more_vertSteve Kay, the new president of The Scripps Research Institute, has big plans for the venerable biomedical research institution. Alongside incoming CEO Peter Shultz, he hopes to extend the institute’s mission beyond basic science to incorporate more translational work, in a complete bench-to-bedside approach. “If you can couple the strength in basic sciences of an institute like Scripps with real pipeline capability to make drug candidates, then you could make a really unique institute that is centred around therapeutics for unmet medical needs”, he says.
Preference: Statistics, epidemiology and research design
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[Comment] Why is suicide the leading killer of older adolescent girls?
In May and June, 2015, media outlets around the world reported a devastating new finding that shocked the public and public health researchers alike. The Telegraph, Guardian, and National Public Radio all published articles highlighting the fact that suicide had surpassed maternal mortality as the leading cause of death among girls aged 15–19 years globally.1–3
Gatekeeper role of GPs under scrutiny in MBS review
The crucial gatekeeper role played by GPs is coming under scrutiny as the Federal Government explores a possible overhaul of the operation of Medicare as part of its review of the MBS.
While around 35 Clinical Committees will be set up to conduct an item-by-item review of the MBS, a memorandum by Review Taskforce Chair Professor Bruce Robinson shows “high-level” issues affecting the overall functioning of the Medicare system are also under active consideration.
The Review Chair was at pains to insist that there was no set savings target for the MBS Review, but added there was “a need to look at the full breadth of the $19.1 billion MBS spend, not just general practitioner services”.
His comments came as it was revealed the final results of the MBS Review would not be submitted to the Government until December 2016, almost certainly putting them beyond the next Federal election, which is due by late next year.
Much of the attention so far has been on the Review’s appraisal of more than 5700 items on the MBS, and the fact that it also encompasses an examination of the over-arching rules governing the operation of Medicare is less well known.
But the far-reaching possibilities this entails started to become clearer at a series of stakeholder forums organised by the Taskforce, including fundamental changes in professional roles and responsibilities, models of remuneration, and the use of the MBS to “actively guide” clinical decision-making.
In his report on consultations, Professor Robinson said some had complained that the gatekeeper role played by GPs was limiting the effectiveness of team-based care, such as by requiring all referrals to be made through the GP.
The Taskforce Chair said that though some participants reaffirmed the importance of GPs as gatekeepers, there were suggestions that specialists be able to make direct referrals in selected cases, such as a physiotherapist requesting a knee x-ray.
Suggestions of any dilution in the central role played by GPs in coordinating care fly in the face of the latest advice from health experts here and abroad, who have argued that, far from diminishing the position of the family doctor, governments should enhance it.
In its latest review of the Australian health system, the Organisation for Economic Cooperation and Development argued strongly against any further fragmentation of the health system, and urged that primary health care be strengthened.
And University of Sydney researchers last month reported that GPs were holding health costs down by coordinating the care provided by hospitals, specialists, allied health professionals and community and aged care services.
“If general practice wasn’t at the core of our health care system, it is likely the overall cost of health care would be far higher,” the researchers said.
The MBS Review process has also included discussion about a shift away from the fee-for-service remuneration model to pay for performance – an issue being explored in detail by the Primary Health Care Advisory Group being led by former AMA President Dr Steve Hambleton.
“While many participants felt the MBS could improve quality of care by paying for performance, concerns were voiced that clinicians may be averse to taking on high-risk patients who are unlikely to achieve target outcomes,” Professor Robinson reported. “Furthermore, some rebates may need to reflect the additional risk that providers would be taking on – potentially a complex analysis.”
In addition to exploring so-called ‘macro’ issues, Professor Robinson provided more detail on how the review of individual Medicare items would proceed.
He said each of the Clinical Committees would conduct an initial “triage” of usage patterns, evidence and descriptors to identify items in need of more detailed investigation.
It would then conduct a rapid evidence review and make recommendations to the Taskforce based on its appraisal.
Given the scale of the task, Professor Robinson said the Committees, which would be peer-nominated and clinically-led, would be likely to appoint subsidiary working groups.
Already, six pilot Clinical Committees have been established, including in obstetrics.
The Taskforce Chair said items suggested for review fell into one of six categories: they were obsolete, misused, under-utilised, placed undue restrictions on providers or did not reflect modern practice.
He said participants stressed the importance of Taskforce plans to share the evidence used to support recommendations about items, to improve clinical practice and inform the future direction of research.
The Review Taskforce is due to provide an interim report to the Government by the end of the year.
Professor Robinson’s Memorandum of the MBS Review Taskforce November 2015 Stakeholder Forums can be viewed at: sites/default/files/Summary%20Memorandum%20MBS%20Review%20Stakeholder%20Forums%20November%202015%20%282%29.pdf
Adrian Rollins
Health funds spend millions on unproven treatments
There is no evidence that any of the natural therapies typically covered by private health insurance deliver clinical benefit, increasing the focus on the value for money provided by health funds.
An exhaustive review of 17 natural therapies conducted by the Office of the National Health and Medical Research Council found that while a small number may provide some short-term pain relief, most lack any scientific evidence to back their health claims.
“Overall, there was not reliable, high-quality evidence available to allow assessment of the clinical effectiveness of any of the natural therapies for any health conditions,” the review, chaired by the Chief Medical Officer Professor Chris Baggoley, said.
The report, which has been with the Government for months, looked at therapies including massage, yoga, pilates, shiatsu, homeopathy, kinesiology, reflexology, naturopathy, aromatherapy, herbalism, iridology, Bowen therapy and Alexander technique – many of which are covered by insurers under their extras cover.
Medibank Private, for instance, will provide up to $200 a year toward consultations for reflexology, kinesiology, Chinese and Western herbalism, exercise physiology, shiatsu, aromatherapy, homeopathy, Bowen therapy, Alexander technique and Feldenkrais for singles with extras cover.
The Baggoley review found there was “moderate quality evidence” that massage therapy could provide immediate-term relief for people with chronic lower back pain, but said there was only very low-quality evidence that tai chi benefited health. For therapies like kinesiology, homeopathy, reflexology and rolfing it found scientific evidence was either lacking, insufficient or uncertain.
The funds argue that natural therapy cover encourages younger, healthier people to take out private health insurance, helping offset the financial drain from older and sicker members.
But critics argue it is a misuse of resources which should only be directed to therapies of proven clinical effectiveness.
The Baggoley review was commissioned by the former Labor Government, which wanted to stop paying the Private Health Insurance Rebate for therapies not backed by scientific evidence. It estimated the cut would save $32 million a year.
The report has been released in the midst of a Government review of private health insurance.
Health Minister Sussan Ley has launched a round of consultations, including a consumer survey, and has aired a range of ideas including allowing insurers to charge higher premiums for smokers or the obese, and to reduce industry regulation.
The Minister said cover for natural therapies would be considered as part of the review, but has so far stopped short of declaring the rebate for such claims would be axed.
She told The Australian that, in theory, she supported the rebate only going toward treatments backed by evidence, but said Labor’s decision to launch the Baggoley review had been “purely about desperate budget cuts…not evidence”.
Ms Ley claimed that around 500,000 dumped or downgraded their health cover in the past 12 months in a clear demonstration that something was wrong.
But AMA President Professor Brian Owler said that although there was clearly a problem, the Minister was misreading what was going on.
Professor Owler said most people were not choosing to downgrade their cover. Instead, insurers were shifting often-unsuspecting consumers onto policies with bigger excesses and more gaps and exclusions, leaving them liable for unexpected charges.
The AMA President warned that insurers, driven more by the search for profit rather than the health of their customers, were taking the health system down a path toward US-style managed care, which would see the poorest and sickest increasingly shunted into the already-stretched public health system.
Public concern about the quality of health insurance has been fuelled by relentless above-inflation premium increases and reducing coverage.
It has been reported that the funds, which are subsidised by the $6 billion a year Private Health Insurance Rebate, are seeking an average 7 per cent premium increase next year.
Adrian Rollins
[Comment] Nature’s bounties: reliance on pollinators for health
Human demands and impacts on the Earth’s life-support systems are at an all-time high. With the sixth mass extinction,1 climate change,2 and other major anthropogenic disturbances underway, understanding the wide range of vital benefits that societies derive from nature has become a global priority. A key research frontier is in characterising and valuing these ecosystem services systematically to inform investments in conservation of service-providing species and their habitats. Worldwide, about 75% of leading crops have improved yield and quality thanks to pollination by animals,3 primarily bees followed by a plethora of wild insects, and in some cases birds and bats.
2015: a year of action on many fronts
It has certainly been a year of pressing issues for the Council of Salaried Doctors. Some we’ve been directly involved in, others we’ve observed with interest. There are too many issues to cover in detail, but here are the highlights:
Bullying and harassment in the medical workplace
You can’t be precious when you work in a medical workplace. People say things in the heat of what is frequently a tense health care moment that may shock those from other environments. At other times, staff need firm direction, even performance management. Australian workplace law recognises that “reasonable management action” is not harassment.
The key thing for us is to recognise when things can go too far, or when there is deliberate sexual or other harassment of a staff member. That is not acceptable, and we must speak out about it. The AMA, along with its associated body, the Australian Salaried Medical Officers Federation, is developing a Position Statement on sexual harassment in the medical workplace to give doctors a framework for appropriate behaviour and responses to harassment.
End of Life/ palliative care
Demand for palliative care is increasing as our population ages. Patients and their families are seeking access to services to provide relevant care to people who are actually dying from their chronic and complex conditions.
Gaps remain, as our health system is not always able to offer the care that is sought. In an ideal world, governments would work together to provide the necessary funding, as well as a strong legal framework within which patient-centred palliative care can be conducted with dignity and certainty. We intend to keep this important issue in our sights.
Employment issues
Once again, the medical workforce has faced challenges to its structures and ability to cope, particularly related to teaching, research and substitution.
The China-Australia Free Trade Agreement may allow Australian health care providers to set up private clinics in China, but its effect on pharmaceuticals and other areas of health care in Australia are, as yet, undetermined.
Activity-based funding has created a situation where funding models may not adequately compensate hospitals in certain areas, leaving salaried doctors to do more work with fewer resources.
The appearance of hospitalists has been considered by the Committee and the Industrial Coordination Meeting (ICM). There aren’t many yet, but numbers are likely to increase, so we are monitoring the situation, and there will be an update of our Position Statement. We don’t want the hospitalist role to usurp that of either Visiting Medical Officers or Doctors in Training.
Safety of doctors in the workplace
The AMA has highlighted evidence that doctors are at greater risk of stress-related problems than the general population. This is why doctors’ health services are vital to both the profession and the public good.
Doctors need physically safe workplaces. They need to be sure that they are safe from hostile patients. Sound policy and proper funding are vital to this. The AMA is reviewing its Position Statement on Personal Safety and Privacy for Doctors, and the Committee is providing valuable input.
The Australian Border Force Act (ABF Act)
The ABF Act threatens two years’ jail for health workers who speak out against conditions in immigration detention centres. Despite this, more than 400 Royal Children’s Hospital Melbourne staff have refused to discharge patients who face being returned to detention, and have demanded that all children be released from detention. The ABF Act is an outrage to medical independence, clinical judgment and the industrial wellbeing of those involved in treating asylum seekers. We will continue to make representations to the Government on this issue.
Alterations to salary packaging arrangements
The Government announced in its 2015-16 Budget that it would introduce a cap of $5000 for salary sacrificed meal entertainment allowances from April 2016. A consultation process saw more than 64 submissions received, AMA included. This change affects salaried doctors more than any other group of doctors. We are greatly concerned about its potential effect on the ability of hospitals to attract and retain staff, especially struggling rural hospitals. Let’s hope the Government recognises the value to hospitals of this small incentive, though to date senators appear unmoved on the issue.
Medicare Benefits Schedule Review
On 22 April, the Government announced a review of the more than 5500 items on the MBS. What this will mean for rights of private practice (RoPP) in public hospitals is not clear yet, but various governments have in the past targeted RoPP with outrageous and unsubstantiated claims of impropriety. Let’s hope we’re not facing another witch hunt, and that the benefits of RoPP will not be overlooked.
This is the final report from the Committee for the year, so I bid you farewell until next year. Enjoy a well-earned break as we prepare for another, doubtless hectic, year ahead. Best wishes for the Festive Season.
Mapping differences in care
The AMA’s Health Financing and Economics Committee (HFEC) considered the issue of healthcare variation at its meeting on 10 October.
Members of the Medical Practice Committee joined the meeting to receive a briefing on the nation’s first Australian Atlas of Healthcare Variation, which is due to published by the Australian Commission on Safety and Quality in Health Care this month.
Associate Professor Anne Duggan, who chaired the committee advising the Commission on the Atlas, told the meeting its purpose was to inform the development of strategies, resources and tools to identify and reduce unwarranted health care variation, and to drive further investigation into variation at the local area level.
The HFEC and its predecessor, the Economics and Workforce Committee, have had a longstanding interest in health care variation, particularly how it reflects the impact of healthcare financing and funding arrangements on the delivery of health care. These are both key terms of reference for the Committee.
In its first iteration, the Atlas will be in hard copy, though later editions may be published in an interactive online format. Internationally, this is not new ground. Both the United Kingdom and New Zealand have published their own atlases of health care variation.
At its simplest, health care variation relates to the gap between what is known to be effective, based on the best available evidence and research, and what actually happens in practice.
Of course, there may be good reasons for variation across areas. When these factors are taken into account, what is left is often referred to as unwarranted variation – differences that cannot be explained by patient factors including illness or medical need, or by the evidence-based medicine that should apply.
How should we, as clinicians, approach the issue of health care variation and the Atlas?
Clinicians have a direct interest in understanding variation in the health care they provide. Knowing the results of the care we provide, how well this meets patient needs, and how these results compare (fairly and accurately) with care for other patients in other locations and from other health care providers, is an inherent part of clinical care. This is essential information for delivering effective health care and for continuing improvement as part of clinical stewardship.
As clinicians, and with and on behalf of our patients, we clearly have the most direct interest in data on health care variation. If clinicians do not engage with this issue, what is assumed to be unwarranted variation, and the actions taken to address it, will be decided by others.
But engaging with the data doesn’t mean slavish acceptance. When publications such as the Atlas are released, our first responsibility is to carefully and critically consider the data. This is essential to determine what is warranted, as opposed to unwarranted, variation.
Members of the Committee said it was important to consider why particular areas have been selected, and whether they reflect preconceptions and existing agendas about variations.
It is also important to understand what data sets have been used to provide the health care data, and whether they have particular limitations that affect comparisons across areas, such as different treatment protocols or different approaches to providing services in or out of hospital.
It should also be recognised that atlases of health care variation are unlikely to address some important factors, such as how the preferences of patients can influence the nature and location of care provided.
Overall, the Atlas should serve as a conversation starter. The data it presents (taking into account necessary qualifications) should be used to explore the amount of, and possible reasons for, variation. That is, it should be used to help inform the start, but not the end, of the health care story.
News briefs
Sonic “tractor beam” could have medical uses
The tractor beam, a Star Trek staple, could be about to happen, and there could be medical applications, report The Japan Times and The Guardian. Researchers from the University of Bristol in the UK, and Spain’s Public University of Navarre say they have developed a tractor beam that “uses high-amplitude sound waves [at a frequency of 40 kilohertz] to levitate, move and rotate small objects without making contact with them”. The waves took the form of “tweezers to lift an object, a vortex to hold a levitating object in place and a cage to surround an object and hold it in place”. “Sound cannot travel through the void of space, but it can do it through water or human tissue. This potentially enables the manipulation of clots, kidney stones, drug capsules, microsurgical instruments or cells inside our body without any incision,” one of the lead researchers said.
Two-thirds of the world’s under 50s have herpes
The World Health Organization reports that more than 3.7 billion people under the age of 50 – or 67% of the population – are infected with herpes simplex virus type 1 (HSV-1). “Some 140 million people aged 15-49 years are infected with genital HSV-1 infection, primarily in the Americas, Europe and Western Pacific”, WHO says. “Fewer people in high-income countries are becoming infected with HSV-1 as children, likely due to better hygiene and living conditions, and are instead at risk of contracting it genitally through oral sex after they become sexually active.” WHO estimated that 417 million people aged 15-49 years have HSV-2 infection, which causes genital herpes. Taken together, the estimates reveal that over half a billion people between the ages of 15-49 years have genital infection caused by either HSV-1 or HSV-2.
23andMe is back in business
Two years after it was banned from distributing health information to its customers, controversial health and ancestry information provider 23andMe is back in business, reports Gizmodo Australia. In 2013, the US’s Food and Drug Administration stopped the company from providing private customers with health and ancestry information directly from their sequenced DNA, saying it was “concerned about the public health consequences of inaccurate results from the [23andMe] device … the main purpose of compliance with FDA’s regulatory requirements is to ensure that the tests work”. Now the FDA has given 23andMe the green light to resume distributing health information, albeit in a more limited way. “The new reports will provide details about what’s known as ‘carrier status’. The tests will identify genetic mutations in DNA samples that could lead to the passing of one of 36 diseases — including cystic fibrosis, sickle cell anaemia and Tay-Sachs — on to offspring. In each case, the disease would only be passed on if both parents shared the same mutation and the child inherited both mutated genes.” 23andMe has also hiked prices from USD$99 to USD$199.
Can Google Glass help autistic kids?
Wired reports that researchers at Stanford University in the US are working on software for Google’s wearable computer, Glass, which will help autistic children recognise and understand facial expressions and, through them, emotions. Lead researcher Catalin Voss has previously developed a Glass app which recognises emotions, which is now being turned into heads-up technology for cars. The new app is designed like an interactive game. “Children are asked to, say, find someone who is happy”, the researchers said. “When they look at someone who is smiling, the app recognises this and awards points. You can plot, as they wear the glasses, how they’re improving, where they’re improving. You can look at video to understand why.” The app is now being tested in a clinical trial with 100 children.
“Flakka” worse than ice, says toxicologist
A synthetic drug considered fatal has been detected in Australia and has the potential to be worse that ice, the International Business Times reports. “Flakka” is man-made, “has a similarity to cocaine and can be injected, snorted or smoked”. It can lead to a series of extreme symptoms called “excited delirium”, marked by violent behaviour, paranoia and spikes in body temperature. Reports from the United States suggest flakka, also known as “gravel” has caused several deaths there. “Flakka comes in bulk from China and is sold through gas stations, via the internet and other dealers”. Forensic toxicologist Andrew Leibie said that the drug has become so popular with people that “it will be appearing on the streets, it will be appearing in schools, it will be appearing in workplaces.”
[Correspondence] The World Bank under the leadership of Jim Kim
I read with interest the Special Report about Jim Kim by Sam Loewenberg (July 25, p 324).1 However, I thought a few points were missing. First, those who have taken up an executive position after working in a particular discipline, know how difficult it is to be fair to their own specialty of interest. For example, when Halfdan Mahler became Director-General of WHO in 1973, after many years of working in the specialty of tuberculosis, funding for tuberculosis was severely reduced. Similarly, when I became head of the Special Programme for Research and Training in Tropical Diseases in 1986, I reduced funding for my own specialty of leprosy.
[Correspondence] Ureteric colic and clinical evidence
A fascinating aspect of clinical research is that it sometimes produces interesting findings that go against the norm. Robert Pickard and colleagues (July 25, p 341),1 for instance, published the results of the SUSPEND trial. Contrary to previous data, showing the benefit of medical expulsive therapy (MET) in the management of patients with ureteric colic secondary to ureteral stones smaller than 1 cm,2 the authors showed that neither tamsulosin 0·4 mg daily nor nifedipine 30 mg daily are effective at decreasing the need for further treatment at 4 weeks.