My Health Record – lessons from the opt-out trial

By Dr Richard Kidd, Chair, AMA Council of General Practice

The recent Federal Budget confirmed that the My Health Record will move to an opt-out model.

While the AMA has drawn attention to the shortcomings of the My Health Record over the past five years, we have always acknowledged the potential for a well-designed and constructed electronic health record to improve patient care.

The AMA originally proposed an opt out model and the Evaluation of the Participation Trials for the My Health Record has demonstrated this is the right approach, with the evaluation report saying opt-out is the only sustainable way forward. Ensuring universal coverage with cross-sector clinical input over time will enhance the value of the My Health Record for patients, their doctors and a patient’s other healthcare providers.

One of the clear outcomes from the trial was that once patients understood the benefits of having a shared electronic health record and the measures in place to protect their information and its use, any concerns they had about privacy and the security of their information were allayed. In fact, the trial highlighted that patients already fully expected their doctors to be sharing their health information with one another.

This is a strong signal to the profession that, whatever reservations we have about the MyHealth record, our patients want us to use it.

Not surprisingly, the trial highlighted a number of critical improvements to the MyHealth record that are needed. These go to the heart of its ease of use, utility and accessibility.

Several of the Evaluation recommendations targeted these areas and reflect much of what the AMA has been saying for some time.

Certainly, more work needs to be done to convince GPs of the merits of the My Health Record and to address its shortcomings. One of the interesting findings in the evaluation was that while most health care providers made it clear that the MyHealth record required additional time with patients, practice managers and practice nurses reported that it made the practice more efficient with less need to chase information from patients and other health care providers. This represents an interesting tension, given that GPs are not funded for this effort. My view, along with the AMA, is GPs need to be properly funded for this work.

The evaluation report contains a number of recommendations on ‘strategy’ to increase uptake and use of the My Health Record. These particular recommendations, which touch on funding mechanisms, are vague and unclear but seem to suggest making use of the My Health Record a requirement for funding. This approach has delivered very mixed results in relation to the PIP e-health incentive and there is no way the AMA would support any change that linked the use of the MyHealth record to patient rebates.

I was pleased instead to see Health Minister Greg Hunt, at the AMA National Conference, say he intends to explore “real incentives to assist the medical workforce in their work”. The profession is looking for support, not punitive approaches that can impact on doctors and their patients.

Over time, we can expect that utilisation of the My Health Record will be woven into standards for practice and accreditation across healthcare, from general practices to hospitals (public and private), to pharmacies and other allied health service providers, and to aged care facilities. Obviously, the AMA’s role is to ensure that this does not happen until we have a clinically useful system.

Digital health will become a key part of future undergraduate and postgraduate training programs, meaning supervisors like me will need to ensure that we too are up to speed.

With more useful content being added to the record such as patient medications, pathology and diagnostic imaging reports, and discharge summaries, the more valuable the record will be for doctors and the patient’s care. In my view, the value of the MyHR could be further enhanced by enabling the uploading of other documents where useful such as Care Plans, including Advance Care Plans and Advance Care Directives. This would help ensure the manner of a patient’s care, particularly if away from home, aligns with their agreed goals and stated preferences.

Changes such as these, along with the reality that the vast majority of Australians will have a record created, should remove some barriers for engagement and facilitate greater interaction.

The AMA will continue working to ensure the My Health Record fulfils the promise that an effective shared health record can deliver.

[Series] Strategies for long-term preservation of kidney graft function

Kidney transplantation has become a routine procedure in the treatment of patients with kidney failure, and requires collaboration of experts from different disciplines, such as nephrology, surgery, immunology, pathology, infectious disease medicine, cardiology, and oncology. Grafts can be obtained from deceased or living donors, with different logistical requirements and implications for long-term graft patency. 1-year graft survival rates are greater than 95% in many centres but improvement of long-term function remains a challenge.

Premature deaths of nursing home residents: an epidemiological analysis

The known Information on the cause and manner of premature deaths of nursing home residents has been scarce.

The new During 2001–2012, the incidence of external cause deaths in nursing homes increased, particularly the incidence of deaths caused by falls.

The implications A national policy framework is needed to reduce the number of premature deaths in nursing homes. Professionals from governments and the nursing home sector should develop strategies for preventing these deaths, and a lead authority established that is responsible for reducing harm by improving practice in nursing homes.

Improving the quality of care for nursing home residents requires a better understanding of how, why, where and when they die. The global population is ageing rapidly, and the need for aged care services is consequently increasing. However, there is a paucity of information1 about the cause and manner of premature deaths of nursing home residents (ie, sooner than necessary2). At the same time, the standard of care provided in nursing homes is under increasing scrutiny by the community and governments; whether this has altered the incidence of deaths from injuries to residents, however, is unknown.

There are two populations of nursing home residents — permanent and temporary (or respite care) residents — and injury prevention strategies should probably be different for the two. Older people move to nursing homes for various reasons, including declining health,3 limited support from caregivers, increased dependence,4 security, and changes in their financial situation.5 A progressive approach to injury prevention is therefore needed, similar to other public health responses, such as the whole organisation (workplace safety) and whole of society approaches (immunisation, road safety) of public health programs.6

Mortality data are conventionally employed as indicators of population health, to identify differences in health outcomes in defined populations, to evaluate health and aged care systems, to assist policy makers assign resources according to set priorities, and to identify modifiable factors for improving quality of life. In Australia, state legislation requires that external cause deaths (ie, deaths resulting from an injury, violence or other external event) be reported to the coroner for investigation. Together with original medical records, coronial medico-legal investigations (which include specialist forensic pathology reports and a police incident report) provide some of the most detailed information about injury-related deaths in nursing homes.

Location of death data provide information about how dying is managed and the responsibility and accountability of those who have the ability to intervene and prevent an injury event. People hope for a “good death”, preferably at home, surrounded by familiar faces.7 Whether an older person has died in a nursing home is not always clear, as vital statistics do not routinely include information about the place of death, although it is recommended as a high priority characteristic by the World Health Organization.8

The aim of our study was to provide detailed information about nursing home resident deaths on the basis of coronial data, and to undertake a descriptive epidemiological analysis of external cause deaths in Australian nursing homes. It was motivated by the fact that deaths of nursing home residents have not previously been quantified nationally.

Methods

This retrospective study analysed data for people residing in accredited nursing homes whose deaths were reported to Australian coroners between 1 July 2000 and 30 June 2013 (Box 1). The definitions applied in our study are included in the online Appendix.

All deaths directly or indirectly resulting from injury or non-natural causes must be reported to coroners. The National Coronial Information System (NCIS) is the Australian electronic data storage and retrieval system that has recorded all deaths reported to coroners in Australia since July 2000 (since 2001 for Queensland). In addition to coded data fields, the NCIS contains full text documents, including the police report on the circumstances of the death, the autopsy report, any forensic toxicology report, and the coroner’s finding.9

Deaths were identified for which the incident location was classified as “home for the elderly/retirement village”, “nursing home”, “hospice, palliative or respite care”, or “residential care facility”. A further search identified deaths of people over 40 years of age at an incident location other than those listed above. Coroners’ findings were also reviewed to identify further nursing home resident deaths.

Cases were included if the death occurred between 1 July 2000 and 30 June 2013, the coroner’s investigation was completed by 31 December 2014, and the death occurred while the deceased person resided in a nursing home accredited by the Aged Care Standards and Accreditation Agency (ACSAA) (determined by comparing the residential, incident or death addresses with a list of accredited nursing homes). Cases were excluded if there was insufficient information to identify the location of the incident leading to death, or if it could not be determined whether the person resided in a nursing home or independent living facility.

Information collected included socio-demographic characteristics; the locations (ie, in or outside the nursing home) of residence, the incident leading to death, and of the death itself; the mechanism and cause of death (including the International Classification of Diseases, tenth revision [ICD-10] causes of death coding assigned by the Australian Bureau of Statistics [ABS]); and the type of care the resident received (permanent or respite resident). The classifications of death recorded in the NCIS, the basis for the ICD-10 mortality classification assigned by the ABS,10 were used. External cause deaths were then disaggregated into subgroups based on whether the death was intentional, ABS ICD-10 cause of death coding, and mechanism of injury.

Information on the broader nursing home population was obtained from government reports.11–13 Population data for nursing home residents were obtained from the Australian Institute of Health and Welfare (AIHW) for each financial year.

Data analysis

A series of descriptive statistical analyses were conducted in SPSS Statistics 23 (IBM) of the causes of death, analysed by sex and age group, and by location of incidents leading to death and location of death; coronial inquests and recommendations; and residential status. Causes of death were grouped into three larger categories — natural cause, external cause (falls), and external cause (other) — as for some specific causes the number of deaths was small. Rates of death were estimated on the basis of ABS population and AIHW nursing home data.

Ethics approval

Ethics approval for the study was granted by the Victorian Institute of Forensic Medicine Research Advisory Committee (reference, RAC 011/13) and the Department of Justice Human Research Ethics Committee (reference, CF/13/8187).

Results

Of the 22 204 deaths of nursing home residents reported to Australian coroners during 1 July 2000 – 30 June 2013, 532 were excluded (Box 1). Of the remaining 21 672 deaths, 3289 (15.2%) had been classified as external cause deaths.

Most external cause deaths were of women (2001 cases, 60.8%), consistent with the proportion of women in nursing homes.14 The age range for residents dying of external causes was 25–106 years for women (median, 88 years; interquartile range [IQR], 84–92 years) and 39–103 years for men (median, 86 years; IQR, 80–90 years). Most external cause deaths involved residents aged 85–94 years (1742 cases, 53.0%). The age distribution of nursing home residents in our study was similar to the age distribution of nursing home residents recorded by the AIHW; differences between proportions for specific age brackets ranged from 0.2% (for those under 65) to 4.7% (90–94 years of age).14

Of the 21 672 deaths of nursing home residents reported to coroners, 11 766 (54.3%) resulted in a full internal autopsy, while 8739 (40.3%) were followed only by an external examination; for 1167 cases (5.4%) there was no information on whether an autopsy had been performed.

Cause and manner of death

The majority of deaths from external causes were unintentional (3067 cases, 93.3%), most related to falls (2679 cases, 87.3% of unintentional cases, 81.5% of all cases). Intentional injuries were involved in 183 external cause deaths (5.6% of all cases), most through suicide (146 cases, 4.4%). Thirty-nine deaths (1.2% of all cases) resulted from complications of clinical care (Box 2).

Using ABS and AIHW data, the rates of death per 100 000 persons aged 65 years or more, per 1000 residential aged care services admissions, and per 100 000 nursing home bed-days were calculated for each financial year (Box 3). The incidence of natural cause deaths of nursing home residents declined during the study period (from 36.2 per 1000 admissions in 2001–02 to 10.7 per 1000 admissions in 2011–12). The rate of external cause deaths increased, particularly those caused by unintentional falls (from 1.2 per 1000 admissions in 2001–02 to 5.3 per 1000 admissions in 2011–12; Box 3).

Unintentional deaths

Almost 60% of fall-related deaths (1533 cases) were of residents aged 85–94 years; the proportion was similar to those for choking, transport, asphyxia and other incident types (data not shown). Most deaths related to thermal injuries, drowning or poisoning were of people aged 75–84 years. Most deaths related to falls, thermal injuries, asphyxia and aspiration or poisoning were of women; deaths related to drowning were more common for men, while equal proportions of deaths caused by choking and transport crashes involved men and women (Box 2).

The largest proportions of deaths attributed to complications of clinical care were of residents aged 85–94 years (17 cases, 44%; data not shown) and of women (25 cases, 64%; Box 2).

Intentional deaths

The largest proportions of deaths by suicide (55 cases, 38%) or consequences of resident-to-resident assault (14 cases, 41%) were for people aged 85–94 years (data not shown); about 70% of suicide deaths were by men (103 cases). There were three homicide deaths of residents aged 75–84 years, two of them men, but more women than men died as the result of resident-to-resident assault (22 cases, 65% of cases; Box 2).

Location of incident leading to death

Most incidents resulting in deaths of nursing home residents occurred in the nursing home (3152 cases, 95.8%; Box 4). Unsurprisingly, the incident occurred in the nursing home for most deaths resulting from choking (249 cases, 95%), suicide (116, 80%), and resident-to-resident assault (34 cases, 100%).

Location of death

Most deaths of nursing home residents resulting from external causes occurred outside the nursing home (2207 cases, 67.1%), usually in a hospital. The proportions were particularly high for deaths resulting from transport crashes (36 cases, 95%), drowning (13 cases, 87%), thermal injuries (19 cases, 83%) or falls (1939 cases, 72%; Box 4). While all resident-to-resident assaults occurred in the nursing home, most resulting deaths were outside the nursing home (22 cases, 65%). Deaths from asphyxia and aspiration (21 cases, 91%), poisoning (14 cases, 78%), choking (176 cases, 67%), homicide (2 cases, 67%) and suicide (89 cases, 61%) usually occurred in the nursing home.

Residential status

More than 98% of external cause deaths of nursing home residents were of permanent home residents (3230 cases, 98.2%). Most deaths of respite residents resulted from falls (44 of 59 respite resident deaths, 75%), suicide (6 cases, 10%) or choking (4 cases, 7%).

Inquests and coroners’ recommendations

There were 95 coroners’ inquests (open court hearings; 2.9% of external cause deaths) and coroners’ recommendations about injury prevention were made for 53 cases (1.6%). The rate of inquests in individual states and territories ranged between 0 and 8%, and that of coroners’ recommendations between 0 and 21%.

Discussion

This study was the most comprehensive descriptive epidemiologic analysis of external cause deaths in accredited nursing homes reported to Australian coroners. We found that premature and preventable deaths occur in nursing homes, and it follows that coroners have an important role in identifying factors that may prevent death and injury. However, formal coroners’ inquests examined fewer than 3% of the external cause deaths, and in 98.4% of all cases coroners made no recommendations about injury prevention. There were substantial variations between jurisdictions in the number of cases for which recommendations were delivered (0–21%).

From an injury prevention viewpoint, it is notable that most non-natural causes of deaths of nursing home residents were related to falls (81.5%); choking (7.9%) and suicide (4.4%) were the other two major causes. In contrast, the number of deaths attributed to complications of clinical care was small (1.2%).

Despite the public policy emphasis on and social expectations about dying well at home,7,15 we found that 95% of fatal incidents occurred in the nursing home, but more than two-thirds of external cause deaths were outside the facility. This reflects the large number of deaths in hospital, usually from the complications of falls.

The increase in the incidence of external cause deaths during the study period was prominent. This is partly attributable to improved coronial advisory systems and better understanding of what constitutes a reportable death, as well as removal of the requirement in some jurisdictions to report all natural cause nursing home deaths.

It is possible that we have under-reported the burden of external cause deaths in this population, as some deaths may have been misclassified as natural cause deaths because of diagnostic minimisation (downplaying the significance of illnesses or contributing injury-related factors) of the background trauma.2 Overcoming this problem would require in depth case analysis by a medico-legal clinical team, beyond the scope of our study. Researchers evaluating quality of care have reported that undertreatment and errors of omission are not easily recognised.16 The multiple comorbidities and frailty of nursing home residents make it difficult to demarcate disease progression from other causes of death, including complications of care and non-recent trauma.

In contrast, direct external cause deaths (deaths resulting directly from environmental events or circumstances)17 are by definition preventable.18 Our findings are similar to those from other developed countries.1,19,20 Disturbingly, there has been no reduction in the prevalence of these types of external cause deaths over the past 12 years. This raises an important question about governance structures for the care and safety of nursing home residents. As most incidents contributing to these deaths occurred in the nursing homes, their operators are regarded as being responsible for improving the residents’ care.

Whether operators are also responsible for deaths of residents outside the nursing home is also worth discussing. A comprehensive public health approach to injury prevention would certainly involve nursing home staff and owners. This conceptual shift provides a unique opportunity for influencing broader societal questions, such as promoting road safety.

Implications

Our study should prompt action in policy, practice and research. National policy must act upon the evidence that premature deaths occur in nursing homes. Our data challenge the misperception that all deaths of frail, older persons with multiple comorbidities living in residential care are natural. Effective planning for high quality aged care requires accurate data about preventable harm, as well as acknowledging that negatively value-laden judgements about the worth of an older person’s life do not justify inaction.

It is estimated that by the mid-2050s Australia’s population will be 31–43 million, 25% of whom will be aged 65 years or more.21 Rapid ageing of populations is apparent worldwide and will contribute to increasing numbers of nursing home residents. Better management of risks contributing to external cause deaths in nursing homes could save some of the financial costs of providing aged care. Responsibility for better management is multilayered, requiring action at the regulatory, organisational, and health and aged care professional levels. This approach is reflected in efforts to reduce the rate of preventable health care-related deaths, and should also be adopted for improving nursing home care.

As compelling as the economic argument is, more persuasive is the principle that a person’s life should not be prematurely shortened. The concept of dying well encompasses a death free of avoidable suffering. Coroners’ investigations provide greater depth to our understanding of premature deaths in aged care and, if accompanied by specific recommendations, can identify opportunities for preventing death and injury.

Although aged care in Australia is actively monitored by a range of mechanisms,22 no one entity is responsible for reducing harm by improving practice. Interventions for preventing some of these premature deaths are contentious, and there has been little empirical investigation of their effectiveness.6 For general health care, in contrast, there is a leading national agency, the Australian Commission on Safety and Quality in Health Care (https://www.safetyandquality.gov.au/), and preventable harm is monitored, investigated and acted upon by providing resources, training, education and research to rectify problems and improve care.

The major strength of our national, population-based, 13-year longitudinal study was that we analysed detailed mortality data to identify the types of deaths occurring in nursing homes. Our findings are likely to be generalisable to other jurisdictions in developed countries with similar population demographics and health and aged care systems. Limitations include the retrospective evaluation of prospectively collected data potentially causing bias, as causes of death may be incompletely recorded, missing, or misclassified.23

Conclusion

The incidence of premature and potentially preventable deaths of nursing home residents has increased over the past decade. A national policy framework and implementation plan for reducing harm in nursing homes is needed. Primary prevention should be a top priority, and professionals from governments and the nursing home sector should be involved in developing evidence-based strategies in consultation with residents and their families.

Box 1 –
Selection of nursing home deaths included in our analysis*

NCIS=National Coronial Information System. *The 21672 nursing home deaths reported to coroners during 1 July 2000 – 30 June 2013 comprised 3.5% of all nursing home deaths (612115) and 8.8% of all deaths reported to coroners (245437).

Box 2 –
External cause deaths of nursing home residents as determined by coroner, Australia, 1 July 2000 – 30 June 2013, by sex

	Women	Men	All residents

Total number of deaths	2001 (60.8%)	1288 (39.2%)	3289
Cause and manner of death
Falls	1710 (63.8%)	969 (36.2%)	2679 (81.5%)
Other unintentional
Choking	128 (49%)	133 (51%)	261 (7.9%)
Transport crashes	19 (50%)	19 (50%)	38 (1.2%)
Asphyxia and aspiration	14 (61%)	9 (39%)	23 (0.7%)
Thermal	16 (70%)	7 (30%)	23 (0.7%)
Poisoning	11 (61%)	7 (39%)	18 (0.5%)
Drowning	3 (20%)	12 (80%)	15 (0.5%)
Other	9 (90%)	1 (10%)	10 (0.3%)
Complications of clinical care	25 (64%)	14 (36%)	39 (1.2%)
Intentional
Suicide	43 (30%)	103 (70%)	146 (4.4%)
Resident-to-resident assault	22 (65%)	12 (35%)	34 (1.0%)
Homicide	1 (30%)	2 (70%)	3 (0.1%)
Age group (years)
<65	49 (46%)	57 (54%)	106 (3.2%)
65–74	70 (35%)	132 (65%)	202 (6.1%)
75–84	452 (54.6%)	376 (45.4%)	828 (25.2%)
85–94	1117 (64.1%)	625 (35.9%)	1742 (53.0%)
≥95	312 (76%)	98 (24%)	410 (12.5%)
Unknown	1 (<1%)	0	1 (<1%)

Percentages for men and women are row percentages; percentages for all residents are percentages of all external cause deaths.

Box 3 –
Rates of death of nursing home residents, Australia, 1 July 2000 – 30 June 2013, by cause of death and financial year

Financial year*	Natural cause				External cause (falls)				External cause (other)
Financial year*	Number	Per 100000 ≥65 years^†	Per 1000 RACS admissions	Per 100000 bed-days	Number	Per 100000 ≥65 years^†	Per 1000 RACS admissions	Per 100000 bed-days	Number	Per 100000 ≥65 years^†	Per 1000 RACS admissions	Per 100000 bed-days

2001–02	2176	85.5	36.2	4.2	72	2.9	1.2	0.1	29	0.9	0.5	—
2002–03	2194	85.4	33.9	4.2	71	2.8	1.1	0.1	36	1.3	0.6	0.1
2003–04	2480	94.6	37.3	4.5	119	4.5	1.8	0.2	51	1.8	0.8	0.1
2004–05	2589	96.4	39.5	4.6	118	4.5	1.8	0.2	45	1.6	0.7	0.1
2005–06	1017	36.3	15.3	1.7	140	5.2	2.1	0.2	51	1.7	0.8	0.1
2006–07	976	34.1	14.6	1.6	151	5.5	2.3	0.3	30	0.9	0.4	—
2007–08	1016	34.8	14.8	1.7	218	7.6	3.2	0.4	53	1.7	0.8	0.1
2008–09	981	31.8	14.2	1.6	315	10.9	4.6	0.5	59	1.8	0.9	0.1
2009–10	808	25.6	11.6	1.3	365	12.1	5.3	0.6	65	1.8	0.9	0.1
2010–11	744	22.2	10.7	1.1	409	13.1	5.9	0.7	77	2.2	1.1	0.1
2011–12	742	21.8	10.7	1.1	368	11.4	5.3	0.6	49	1.3	0.7	0.1

RACS=residential aged care service (the term used by the Australian Institute of Health and Welfare for nursing homes).*Financial year 2000–01 is excluded because Queensland did not contribute data to the National Coronial Information System until January 2001; financial year 2012-13 was excluded because of the requirement to exclude active coronial investigations.†Residents under 65 years of age were excluded from all analysis for this table.

Box 4 –
Locations of incident and death for external cause deaths of nursing home residents, Australia, 1 July 2000 – 30 June 2013, by cause and manner of death

	Location of incident			Location of death
	Outside nursing home	In nursing home	Total	Outside nursing home	In nursing home	Total

All external cause deaths	137 (4.2%)	3152 (95.8%)	3289	2207 (67.1%)	1082 (32.9%)	3289
Falls	42 (2%)	2637 (98%)	2679	1939 (72%)	740 (28%)	2679
Other unintentional
Choking	12 (5%)	249 (95%)	261	85 (33%)	176 (67%)	261
Transport crashes	33 (87%)	5 (13%)	38	36 (95%)	2 (5%)	38
Asphyxia and aspiration	0	23 (100%)	23	2 (9%)	21 (91%)	23
Thermal	2 (9%)	21 (91%)	23	19 (83%)	4 (17%)	23
Poisoning	2 (11%)	16 (89%)	18	4 (22%)	14 (78%)	18
Drowning	12 (80%)	3 (20%)	15	13 (87%)	2 (13%)	15
Other	0	10 (100%)	10	6 (60%)	4 (40%)	10
Complications of clinical care	3 (8%)	36 (92%)	39	23 (59%)	16 (41%)	39
Intentional
Suicide	30 (20%)	116 (80%)	146	57 (39%)	89 (61%)	146
Resident-to-resident assault	0	34 (100%)	34	22 (65%)	12 (35%)	34
Homicide	1 (33%)	2 (67%)	3	1 (33%)	2 (67%)	3

President highlights AMA influence

AMA President Dr Michael Gannon opened the 2017 National Conference lauding the political influence of the organisation he leads.

He told delegates that the past 12 months had been eventful and had resulted in numerous achievements in health policy.

“The AMA is a key player in Federal politics in Canberra. The range of issues we deal with every day is extensive,” Dr Gannon said.

“Our engagement with the Government, the bureaucracy, and with other health groups is constant and at the highest levels.

“Our policy work is across the health spectrum, and is highly regarded.

“The AMA’s political influence is significant.”

Describing the political environment over the past year as volatile – which included a federal election and two Health Ministers to deal with – Dr Gannon said the AMA had spent the year negotiating openly and positively with all sides of politics.

“Our standing is evidenced by the attendance at this conference of Prime Minister Malcolm Turnbull, Opposition Leader Bill Shorten, Greens Leader Senator Richard Di Natale, Health Minister Greg Hunt, Minister for Aged Care and Minister for Indigenous Health Ken Wyatt AM, and Shadow Health Minister Catherine King,” he said.

“Health policy has been a priority for all of them, as it has been for the AMA.”

While the Medicare rebate freeze was the issue to have dominated medical politics, there are still more policy areas to deal with in the coming year.

The freeze was bad policy that hurt doctors and patients.

“I was pleased just weeks ago on Budget night to welcome the Government’s decision to end the freeze,” Dr Gannon told the conference.

“The freeze will be wound back over three years. We would have preferred an immediate across the board lifting of the freeze, but at least now practices can plan ahead with confidence.

“Lifting the freeze has effectively allowed the Government to rid itself of the legacy of the disastrous 2014 Health Budget.

“We can now move on with our other priorities… We will maintain our role of speaking out on any matter that needs to be addressed in health.”

Dr Gannon said while the Medicare freeze hit general practice hard, it was not the only factor making things tough for hardworking GPs.

General practice is under constant pressure, he said, yet it continues to deliver great outcomes for patients.

GPs are delivering high quality care and are the most cost effective part of the health system.

“One of the most divisive issues that the AMA has had to resolve in the past 12 months is the Government’s ill-considered election deal with Pathology Australia to try and cap rents paid for co-located pathology collection centres,” Dr Gannon said.

“We all know that our pathologist members play a critical role in helping us to make the right decisions about our patients’ care. They are essential to what we do every day.

“It was disappointing to see the Government’s deal pit pathologists against GPs.

“The pathology sector is right to demand that allegations of inappropriate rents are tackled, and the GPs are equally entitled to charge rents that place a proper value on the space being let.

“The recent Budget saw the rents deal dumped in favour of a more robust compliance framework, based on existing laws. This is a more balanced approach.

“The AMA will work with Government and other stakeholders to ensure that allegations of inappropriate rents are tackled effectively.

“We want to ensure that patients continue to access pathology services solely on the basis of quality.”

The AMA is a critical adviser to the Government on its roll-out of the Health Care Home trial.

It shares the Government’s vision for the trial, but will continue to provide robust policy input to ensure it has every chance of success.

The AMA has secured a short delay in the roll-out of the trial.

Other issues the President highlighted as areas the AMA is having significant influenced included: the Practice Incentive Program; My Health Record; Indigenous Health; After-Hours GP Services; the MBS Review; public hospitals; private insurance; and the medical workforce.

Chris Johnson

Government had to reassure Australians about Medicare

After almost losing last year’s federal election over cuts to Medicare, the Government has used this Budget to display its commitment to the national health scheme.

It is setting up a Medicare Guarantee Fund and from July this year money from the Medicare Levy as well as from personal tax receipts, will be poured into the fund to cover the costs of Medicare and the Pharmaceutical Benefits Scheme.

(A 0.5 percentage point Medicare Levy rise in 2019 will help fund the National Disability Insurance Scheme.)

Labor hammered the Coalition during the 2016 election with its so-called Mediscare campaign, requiring a clear message on Budget night from the Government.

“Tonight, we put to rest any doubts about Medicare and the Pharmaceutical Benefits Scheme,” Treasurer Scott Morrison said in his Budget address.

“We are lifting the freeze on the indexation of the Medicare Benefits Schedule. We are also reversing the removal of the bulk billing incentive for diagnostic imaging and pathology services and the increase in the PBS co-payment and related changes.

“The cost of reversing these measures is $2.2 billion over the next four years

“Tonight, I also announce we will legislate to guarantee Medicare and the PBS with a Medicare Guarantee Bill.

“This new law will set up a Medicare Guarantee Fund to pay for all expenses on the Medicare Benefits Schedule and the Pharmaceutical Benefits Scheme.

“Proceeds from the Medicare Levy will be paid into the fund. An additional contribution from income tax revenue will also be paid into the Medicare Guarantee Fund to make up the difference.

“The Bill will provide transparency about what it really costs to run Medicare and the PBS and a clear guarantee on how we pay for it.”

But Shadow Health Minister Catherine King said the Budget was an insult directly from Prime Minister Malcolm Turnbull to every Australian who relies on Medicare.

She said instead of a staggered lifting of the rebate freeze, it should have been removed across the board immediately.

“When it comes to health, the Liberals haven’t learned a thing. The Turnbull Medicare freeze remains in place across the health system for years to come,” Ms King said.

“The failure to drop the freeze immediately will impact on many of Australia’s most vulnerable patients – such as those needing critical oncology treatment, obstetric services, and paediatric treatment.

“Australians will have to wait more than 12 months for relief and will be left waiting more than two years for the freeze on specialist procedures and allied health to be lifted.”

Greens leader Richard Di Natale described the Budget as a missed opportunity for health.

“The Medicare Guarantee Fund is a glorified bank account and ending the Medicare freeze just undoes a bad decision,” Senator Di Natale said.

“We should be investing more in prevention and redirecting the Private Health Insurance rebate into the public health system.”

Health Minister Greg Hunt said all Australians can be assured Medicare was not only here to stay, but will be strengthened into the future.

“This Budget includes a $2.4 billion additional investment in Medicare over the next four years,” he said.

“Partnerships have been struck with the nation’s GPs, specialists, pharmacists and the medicines sector. These are key to the Turnbull Government’s initiatives that will support the long-term future of Australia’s health system.

“As part of our compacts with Australia’s GPs and specialists, the 2017-18 Budget restores indexation of the Medicare rebate at a cost of $1 billion, starting with GP bulk-billing incentives from 1 July 2017.

“With GP bulk-billing at a record high 85.4 per cent, more Australians are visiting the doctor without having to reach into their pockets. This Budget will help ensure that continues with our indexation commitment to GPs alone worth $543.1 million over 4 years and around $2.2 billion over ten years.

“Indexation of standard GP and specialist consultations will resume on 1 July 2018, and specialist procedures and allied health from 1 July 2019.”

Chris Johnson

Federal Budget delivers – Medicare rebate freeze to be lifted

The AMA welcomes much of the health measures in the Federal Budget and commends the Government for taking action on the Medicare rebate freeze.

AMA President Dr Michael Gannon said the Coalition had won back much of the goodwill it lost with its disastrous 2014 Health Budget by this time handing down a Budget with numerous positive health measures.

Dr Gannon said the staggered lifting of the freeze on Medicare patient rebates was well overdue.

“This is a monkey that has been on the back of the Coalition Government since the 2014 Budget that cut significant dollars out of health. This is the chance to correct those wrongs,” he said.

The freeze will be lifted from bulk billing incentives for GP consultations from 1 July 2017, from standard GP consultations and other specialist consultations from 1 July 2018, from procedures from 1 July 2019, and targeted diagnostic imaging services from 1 July 2020.

The lifting of the freeze on Medicare rebates will cost the Government about $1 billion.

“The AMA would have preferred to see the Medicare freeze lifted across the board from 1 July 2017, but we acknowledge that the three-stage process will provide GPs and other specialists with certainty and security about their practices, and patients can be confident that their health care will remain accessible and affordable,” Dr Gannon said.

“Lifting the Medicare rebate freeze is overdue, but we welcome it.”

Dr Gannon also described many of the health policy breakthroughs in the Budget as a direct result of AMA lobbying and the consultative approach of Health Minister Greg Hunt.

“Minister Hunt said from day one in the job that he would listen and learn from the people who work in the health system every day about what is best for patients, and he has delivered,” Dr Gannon said.

AMA advocacy has also seen, in this Budget, the reversing of proposed cuts to bulk billing incentives for diagnostic imaging and pathology services; the scrapping of proposed changes to the Medicare Safety Net that would have penalised vulnerable patients; the delaying of the introduction of the Health Care Homes trial until October to allow fine-tuning of the details; the moving to an opt-out approach for participation in the My Health Record; and recognising the importance of diagnostic imaging to clinical decision-making.

The AMA supports the Government’s measures to increase the prescribing of generic medicines, when it is safe and appropriate and discussed with the patient, and preserves doctors’ clinical and prescribing independence, with savings to be invested back into the Pharmaceutical Benefits Scheme.

“We also welcome the Government’s allocation of $350 million to help prevent suicide among war veterans; the expansion of the Supporting Leave for Living Organ Donors Program, which allows donors to claim back out-of-pocket expenses and receive up to nine weeks paid leave while recovering; measures to increase the vaccination rate; and the ban on gambling ads during live sporting broadcasts before 8.30pm,” Dr Gannon said.

Mr Hunt said the Budget delivered on the Government’s commitment to guarantee Medicare and ensure Australia’s health system continues to be one of the best in the world.

“It ensures the essential healthcare services Australians rely on,” the Minister said.

“The 2017-18 Budget includes a $10 billion package to invest in Australia’s health system and the health of Australians.

“The Government will establish a Medicare Guarantee Fund from 1 July 2017 to secure the ongoing funding of the Medicare Benefits Schedule and the Pharmaceutical Benefits Scheme, guaranteeing Australians’ access to these services and affordable medicines into the future.”

The Medicare levy will rise by 0.5 percentage points in two years’ time, to help close the funding gap for the National Disability Insurance Scheme.

“This measure will collect $8.2 billion over four years for the NDIS,” said Treasurer Scott Morrison when handing down his Budget.

Shadow Treasurer Chris Bowen said the Government had failed the Medicare test because it had delayed reversing cuts to Medicare for three years.

“Budgets are about choices and Prime Minister Malcolm Turnbull has made his choices tonight,” Mr Bowen said.

“He has chosen multinationals over Medicare. He has chosen big business over battlers.”

Dr Gannon said the Health Budget effectively ends an era of poor co-payment and Medicare freeze policies, and creates an environment for informed and genuine debate about other unfinished business in the health portfolio.

“We now need to shift our attention to gaining positive outcomes for public hospitals, prevention, Indigenous health, mental health, aged care, rural health, private health insurance, palliative care, and the medical workforce,” he said.

“The thaw in the freeze is the beginning, not the end.”

Chris Johnson

[Perspectives] The penicillin girls (and guys)

Have you heard of “the penicillin girls”? Perhaps one of them was your grandmother? If so, the Oxford University Museum of the History of Science wants to learn more about her. These six women—Ruth Callow, Claire Inayat, Betty Cooke, Peggy Gardner, Megan Lancaster, and Patricia McKegney—comprised a team recruited by Howard Florey, Professor of Pathology at Oxford’s William Dunn School of Pathology, in the late 1930s. They “farmed penicillin”, working in laboratory conditions to collect a few milligrams of solid penicillin each week from hundreds of litres of what they called “mould juice”.

Hep C cure’s $1bn price tag

The Federal Government has spent almost $1 billion on drugs in the first four months of its campaign to eliminate hepatitis C, reinforcing estimates that it will ultimately cost taxpayers $3 billion to cure chronic sufferers.

Figures compiled by Australian Prescriber show that since the hepatitis C treatments sofosbuvir and ledipasvir were listed on the Pharmaceutical Benefits Schedule in March, the Government has paid out $942.8 million on 43,900 prescriptions for the drugs, at an average cost of almost $21,500 per script.

Sofosbuvir has been hailed as a “game-changing” medicine that can cure hepatitis C in as little as 12 weeks, but the cost for most individuals is prohibitive – $110,000 for a course of treatment.

But following its listing on the PBS, chronic hepatitis C sufferers can get for as little as $6.20 a prescription.

Health Minister Sussan Ley has linked the subsidisation of the hepatitis C treatments to $650 million in savings from the controversial axing of bulk billing incentives for pathology and diagnostic imaging services.

“These two new hepatitis C medicines have come on to the market and rocketed into the number one position on the list of top drugs by cost to the Government,” Australian Prescriber medical editor Dr John Dowden said. “They were only approved in March, and in the four months to June have cost the Government almost $1 billion for 43,000 prescriptions.”

While the hepatitis C treatments grabbed the crown as the most costly drugs for 2015-16, the most common medicines prescribed were statins and proton pump inhibitors.

Altogether, more than 14 million prescriptions where issued for the statins atorvastatin and rosuvastatin last financial year, while almost 6.9 million were written for the proton pump inhibitor esomeprazole.

The next most commonly prescribed drug was the painkiller paracetamol (5.05 million prescriptions), followed by the reflux medication pantoprazole (4.7 million), the blood pressure drug perindopril (4.05 million) and the diabetes medicine metformin (3.57 million).

While hepatitis C treatments have grabbed a big slice of the Commonwealth’s medicine’s budget, other expensive treatments for leukaemia, multiple sclerosis, arthritis and eye disease are also grabbing a hefty share.

The anti-inflammatory biologic adalimunab, a drug used to treat rheumatic and psoriatic arthritis, Crohn’s disease and chronic psoriasis, has been supplanted at the top of the expenditure table by ledipasvir and sofosbuvir, but still cost the taxpayer almost $334 million last financial year.

Top 10 drugs by cost

Medicine	Cost (A$)
Sofosbuvir and ledipasvir	570 730 056
Sofosbuvir	372 094 623
Adalimunab	335 857 859
Ranibizumab	241 256 012
Aflibercept	231 194 036
Esomeprazole	170 554 177
Etanercept	166 538 773
Trastuzumab	157 134 211
Fluticasone & Salmeterol	148 878 399
Insulin Glargine	146 202 125

Source: Australian Prescriber

Latest news

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.

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