Mt Lawley, just a few kilometres north-east of Perth’s city centre. 

In an area that overall has a somewhat middle-class flavour, his patient demographic is quite mixed.

“It’s mainly mortgage belt and professionals – I have quite a few doctor patients – but also a significant number of elderly, less wealthy patients who have lived in the area for many years, plus some tenants of cheap unit accommodation,” he said.

“We are privately billing, although we bulk bill most pensioners. Our standard appointment is 15 minutes and most doctors see four patients per hour or somewhat less, as we do not discourage longer appointments and have a focus on quality care and patient satisfaction.” 

Third Avenue Surgery has 10 consulting rooms.

“The work is so varied. From parents worried about their small children with fevers, to depressed and anxious teenagers,” Dr Torvaldsen said.

“My oldest patient died recently aged 104. I managed the sudden and somewhat unexpected deterioration, counselled family, provided palliative care, arranged nursing support and she passed away peacefully at her low-care aged care facility. It avoided hospital admission, which would have been expensive, futile, and most likely a poor quality, undignified end to a long and worthwhile life.

“Also recently, I had to gently nag an ophthalmologist who came in with wax impacted in his ear, jammed in by his attempts to remove it using various eye surgery instruments. Fortunately, it was easily removed by me. We doctors are not good at self-care, and general practice is a specialty in its own right. He will get me to do it next time.

“It is certainly not all coughs, colds and minor illnesses. Although we see plenty of that and the real skill is in picking the more serious conditions from the minor illnesses, especially as they often present to us in the very early stages.

“So much of what we do in general practice is about ensuring good communication and good understanding. It is not enough to just write the script.

“The reward is in the long-term care and seeing people through all sorts of things, as well as seeing the results of our medical care and the difference we make to people’s lives. 

“We sometimes forget the degree of trust they put in us. And for me, the sheer variety keeps the day interesting and the brain nimble.”

CHRIS JOHNSON

 

 

AMA ramps up its aged care advocacy

BY DR ANDREW MULCAHY, CHAIR, AMA’S MEDICAL PRACTICE COMMITTEE

It only takes a skim of the media headlines to know that the aged care system is failing older people. Many reported cases of poor quality care are a result of delayed medical care and neglect, and AMA members are deeply concerned for their older patients. There have been multiple inquiries and reviews into the system in the past couple of years. Government are well aware of the issues and, while there was a $5 billion funding increase in the aged care 2018-19 budget, more urgently needs to be done.

The AMA is responding to its members’ concerns by ramping up its aged care advocacy. In November 2017, the Medical Practice Committee (MPC) conducted a survey on AMA member experiences and perceptions of aged care to inform future AMA policy. In April 2018, a new Position Statement, Resourcing aged care was released. This Position Statement focuses on workforce and funding measures required for a good quality aged care system, and draws from the learnings of the aged care survey.

Aged care calls for adequate resourcing to ensure doctors are supported to deliver medical care to their older patients. One such measure includes appropriate remuneration to cover the opportunity cost of leaving a surgery to visit patients in Residential Aged Care Facilities (RACFs). The AMA also advocated for this policy change at the MBS Reviews’ General Practice and Primary Care Clinical Committee (GPPCCC). Dr Richard Kidd (Chair, Council of General Practice) and AMA Federal Secretariat called for increased MBS rebates for GP RACF attendances, telehealth consultation items for GPs, and for the Practice Incentive Program (PIP) Aged Care Access Incentive (ACAI) to remain.

MPC, with input from the Council of General Practice, has lodged six aged care submissions this year alone. These include:

  • Aged Care Workforce Strategy Taskforce – The Aged Care Workforce Strategy;
  • Australian Aged Care Quality Agency – Draft Standards Guidance (for the new Aged Care Quality Standards);
  • House of Representatives Committee on Health, Aged Care and Sport – Inquiry into the Quality of Care in Residential Aged Care Facilities in Australia;
  • Medical Services Advisory Committee – New mobile imaging services for residential aged care facilities;
  • Aged Care Financing Authority – Respite Care; and
  • Department of Health – Specialist Dementia Care Units.

In addition to the House of Representatives Committee on Health, Aged Care and Sport for the Inquiry into the Quality of Care in Residential Aged Care Facilities in Australia submission, Dr Tony Bartone and Dr Kidd gave evidence at a public hearing in May. Dr Bartone and Dr Kidd highlighted that AMA members have major concerns that the current aged care system is failing older people, and called for more appropriately trained aged care staff, especially registered nurses, in RACFs. Dr Bartone and Dr Kidd also highlighted that doctors need to be recognised and supported as a crucial part of the aged care workforce to improve medical access, care and outcomes for residents.

In addition to the Aged Care Workforce Strategy Taskforce submission, Dr Bartone recently attended both Aged Care Workforce Taskforce Summits. The summits are aimed at engaging stakeholders in developing a strategy for ensuring aged care workforce growth to meet older people’s needs. Dr Bartone highlighted that the current aged care workforce does not have the capacity, capability and connectedness to adequately meet the needs of older people.

MPC aged care advocacy efforts were also reflected in several Budget announcements, including:

  • the establishment of an Aged Care Quality and Safety Commission ($nil);
  • investment in rural aged care ($40million);
  • improvements to My Aged Care website access ($61.7million) and faster Aged Care Assessment Team (ACAT) assessments ($14.8million);
  • improved access to specialist palliative care services in RACFs ($32.8million);
  • a new mental health service for older people living in RACFs ($82.5million); and
  • 14,000 additional home care packages (plus 6000 additional packages as announced in the Mid-Year Economic and Fiscal Outlook) ($1.6billion).

However, more needs to be done to ensure older people receive quality care. 20,000 additional home care packages makes a small dent in the 104,602 people currently on the waiting list. The Productivity Commission stated in 2011 that the aged care workforce must quadruple by 2050 to meet demand, but there was no mention of a workforce strategy in the budget. MPC is waiting with bated breath for the Aged Care Workforce Strategy to complete its work (by the end of June 2018).

MPC will continue advocating for a better quality aged care system. 2018 will see the introduction of four additional aged care Position Statements, covering topics such as the health of older people, palliative care, clinical care, and innovation in aged care. So watch this space.

AMA aged care Position Statements and submissions can be accessed through: advocacy/aged-care.

 

[Department of Error] Department of Error

Knaul FM, Farmer PE, Krakauer EL, et al. Alleviating the access abyss in palliative care and pain relief—an imperative of universal health coverage: the Lancet Commission report. Lancet 2018; 391: 1391–454—In this Commission (published online first on Oct 12, 2017), Camilla Zimmermann’s surname has been corrected, and Odontuya Davaasuren (Mongolian National University of Medical Science) has been included in the Acknowledgments section. Minor typographical and citation errors have also been corrected.

WHO public health awards for Western Pacific Region

Public health champions from the World Health Organization (WHO) Western Pacific Region were recognised at the 71st World Health Assembly in Geneva, Switzerland.

Dr Nazni Wasi Ahmad from Malaysia received honours for her innovative research using insects to treat people with diabetes, and the Korea Institute of Drug Safety and Risk Management (KIDS) for contributions to drug safety in the country.

“Dr Nazni Wasi Ahmad and the Korea Institute of Drug Safety and Risk Management have made outstanding contributions to public health in our Region,” said Dr Shin Young-soo, WHO Regional Director for the Western Pacific.

“The recognition they are receiving today is a strong affirmation of the significance of that work, which positively impacts the lives of many people in Malaysia, the Republic of Korea and beyond.”

Dr Ahmad was awarded the Dr LEE Jong-wook Memorial Prize for Public Health for her research on the therapeutic use of maggots (fly larvae) to clear and expedite the healing of wounds and foot ulcers caused by diabetes. The maggots remove dead tissue and secrete antimicrobial substances that fight infection and promote healing.

The number of people with diabetes is growing around the world, and diabetic foot ulcers are a serious but relatively common complication. If these wounds are not properly treated and become infected, especially with antibiotic-resistant bacteria, it could result in needing to amputate the affected limb.

In Malaysia, about six per cent of patients attending diabetic outpatient facilities develop foot ulcers, and foot complications account for 12 per cent of all diabetes hospital admissions.

Dr Ahmad’s method is effective, affordable, simple and available at any time and in any healthcare setting, including small local clinics, said the WHO.

When accepting the award, Dr Ahmad said: “Today, our therapy is being practised in health clinics in most districts in Malaysia, including in hard-to-reach areas. It is easy to access and affordable for the people, especially socially and geographically disadvantaged groups.

“We brought our research findings from the laboratory to the bedside, and now we’re preventing limb amputation in diabetic patients in health clinics. This is in line with achieving the ultimate goal of primary health care as advocated by WHO—reducing exclusion and social disparities in health and organizing health services around people’s needs and expectations.”

KIDS received the 2018 United Arab Emirates Health Foundation Prize for its outstanding contribution to health development. The Institute works to improve health in the Republic of Korea by working on prevention and recognition of drug safety-related issues, supporting evidence-based decisions on drug safety, disseminating safety information, and increasing public awareness.

The country’s pharmacovigilance system to monitor the effects of medical drugs consists of 27 regional centres. In this decentralised system, KIDS functions as the focal point, gathering and reporting data from these centres.

The data are used to provide the Ministry of Food and Drug Safety with statistics, safety information and reports of all adverse events. The reporting system further feeds into Vigibase, the global database managed by the WHO Programme for International Drug Monitoring.

“Nationwide, KIDS operates 27 regional pharmacovigilance centres, promoting the reporting of adverse drug reaction cases and incorporating the data into the WHO international pharmacovigilance programme. We take various safety measures proactively and are keen to share with WHO and other countries our experience and achievements in drug safety management,” said Dr Soo Youn Chung of KIDS. 

Each year, at the World Health Assembly held in Geneva, prizes are given to recognise expertise and accomplishments in public health.

The prizes have been established either in the name of eminent health professionals and international figures or by prominent foundations committed to supporting international and global public health. Nominations are submitted by national health administrations and former prize recipients and reviewed by specialized selection panels of each of the foundations awarding a prize. The WHO Executive Board, in its January session, designates the winners based on recommendations made by the selection panels.

The Dr Lee Jong-wook Memorial Prize for Public Health is given to an individual whose work has gone far beyond the performance of duties normally expected of an official of a government or intergovernmental institution.

The United Arab Emirates Health Foundation Prize is awarded to a person, institution or nongovernmental organization that has made an outstanding contribution to health development.

Other prizes presented at the World Health Assembly this year were: the Ihsan Doğramacı Family Health Foundation Prize to Professor Vinod Kumar Paul (India); the Sasakawa Health Prize to the Fundación Pro Unidad de Cuidado Paliativo (Pro Palliative Care Unit Foundation) (Costa Rica); and His Highness Sheikh Sabah Al-Ahmad Al-Jaber Al-Sabah Prize for Research in Health Care for the Elderly and in Health Promotion to Association El Badr, Association d’aides aux malades atteints de cancer (El Badr Association, Cancer Patient Association) (Algeria).

CHRIS JOHNSON 

 

[The Lancet Commissions] Alleviating the access abyss in palliative care and pain relief—an imperative of universal health coverage: the Lancet Commission report

In agonising, crippling pain from lung cancer, Mr S came to the palliative care service in Calicut, Kerala, from an adjoining district a couple of hours away by bus. His body language revealed the depth of the suffering.We put Mr S on morphine, among other things. A couple of hours later, he surveyed himself with disbelief. He had neither hoped nor conceived of the possibility that this kind of relief was possible.Mr S returned the next month. Yet, common tragedy befell patient and caregivers in the form of a stock-out of morphine.