Following the ABC Four Corners program on health costs in Australia, there have been a number of very good follow up articles.
The first, in The Conversation on 29 September is by Ray Moynihan ‘Costly and harmful: we need to tame the tsunami of too much medicine’.
The second, in the AFR on 5 October, is by Neil Soderlund, Sam Stewart and Jan Willem Kuenen is entitled ‘Why overtreatment is costing Aussies $30 billion per year and how to fix it’.
A quick glance at the last page of the most recent issue of the MJA reveals that there is as yet no replacement editor-in-chief and that two of the most senior medical editors – Janusic and Armstrong – are missing in action, as is the Editorial Advisory Committee. There is an interim editor. Many of the assistant editors have gone as well – replaced in the AMA president’s memorable words on ABC Radio because all they did was move words around on the page. This they had been doing, together with checking facts, assertions, arithmetic, grammar, syntax, clarity and originality of submitted papers and keeping the faith in the MJA community some for 20 years. This activity was now to be done by anonymous staff employed often overseas by the publishing giant Elsevier.
How this role for Elsevier allows them to claim copyright if all that they are doing is moving words around on the page as you will find they do in the fine print at the bottom of the back page of the MJA describing the editorial staff, I do not know. I assume that it is part of the commercial deal done by the Australasian Publishing Company, AMPCo that used to be the sole publisher of the MJA on behalf of the Australian Medical Association. If you publish in the MJA now, copyright over your paper is held in part by Elsevier.
The large publishing companies that have scooped up and repackaged knowledge and science are like giant fishing trawlers. I leave it to you to contemplate the similarities.
When I took on the job as editor-in-chief a little over two years ago I did so understanding the risks because AMPCo has a grim reputation as an employer and because the AMA and I are not natural bedfellows, but those risks did not extend to working with or for Elsevier. I do not propose to rehearse today the many reasons why I consider Elsevier to be an untrustworthy company – you can read about the rebellion of the Dutch and French governments over their pricing policy in selling subscriptions to their journals on the Web site friendsofmja.net and a Google and Wikipedia search will lead you down into the dangerous and murky canyons of their dealings with research workers, pharmaceutical companies, universities and libraries. They are not the kind of organisation that you would consider taking home to meet mother, assuming that you get on well with your mother.
Few academics know the details of what the big publishers have been up to for the past 20 years and anyway many scholars have vested interests in not rocking the boat because they need to publish to progress. I am 73 and at a point in my career where these things no longer matter. But this aside, what does matter is what happens to a journal, 101 years old that has belonged to the premier medical association in Australia. Despite lots of ups and downs and complex dealings with advertisers and its owner it has been a good custodian of professional values, committed as promised in its first issue, to the publication of research and policy. What happens when it becomes part of the Elsevier stable?
A quotation to outsource production of the MJA was obtained from three companies of which Elsevier was one and presented to the AMPCo board in November last year after I had left the meeting and without my knowledge. The bid had been prepared with no consultation with me or the editorial staff but with the AMPCo management staff. I disagreed with the generous estimates the bid contained of how much could be saved and my colleagues and I offered detailed alternatives. These were not accepted.
On April 28, without discussion of alternatives, I was summonsed to meet the chairman of the AMPCo board at midday who issued me with a letter of termination. I was then accompanied to my office by the HR manager to identify my goods that were to be packed and sent to me. The shocked editorial staff who had gathered outside my office and I repaired at 1 pm to a local coffee shop for an hour. This event was described by the AMA president at the AMA Conference in Brisbane recently as the staff taking the afternoon off to go to the pub with me and that AMPCo paid. AMPCO indeed DID pay (I had offered), all of $100 but for coffee. The receipt is on file. A PR company was hired, I assume at a generous rate, to handle this debacle, all remaining staff being prevented from public comment. AMPCo’s second sacking of an editor-in-chief in the past four years – there have been several before us as well – proceeded with surgical precision and the guillotine blade did not squeak through disuse as it fell. I was not warned about dismissal or given a chance to resign. All these details and more can be read in full detail on our Web site friendsofmja.net You will be relieved to know it is open access.
Like my predecessor, whatever our faults, I was passionately committed to the future of the Journal and all the editorial staff – not just the medical editors. These people were my professional colleagues who participated in planning substantial changes to the journal following reader consultation. We were doing well. But the bottom line is what matters. What lessons can be drawn from this?
First, corporate values rule in publishing at present. Others will speak about this. The effects of the commodification of knowledge – where a publisher asks to be paid to publish your paper, keeps the copyright, limits access to the paper and charges libraries a king’s ransom for bundled subscriptions, is scandalous. Universities pressed on all sides to conform to bureaucratic and mangerialist principles to maintain their funding base, judge the performance of their academics by publication citations and indices of unproven validity about research productivity, provided by the publishers.
Second, academics have let this happen under their noses and I do not believe that the indifference to what has been happening in libraries and journals has been ethical or impressive. Colin Steele, a research fellow at ANU who has taken a detailed and long-standing interest in this process, has written:
There are two competing, and at the moment, irreconcilable forces operating in scholarly communication. On the one hand [there is] the recognised need for scholarly exchange and, on the other, the increasingly embedded publishing system, and the rewards enshrined in the dominant Thomson and Elsevier article metrics used for research assessment and University league tables.
Specialty journals have profited from aligning with big publishers every bit similar to the snouts-in-the-trough behaviour involved in accepting sponsorship for conferences and travel from the pharmaceutical industry. We academics and universities are far from blameless.
Third, information technology is transforming the collection, collation and dissemination of knowledge. This offers hope. Knowledge has been commodified in recent decades but this will not last. The big publishers had best make their bucks during the remaining fat years because the lean years are coming when now forms of information dissemination out will displace them. Neoliberal managerialism and commercialisation will pass as surely as older faded ideologies have done. Think of open access and new forms of electronic information management as being like a vaccine against polio. When we have it we will not need the iron lung corporations with metal pumps to help us breathe.
Stephen Leeder is the immediate past Editor-in-Chief of the MJA. He is Emeritus Professor of Medicine at Sydney University. Professor Leeder presented the above speech at a recent symposium ‘Reclaiming the Knowledge Commons: The Ethics of Academic Publishing and the Futures of Research”. The speech was published in the Weekly Report Issue 15 of the ‘Friends of the MJA‘.
A recent study from Monash University found that a quarter of all alcohol advertising on Australian TV was during televised sports. Importantly, 86% of alcohol advertising between 6.00am and 8.30pm (that is, when kids are most likely to be watching TV) was during sports programming.
The broadcast of alcohol advertisements on commercial television in Australia is restricted in order to limit the exposure of young people to alcohol advertising. Alcohol advertising is only permitted during periods of M (mature classification), MA (mature audience classification) or AV (adult violence classification) programs (which are restricted to between 8:30pm and 5.00am).
The one – completely counter-intuitive – exception to this is that the broadcast of alcohol advertisements is permitted during the live broadcast of sporting events on weekends and public holidays. It is not surprising that this ‘exception’ results in alcohol advertising being shown at the time that children and teenagers are most likely to see it and most likely to be influenced by it.
Free TV, which represents the television networks, wants to bring forward unrestricted viewing hours from 8.30pm to 7.30pm. Conversely, Prof Kerry O’Brien and his team at Monash (like most of us in public health) wants the reverse – moving the kick-off time for alcohol advertising from 8.30 to 9.30pm..
Even more than that, what we’d really like to see is the removal of the ‘exemption’ for live sport; an exemption that FreeTV defends but is unable to justify. An exemption that the rest of us recognize for what it is: a clear message that the money-makers are more interested in protecting alcohol advertisers than protecting kids.
The World Health Organization’s European Charter on Alcohol 1995 asserts that:
“All children and adolescents have the right to grow up in an environment protected from the negative consequences of alcohol consumption and, to the extent possible, from the promotion of alcoholic beverages (and) … no form of advertising is specifically addressed to young people, for instance, through the linking of alcohol to sports.”
In relation to sport, the current iteration of the Alcohol Beverages Advertising Code (ABAC) states that a Marketing Communication must NOT show (visibly, audibly or by direct implication) the consumption or presence of an Alcohol Beverage as a cause of or contributing to the achievement of personal, business, social, sporting, sexual or other success.
The previous version of the Code also used to say that alcohol advertisements must NOT “depict any direct association between the consumption of alcohol beverages, other than low alcohol beverages, and the operation of a motor vehicle, boat or aircraft or the engagement in any sport (including swimming and water sports) or potentially hazardous activity” but now it says “before or during any activity that, for safety reasons, requires a high degree of alertness or physical co-ordination, such as the control of a motor vehicle, boat or machinery or swimming”.
Somehow, in its efforts to toughen up the Code and better protect kids from inappropriate messages about alcohol, the ABAC managed to drop the specific reference to sport. Does that make you wonder whose well-being they are protecting?
What is particularly problematic about the ‘exemption’ for alcohol advertising during live sport broadcasts is that it opens up a mammoth marketing opportunity that goes far beyond the commercial breaks.
In a study funded by the Cancer Council Victoria, we analysed the television coverage of the 2012 AFL and NRL finals matches on WIN and Prime (in the Illawarra NSW). The AFL finals averaged three minutes of alcohol commercials and an additional 17 minutes of alcohol marketing per game. The NRL finals averaged just over two minutes of alcohol commercials and an additional 28 minutes of alcohol marketing.
A few years ago we conducted interviews with children aged 10 to 12 years about their engagement with sports. The children associated playing sport with positive life outcomes such as good health, success and maintaining a healthy weight. Watching sport on TV was a regular part of life, especially for boys. The children were also aware of the concept of sponsorship and were able to identify the sponsors of the sporting teams, including the alcohol sponsors. They also remembered and recognized alcohol ads, and expressed strong positive associations between alcohol brands and sport.
Participant: that’s a very good one [VB] because most men drink. . . Especially like when they play sports, and yeah and when they’re tired from sports they might go and then have a drink and stuff.
Public health advocates and organizations focused on the wellbeing of young people are united in their view that alcohol advertising and alcohol sponsorship are harmful to young people.
While the industry would state that they are only targeting those over the age of 18, their messages are clearly being heard, and internalized, by even very young children. Surely it is time for our government to recognize that, even in a country that supports free trade, protecting our children must be a higher priority than protecting the alcohol industry.
Professor Sandra Jones is an ARC Future Fellow and Director of the Centre for Health and Social Research (CHaSR) at the Australian Catholic University (Melbourne).
I have frequently raised my concerns about the ability of the Department of Health and Ageing to develop good health policy and manage health reform. A test of the new Minister is whether she can help facilitate the necessary reform. See below links to two earlier articles I wrote on this problem. The first is a capability review of the Department of Heath and Ageing by the Australian Public Service Commission. The second is a report by the Australian National Audit Office of DHA’s administration of the Fifth Community Pharmacy Agreement.
Both reports raise very serious issues.
Harry Anslinger’s dream to rid the world of drugs was given legs in 1930 when he was appointed the first commissioner of the U.S. Treasury Department‘s Federal Bureau of Narcotics.
He was a brilliant bureaucrat with a grand vision underpinned by prohibition; a man who single-handedly turned a marginalised, underfunded Bureau into an uncompromising and powerful war machine.
But, as Johann Hari reveals in his compelling book “Chasing the Scream – the first and last days of the war on drugs,” Anslinger was also a zealot and racist:
“The most frightening aspect of marijuana, [Anslinger] warned, was on blacks. It made them forget the appropriate racial barriers – and unleashed their lust for white women.”
Harry’s dream has become a global nightmare.
A story:
I’m not sure of the exact date, but I’ll never forget the encounter.
I first met ‘Sally’ (not her real name) in late 1997 at St Canice’s parish, Kings Cross.
She was homeless. She was an addict. She was paid for sex.
Sally was exhausted – her life was exhausting.
She needed some respite – just a couple of nights in a safe place, please.
At that time, St Canice’s was providing temporary shelter for working girls just like Sally. The accommodation was very basic: a small room with a single bed and a sink overlooking the church’s carpark.
For a brief period, it was my responsibility to help clean the room and welcome its guests. It was a simple process: strip the bed, put on clean sheets, wash the floor and sink, and empty the bedside bin which was a popular hang-out for used syringes.
This is how I came to meet Sally. She arrived one afternoon set for a couple of night’s accommodation and we had a chat:
Cuppa, Sally?
Yeh, that’d be good, thanks.
How’d you sleep?
Not bad; it’s nice to be safe, which ain’t too common given me lifestyle.
It must be awful feeling so unsettled …
Yeh, not much fun; not much of a life, neither.
If you don’t mind me asking, how long have you been using … and living on the streets?
God, I’ve been usin’ since I was a teenager … almost 20 years now!
Sorry, excuse me; the kettle’s boiled; any sugars?
Yeh, three, please … make it four.
Biscuit?
Ta; that’d be nice.
There you go, hope it’s not too strong.
Perfect, ta.
Yeh, I had me first shot when I was fourteen. Mum used to entertain a lot, if you know what I mean; not nice blokes, neither. They used to rough me up quite a bit; had a pretty terrible childhood, really. Mum was a user too. That’s how I got into the gear … and prostitution.
Hope you don’t mind me asking; but do you think you’ll ever escape all this; the drugs, the …?
Look, gettin’ off the gear’s the easy bit; but what for? What am I goin’ to do when I get off it? I’ve been a prostitute and user since I was fourteen; haven’t worked for nearly 20 years; not much of a CV. Not much of a story for a future employer, is it? The thing people don’t understand is that all me friends are users, too. This is my world. This is all I know. So, if I stop usin’, it means I’ve gotta give up me friends as well. I’d have to find another world. It’d be like startin’ all over. I’m not sure I can do that. I’m not sure I’d know where to start … it’s not just a physical thing, drug addiction …
_________________
When one listens to stories like Sally’s, two things become apparent: firstly, how traumatised and sick she is, and secondly, how much her drug induced chaos makes sense, as terrible as that may sound. After all, why wouldn’t she pursue relief from such unbearable psychological pain – ever had a knee replacement or a tooth pulled and refused pain-killers?
As many addicts will tell you, addiction is really a disease of loneliness and self-worthlessness – much of it stemming from abuse.
Indeed, “it’s not just a physical thing, drug addiction.”
And here-in lies the problem with the war on drugs: it is a war that predominately targets the sick and the weak and the poor.
It is a war against the Sallys of the world who, thanks to prohibition, are forced to hunt for their pain relief amidst wicked and brutal people in wicked and brutal places.
One might even say we have criminalised pain relief.
Yet still, after almost a century, most of the generals and policy boffins prosecuting this war continue to pursue Mr Anslinger’s ideology of prohibition and criminalisation: if you get rid of the chemicals and swat away the users and sellers, all will be well.
But all is not well wherever this ideology abounds.
Indeed, prohibition has inadvertently created another war: the war FOR drugs: a murderous, multi-billion dollar free-for-all overseen by transnational cartels, gangs, and assorted opportunists.
The global misery and damage is incalculable.
This tsunami of crime has also spawned a brutal and unjust judicial system; one which powerfully prosecutes the weak and weakly prosecutes the powerful. Look who is filling our gaols: in the U.S. and Australia it is those who are poor and black and addicted – Mr Anslinger would be pleased.
The nature of this racist backdrop is encapsulated in the following exchange between decorated American police officer, Matthew Fogg, and one of his superiors. Once again, we turn to Hari’s “Chasing the Scream”:
“Fogg was bewildered as to why his force only ever went to black neighbourhoods to chase drug users. He suggested to his boss they start raiding white neighbourhoods as well.
“‘Fogg,’ his boss said, ‘you know you’re right they are using drugs there but you know what? If we go out and we start targeting those individuals, they know judges, they know lawyers, they know politicians, they know all the big folks in government. If we start targeting them … you know what’s going to happen? We’re going to get a phone call and they’re going to shut us down … There goes your overtime. There goes the money that you’re making. So let’s just go after the weakest link. Let’s go after those who can’t afford the attorneys, those who we can lock up.’”
The war on drugs has encouraged governments, police, the law, and us to look upon the Sallys of our world with a dismissive contempt. Thus, Sally and her ilk are swatted off to the streets and into humiliating prison settings which are far more adept at re-traumatising the traumatised than rehabilitation.
When asked how Australia might most effectively respond to the drug problem, Dr Alex Wodak AM, President of the Australian Drug Law Reform Foundation, had this to say:
“We should be making primarily a health and social response. I say ‘primarily’ because there should always be some law enforcement; if there was a tanker full of heroin coming to our ports I like to think something would be done about that.
“But this is also about gross inequalities in our communities. Australia is a much more unequal county compared to countries in Scandinavia, or Japan that have lower levels of drug use. Generally the more unequal the country the higher the levels of drug use.
“From a social perspective, we should do everything we can to keep people who use illicit drugs integrated in the community, and if they fall out then we should help them reintegrate. One of the most helpful things we can do is encourage them to get a decent education and some training and help them gain meaningful employment that will maintain their self-respect.
“From a health perspective, let’s say it was your sister with the drug problem and she really wanted to stop. Every relative would want her to go to a counselor or health professional rather than be picked up by the police. The criminal justice system is stigmatizing, if your sister was to go to jail the stigma will always hang over her… when finding a boyfriend, getting a job, renting a place. Making sure people are not irretrievably damaged is very important.”
Hear, hear. Sally’s worth it.
Peter Day is a Catholic Priest in Canberra.
As I reflect on the ongoing complaints at federal and state level about our ailing health system, widespread community concerns and a medical culture which is still often hospital- and doctor- centric, I wonder how we will be able to sort it all out.
In the 20th Century, when average life expectancies were in the 60s and 70s, we died from a range of illnesses, but often from vascular diseases (heart attacks and strokes) and cancers. With our increasing longevity, the 20th Century diseases are being replaced by the neurodegenerative diseases of the 21st Century. These include Parkinson’s, motor neurone disease, the dementias (Alzheimer’s being the most common one in Australia) and many more less well known. They involve physical and very often cognitive elements, marked by increasing frailty and dependence. Impairment of mobility, balance and all the senses (hearing, vision, taste, smell and touch) are common features. They are all progressive.
In what ways is this world of neurodegeneration different?
Our hospitals are no longer full of acutely unwell younger people, as they were even during the period of my training. Many hospitalised patients now are older people who have had a fall, become delirious with a trivial infection, become confused after some “relatively” minor event, or are just not coping. The old rules simply no longer work.
First, our patients very often lack adequate cognition to give us a good history so that an appropriate diagnosis might be made, or lose their cognition over time. This means that a collaboration with family or care-givers is required to provide satisfactory management.
Second, the notion of confidentiality and privacy must be reconsidered. Those patients with failing cognition are vulnerable to their own lack of understanding, judgement and decision-making, abuse by others, bureaucracies, and a community health system which is still the poor cousin of hospital care. Families and care-givers frequently complain that doctors will not hear their concerns, and feel demeaned or angry when their stories are not heard or believed.
Third, neurodegeneration is not “curable”. There might be exacerbations of ongoing problems, or superimposed illnesses (often due to falls or infections) which can be treated. But in the main, these conditions are palliative. That means that there should be an early diagnosis, a plan generated, and families and care-givers as well as health professionals all party to it. Care-givers must know what’s ahead. It is essential that there is recognition of the palliative focus, and that each of these conditions is relentlessly progressive. Just how much do we put a frail elderly person through so that the same thing can occur within days or weeks of hospital discharge? How often do we ask our patients (and their families or care-givers) what they want? It’s OK to die. We will all do it, and we have no control over that. But we do, or should, have control over the manner of our death.
Fourth, admitting to hospital these frail elderly people is often bad medicine and it’s bad for the health system. The effect will be to “decondition” the patient so that an admission of a week with the presenting problem my well require a month or longer in rehabilitation in an effort to restore to function.
Solutions to the myriad problems of our ailing health system are complex. But talk of more beds and more doctors in hospitals misses the point. We need to understand our patients, and their needs and preferences. We need to stop pouring our precious health dollars into the seemingly bottomless pit of our hospital system and concentrate on prevention of these precipitants of admission, and to re-direct the resources into the community. Dementia alone is threatening to cripple the health system. Carers are carrying a huge and increasing burden with little recognition or meaningful support. When things go wrong, the fall-back position seems to be to admit to hospital, a choice which just happens to be the worst for everyone. Having a proper, well-resourced and comprehensive system of community care for those with dementia, backed by well-informed health professionals, supporting families and carers, is essential.
Reading Death Rules: how death shapes life on Earth and what it means to us by Queensland Palliative Care physician Dr Will Cairns (Vivid Publishing, 2015), and Being Mortal: Medicine and What Matters in the End (2014) by American writer and surgeon, Dr Atul Gawande should be mandatory for health bureaucrats and clinicians.
As we learn to appreciate the impact of neurodegeneration, we should constantly reflect on this question: what are we really trying to achieve? It’s all about people, and about how to give each of us the best time possible. It is not now about prolonging life at all costs.
Improving care for those with neurodegenerative conditions and supporting their carers, will also serendipitously aid the health care system. It might be more expensive in the short term. And certainly there will be considerable system reconfiguration, with substantial emphasis on education for both health professionals at all levels, and the community. The biggest challenge, though, might be the required culture change.
Advertisement: a good start for education on dementia might be to enrol in our Understanding Dementia MOOC (Massive Open On-Line Course) which can be found at www.utas.au/wicking/wca/mooc
Jane Tolman
(Associate Professor in Aged Care at the Wicking Dementia Centre at the University of Tasmania, previously Director of Aged Care in the Tasmanian health system)
Nurse Practitioners were provided access to the MBS in November 2010. Besides limited access to pathology/radiology, nurse practitioners were provided with four time-tiered MBS item numbers for professional attendances. While most nurse practitioners have established themselves in public hospitals, primarily because of the relative financial certainty it provides, there are a handful of NPs trying to establish a niche in primary care.
There is tremendous amount of debate in primary care about burgeoning Medicare costs and the ability to offer fully subsidised primary care. Whilst GPs are well placed in primary care, primary health care nurse practitioners have demonstrated to be an excellent resource in providing care that is safe, effective and affordable. Besides improving patient satisfaction, primary health care nurse practitioners facilitate a focus on complex and chronic care needs, which may increase patient throughput and productivity. Such services provide excellent examples of nurse practitioners offering value-added service at little cost. Nevertheless, primary health care nurse practitioners face daily challenges, some of which are worth mentioning. This in order to gain better understanding of these problem/s and convert such challenges into possibilities for change into the future.
Challenges:
Opportunities:
Minister of Health Hon Sussan Ley recently announced a new payment model that encourages General Practices to provide after-hours services. Though specific eligibility has not been announced, it is hoped that nurse practitioners working in collaboration with GPs are included in this arrangement.
At the same time an MBS Review Task Force has been announced. This taskforce will examine the relevancy of 5500 MBS item numbers and align them with clinical evidence. While this is encouraging there are no nurse practitioners on the review panel. This presents a missed opportunity to provide informed financial consideration of the nurse practitioner role in general practice.
The Primary Health Care Advisory Group (PHCAG) is another excellent announcement and shows the Minister’s commitment to support patients with chronic and complex health conditions. Except for the inclusion of the chair from the Australian Practice Nurse’s Association, nurse practitioners are missing from the advisory group. Perhaps it is time for a change of heart.
Nurse practitioners are underutilized in primary care due to financial constraints. This missed opportunity places added burden on GPs, and contributes to strain on the public health system. Small increases in government spending to improve access to existing MBS item numbers (at a reduced rate, e.g. 85%) will encourage nurse practitioner numbers in primary care and provide an impetus for practice nurses to enroll in nurse practitioner programs. While practice nurses work tirelessly, nurse practitioners provide an advanced level of expertise that can support general practices in a greater cost-effective manner.
Conclusion:
The current government is committed to cost savings in health and primary care is proving to be one of their toughest challenges. Primary health care nurse practitioners working together with GPs offer real support to all aspects of chronic and complex health problems, with the potential to contribute to real health systems savings. New payment initiatives and advisory committees demonstrate the government’s commitment to cost savings and evidenced-based care. Greater consideration of the primary health care nurse practitioners role can help support this Government’s aspirations. This valuable resource should be allowed to work to its full potential to demonstrate the potential of a cost saving alternative in the long term.
Mack Madahar is a PHC and MH nurse practitioner. He acknowledges the valuable input of Chris Helms, RN, NP, MSN, ANP-BC, FACNP, in writing this paper.
To justify an increase in the GST, Premier Baird has joined the long list of conservatives who keep telling us that our health system is unsustainable. Earlier the Treasurer, Ministers for Health and the Commission of Audit warned us in one way or another that the Australian health service is unsustainable, particularly with an ageing population.
The fact is that it is sustainable. .
We need to keep modernising Medicare but by almost any international comparison we have one of the best and most sustainable health services in the world. We need to keep our problems in perspective.
The Commonwealth Fund publishes a regular research report on health systems in major countries. The Commonwealth Fund is a highly regarded private US foundation that compares major systems around the world to stimulate innovative policies and practices in the US and elsewhere.
In its 2014 report ‘Mirror, mirror on the wall’ it compares the performance of healthcare systems in eleven major countries. The comparisons cover quality of care, access, efficiency, equity,‘healthy lives’ and health expenditures per capita.
Its overall health ratings for these eleven countries were as follows:
On almost all the measures the UK with its National Health Service is a stand-out performer. . Grounded in primary care and with a single payer it has well and truly stood the test of time. The regular laggard in almost all these rankings is the US. It tells us a great deal about the failure of a health service based on multiple private insurance payers. Our private health insurance lobby is trying to take us down this disastrous US path.
When one looks at the break-down of these rankings, the UK ranks at the top in quality of care, access, efficiency and equity. US ranks last in access, efficiency and equity. What is more, the UK system is the cheapest at $US3,405 per capita in 2011 compared with the US, the most expensive at $US8,508 per capita in that same year.
As indicated, Australia stands at number four in overall rankings amongst the eleven countries. In particular areas we ranked as follows
Another measure of our success of course is our high life expectancy.
It is quite clear that by world standards we rank quite well. We are behind the UK, but far ahead of the US. . Medicare has served us well but is 40 years old without major review.
But there are ways that we could improve our health services.
There are many ways in which the efficiency of our system could be improved and costs better managed.
There is clearly a lot we can do to improve healthcare in Australia and better manage costs. But overall, we have a very good and sustainable health service which ranks well against comparable countries.
Sorry if I keep repeating myself on health care but the myths about our unsustainable health care are recycled time and time again and seldom contested.
Premier Baird has announced that he will require a 15% GST to fund our public hospital system in the coming years. It is certainly true that with present policies, revenue won’t match the cost of the anticipated future demand for hospital care. Hospital admissions climb steadily each year (average increase 3%) and the additional patients tend to be sicker and older. Our current health system puts pressure on our State and Territory governments to constantly find more beds and provide new hospital stock. Without financial restructuring his government will not be able to provide us with the quality service we need and expect. The better targeted suggestion from Victoria that we increase the Medicare levy won’t provide the money needed. The current levy only covers about 50% of the cost of Medicare.
However financial restructuring can involve two, not necessarily mutually exclusive tactics. In the policy vacuum that has absorbed Australian politics like a black hole, the easy tactic is for government to ask Australians for more money. A far better approach would see us at last addressing the structural inefficiencies in our health system that would provide savings that at least for health care, would make this huge increase in a regressive tax unnecessary.
Premier Baird’s problem is that the structural levers that need to be pulled to improve the health of the nation and its budget are in Canberra. It’s the Federal government that funds the majority of our primary (GP) and community care and it’s the inability of both, as currently structured, to reduce the demand for hospital care that so frustrates State and Territory governments. Any review of the benefits or otherwise of our federal system will reveal that it has created rather than solved many problems for cost-effective, equitable delivery of health care.
Our taxpayer funded public health system spends more than 55 billion dollars a year on hospital care but only 19 billion dollars a year on primary care. However, wearing federal blinkers, the federal government looks at Medicare as if it was a stand-alone health system and State and Territory governments are forced to focus on hospital care. Health economics 101 and much reliable international evidence tells us that if we spend more money on a structurally reformed primary care system we would save far more than these reforms would cost by significantly reducing the demand for hospital services. This is the “win, win” path we should be taking, not an increase in the GST.
Premier Baird and his fellow Premiers are looking at escalating fiscal problems for hospital funding over the next ten years. What we need is to take a reform journey through that decade that would see us still spending about 10% of our GDP on health but having a healthier population requiring far fewer trips to hospital. At least eight OECD countries are well advanced on that journey and many have evidence of reductions in hospital admission rates of 20-35%.
Available evidence tells us that the most important change our health system needs would see us introduce a model of primary care known as “Integrated Primary Care”. This model places an emphasis on prevention of disease (only 2% of our current health budget is spent on prevention), early detection of changes that could develop into chronic conditions if not treated in time, in house “team management” of all the health needs of those who have an established illness and outreach services from the practice into the community to treat individuals who otherwise might need hospital care. Research reveals that more than 600,000 admissions to our public hospitals each year could have been avoided with an appropriate community intervention. Around the world the model is increasingly referred to as a “Medical Home”. One enrols in this entity wherein multidisciplinary teams of health professionals can provide the above services. International experience shows us that patients and health professionals enthusiastically embrace the model.
As our federation is reviewed and our health care costs are wrestled with, consider the following inefficiencies that should also be addressed before considering an increase in the GST. We have nine departments of health for 23 million people. Duplication costs us 2-3 billion dollars a year. We spend over 6 billion dollars a year subsidising private health insurance using the false argument that such spending will see private hospital care reducing the demand for public hospital services. It doesn’t. The money would be much better spent on improving primary care and reducing admission to both public and private hospitals. My profession is steadily tackling the very unprofessional expenditure of up to 10 billion dollars a year on low value or no value procedures and tests. Australians spend 3 billion dollars a year buying vitamins and “supplements”, not needed by the vast majority of us, as they are led to believe you can neutralise an unhealthy lifestyle with something out of a bottle.
Tackling these problems as we progress along our health reform journey will provide us with a health system for the future that is second to none, equitable and cost effective. Even if we could afford a massive increase in the GST it would be money poorly spent on a health system calling out for reform. Now where oh where is the political leadership to take us on this productive journey?
John Dwyer is Emeritus Professor of Medicine at UNSW.
Troubles at the Medical Journal of Australia and the birth of ‘Friends of the MJA’
The Medical Journal of Australia (MJA) has been in existence for over 100 years and has become the most important national publication for every aspect of the health and health care of Australians. It is owned by the Australian Medical Association (AMA) and is published by the Australasian Medical Publishing Company (AMPCo), a wholly owned subsidiary of the AMA. AMPCo makes a profit on its Medical Directory* but, like other journals of medical associations around the world, makes a loss with the MJA. The loss is subsidised by the annual membership fees of AMA members and the current subsidy per member is believed to be approximately $80 per member. Annual membership of the AMA costs up to $1446. [*The Medical Directory is the only available comprehensive listing of all doctors, with information about qualifications, special interests, practice addresses, publications etc.]
In early May, 2015, AMA members, and the medical profession generally, learnt via the media that the AMPCo Board had sacked its Editor-in-Chief, Professor Stephen Leeder without warning and had contracted with international publishing conglomerate, Elsevier, to publish and subedit the MJA(see (http://www.smh.com.au/national/medical-journal-editor-sacked-and-editorial-committee-resigns-20150503-1myr8q.html). The reason for sacking Professor Leeder was stated to be his unwillingness to work with the AMPCo Board in the outsourcing move to Elsevier. The justification given for outsourcing was to reduce costs. No information has been provided about the terms of the Elsevier contract. The future of the entire editing and subediting staff of the MJA remains unclear. In response to the news, eighteen*of the 22 members of the Editorial Advisory Committee of the MJA resigned, along with two full-time deputy editors. [* A nineteenth has since resigned.]
Senior members of the medical profession were astonished at these events and extensive media coverage resulted. Adverse coverage also appeared in Canada, USA, UK, India and France. In response to widespread concern within the medical profession, a group known as Friends of the MJA established a web site http://www.friendsofmja.net.au/ with the purposes of providing interested parties with all the available background information on this matter and of assessing the level of support for the actions of AMPCo.
To date, over 350 people, including many senior members* of the medical profession and of allied professions who rely on the MJA, have used the website to sign on as ‘Friends of the MJA. These people are listed on the website. Not one has supported the AMPCo actions. [The group includes 124 full professors and 65 doctors who have been awarded Australian honours for services to medicine.]
Initially, the dismay and distress over the actions of AMPCo centred on two aspects: (a) how such an effective and highly respected Editor-in-Chief could be not listened to by the Board of AMPCo and be summarily sacked and (b) the selection of Elsevier as a publishing partner. AMPCo responded by claiming that “due diligence” had been undertaken with regard to Elsevier but declined to comment on whether the four AMPCo Board members were fully aware of Elsevier’s track record (see http://en.wikipedia.org/wiki/The_Cost_of_Knowledge and https://en.wikipedia.org/wiki/Elsevier).
While these two aspects are still of deep concern, a much more important issue has emerged, namely the effect of a working relationship with Elsevier on access to the research findings of publicly (taxpayer) funded research. Internationally, boycotts of Elsevier have been sponsored by researchers and even government in reaction to Elsevier’s pricing and related policies. (see http://www.theguardian.com/commentisfree/2011/aug/29/academic-publishers-murdoch-socialist and https://unlockingresearch.blog.lib.cam.ac.uk/?p=192). This issue, together with the lack of any reassurance that a future editor of the MJA will have editorial independence from the AMPCo Board, and that the AMPCo Board itself will be free of interference by the AMA leadership of the day, make many in the medical profession fearful for the future of the MJA.
The Steering Committee of Friends of the MJA have asked that the AMPCo Board decisions be reversed, that a new Board be appointed and that an independent expert be commissioned to advise the new AMPCo Board on the best way forward from here. In the absence of any willingness of the AMA leadership to revisit these ill-judged decisions, the AMPCo Board must, at the very least, be restructured to bring in additional members with experience in medical publishing and a charter of independence for the Editor must be agreed upon. Without these latter two minimal steps, it is highly unlikely that a new editor* of standing will be recruited, making the future of the MJA bleak. [*Note: The MJA was expelled from the International Committee of Medical Journal Editors after the previous editor was sacked in 2012. It has not been readmitted.]
As at 10 July 2015, the leadership of the AMA and the AMPCo Board have been unmoved by these protests and instead have responded by criticising the Friends as being “mates” of Professor Leeder and being intent on harming the MJA.
Dr Kerry Breen (convenor of the Steering Committee of Friends of the MJA) may be contacted via friendsofmja@friendsofmja.net.au . He is a Specialist Physician who has been a member of the AMA for fifty years and a regular contributor to and reviewer for the MJA. He currently holds a post of Adjunct Professor in the Department of Forensic Medicine at Monash University. He is a Past President of the Medical Council of Australia, a Past President of the Medical Practitioners Board of Victoria and a Past Chair of the Australian Health Ethics Committee of the NHMRC.
More information, including material issued on behalf of the AMA and AMPCo can be found at http://www.friendsofmja.net.au/ where readers can also register their view and sign on as Friends of the MJA.
I understand that at the recent National Conference of the AMA there was general support for a move to help funding systems other than just fee-for-service. Ross Kerridge examines this issue below. John Menadue
Healthcare Heroes. How to reward GPs for what they do best: a hospital specialist’s proposal
There is an old saying in healthcare: – “If the GP is good, a specialist may be able to help. If the GP is bad, nothing will help.”
The Junior Doctor has asked my advice about a 78 year old woman who has been booked for a hip replacement next week. She has the features common for her age – touches of heart disease, diabetes, emphysema, and her husband died three years ago. Children interstate. She’s maybe a bit forgetful. Not really sure about her regular medication, but says she is still living independently. “Seems a nice old lady and quite active but it’s a bit hard to be sure from just meeting her today.”
Preparing her properly needs more information. So does planning her postoperative care. The GP is the key to sorting it out….. “OK, who is her GP?” I ask.
“She doesn’t have a regular GP any more. She goes to the 24-hour medical centre. We have two different versions of her medication and little information about her visits to specialists. She’s a bit vague about where she’ll go after discharge. The family situation might not be as good as she said at first….”
Heart sinks. Groan. Oh dear….
I start… “OK. She needs proper assessment. Can we get someone from General Medicine to check her over? What about Geriatrics? Has she had spirometry from the respiratory team? Does she need a cardiologist? Social work will need to be involved for discharge postop. We need results of bloods, echo, any other tests from the last year or two. Need to clarify the home and family situation. We could get caught here with her stuck in hospital and not able to go anywhere. Hmmm. This is going to take a while to sort out. We’d better postpone her op. Hopefully we can get someone else to take her place on the list…… I just wish patients understood why they need to get a proper GP.”
I feel a failure. But the system of Medicare payments has failed our patient.
Modern medicine can perform extraordinary things. But the major challenge of healthcare in the 21st century is coordinating all the ‘simple’ tasks: managing the evaluation, treatment and coordination of multiple chronic conditions in the elderly. While patients and families must play a role, a single health professional needs to coordinate what is going on. And they should be paid for the value of that role. In Australia, the General Practitioner is the key to achieving this increasingly complex challenge. But Medicare does not support this role, and is increasingly undermining it.
Medicare is based on Fee-for Service payments. Services are defined on the Medicare Benefits Schedule. So a patient seeing a GP for a standard consultation can claim a standard rebate. For one-off patient problems, the Medicare system has worked well, and provides a baseline level of access to medical services. But patients have sets of inter-related problems. Bizarrely, Medicare does not reinforce the most important and valuable service that a GP can provide – that of co-ordinating and supervising all the various interventions by hospitals, clinics, specialists, allied health professionals and so on. The GP is not rewarded for providing a clear overview of what is going on, both FOR the patient, and ABOUT the patient (with their permission) to all those treating her/him.
Our health system is like a large collection of highly talented musicians all attempting to play a complex symphony. The GP should be the conductor of the healthcare orchestra, but they are not recognised (nor paid) for their crucial role of keeping everyone playing together. It is little wonder that the healthcare system often fails to function effectively or efficiently.
Some suggest that the whole Medicare Fee-for-Service structure should be completely reorganised and redesigned, with staff employed on salaries. It is entertaining to talk about what a ‘perfect’ system would be like. But it is also nice to dream of peace in the Middle East.
Attempts have been made to provide special payments for the long-term management of particular (complex) conditions such as diabetes. These initiatives are a step in the right direction, but their aims have been seen as cost-cutting, rather than quality-improvement. Regardless, these schemes are fundamentally flawed because the complexity is not so much the disease itself, but the multiple ‘simple’ problems that occur together in the same patient. Or as William Osler, the ‘Father of Modern Medicine’ said, “The most important thing to know is not the disease that the patient has, but the patient who has the disease”.
Every system has advantages and disadvantages. Our current Fee-for-Service based Medicare system works well for simple one-off consultations. It also has the advantage of being relatively easy to understand and administer. The improvement most needed for Medicare is to modify the existing MBS schedule to provide recognition and payment for the Service that patients need.
There needs to be a new Fee (i.e. an MBS Item number) for ‘Supervising and Coordinating care’ for an extended period of time, over and above the current system based on separate episodes of care.
What would be the features of such a Fee?: –
This plan would reinforce the strengths of Australia’s existing system of GPs being the foundation of the healthcare system. It rewards GPs who attract patients who are healthy and use self-maintenance to avoid medical consultations. It provides a framework to encourage GPs to move to underserviced areas where they will gain income for having patients ‘on their books’. It acts to shift the balance away from high-activity clinics focussed on short-term one-off consultations. It reinforces the status and importance of good patient-centred medical care. It might also encourage GPs to develop models of care less dependent on requiring the patient to physically attend the consultation. This may particularly help complex patients such as disabled, frail aged, or residential care patients.
The cost of this new item could be offset by removing some of the current ‘add-on’ programs that are costly to administer and do not necessarily or systematically encourage long-term supervision of care. It would also result in a reduction of waste because it would reduce duplication and provide a single place of reference about the patient’s health care. Treasury would be delighted to know that this particular part of the healthcare budget was fixed – each Australian could only generate one fee annually.
The system would enhance the status, rewards, and professional satisfaction for ‘traditional’ GPs as the foundation of the healthcare system. This may encourage more young doctors into general practice, by formalising a position of the ‘supervisory GP’; the GP’s involvement in high-stakes decision-making (such as planning complex surgery, or care at the end of life) would be established. This would clarify decision-making in hospitals considerably. Most importantly, it would improve long-term patient care.
This modification to Medicare maintains the positive aspects of the Fee For Service system, but rewards important long-term patient care that is not funded by the current system. It can be implemented as a modification of the current system without major redesign, but would nevertheless have major positive ramifications.
The Medicare system is imperfect. Some dream of major reform and wholesale redesign. Maybe that can happen in the long-term.
But in the meantime, who is your GP?
Associate Professor Ross Kerridge is an Anaesthetist and Perioperative Physician at John Hunter Hospital, a large teaching hospital in Newcastle. He is Associate professor at University of Newcastle and a member of AMA NSW State Council. These are his personal opinions.
The catalyst for my need to share with you frustrations associated with the penetration of pseudoscience into Australian health care and the poor protection of consumers from same, was generated by the release of the details of the long awaited Free Trade agreement between Australia and China.
We now know that Chinese medicine was the subject of a side letter from Australia’s Trade Minister, Andrew Robb, to the Chinese government, which outlined plans to strengthen cooperation on traditional medicine, which among other things, could open the door for hundreds of contractual service providers from China to be officially registered to work here. The CEO of the Acupuncture and Chinese Medicine Association was delighted by the news, “We do know that the Chinese government has set globalisation of traditional Chinese medicine as a major priority and they’ve invested a lot of funding into this process”. Minister Robb also noted the opportunities that would be available for Australian manufacturers of supplements and “Complementary” medicines to penetrate the huge Chinese market.
The above association has dismissed concerns raised by this policy noting that practitioners of Traditional Chinese Medicine (TCM) in Australia must be registered by the Australian Health Practitioners Regulatory Agency (AHPRA) which has established a TCM board to protect consumers from inadequate practitioners. AHPRA has, however, been distressingly unsuccessful in protecting consumer from pseudoscience. What do I mean by “pseudoscience”? Concepts that, in reality, are pre-scientific “belief” systems. They are not supported and could never be supported by any credible scientific evidence. Such concepts are an affront to our understanding of physiology and pathology. Homeopathy is a good example.
The previous federal government made a big mistake in deciding that practitioners of Chiropractic, Osteopathy and Traditional Chinese Medicine should be nationally registered as was required of many other health professionals. Intense lobbying saw Tanya Plibersek agree that chiropractors could call themselves doctors. Hard to believe but as constituted neither AHPRA nor its subspecialty boards have any authority to limit the scope of practice of registrants. They can only respond to complaints about individuals and even that takes many months to resolve. This is a major problem as pseudoscientific beliefs and practices dominate all three of these newly registered professions.
The chiropractic profession is polarised. About 30% of chiropractors limit their care to evidence based treatments for definite muscle and bone problems particularly those effecting the back and neck. However recent research found that 70% of chiropractitioners’ websites claim to be able to help patients with many conditions not associated with any discernible musculo-skeletal problems. They make these claims based on their acceptance of the reality of “subluxation” theory as espoused by their founder in 1895. The belief is that there is associated with the spinal cord an invisible but vital energy the integrity of which is essential to health and the functioning of body systems remote from the spinal area. Minor, indeed undetectable, distortions of the normal spinal cord anatomy, (”subluxation”) interfere with this innate energy causing disease. Subtle “adjustments” of the spinal cord anatomy by chiropractors can correct the flow and restore health. The executive of the professions peak body, the Chiropractic Association of Australia, supports this concept. There is no credible scientific evidence to support this theory.
Particularly disturbing is the harnessing of this theory and its implications to bring chiropractic into paediatrics. Hundreds of registered chiropractors claim to be able to assist children with Autism, Asthma, bed-wetting, developmental disorders, colic, fever and over 60 other conditions. Many chiropractors combine their adjustments with a range of naturopathic treatments such as homeopathy and a nonsense called “Applied Kinesiology” wherein palpation of muscles can allow one to diagnose a range of diseases. One feels sorry for the chiropractors trying to stick to evidence based care.
There are also major concerns regarding the practices of many registered Osteopaths. Many osteopath’s websites talk about “Osteopathy of the Cranial Field” and the wonders of “Visceral Manipulation”. The former involves feeling for pulsations in the head associated with the propulsion of cerebro-spinal fluid around the brain, the nature of which diagnoses a disease process and subsequent cranial manipulation is used to fix the problem. The latter involves pushing around the contents of one’s abdomen to set up a chain reaction of pulsations that corrects remote, disease producing distortions.
The “Friends of Science in Medicine”, of which I am the current president, has been established to fight this penetration of pseudoscience into our health care delivery system. More than a thousand leaders in science and clinical medicine in this country support us. We have had a voluminous correspondence with the AHPRA executive team and the appropriate Boards in an attempt to have these regulatory authorities protect the public from such misleading claims and practices, which is their statutory obligation one would have thought. The task is that much more difficult as many members of the regulatory boards actually practice such pseudoscience. We have made no progress as AHPRA does not have the authority, (or the in house expertise), to issue directives re the acceptable scope of practice for its registrants.
Which brings us to TCM, a tradition founded on pseudoscientific principles. The theoretical basis of acupuncture for example, is pre-scientific and involves imaginary structures and vitalistic forces. An undetectable, immaterial life force, “qi”, is said to flow through channels (meridians) on the body. Disease occurs when the flow of qi becomes blocked. Inserting needles at specific acupoints on those meridians somehow restores the flow of qi. No such structures and forces have ever been identified by anatomists or physiologists. The World Health Organisation has recently taken down its Acupuncture website for revision after intensive analysis of all the credible research on the subject concluded that Acupuncture was no more than a superb placebo. Interestingly the number of TCM practitioners in China has plummeted in recent decades while the number of doctors trained in the “Western” tradition has soared.
Recently the National Health and Medical Research Council, our peak clinical science body, working with a committee set up, on government instructions, by the Chief Medical Officer, analysed the scientific data available for 18 popular “Alternative” practices (Homeopathy, Reflexology, Iridology, Applied Kinesiology Reiki etc.) The investigation found no credible scientific evidence that any of them were effective. Unfortunately the equally implausible antiscientific practices described above for Chiropractic, Osteopathy and TCM were excluded from the review because their practitioners now had national registration and therefore must be practising evidence based care!
Apart from pseudoscience, Australian health consumers are disadvantaged by misinformation from the very profitable Complementary and Alternative Medicine (CAM) industry. The vast majority of Australians get no benefit from taking vitamin supplements, probiotics, detoxification regimens etc. The impression given by advertising is that you can neutralise an unhealthy lifestyle with something out of a bottle. We spend three billion dollars a year as a result of this misleading urging. Now we will see those marketing these supplements urge middle class Chinese to use products that most will not need. In return our government will actively support the further penetration of TCM into our health system.
None of the above implies that we should not subject strong anecdotal and plausible evidence of a possible beneficial effect of a traditional herb or concoction to rigorous scientific evaluation. After all that is how much of our modern drug repertoire was developed. Research dollars and health care dollars are precious and in short supply so despite the cries of the alternative industry that their practices would be found to be beneficial after more research, not a further penny should be spent on the pseudosciences. In fact billions of dollars have been spent because of the widespread use of CAM justified attempts at validation.. The National Institutes of Health in the USA has spent more than 2 billion dollars on CAM in recent years and found very little that was useful.
There are many barriers to further protecting consumers from fraudulent and misleading health care claims and practices. General health literacy is inadequate for a modern society, the Therapeutic Goods Authority is a “toothless tiger” and lacks the authority, resources and political support to adequately protect the public and our pharmacists, men and women trained in, and promising to adhere to, evidence based medicine have stores full of products that they know lure buyers with false or exaggerated claims. A number of our universities give undeserved credibility to pseudoscience. At a recent open day for the TCM course at one university, visitors were shown by faculty how “Cupping” could be used to treat disease and all who attended went on their way with a clip to put on a certain spot on their ears to prevent depression!
Sharing my frustrations has been cathartic but there is one more I will document before stopping. After the NH&MRC report on the uselessness of Homeopathy the government announced that it would no longer allow taxpayers dollars to be used to supplement private health insurers coverage for homeopathy. FSM wrote to Christopher Pyne requesting that the more than $6000 subsidy paid to students studying to be Homeopaths in tertiary colleges should be withdrawn. After all how can you justify taxpayers supporting students training to implement treatments you accept are worthless? Minister Pyne replied that he was confident the homeopathy course met required academic standards.
Why is it that governments of all persuasions will not give regulatory agencies the resources and authority to better protect the public and contribute to efforts to insure that our health care is cost effective? The only evidence-based conclusion is that the political power of vested interests is outweighing the imperatives provided by modern science.
John Dwyer is Emeritus Professor of Medicine, UNSW.
The major pharmaceutical companies in Australia, almost all foreign owned, keep pushing their luck at the expense of Australian consumers and taxpayers.
In my series on health reform, I pointed to a minimum of $2 b. p.a. that we could save in drug costs if we had a government purchasing system like the New Zealanders. In the last budget the Minister for Health made a few changes around the edges but the high prices charged by Big Pharma will continue.
It is the same story around the world. Many American consumers find it worthwhile to cross into Canada to buy pharmaceuticals.
It is no surprise to know that Big Pharma is also highly influential in the secret negotiations for the Trans-Pacific Partnership (TPP). It is quite a scandal that we are kept in the dark on a trade arrangement which could have quite serious consequences for Australia.
Apart from the secrecy there are major concerns. As Choice Magazine has pointed out ‘The leaked chapters of the TPP indicate that the agreement may contain an investor-state dispute settlement clause(ISDS), which allows foreign corporations to sue Australia’s government for loss of future profits.’ Dr Matthew Rimmer, Associate Professor at the ANU College of Law, has said ‘Australian consumers have been betrayed. The intellectual property chapter of the TPP is a monster. The proposals in respect of copyright law, trademark law, patent law and data-protection would hit Australian consumers hard’.
There is major concern that the Australian government could become more vulnerable to law suits from multinational companies and particularly, Big Pharma. As Choice has pointed out, after the introduction of tobacco plain packaging rules in Australia, cigarette companies unsuccessfully challenged the new laws twice in the High Court and lost. Philip Morris then announced its decision to challenge plain packaging again, this time under international law by invoking a 1993 bilateral investment treatment that included ISDS provisions between Australia and Hong Kong.
And we know from experience, that US corporations have massively disproportionate lawyering power compared to our legal defence resources in Australia.
Joseph Stiglitz, the Nobel Prize winning economist, told us recently on the ABC about the benefits to the drug companies of TPP. He said ‘I talked to all the other trade negotiators involved in the drug provisions [of the TPP] and we know that the US is negotiating for a position that would make it much more difficult to get access to generic medicines and that would drive up drug prices.
Then there is the problem of tax avoidance. The Australian Parliamentary Library told a recent Senate Committee that in total the top five pharmaceutical suppliers to the PBS in Australia received $2.8 b. in public money. Their total Australian sales were $4.8 b. But research found their combined profits were only $50 m. They paid $53 m. in tax between them, or roughly one cent in tax for every dollar earned in Australia. For a full report by the SMH for June 15, see link here. http://www.smh.com.au/federal-politics/political-news/pharmaceutical-companies-called-on-to-explain-tiny-tax-contribution-20150602-ghf59s.html
We are really in triple-dipping country here – high prices for Australian consumers, attempts through TPP to weaken Australia’s bargaining position and widespread tax avoidance.
I think we are being taken for a ride.
The Minister for Health and Ageing, Sussan Ley has said she wants to canvas community and expert views on PHI (private health insurance).
If she does consult the community on this issue that will be a welcome change, for consideration of the PHI is usually a private discussion with the vested interests – the PHI industry, doctors and private hospitals.
I am not holding my breath about real consultation with the community. So much ‘consultation’ is purely token. Furthermore the community is genuinely confused about the range of look-alike policies that are very hard to understand until the patient has to pay. (more…)
Ms Sussan Ley, the Federal Health Minister, recently acknowledged that medicinal cannabis was likely to proceed in Australia but advocated proceeding cautiously. A Private Members Bill is under consideration and seems to have strong support including backing from both sides of the aisle. So the question is now increasingly moving from ‘whether’ to ‘how’ to proceed with medicinal cannabis.
Hippocrates said that doctors should ‘cure sometimes, treat often, and comfort always’. Medicinal cannabis is about the need for the health care system to try to ‘comfort always’. What should the lawful provision of medicinal cannabis in Australia hope to achieve?
First, medicines are expected to be effective. Medicinal cannabis usefully reduces distressing symptoms in a number of conditions when conventional medicines have proved ineffective and/or had unacceptable side effects. There is sufficient evidence of sufficient quality to conclude that medicinal cannabis is effective. Though conventional medicines may often be more effective, they don’t work often enough for medicinal cannabis to be a useful back up. This is the view of many experts and many highly regarded scientific organisations. However some experts and organisations have different views. Medicinal cannabis does not appear on current evidence to cure any condition. But some laboratory research suggests that cannabis may cure some conditions. A different conclusion could be justified in the future.
Second, we expect medicines to be safe. A recent review concluded that ‘97% of the adverse effects of medicinal cannabis in clinical trials were minor, with dizziness (20%) being the most common’. The prestigious US Institute of Medicine determined that the acute adverse effects of cannabinoids were ‘within the risks tolerated for many medications’.
Third, these days we increasingly insist that medicines are also cost-effective. There is little information about the cost-effectiveness of medicinal cannabis but it is likely to be cost effective. It may sometimes help to avoid expensive conventional medications or even shorten costly hospital stays.
And fourth, we would want to make sure that medicinal cannabis does not impair the integrity of Australia’s highly regarded pharmaceutical regulatory system (i.e. the Therapeutic Goods Administration).
As our politicians increasingly move from the ‘whether’ to the ‘how’ question, we should start thinking about the guiding principles for implementation.
A national approach is preferable to individual approaches from six states and two territories. So far we have had, or soon will have had, five parliamentary inquiries (Tasmania, NSW, Commonwealth, ACT, Victoria). Let’s hope that we can avoid a situation where residents of one jurisdiction where medicinal cannabis is not approved try to obtain what they desperately want from another state or territory where cannabis has been approved.
Regulated cannabis is always preferable to black market cannabis as it is virtually identical from one batch to the next, has known concentrations of the key psychoactive constituents and any chemical or microbiological contaminants will be below set safety limits. Currently an unknown but presumably large number of people, some for probably legitimate reasons, use unregulated cannabis they have cultivated or bought from the black market. Surely we can do better than that.
When deciding whether or not to start medicinal cannabis, the recreational use of the drug should be ignored. The ‘whether’ question should be decided only on the evidence of effectiveness and safety – and ideally also cost effectiveness. When considering ‘how’ medicinal cannabis should be provided, we cannot ignore the large unregulated market for recreational cannabis.
The introduction of an intervention not previously part of the official health care system should be slow and cautious. It is easier to liberalise a too-restrictive approach than restrict a too-liberal approach. Getting the balance right is important as the more restrictive the approach adopted, the larger the proportion of patients who will use unregulated supplies.
Any system for administering medicinal cannabis should be sufficiently flexible to allow for changes as knowledge increases over time.
Ill people who use medicinal cannabis and their carers and doctors should not have to worry about possible legal repercussions provided that they stay within unambiguous legal boundaries covering cultivation, purchase, possession, use and prescribing.
The system established for medicinal cannabis should identify approved medical conditions and may also need to identify required diagnostic criteria and criteria indicating sufficient severity. As knowledge of the benefits of medicinal cannabis is increasing rapidly, the approved medical conditions should be reviewed frequently. In some exceptional cases, where there is limited evidence there should also be scope for approving medicinal cannabis on compassionate grounds.
Decisions about medicinal cannabis for individual patients should be made by independent experts and not by Ministers, Department of Health officials or Members of Parliament.
Lawful cultivation by patients and/or their carers should be an option but not the only option as some will be unable or too ill to cultivate their own cannabis.
Most patients requiring medicinal cannabis are likely to have limited funds after some years of poor health, so affordability is an important consideration.
The least-worst way of ingestion at present is inhalation of cannabis vapor. A new pharmaceutical product (nabiximols, Sativex®), the next best option, is in Australia currently approved for only one condition, virtually unavailable and expensive. Older pharmaceutical preparations (Nabilone, Marinol), now obsolete, were too poorly and erratically absorbed to succeed commercially and are therefore unsuitable. Administration of cannabis by inhalation of smoke may sometimes have to be grudgingly tolerated, for example patients with a short life expectancy who have been happily smoking cannabis for some time. Liquid preparations will be needed for children.
Medicinal cannabis presents a number of challenges for policy makers but none are impossibly difficult. After all, medicinal cannabis is now available in about twenty other countries.
As Whitlam’s 1972 campaign slogan said ‘it’s time’.
Dr Alex Wodak AM, President, Australian Drug Law Reform Foundation
A new medical school in Perth will create more problems than it will solve.
As must also be true for many colleagues who have been focussed on evidence based solutions to the serious shortage of Australian trained doctors working in rural communities, I am frustrated and annoyed by the Prime Minister’s capricious decision to fund a new medical school in Perth. In an attempt to solve the maldistribution of Australian trained doctors that has resulted in almost 50% of the General Practitioners available to people in rural and remote communities having been trained overseas, governments have applied a “market place” philosophy to the problem. This logic suggested that if we doubled the number of Australian trained doctors there would inevitably be competition for rural careers, as metropolitan opportunities would all be taken! In 2016 our intake of Australian students into medical schools will peak and many readers will know that (a) we are already having difficulty in finding quality clinical placements to maintain educational standards and (b) the flood of new graduates has done nothing to ease the shortage of Australian doctors working in “the bush”. This continuing problem is responsible for much unacceptable inequity with health outcomes in all categories being less satisfactory for rural Australians. Were rural patients able to access medical services as readily as their city cousins it would increase Medicare payments by two billion dollars a year!
Here is the irony. To solve this problem we do need new medical schools but not schools situated in metropolitan areas providing a standard metropolitan centric curriculum. Here is the major cause of frustration. At least three thorough enquiries seeking evidence-based strategies to address the above inequity have been conducted in the last four years and all have agreed on the major initiatives required. These have been presented to government and as far as I know only one of the suggestions has been accepted (but not implemented).
There is abundant national and international experience that tells us that medical students who will actually want and pursue a rural career are students who are emotionally, intellectually and even financially wedded to a preference for rural life and hence a rural career. The closest we have come to applying this knowledge involves all medical school having a quota for 25% of their students to be “rural”. The definition of what constitutes “rural” is ridiculous. You are so designated if you have spent five years of your life in a rural postcode. You could have been born in Broken Hill, moved to Melbourne when you were five and not laid eyes on a cow since then but still qualify as “rural” student. The accepted suggestion referred to above would see medical schools fined if they did not achieve their 25% quota.
At least five universities have been lobbying government for funds for rural based medical school. In general these would involve expansion of excellent existing rural clinical schools into rural medical schools. I have been heavily involved in developing an evidence-based initiative proposed by a Charles Sturt/ Latrobe partnership for the Murray Darling basin. As had been true for other universities both the Gillard and Abbott governments have said they were attracted to the models but there was no money available. In the background many existing medical schools, concerned that such developments might require them to reduce the number of students they admit, have argued against the establishment of rural schools. Now to have the Abbott government, without consultation with key players, announce a Perth based medical school is nothing short of disgraceful; a “keep WA happy” imperative trumps any need to improve the health of rural Australians.
What are the key recommendations that we must continue to pursue despite the damaging political intransigence so far on display? Space will only permit a summary.
Create opportunities for whole of medical education requirements to be fulfilled in the country, too many medical graduates dependent on city placements for vocational training will not return to a rural community. For this reason rural medical schools should be based on undergraduate programs. Admission to a rural based medical school will involve “affirmative action” philosophies to provide for example, the flexibility to overcome rural high school educational disadvantage and an interview to assess genuine “rurality”. Students will enjoy a rural specific curriculum with an emphasis on early development of procedural skills and a focus on indigenous health issues. The medical course will have strong inter-professional learning modules that will involve shared learning with other health related students. Team learning to prepare for team medicine is an imperative for the best use of a scare workforce in the country. Graduates will be guaranteed an internship in a rural based hospital. It is worth debating the merits of redistribution of existing medical school placements rather than increasing further the number of enrolled students.
A lot of work by dedicated knowledgeable professionals from a number of universities, rural community advocates, the now defunct Health Workforce Australia and numerous rural health organisations has generated the above suggestions and all would have expected that a rural based medical school with the above features would be the “next cab of the rank”. ‘How naïve’ says Mr. Abbott.
John Dwyer is Emeritus Professor of Medicine at UNSW.
Among the most significant reforms proposed by recently released Harper Competition Policy Review is the removal of regulatory restrictions that greatly limit competition in the community pharmacy sector. But implementing the recommendation will require politicians who are up for a real challenge.
Any changes to how the pharmacy sector works involves taking on what has been described as “the most powerful lobby group you’ve never heard of.” The Pharmacy Guild of Australia, which represents the interest of pharmacy owners, is widely perceived as one of the most influential lobby groups in Australia.
Australian pharmacies are currently protected from competition by two sets of government regulations that form part of what’s known as the Community Pharmacy Agreement. Negotiated every five years between the Federal government and Pharmacy Guild of Australia, the agreement regulates most aspects of the pharmacy sector, from remuneration for supplying government-subsidised drugs to rules about the ownership and location of pharmacies.
The ownership rules disallow non-pharmacists from owning a pharmacy. So they effectively keep supermarkets and large international pharmacy chains, such as the UK’s Boots, from owning pharmacies in Australia.
The location rules were introduced as part of the first pharmacy agreement in the early 1990s. It prevents new pharmacies opening within a kilometre and a half of an existing pharmacy.
These ownership and location restrictions have effectively prevented new entrants into the sector and created what economists call monopoly rents for existing pharmacy owners. Monopoly rents represent the benefits that an industry gains from politically-enforced regulations to restrict competition.
While reform of the pharmacy sector by removing these restrictions has been championed by commentators from as diverse political backgrounds as Paul Howes and Janet Albrechtson, none of Australia’s politicians from any of the major political parties have so far taken up the cause.
The competition review recommendation is unequivocal:
the pharmacy ownership and location rules should be removed in the long-term interests of consumers.
And it comes after a similar recommendation from the 2014 National Commission of Audit report, which advocated:
opening up the pharmacy sector to competition, including through the deregulation of ownership and location rules.
Then there’s the report from the Australian National Audit Office (ANAO), which conducted a performance audit of the administration of the fifth Community Pharmacy Agreement (ending June 2015). The ANAO found so many shortcomings in administration of the agreement by the Department of Health that it was:
not well positioned to assess whether the Commonwealth is receiving value for money from the agreement overall.
The ANAO report quantified the remuneration pharmacies have received from government since the early 1990s, when the first Community Pharmacy Agreement was put in place. The figure below shows payments pharmacies receive for dispensing and mark-ups (the amount of money added to the price of drugs, to cover overheads and profit) have tripled from around $750 million in 1991 to over $2 billion by 2013 – even after adjusting for inflation.
This growth is due to much higher volumes of dispensing due to a combination of population increase, ageing, and expanded prescribing from newer classes of drugs, such statins. But as well as the increase in amounts paid to pharmacies each time a drug is dispensed, government payments are now around 20% higher in real terms than in the early 1990s, due largely to greater pharmacy remuneration from mark-ups.
And while total remuneration has substantially increased, restrictions on competition mean there are actually fewer pharmacy businesses in Australia than when the first community agreement was negotiated in the early 1990s.
The ANAO report also provides a distribution breakdown of this remuneration across different types of pharmacies. As the graph below shows, around 18% of pharmacies receive more than $1 million in remuneration from dispensing drugs listed on the Pharmaceutical Benefits Scheme. A comparison of the 2012 and 2013 financial years indicates a further 140 pharmacies moved into this top-earning bracket.
The high profitability of established pharmacies mean business sale prices for inner city and suburban pharmacies can run into the millions. And this high purchase price locks out many pharmacy graduates from ever owning their own business. It also means new entrants are saddled with levels of debt that turn what should be profitable business into marginal ones.
All this creates what might be termed a cycle of rent-seeking: while the ownership and location rules protect existing owners, the next generation of pharmacy owners will have to buy their businesses at inflated prices. And this makes new owners seek ever more protection from competition to make their business profitable and, in some cases, viable.
This might also partly explain campaigns such as “Pharmacy Under Threat”, which was run by the Pharmacy Guild of Australia. It was held in the middle of the last Federal election campaign against the relatively modest reforms proposed by the former government to accelerate reductions in price of generic drugs.The Guild claims that a petition distributed through a network of community pharmacies attracted 1.2 million signatures.
Of course, the lack of competition in the sector comes at a cost to the consumer, both in terms of the choice of where they can shop and in the prices that must be paid. As the ANAO report demonstrates, a packet of aspirin, which may cost as little as $3 in retail marketplace costs up to $12 when it is dispensed under the PBS.
Still, while the economic arguments for increased competition are strong, the politics of implementing community pharmacy reforms remain another matter. As one of history’s most astute political commentators Niccolò Machiavelli once observed, there is:
nothing more difficult to plan, more doubtful of success, nor more dangerous to manage than a new system. For the initiator has the enmity of all who would profit by the preservation of the old institution and merely lukewarm defenders in those who gain by the new ones.
It’s this challenge that faces any reform-minded politician wanting to introduce more competition into Australia’s pharmacy sector.
Philip Clarke is Professor of Health Economics at University of Melbourne. This article was first published in The Conversation on 7 April 2015.
The fall out from Indonesia’s execution of Chan and Sukumaran for drug trafficking continues. In their unprecedented press conference on 3 May, the leaders of the Australian Federal Police argued that under existing laws and guidelines, they were obliged to share intelligence with their Indonesian counterparts. Moreover, under similar conditions in future, the AFP expects that similar decisions will be made. The basic problems are that many young Australians travel to countries that still retain the death penalty for drug trafficking (and some other offences) and prohibition is still the global drug policy. So the execution of Australians and citizens of other nationalities for drug trafficking in future are inevitable.
As so often happens with tragedies, the search is now on for someone or some organization to blame. The problem is that everyone is responsible while no one is also responsible: this is in reality a system problem.
The members of the firing squad weren’t really responsible as they were just carrying out orders. The Indonesian police and court officials weren’t really responsible as they were merely implementing laws that their parliament had passed. President Widodo wasn’t really responsible as he was, like any good democratic leader, merely responding to overwhelming popular opinion in his country. Howard and Rudd weren’t responsible either because in their earlier support for the execution of the Bali bombers they reflected overwhelming popular opinion in their country at the time. Abbott and Bishop weren’t responsible as they inherited this mess from their predecessors. And Chan and Sukumaran weren’t really responsible because they were merely pawns of higher-level criminals who managed to evade detection. The seven mules weren’t responsible either because Chan and Sukumaran had coerced them. As is so often the case in drug trafficking cases, the fall guys who got caught and paid the ultimate price came from poor minority families.
Compounding the tragedy is the ineffectiveness of drug prohibition, now acknowledged with increasing frequency. More than half a dozen retired and now even serving Australian Police Commissioners have conceded that drug law enforcement has minimal impact on the drug market. A year ago, Prime Minister Tony Abbott admitted that the war on drugs is a war we cannot win but nevertheless argued that it is a war we should keep fighting. In June 2011 the Global Commission on Drug Policy, consisting of more than twenty retired world leaders, released a report documenting the failure of drug prohibition and called for a consideration of options. In the last four years, the Global Commission on Drug Policy has recruited more world leaders and issued more reports. Some countries are now starting to reform their drug policy. In April 2016 in New York, a United Nations General Assembly Special Session will consider the growing crisis in global drug policy.
The seizure of 390 kg of heroin off the coast of Part Macquarie in 1998 did not affect the price or purity of heroin in Australia. Chan and Sukumaran were executed for their role in the attempted trafficking of 8 kg of heroin. What these executions may have done for a time is increase the perception of risk for drug traffickers. That might then get translated into higher prices and greater profits which might in turn convince some wavering wannabe drug trafficker to try their luck. Whatever else drugs might be, they are also a market with buyers and sellers agreeing on a price for a quantity of a commodity. But unlike most markets, drugs are bought and sold in a pyramid market where buyers are also sellers.
If drug prohibition was to ever be effective anywhere it should be in prisons. Yet drugs are available in most prisons. A few years ago on an international assignment I asked a prisoner in an Indonesian drug prison near Jakarta whether inmates could still obtain drugs. ‘Yes’ he replied, ‘but they are usually more expensive than in the community though sometimes drugs are less expensive inside than outside prisons’.
So why do we keep fighting a war on drugs when an increasing number of prominent members of the community accept that this is futile?
Professor Craig Reinarman, a US academic concluded that ‘drugs are richly functional scapegoats. They provide elites with fig leaves to place over unsightly social ills that are endemic to the social system over which they preside. And they provide the public with a restricted aperture of attribution in which only a chemical bogeyman or the lone deviants who ingest it are seen as the cause of a cornucopia of complex problems.’
We continue to fight a war on drugs for several reasons. Drug wars are still useful politically. Many politicians still think the transitional costs of changing drug policy are too high. But there are now supporters of drug law reform among politicians of virtually all parties. Law enforcement aimed to reduce the supply of drugs employs many people. The costs of continuing the current failed policy are increasing while the costs of changing policy are declining as more countries move out from the crumbling straightjacket of international drug control.
Australians who wish to avoid more tragedies like Chan and Sukumaran should support drug law reform and the universal abolition of the death penalty.
Dr. Alex Wodak AM, President, Australian Drug Law Reform Foundation, Director, Australia21
Mental health challenges in rural and remote Australia are widespread and serious. Although the prevalence of mental illness is about the same across the country – about one in five people report having had a mental health problem in the last 12 months – a higher proportion of people in rural and remote areas pay the ultimate price of mental illness and related concerns; suicide rates in rural and remote Australia are 66 per cent higher than they are in major cities.
There are many positive aspects to rural and remote living: people in rural areas, for example, report higher levels of civic participation, social cohesion and social capital. However, there are also many particular challenges associated with rural life. Some people have a sense of pessimism about future prospects; others experience financial uncertainty and pressure, socio-economic disadvantage, or struggle living with chronic conditions. Such challenges may well prejudice the mental health and wellbeing of people in rural areas.
Also, people in rural Australia often have trouble getting to see a mental health professional when they need to. Medicare data bears testimony to this. They show that Medicare expenditure per person on mental health services in the bush is only 60 per cent of what it is in the city. This is likely to be because there are far fewer GPs, psychiatrists and psychologists per person practising in rural and remote Australia than in the cities.
Some rural people appear to be suffering more than others. Farmers, for example, are twice as likely to die by suicide than the general employed public. The rate of suicide among young men living outside major cities is twice as high as it is in major cities. And the suicide rate among young Aboriginal and Torres Strait Islander people is five times higher than that for young non-Indigenous Australians.
In response to these startling statistics, the National Rural Health Alliance has developed three modest proposals that will help make it a little easier for people to access the care they need. The proposals are as follows.
The Alliance has taken these proposals to Parliamentarians, suggesting that they should be considered for funding in the upcoming Budget. We will continue to advocate for these proposals in the coming months because they are cost-effective and practical measures that would make a real difference to the health and wellbeing of people living in rural and remote Australia.
The Alliance has recently published a Fact Sheet highlighting some of the issues relating to mental health in rural Australia. We have also published a Rural Mental Health Help Sheet with valuable information on where to find advice and support. Both are available at http://ruralhealth.org.au/factsheets/thumbs.
Anne-Marie Boxall, National Rural Health Alliance.
Imagine the following scenario. You are checking in with your GP’s receptionist for your scheduled appointment and are asked to produce your Medicare Card and, if you have one, your private health insurance membership card. If you have both you move into the waiting room on the right reserved for patients with private health insurance for whom the practice will provide a range of additional services not available to those in the waiting room on the left. Health outcomes are resource dependent so patients who can expect more quality time with their doctor and a range of services from other health professionals because private health dollars make it possible will, in many cases, have better outcomes. This is particularly likely if they are troubled by chronic and complex conditions. In such circumstances it’s also not hard to imagine practices over time, deciding to accept only patients with private insurance, as is commonplace in the US.
Unlikely scenarios for Australia? I hope so but certainly don’t know so and recent developments convince me that both health professionals and consumers need to be pro-active in making it clear to our politicians that such discrimination would be totally unacceptable. There is already much in our health system that is unfair and expensive. Unfair in that increasingly timely access to quality care is often determined by personal financial wellbeing rather than need, and expensive in that inferior care to socio-economically less privileged Australians results in much chronic disease that eventually costs the taxpayer dearly. As we struggle to reverse that situation we have, for the first time, an Australian government encouraging private health insurers (PHIs) to become involved in our primary care space. Four of the successful tenders for the operation of the 31 new Primary Health Networks (PHNs) will utilise consortia involving for profit and not for profit private health insurers.
Labor’s “Medicare locals’ have morphed into the Coalition’s Primary Health Networks. The health minister has explained that this new initiative will see PHN’s co-ordinating care offered by local hospitals districts (of which there are more than 150 in Australia) and local GPs. The networks are not to provide health services directly but use their 900 million dollars to “improve front line services”. Currently private health insurers are not allowed to offer additional insurance for any services funded by Medicare. However there is every chance that Insurers involvement in PHNs, which will include input into GP training, and workforce planning, could be the start of an ever-larger role for private insurance in primary care. At the time of the PHN announcement a spokesman for the peak body for insurers, “Private Health Care Australia”, said, “the best way to improve Australia’s health system is to increase the role it (PHI) plays in GP care”.
While the new initiative is unlikely to be any more successful than its predecessor given the vagueness of the terms if reference and the small number of networks covering a huge country yet asked to act locally, the conflict of interest that is inherent in having PHIs involved is very real. PHIs primarily exist to benefit their members, by and large better off Australians while PHNs to be successful must target better services for less advantaged Australians.
Global experience tells us that these networks should indeed be subdivided to become locally relevant and offer model Integrated Primary Care and secondary services. They should play a “hub” role for affiliated practices helping with IT, documenting health outcomes, continuing education, bulk purchasing, in house drug education, research etc. etc. About as different from what is on offer as is possible to imagine.
Why are PHIs so keen to get involved in Primary Care? While business models involving large numbers of Australians buying primary care insurance may be attractive the main reason for PHIs interest in primary care is their need to have fewer members admitted to hospital. This is particularly important for those admitted frequently as a result of advanced disease. Our larger PHIs tell us that 5-10% of their members who are frequently admitted to hospital generate 50 -60 % of their costs. Better-resourced primary and community care for these members might reduce admissions and save them large amounts of money. The political and public relations dilemma is easy to understand. How can they provide their member’s primary care team with the needed resources without creating a two-tiered system?
Of course the exact same problem, though on a much larger scale is troubling, or perhaps more accurately, should be troubling Australia’s national insurer. As has often been discussed in these blogs it is public hospital care and associated costs that are consuming most of our health care dollars, not Medicare. With our State/Federal divide in health care responsibilities it is State budgets that are in the same boat as the PHIs, ever increasing numbers of older and sicker patients requiring hospitalisation. A number of studies have found that as many as 600,000 admissions to public hospitals could be avoided annually if our primary carers were resourced to offer better community care.
We hospital doctors know only too well that many of the patients who return to hospital frequently have such advanced disease that little can be done in the community to manage their recurring crises . We certainly know that many such patients will die in hospital when a better death with more dignity at much less expense is not available at home. But the real challenge is to develop a primary care system that reduces the tsunami of Australians who are at risk of developing Chronic and Complex conditions and do so.
Is there a role for PHI in the creation of such a system? Certainly PHIs can and often do help their members with resources to improve their health literacy and their understanding of how they can best help themselves to manage their problems. Many in the private health industry are enthusiastic about the “Medical Home” model of care that I, and others, have described enthusiastically in detail herein the following link. https://publish.pearlsandirritations.com/blog/?p=3192 Some insurers have expressed interest in funding “proof of concept” practices resourced to offer the Integrated Primary Care (IPC) that is at the heart of the Medical Home model. There is proof from many countries that this model does very significantly reduce hospital admissions. Our federal government should be even more interested in this model as the majority of hospital admissions involve people without private health insurance. Canberra not the PHIs should be establishing Medical Home practices to demonstrate the benefits of the model in Australia. Some in the private health insurance industry have called on government to join them in supplying our primary care system with resources that emphasise prevention, early diagnosis and management of potentially chronic problems and care in the community for many currently sent to hospital. It is hard however to envisage a mechanism for such cooperation.
International experience warns us of the many problems associated with a mix of public and privately funded primary care. We do not want insurers (be the private or public) interfering with decisions about treatment programs for individual patients. We do not want a two-tiered system. On balance we should be urging government to maintain the current restrictions on PHI supplementing Medicare funded services. In so saying we should immediately add that Medicare does need a major structural overhaul to become a funder of a primary health care system not a fee payer for doctors.
The health minister has indeed just announced a review of many aspects of Medicare. The review will be led by two good people, Dean Bruce Robinson from Sydney University and Dr Steve Hambleton a former head of the AMA. The minister’s statements suggest that she feels that our current model of primary care would be fine if over servicing, rorting doctors and low value test and procedures were contained. The reviews will take 18 months and to encourage GPs to participate the current freeze on cost of living adjustments to Medicare rebates will remain until efficiencies are providing extra dollars. No talk of PHI involvement and no talk of Integrated Primary Care!
In reality we don’t need more reviews asking, “what should we do?” but rather a health care reform commission to drive changes (“how do we do it?) that are evidence based providing us with a cost sustainable and fairer health system detailed in these columns on any number of occasions.. The result would be a generation of healthier Australians with government and PHIs spending far less on expensive hospital care. A real “win, win” situation.
John Dwyer is Emeritus Professor of Medicine at UNSW.
John Ehrlichman, the Watergate conspirator, claimed to have come up with the idea of waging a war on drugs while he was a member of President Nixon’s ‘Committee for the Re-Election of the President’, wonderfully referred to as ‘CREEP’. The aim, Ehrlichman told Nixon, was to ensure that the elderly wealthy white voters who turned out in such large numbers to vote for Nixon in 1968 would turn out again in 1972 on polling day. The plan was to appeal to their contempt for the young, poor and black using illicit drugs as the perfect ‘dog whistle’. Despite the albatross of the Vietnam War hanging around his neck in 1972, Nixon won 49 of the 50 states in a landslide victory. Politicians around the world took note. An electoral magic pudding had just been discovered.
In the early 1970s, US Congress established a National Commission on Marijuana and Drug Abuse but President Nixon got to appoint most of the members. Nixon stacked the Commission with people he thought would support the sorts of recommendations he wanted. When Nixon heard that the Commission was leaning to recommend ending cannabis prohibition he called in the chair, Raymond Shafer. The Watergate tapes recorded the conversation: Nixon: “You’re enough of a pro to know that for you to come out with something that would run counter to what the Congress feels and what the country feels and what we’re planning to do, would make your Commission just look bad as hell….Keep your Commission in line.” Towards the end of the meeting Nixon advised Shafer that he had not heard yet from the committee that was considering Shafer’s application to become a Federal judge. In the end Nixon rejected the Commission’s recommendations and Shafer did not get the judicial position he had applied for.
Fast forward to 5 September 1989 when US President George HW Bush addressed his nation on television and held up a bag of crack cocaine from a recent arrest close to the White House. President Bush used the address to announce a major ramping up of the war on drugs but he did not tell his fellow Americans that, on instructions, law enforcement officials had lured the reluctant black crack seller to Lafayette Park, near the White House. President Bush was under considerable pressure at the time as opposition rose to his economic restructuring.
On 8 April, 2015, Prime Minister Abbott, also under considerable political pressure, announced a new Ice Task Force. Yet not so long ago, in December 2014 the Abbott government had established a new drug advisory body, theAustralian National Advisory Council on Alcohol and Drugs (ANACAD) whose top priority was to come up with effective responses to ice. ANACAD had earlier taken over from the Australian National Council on Drugs.
For decades drug policy has been a very useful prop for those seeking election or re-election or a boost to sagging opinion polls. But communities around the world are starting to be a lot more discerning about fear-based political machinations involving drugs. In the USA, several different polling organisations have found that a growing majority now supports regulating ‘marijuana’ (i.e. cannabis). In Australia, support for once controversial but pragmatic interventions like needle syringe programs and supervised injecting facilities continues to slowly climb.
A few years ago, some retired Australian Police Commissioners started commenting that our drug law enforcement was more effective than previously and about as effective as it ever could be but still the impact on the drug trade was negligible. Now even some serving Police Commissioners have made similar comments.
The community’s favourite drug intervention is education. But the results of mass and school based education campaigns are pretty modest. The expectations of the community and politicians about the impact of drug education are unrealistic.
Drug treatment has worthwhile benefits but improvements are usually much slower than the dramatic progress the community wants. But drug treatment in Australia, as in most countries, has a limited capacity, range of options and flexibility. During alcohol prohibition in the USA (1920-33), treatment for people with alcohol problems disappeared. Similarly, drug treatment struggles in countries where drugs are defined primarily as a criminal justice issue. Australia will make very little progress with ice while most people badly wanting help have to wait in a queue for six months as they mostly do now.
Although drug problems are found across the economic and social spectrum, they are more common in severely disadvantaged populations. Also, countries with greater inequality, like Australia, seem to have worse illicit drug problems. Support for reducing inequality in Australia and other countries is growing with the case so far made largely on the grounds of improving the economy. But a fair case can also be made that less inequality would reduce some of our social problems including illicit drug use.
The $64 million question that has not been asked about ice is why the drug market started providing this drug in the first place. For me the answer seems clear. Drug prohibition encourages more dangerous drugs to replace less dangerous drugs just as bush cannabis morphed into skunk and then Spice, powder amphetamine morphed into ice and ecstasy morphed into related but much more dangerous compounds.
We haven’t got there yet but Australia is slowly moving to acknowledge that it’s not so much illicit drugs that are dangerous as having a drug market that is completely unregulated. Economic forces ensure a vibrant drug black market while political forces till now have precluded a pragmatic arrangement. In the short term, political forces usually dominate but in the long term, economic forces prevail.
Dr Alex Wodak AM, President, Australian Drug Law Reform Foundation, Board Member, Australia21
“If we wish to annihilate the junk pyramid, we must start at the bottom of the pyramid: the addict in the street, and stop tilting quixotically for the higher-ups so-called, all of whom are immediately replaceable. The addict in the street who must have junk to live is the one irreplaceable factor in the junk equation. When there are no more addicts to buy junk there will be no junk traffic. As long as the junk need exists, someone will service it.”
(William S Burroughs, Naked Lunch, 1959)
Are we in the midst of an “ICE” epidemic? Was the PM correct to say methamphetamine (“ICE”) is our “worst drug problem”, it is a “pernicious and evil” drug, it is “far more addictive than any other illicit drug”? Mr Abbott was launching the national task on “ICE”.
Or is this another cycle of drug alarm and groupthink? Recall, “reefer madness”, the “killer weed”, “the next crack cocaine”, “the meth mouth”, “the faces of meth” and “hashish assassins” ad infinitum.
On 8th April Leigh Sales introduced the ABC 7.30 Report, “Revelations of ice use and suicide in the Australian Navy have shocked the Defence establishment and Australia’s political leaders.” This followed the previous night’s tragic report by Louise Milligan of nine suicides in young sailors at the West Australian naval base, HMAS Stirling. These perplexing and disturbing events demand reflection on the underlying causes of mental distress and suicide. But these important questions were conflated with “ICE”, a spin-off from the PM’s announcement of the task force. Next day, on Radio National’s AM program, Green Senator Peter Whish-Wilson, himself a military veteran, was interviewed about the parliamentary inquiry he had instigated into mental health in the military community. Again “ICE” was dragged to centre stage, not by the Senator but by Fran Kelly, the interviewer. Other media have been even more caught up in the “ICE” frenzy.
Addiction is not a switch to be turned off and on. Addiction takes time, months, sometimes years, to develop. Methamphetamine use over a long period becomes the substrate for addiction. The majority of long-term users have already well-established dependence on other drugs – polydrug users. They are drug tolerant and in drug-seeking overdrive; they seek more potent drugs.
Simple exposure does not cause addiction. Think for a moment of the hundreds of hospital patients receiving pain relief, virtually none will become “addicted”. The same drug, morphine, injected in the ‘street’ carries a high risk of addiction. Addiction (drug dependence) arises from an interaction between a vulnerable person (nature and nurture), the social environment (attitudes, norms of peers) and a drug.
Medicine is long familiar with amphetamines. They are not new. They have been used in asthma, depression (even anxiety), for appetite suppression and now may be prescribed for narcolepsy and attention deficit hyperactivity disorder. University students take the stuff to cram for exams and US pilots are kept alert by amphetamines during combat missions. Their stimulant effects are understood and the potential harms to the cardiovascular system are known.
Where do the amphetamines, methamphetamine, stand in relation to other substances?
The population prevalence rate of methamphetamine use in 12 months is 2 – 3 per cent compared with the 83 per cent for alcohol. Alcohol use disorders occur at 15 – 20 times the rate of methamphetamine disorders. For every methamphetamine-related death there are 65 alcohol-related deaths; for every emergency presentation there are 30 alcohol-related presentations; for every ambulance emergency call-out there are 25 alcohol-related call-outs.
Many suicides are underpinned by illicit drug use, including methamphetamine, but alcohol intoxication and dependence is a far more potent factor in suicide worldwide; of attempted suicides presenting to hospitals, 50 to 80% had been drinking heavily or were intoxicated at the time and at post mortem alcohol is the drug most commonly found.
The amphetamine drugs are harmful. They can cause psychotic disturbances; about one in seven admissions for schizophrenia have a concurrent stimulant disorder. They cause anxiety, aggression and depression, on withdrawal, as well as affecting the cardiovascular system. These are features too of alcohol intoxication and dependence as well as there being a veritable textbook of alcohol-caused mental and physical conditions and harm to others.
Policing and law enforcement are important especially to prevent the exploitation of vulnerable people. They can’t solve the “ICE epidemic despite the current wave of interdictions and arrests. Community-based solutions are needed – supports for families and children, educational and work opportunities for young people, early intervention and prevention, access to primary care interventions and to treatment and rehabilitation services; none of which are given priority compared with resources devoted to law enforcement.
As William Burroughs said,
“When there are no more addicts to buy junk there will be no junk traffic. As long as the junk need exists, someone will service it.”
And he should know.
Ian Webster is Emeritus Professor of Health and Community Medicine at UNSW and patron of the Alcohol and Other Drugs Council of Australia. He was formerly a National Mental Health Commissioner and Chair of the Australian Suicide Prevention Advisory Council.
In the Herald Sun on April 8, 2015, Jeff Kennett, the former premier of Victoria, said that it was time to stop the promotion of alcohol. See link to article below.
In this article he says ‘If it is good enough to ban the advertising of tobacco products, if it is good enough to make the wearing of seat belts compulsory, surely if the serious about family violence, the road toll, our crime rate, it is time to ban the promotion of alcohol. … The time has come to do what we have done for tobacco – ban all advertising of alcohol products and ban all sponsorships by alcohol companies.‘
Todd Harper, the CEO of Cancer Council of Victoria tells us in The New Daily of April 10 that ‘There is already a complete ban on alcohol advertising in sport in France and there have been moves to phase out alcohol sponsorship in sport from Ireland, the UK and South Africa.‘ John Menadue
Prime Minister Tony Abbott has declared the Medicare co-payment proposals “dead, buried and cremated”, but two related ideas behind it live on: Medicare is becoming “unaffordable” and our universal health system should morph into a program reserved for the poor.
The government’s original justification for the co-payment was to bring more “price signals” into Medicare. In itself the idea has merit, but the government has been going about it in a ham-fisted way.
Whether by design or accident, the government seems to be undermining the principle of Medicare as a universal tax-funded program, paving the way for private health insurance toplay a role in funding primary care.
But private insurance, by its very nature, suppresses price signals and encourages over-servicing and cost escalation. It is an expensive way to fund health care.
If the government wants more price signals in health care, it can start by standardising the mess of arbitrary co-payments in health care. If those co-payments can be re-designed to carry meaningful price signals, they will guide wise choice and contribute to efficient resource allocation.
The government should also consider requiring those better-off Australians, who have much more liquid savings than in times past, to contribute more to their own health care from their own pockets rather than assuming that someone else – Medicare or private insurance — will cover the minor outlays they could easily afford themselves.
It’s easy to panic about the looming cost of health care as Australia ages. That has been the message of successive Intergenerational Reports, the latest of which suggests that under “previous policy” (Labor government) setting, Commonwealth health expenditure would rise from 4.4% to 7.1% of GDP by 2054, but would be contained to 5.7% of GDP under the government’s “proposed policy”.
The sensible response to these projections is to ask “so what?”. As the population ages, Australians will indeed spend more on health care.
But simply shifting costs off-budget and on to individuals, or to private insurance mechanisms is an expensive and clumsy way to fund health care. It does not make health care more “affordable” – we still have to pay for it.
As John Deeble, one of Medicare’s original designers, pointed out, the simple solution to fiscal pressures on the Commonwealth’s health budget is to raise the Medicare Levy.
The government said that imposing a co-payment and reducing bulk-billing would result in reduced use of Medicare services, which have risen from 11 to 15 a head over the last ten years.
That idea would be sound if Medicare services were stand-alone, but any reduction in demand would most probably be among those in most need of care, particularly early intervention to stave off costly episodes of hospitalisation and chronic disease. And there would be a shift of demand on to hospital emergency services.
The costs to health budgets and to the whole economy (in terms of lost workforce participation resulting from chronic illness), could well be far greater than any saving in Medicare.
But, as the Public Service Commission’s capability review of the health department points out, the department tends to work in “silos”, and seems to lack the capability of considering “whole-of-health-system policy”.
Under pressure to cut expenditure, Medicare is the easy target. Costs outside the “Medicare” silo are not their concern, and if they can move some load on to individuals, private insurers or state government hospitals, that’s clever cost-shifting. That’s not so much a “policy”, which would be concerned with the public interest, as an attempt to contain outlays within an arbitrary fiscal limit.
The specific co-payment idea came from the government’s Commission of Audit, which saw it as a first step in a stealthy but radical transformation of health services away from universalism, towards a US-style system with “an expanded role for private insurance” to “cover all services covered by Medicare and public hospitals”.
Medicare would be reduced to a service for the “indigent” (to use the US term).
Despite dumping the co-payment, health minister Sussan Ley still wants to “reduce the number of bulk billed consultations to people who can afford to pay something”. This suggests she sees Medicare as a charity or distributive welfare system, not a universal system as it was originally envisaged.
As the freeze on Medicare reimbursements bites harder, bulk-billing will probably fall (as intended), resulting in mounting pressure on the government to change the legislation and permit private health insurance to cover the gap.
The Commission hypocritically calls for people with means to take “individual responsibility for their health care”, but to be guided by “price signals” while they are herded into private health insurance.
But private insurance is no more about “individual responsibility” than Medicare is: it’s still about handing over responsibility to a third party. Far from incorporating “price signals”, it simply changes the message from “Medicare will pay for it” to “HCF/BUPA/Medibank Private will pay for it”. This incentive for over-use is known as “moral hazard”.
It’s easy to forget that we already have co-payments in health care. Out-of-pocket expenses, not covered by public or private insurance, account for 18% of health care expenditure, in line with other prosperous countries.
But the breakdown of out-of-pocket expenses is messy and haphazard; a reflection of the “silo” arrangements in the health department. Expenses fall heavily on dentistry, specialist services and non-prescription medications. Many are uncapped, meaning the consumer is left bearing open-ended risk.
It’s also easy to forget that Australians, on average, have enough liquidity to cope with modest co-payments when a need arises. Australian Bureau of Statistics data show that on average, households have A$37,000 in available funds.
If we want price signals in health care, then there is a good case for requiring personal payments for those with means, without the moral hazard of third party payment.
Some commentators suggest we should go down the path of health savings accounts, whereby people are required to set aside funds in personal accounts to be drawn on only for health care needs. Only when a person’s health savings account is depleted does the state cover additional expenses.
Health savings accounts certainly have advantages over private insurance, in that they retain a measure of individual responsibility, and they tend to accumulate with age.
But they have their own problems, in that when someone’s HSA reaches a high level there is a “use it or lose it” form of moral hazard. And in economic terms, they tend to privilege health spending over other consumption, thus distorting consumer choice.
In any event, Australia’s compulsory superannuation is already serving some of the same purpose as health savings accounts. Once Australians retire, their superannuation balances become accessible as personal accounts (apart from those whose superannuation is in annuity form). Including superannuation, singles over 65 have on average A$170,000 in reasonably liquid assets, while couples have A$430,000.
We could be served well by a requirement that all with means pay for their health care up to a limit before Medicare kicks in to cover high costs. That’s essentially the policy the Coalition took to the 1987 election, when it proposed that all who could afford it should contribute the first A$250 a year to their health costs (equivalent to about A$800 now), without the support of insurance.
That would mean most people make no call on public funds in any one year, while preserving the universality of Medicare as a single national insurer, covering those with high needs or limited means.
That’s essentially the Nordic model. It combines the best or market price signals and the power of a government insurer, without the distortion and high cost of private health insurance or fiddly and paternalistic measures such as health savings accounts.
Ian McAuley is Lecturer, Public Sector Finance at University of Canberra. This article was first published in The Conversation on 1 April 2015.
If you seriously follow almost any major Australian sport as I do, you will be conscious of the saturation alcohol and junk food advertising.
And in the run up to the centenary of Gallipoli there are no holds barred to link heroes and booze… VB now have a new television advertisement filmed at Melbourne’s Shrine of Remembrance which tells us to bow our heads to the 16 th Battalion,AIF at Gallipoli and raise a glass of VB to their heroism. How tacky can you get!
This is a re run of the campaign that VB have been running since 2009. The 2012 campaign was fronted by General Cosgrove now our Governor General. He sits at a bar and tells us how good VB is in supporting veterans and their families. There is an explicit link between the military, heroes and alcohol.
The evidence is clear that alcohol and junk food are causing long-term damage to our health. We cannot ignore it.
The Council of Australian Governments’ (COAG) National Partnership on Preventative Health was established because of the alarming increase in preventable chronic diseases as a result of people’s lifestyles. As Nanny Endovelicus pointed out in this blog in October last year and reposted on 22 and 23 January this year ‘These lifestyle issues – in particular smoking, poor nutrition, alcohol misuse and physical inactivity already account for some 40% of potentially preventable hospital admissions. … The growth of lifestyle diseases worrying those watching health expenditure were primarily in diabetes, various cancers, COPD, strokes and other preventable cardiovascular system diseases.’
Alcohol Consumption
Latest statistics are that about 20% of the population continues to drink at levels risky to their long-term health – pretty well unchanged from the ABS results in 2007-08; half of males and one third of females drank riskily for single occasion risk. The estimated economic and social cost of alcohol is over $30 b. per year.. The good news is that since the 1970s our per capita alcohol consumption has declined although it remains above the OECD average.
Obesity
By mid-2012 almost two thirds of Australians over 18 years were over overweight or obese according to the ABS, a significant increase from a decade ago. The current combined level for obesity and overweight is 63% for adults. Of children between the ages of five to 17, about 18% are overweight and 8% are obese. This is very bad news. Australia is now in the top league tables in the obesity stakes, still lower than the US, but we are catching up fast.
Smoking
We have clearly made progress in reducing tobacco consumption despite the activities of The Australian newspaper and Institute of Public Affairs in defending. Big Tobacco. In 1980, 35% of our population smoked. In 2012 it was down to 20%. It has been a success story and major contributing factors have been the bans on tobacco advertising on TV and radio, and major public education programs. It is quite a success story in showing what can be done although smoking amongst our indigenous communities and country people is still high.
We have a job ahead of us to address poor health, particularly as a result of alcohol addiction and junk food, including sugary drinks that are driving our obesity epidemic.
But the signs are that the federal government is turning its back on the problem. .
In the last federal budget, Program 1.2 for the Health Department which deals with drugs like alcohol, education against illicit drug use and tobacco was reduced from $224 million in 2013-14 to $161 million in 2014-15. According to the forward estimates it will be down to $131 million in 2017-18. In money terms this is a reduction of 40%.
The COAG Partnership on Preventative Health with the states has been abolished together with some $400 of promised funding. The programs that will be mainly affected were focused on children, community exercise, nutrition, education and lifestyle risks.
The Australian National Preventative Health Agency was abolished in the 2014 budget.
The Australian Institute of Health and Welfare which provided invaluable data on health risks and preventable disease has been abolished and its functions transferred to a large productivity and performance authority.
The government’s compromised position on prevention was also clearly shown a year ago when the Assistant Minister of Health Fiona Nash hired a junk food lobbyist as her Chief of Staff. She tried to wipe out the industry’s voluntary food-star labelling system. With control of ministers’ staff by the Prime Minister’s Office this appointment of a junk food lobbyist could not have been a misunderstanding..
This all adds up to a story of short term success for the alcohol and junk food industries with the complicit national sports organisations, sports people and the broadcasting media.
It is also a good example of budgetary cuts for financial short term advantage which have long term and damaging consequences for our health. The bad health consequences of alcohol and junk food consumption don’t show up immediately. But the consequences down the track are clear and horrible.
In this post I have drawn heavily on earlier posts by Nanny Endovelicus, Preventing Prevention.
The six previous papers in this series highlight the poorly defined role private health insurance plays in the funding and delivery of Australian health care, and how the Abbott government might allow this role to expand.
But major changes to Australia’s iconic Medicare system should not happen by stealth. They require full analysis and debate about whether a more integrated public-private system is a feasible option that fits with Australian values and can improve efficiency in health care financing.
Successive governments of both persuasions have failed to convincingly articulate why Australians need what is increasingly a duplicate health care system – with duplicate costs for many – and why the federal financial contribution to private health insurance should be so substantial. The 2014-15 Budget Papers show the cost of the private health insurance rebate will grow from A$5.997 billion in 2013-14 to A$7.187 billion by 2017-18.
Private health insurance is variously seen as an essential feature of a “balanced” health care system comprising both publicly and privately funded and provided health care, or as an instrument of patient choice and responsibility that relieves the pressures in increasingly strained public services.
Most recently, the National Commission of Audit (NOCA) has raised the possibility of requiring higher-income earners to take out private health insurance for basic health services in place of Medicare. Both the NCOA and the Harper Competition Policy Review advocate an expanded role and less regulation for the private health insurance sector.
These are ideological arguments and much of the dilemma facing those who would work to implement effective policy in this area is the dearth of information about what drives people to purchase health insurance and to use it.
Since 1999 a raft of government initiatives – financial carrots and sticks – have aimed to encourage more Australians, especially those who are better off, to purchase private health insurance.
For the most part, these were not evidence-based and consequently have had little or no impact. Only the Lifetime Health Cover Loading and the “run for cover” campaign had an impact and this has been interpreted as a response to a deadline and an advertising blitz, rather than a pure price response.
University of Adelaide economist Terence Cheng has estimated the price elasticity of demand and found that a 10% increase in premiums would result in a reduction in private health insurance coverage of less than 2%. So most Australians who have private health insurance would retain it even if the rebate was completely dropped.
The prevailing wisdom is that people purchase private health insurance to have their choice of doctor and hospital facilities, but as researcher Sophie Lewis and her colleagues at the University of Sydney have found, it is really more about shorter wait times for hospital procedures, perceived quality of care and “peace of mind”.
Having private health insurance provides the ability to “jump the queue” to access a range of elective procedures in private hospitals. But this comes at a price for all patients.
People with private health insurance are likely getting services ahead of people without insurance but with greater need. The private patient who gets their orthopedic or cataract surgery within weeks rather than months will very often end up with substantial, unexpected out-of-pocket costs.
Contrary to government claims, the increase in services delivered in private hospitals has done nothing to ease the pressure on public hospitals and in fact waiting times for urgent procedures in public hospitals has increased.
Private health insurance does not buy extra quality and safety either. The Productivity Commission found that the larger, most comparable public and private hospitals have similar adjusted premature death ratios. And team-based care in large public hospitals means better care coordination.
The peace of mind that private health insurance is supposed to bring is very often illusionary. Sometimes it’s the realisation that certain procedures or prostheses are not covered; more often it’s the shock of unexpected out-of-pocket costs. More than 20% of private care is paid for by patients’ out-of-pocket costs, which in 2014 averaged A$285 per hospital episode.
The mix of levies, surcharges and rebates – and funds that constantly change their policies – make it difficult for even astute consumers to judge the true cost and value of their private health insurance.
In fact, many people know little about the policy they purchase – what it covers, how much it covers, whether it is good value and suited to their needs.
The Commonwealth government’s decision to subsidise private health insurance means it has a substantial financial stake in the private sector alongside its existing stake in the public sector. However, while there are incentives to encourage the purchase of private health insurance, there is no requirement for it to be used.
About a quarter of people with private health insurance choose to use the public system. Therefore, a significant proportion of the private health insurance rebate is effectively wasted as people purchase cover for financial rather than health reasons.
Public policy experts Ian McAuley and John Menadue have made the case that private health insurance is an expensive and clumsy way to do what the tax system and Medicare does better: distribute funds to those who need health care and the effective management of health care costs.
International evidence shows that private health insurance decreases cost controls and it has been argued that gap insurance has underwritten the dramatic growth in specialist fees. Further, pushing higher income earners (who generally have better health) to take out private health insurance, and then increasingly prejudicing access to services in their favour ensures a widening of existing health disparities.
In the absence of a clearly stated and managed role for private health insurance – either as competitor or collaborator – it is effectively undermining the power of Medicare as a single payer and the role of Medicare as a universal provider. This situation is predicted to unravel further, as the Abbott government signaled its agenda to allow private health insurance to play an expanded role in primary care.
Some of larger funds are already expanding their activities in this sector, but with little oversight.
Last year Medibank Private began a program in Queensland that guarantees Medibank members same day GP appointments, fee-free care, after-hours GP visits and a range of health assessments. Medibank claims the trial is operating within the bounds of the law because it pays only for administrative costs, as opposed to funding the doctors directly.
The concerns this raises about the generation of a two-tiered health system are further fuelled by the possibility that private health insurance funds were eligible to tender to run the new Primary Health Networks.
It’s an indictment of the passivity of federal government policymakers that private health insurance funds are more willing to kick start the innovative initiatives that are needed to deliver more proactive preventive care, better care coordination and a greater focus in health outcomes.
It’s more troubling that these initiatives are currently occurring in a policy vacuum with a narrow focus on solutions led by the funds for the benefit of their members. This will not assist the millions of Australians who don’t have private health insurance and could have a major impact on the equity and efficiency of the health care system and the budget bottom line.
Lesley Russell is Adjunct Associate Professor, Menzies Centre for Health Policy at University of Sydney. This article first appeared in The Conversation on 2 April 2015.
Michael Thorn is right; the ICC Cricket World Cup was an alcohol-drenched event (SMH Tuesday, 31st March 2015).
Cricketers were once models of sportsmanship. There was even altruism and some became statesmen. Recall, “That’s simply not cricket.” No longer, as the game is subverted by money and alcohol. As I write, the ABC is broadcasting the “performance-enhancing” drug scandals in the AFL. Just as scandalous, more scandalous, is that sport is a vehicle for promoting our most socially damaging drug, alcohol.
To adolescent binge drinking, we respond – they should be taught at school; the drinking age should be raised; they need other outlets and activities; they should be disciplined and so on. But in this hand-wringing adults are forgotten. It is the behaviour of adults that the young seek to emulate. They aim to become like us.
In becoming adults, young people test limits and learn social skills for the future. They want to be acknowledged, to fit in, to be one of the group. Herein lies the problem. Skilled marketers can exploit these vulnerabilities and link sporting achievements, heroic performances, glamour and attractiveness to the brands of alcohol; welding loyalty to a brand.
There are physiological and psychological reasons for concern about drinking in adolescence. A lifetime pattern of heavy drinking is more likely to be established if drinking starts at a young age and the developing brain is at risk. Governments know this and restrict alcohol ads during TV viewing times of young people. But sport gets around it.
That advertising alcohol creates problems is accepted, but not by all. The alcohol industry in 1998 set up a voluntary Alcohol Beverages Advertising Code to adjudicate complaints about alcohol advertising. The code covers – the responsible and moderate portrayal of alcohol, responsibility towards minors, responsible depiction of the effects of alcohol and safety. It is hardly surprising that independent evaluations have shown its determinations generally favour the advertisers. And it has been criticised for lack of transparency and inability to cover ‘new media’. Also there are other advertising codes for television, radio, outdoor and publishers’ which include alcohol in their codes of practice.
An alternative and independent body was set up in 2012 by the McCusker Centre for Action on Alcohol and Youth and the Cancer Council of Western Australia– the Alcohol Advertising Review Board. It has 122 independent panel members. The Board’s chair, Professor Fiona Stanley AC, said in the 2014 Annual Report that many of the complaints were about sport and alcohol. The Board has recommended that,
“…the loophole in the Commercial Television Industry Code of Practice should be closed as part of a comprehensive strategy to reduce young people’s exposure to alcohol promotion. This should be accompanied by measures to remove advertising and promotion related to alcohol company sponsorship of sporting associations, teams and events where children and young people may be exposed.”
Australia has tinkered around the edges of controlling the promotion of alcohol and balks at going as far as countries like France and New Zealand. France, a country with a passion for alcohol, has banned alcohol sponsorship, advertising in cinemas and television and targeting young people.
Alcohol is not ice cream or cornflakes. It has toxic effects on the mind and body with manifold social consequences. Yet worldwide it is one of the most heavily advertised products. More than 94% of Australian students aged 12 to 17 have seen alcohol advertising on television as well as in magazines, billboards and a myriad of other locations. Current industry self-regulation is an abject failure.
If there is any good news out of the World Cup ‘booze up’ it is that the cricketers’ behaviour has offended the sensibilities of many Australians. Time then, to break the nexus between sport and alcohol.
Ian Webster is Emeritus Professor of Health and Community Medicine at UNSW and patron of the Alcohol and Other Drugs Council of Australia. He was formerly a National Mental Health Commissioner and Chair of the Australian Suicide Prevention Advisory Council.
Many media outlets today have drawn attention to the alcohol influenced behaviour of Australian cricketers as they celebrated winning the International World Cup. At the celebration in Federation Square in Melbourne yesterday morning, the Australian captain Michael Clarke seemed to be proud of the fact that all the team members had hangovers.
In the link below Michael Thorn, the chief executive of the Foundation for Alcohol Research and Education, in today’s SMH, draws attention to the influence of the alcohol lobby,the alcohol consumption of the Australian cricket team and advertising. See link below.
Michael Thorn comments that ‘It is time to roll back Australia’s toxic drinking culture. ‘
Ministers for Health in Australia are seen very largely as ministers in charge of health services rather than health. The fact is that some major issues causing poor health or which could be the means to improve health are outside the normal health portfolio.
In short, the health Minister and his department must have expertise beyond ‘health services’ and particularly economic expertise in a joined-up government approach. Unfortunately they usually rank well down the ministerial and public service ladder. There is reluctance by policy makers to look on healthcare as an industry and to apply the normal evaluative mechanisms which are applied to other industries. Such a blinkered view allows the development of an idea that health should be exempt from the normal economic considerations of efficiency and equity. It’s a notion that pushes economic thinking to one side, in the erroneous belief that economics is intrinsically illiberal and dismissive of human welfare.
For a country reviewing its healthcare industry, it is useful to take a broad view and consider the whole industry and not just that part of concern to the health portfolio…
We keep pouring money into hospitals. We never seem to appreciate that like the family refrigerator hospitals will always be kept full. Health problems are best addressed first in primary care, prevention and often outside the health portfolio
It seems self-evident to many that the use of illicit drugs is evil. But why? When pressed, the most common response to this question is that illicit drug use is evil because it is against the law. So the next question is ‘why is the use of certain drugs illegal?’ State parliaments in Australia started banning the use of certain drugs even before Federation. In the last half century, Australia signed and ratified three international drug treaties (1961, 1971, 1988) which required domestic parliaments to pass laws imposing criminal sanctions on people who use or traffic drugs.
In the late 19th century, opium became the first drug banned in Australia. But opium was initially only prohibited if it was smoked. At that time, Chinese people on the goldfields were the only people in Australia smoking opium. The majority of Australians at that time had access to edible opium which remained lawful and taxed until it was prohibited in 1906. Edible opium is said to have remained readily available after the 1906 ban but the Commonwealth lost an annual income of £ 60,000. Was opium smoking acceptable before it was banned and evil afterwards? Likewise, was edible opium acceptable until 1906 but did it only become evil afterwards?
Australia was represented at the 1925 Geneva Convention on Opium and Other Drugs which agreed to ban the non-medical use of the opium, coca and cannabis plants and drugs derived from them. Accordingly, the Commonwealth Government banned the importation of cannabis in 1926 and requested the states to pass legislation banning cannabis. Victoria (1928), South Australia (1934), NSW (1935), Queensland (1937), Western Australia (1950) and Tasmania (1959) complied. If cannabis use in Australia is now evil, when did it become so? Was it evil when Prime Minister Tony Abbott, Communications Minister Malcolm Turnbull and former Prime Minister Julia Gillard used cannabis in their youth to become relaxed and comfortable? Was it evil when US Presidents Bill Clinton, George W Bush and Barack Obama used cannabis in their youth?
Following international pressure, believed to have originated in the USA, Australia banned the production and importation of heroin in May 1953. Existing heroin stocks could be used medicinally till exhausted but could not be replenished. The decision to ban medicinal heroin was criticised at the time by the then Director General of the Commonwealth Department of Health, the Presidents of several Royal Colleges (Surgeons, Physicians and Obstetricians andGynaecologists) and the President of the British Medical Association (before the Australian Medical Association was established). So if the use of heroin is now evil, was it already evil when used medicinally before 1953 or did it only become so when used recreationally after it was prohibited?
If the use of illicit drugs is not intrinsically evil, then we have to ask why their sale and purchase is evil? The use of illicit drugs might well be unwise, even recklessly unwise, without such use constituting evil. Most members of the community will need little convincing that the injection into a vein of an unsterile powder of uncertain constituents and strength bought from a stranger is extremely unwise. But is it evil?
In 1895, Oscar Wilde received a 2-year prison sentence with hard labour for sodomy. Alan Turing, who had contributed substantially to the Allied defeat of the Nazis in WW II and the development of computers, was found by a British court in 1952 to have had sex with another man. Turing committed suicide rather than face the consequences. Homosexuality was considered a crime when Wilde and Turing were alive although it has since been removed from the criminal code. Same gender marriage is now lawful in the UK. Did Wilde and Turing commit evil acts even though today the same acts are no longer considered a crime? Queen Elizabeth has apologised for the way Turing was treated. It is not just the law and the community which has changed its view about the nature of homosexuality. In 1973, the American Psychiatric Association reclassified homosexuality as a lifestyle rather than a disease.
A vigorous international debate about the effectiveness of drug law enforcement is now growing. Senior drug law enforcement figures now increasingly acknowledge the futility of efforts to restrict the availability of illicit drugs. But the real debate we should be having is about the fairness and justice of laws which criminalise the use of certain drugs (but not other drugs which create much more harm).
In 2008, (then) Father Peter Norden noted that the gospel said ‘When I was hungry, you gave me to eat, when I was naked you clothed me, when I was in prison you visited me.’ Norden argued that “Jesus today would have included another couple of phrases, perhaps, ‘When you were mentally ill, you walked with me, when you were addicted, you stood by me. ‘ Not that you walked away from me or sat in judgement of me”. (http://www.abc.net.au/radionational/programs/encounter/faith-and-the-fix/3174376#transcript) Walking away from and judging people struggling with drug problems worked well politically for decades. But it has been a disaster for many people who use drugs, their families and communities. This doesn’t even begin to describe its impact on countries which have been the source of illicit drugs or through which such drugs have been transited.
Whether or not our current drug laws are effective, or whether alternative policies might be less ineffective are important questions. But the most fundamental question we should be asking ourselves is whether our drug laws are fair and just.
Dr Alex Wodak AM is President, Australian Drug Law Reform Foundation.