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This section currently contains full-text articles written by Doctors Reform Society members, however every view expressed is not necessarily that of the DRS. Also see Andrew Gunn’s articles.
Media Releases
21st May 2024
Health Care: A Disappointing Budget
“Why has health care been almost ignored in this year’s budget”, asks Dr Peter Davoren, Secretary, Doctors Reform Society. In January last year Health Minister Butler said, “Frankly I think our general practice right now is in the worst shape it has been in the 40-year history of Medicare,” His Strengthening Medicare Taskforce made many recommendations and the Minister said at the time that ‘a comprehensive revamp’ was required, including addressing ‘structural issues’. Read more
10th Apr 2023
Save Money or Save Patients: What is Medicare About?
“As suggested today by an article in The Australian, Medicare itself is under disastrous mismanagement,” said Dr Tim Woodruff, President, Doctors Reform Society. “The Department of Health, along with the Professional Services Review Board appear incapable of looking after the interests of patients trying to access services from an out of date not fit for purpose Medicare.” Read more
Articles
12th Apr 2024
Aged Care Funding: On the Road to Entrenched Inequity
Pearls and IrritationsUK Health Minister Aneurin Bevan introduced the National Health Service (NHS) pointing out that “Illness is neither an indulgence for which people have to pay, nor an offence for which they should be penalised, but a misfortune the cost of which should be shared by the community.”
Advancing age brings with it infirmity and a much higher likelihood of ill health. People do not choose to become old and infirm.
Whilst conservatives despise the sentiments expressed by Bevan, particularly the concept of sharing by the community, liberals do agree, but with very variable degrees of commitment.
Aged Care is a major concern. Recent discussion following the Royal Commission has been about what services should be provided, how to regulate quality, how to get appropriate workforce, and how to fund what is needed.
The main funding recommendations from the recently released Aged Care Taskforce report are means tested co-payments and a safety net to supplement ongoing government funding.
Examples of co-payments and safety nets.
The public hospital system provides first class hospital care to all and if it’s an emergency the care will be timely. If not, unacceptable wait times prevail. Public hospital care becomes a safety net. Those with means bypass the wait times and use the government subsidised private hospital system. Those without suffer.
Primary health care through GPs or other health providers is in theory accessible to all, except for the geographical inequities which have the greatest negative impacts on low-income earners in rural and remote locations. But even in the cities inequities abound. Co-payments make a mockery of affordable access to care. The recently introduced increased rebates for pensioners, health care card holders (HCCH), and children does not mean they will be bulk-billed. It also leaves people just above the cut-off for an HCCH facing an average $40 co-payment per GP visit.
Visits to specialist physicians and surgeons regularly incur a $100 co-payment which sends many patients away and onto the years long waiting list at a public hospital.
A rebate subsidised psychology visit regularly costs $100 co-payment, well outside the affordability of an unemployed patient on sickness benefits, and a challenge to a low wage earner.
The above relate to voluntary co-payments applied by providers. Then there are government-imposed co-payments with safety nets. Prescription drugs are subject to co-payments of $7.30 per prescription for Pensioners and HCCHs and $30 per prescription for others. Despite the existence of a Safety Net, an estimated half a million people delayed or did not fill a prescription in 2021 according the Australian Bureau of Statistics Patient Experience Survey.
No Australian Government in recent history has delivered equity through a co-payment system. Equity in health has been defined by Starfield as ‘the absence of systematic and potentially remediable differences in one or more aspects of health across populations or population groups defined socially, economically, demographically, or geographically.’ The definition could be easily applied to Aged Care and education.
Conservatives are not interested in equity. Successive Labor Governments however, have also shown a lack of commitment. Many Labor politicians would describe themselves as social liberals. Perhaps this lack relates to the reality that equity is not at the heart of any form of liberalism. It is an optional extra, talked about by social liberals as an aspiration, but falling second to the priorities of the individual.
Problems with co-payments, fee-for-service.
Co-payments limit access to items of care. The size of the co-payment is at the whim of the provider or the Government. A Labor Government, led by Julia Gillard from the left faction, introduced a GP co-payment for economic reasons, knowing such payments would be inequitable. The vagaries of economic and political factors determine how much and who will pay.
To determine a co-payment, one needs an item of care. There are some situations where itemised care with appropriate caveats can help to determine appropriate payments. Itemised care, especially in primary health care and Aged Care, leads to a siloed approach, which is completely at odds with the complex care needs in Aged Care and chronic disease. It limits teamwork, including teamwork which involves the consumer/patient interaction with the provider team.
Problems with safety nets
Look at a net. It has holes in it. It sags. It has edges. One could regard the Aged Pension as a safety net. Imagine being a 70-year-old widow whose only work throughout life was low paid, and whose rental cost is 50% of her pension. She has rental assistance, another safety net. She lives below the poverty line.
The Safety Net for prescription drugs helps. But a 20-year-old couch surfer, living with a mental illness, doesn’t register for the net. Even if he did, it doesn’t cut in until he’s spent a certain amount. How does he afford his drugs until then?
The vagaries of economics and politics determine the level and quality of safety nets.
Conclusion
Firstly, when the more powerful and articulate in a community are not subject to the inadequate service provisions of health, Aged Care, and education because they buy their way past such inadequacies, their advocacy for improvements in the system for all is weakened. The safety net sags lower.
Secondly, to adapt Aneurin Bevan’s 1948 quote regarding introducing the NHS: “No society can legitimately call itself civilized if an elderly and infirm person is denied Aged Care because of lack of means”
Thirdly, inequity is entrenched with every introduction of a user pays, means tested co-payment system with safety nets. If Labor does not want inequity, the alternative is funding through an adequate progressive revised tax system.
26th Jul 2023
Prescription Co-payments: Time to Stop the Silent Killer
Pearls and IrritationsPrescription co-payments are imposed by the Federal Government for subsidised drugs. Australians pay $1.6 billion a year in co-payments. Why do we continue to have financial barriers to accessing these drugs?
Co-payments are $7.30 or $30 per prescription for Pensioners and Health Care Card Holders or the remainder respectively. Scotland, Wales, and Northern Ireland abolished prescription co-payments in 2011. New Zealand has just abolished co-payments in July 2023.
Purpose of Co-payments
Co-payments in general are designed to reduce inappropriate use and to generate income. Some also believe that without co-payments the consumer will not value the product appropriately. In terms of medical care that sad view of human nature would appear to contradict my reality of many gifts and thanks from my bulk billed patients. Humans value good service. They value prescriptions which help.
Determining appropriate use of prescription drugs is the task of the prescriber, not the patient. Arguments for co-payments to reduce inappropriate use are nonsense.
Co-payments are taxes, levied on those unfortunate enough to need prescription drugs. People do not choose illnesses. One must ask if the purpose of co-payments is therefore also to punish the sick?
Health and Social Impacts of Co-payments
Prescription drugs are approved for listing on the PBS because they have been shown to save lives and/or reduce severity of illnesses. However, multiple studies show a reduction in use of medication with introduction or increase in co-payments. Repeated surveys over decades have reported that patients delay or do not fill prescriptions because of costs. Half a million people delayed or did not fill a prescription in 2021 according the Australian Bureau of Statistics Patient Experience Survey. The largest effects are in those living in areas of low socio-economic status, the elderly, those with long term health conditions, and females. There are widespread reports from doctors that their patients are reducing the dose or taking the drug every second day to save money.
It is well established that mortality and morbidity correlate with income, socio-economic status, and postcode. Access to health care probably accounts for 20% of the differences in life expectancy in first world countries. Socio-economic status accounts for most of the rest. Cost barriers are either met by decreased usage of life saving drugs or forcing the most vulnerable to pay co-payments and forgo spending on other basics in their lives which contribute to improved socio-economic status.
Studies of the direct effect of prescription co-payments on health show for example, improved compliance with taking heart medication if drugs are free, increased adverse events after the introduction of co-payments, and most recently a study in New Zealand showed decreased hospitalisation rates across a variety of medical conditions following the removal of co-payments for a selected group.
Economic Impact of Co-payments
An inflation adjusted figure from the Australian Institute of Health and Welfare 2012 data indicates that the day cost of a public hospital admission in 2013 is $1300. The Grattan Institute estimates there are 750,000 potentially preventable hospital admissions adding up to three million unnecessary days in hospital per year . Most of these are due to inadequate primary health care which includes financial barriers to access as well as adverse socio-economic factors. The government would only have to see a reduction of 185,0000 admissions across Australia to have easily saved the estimated $1.2 billion cost of abolishing all co-payments. Whilst the causes of these preventable admissions are multiple, medication compliance is likely to be a significant part of the problem. Improving compliance by abolishing co-payments will save money and reduce the net cost. It might even be budget neutral.
Thus, we have both an ethical and an economic argument for abolishing co-payments.
Current Policy Initiatives
The current Federal Government has done well with respect to reducing cost barriers to accessing prescription drugs. It implemented a reduction in the general co-payment from $42 to $30 in January.
It has since taken on one of the most powerful lobby groups in Australia, the Pharmacy Guild by extending prescription lengths from the usual month to two months. This halves the cost to patients for many drugs.
It has supported the concept of increased prescribing by pharmacists for some specific limited conditions, thus saving patients the challenge of finding and paying for an appointment to get a prescription. These changes combined will lead to a decrease in revenue from patients from $1.6 billion to about $1.2 billion.
It has maintained safety nets so that over a year there is a limit to how much one pays per prescription. But just because a safety net kicks in after a patient had spent $262 or $1563 (different depending on Health Care Card) on drugs for the year, this might not happen until May or October. It doesn’t help the budget in March or January.
What Now?
More should be done. The Federal Government updated its National Medicines Policy in February this year. The stated aims of the policy include that
All Australians have fair, timely, reliable, and affordable access to high-quality medicines and medicines services.
It’s time to align actual policy with the above. Co-payments continue to be a financial barrier to accessing lifesaving medication. Co-payments kill, lead to more hospitalisations, and waste money. It’s time to axe killer co-payments.
Published Letters
3rd Oct 2024
Health system needs reform
The AgeWe ranked No. 1 out of ten for our health care system according to the US based Commonwealth Fund (This healthy nation’s fit for a fall 2/10). The ranking was based on combining 5 different measures. On access to health care we ranked ninth, just above the USA. Somehow, despite that appalling ranking, we ranked No,1 on equity. How could that be? The measure of equity this think tank uses is obviously grossly inadequate. We are clearly not number one, as the many patients struggling to access care, will attest.
In addition, we rated No.1 on health outcomes, another of the five measures. Health outcomes are hugely determined by the social determinants of health, the conditions in which we work, live, and play. These are not part of the health system.
Let’s not kid ourselves. Our health system needs reform.
20th Jun 2023
Labor’s shameful silence
The AgeOne hundred and twelve deaths from Covid in a week in Victoria and not a squeak from our politicians (Sunday Age 18/6). No press conference to encourage mask wearing especially in indoor crowded places and public transport, to once again explain that if it’s 6 months since your last vaccination or infection you should have another vaccination, and no encouragement to have HEPA filters in indoor spaces.
The lowest death rate for Victoria in the last 12 months was about 20 per week in late January. Up to 10% of those infected get long Covid even with mild disease. Most deaths occur in the elderly. If the preventive measures were repeatedly encouraged the death rate might be halved. These preventable deaths are the responsibility of our politicians who refuse to lead. Their policy is ageist. Old people don’t matter. Their behaviour is morally indefensible.
Submissions
28th May 2020
Senate Select Committee on COVID-19
Senate Select Committee on COVID-19Prepared by Dr Tim Woodruff, President, Doctors Reform Society
The Doctors Reform Society is an organisation of doctors and medical students which formed in 1973 to support the introduction of a universal health insurance scheme (Medibank). It is an organisation which continues to advocate for a health system and a society which aims to address all causes of poor health outcomes for all people irrespective of income, socioeconomic status, race, culture, and geographical location.
Terms of Reference
On 8 April 2020 the Senate established the Select Committee on COVID-19 and referred the following matters to it for inquiry and report on or before 30 June 2022:
the Australian Government’s response to the COVID-19 pandemic; and any related matters.
Thank you for the opportunity to comment on this crucial and ongoing issue. The following is about the response to date and the response as the pandemic evolves and we adjust to the new normal.
The Economy
The pandemic has brought to the fore a realisation firstly that a healthy community helps the economy and secondly that having many Australians with an inadequate income severely compromises the economy. This inter-relationship between an adequate, secure income, health, and the economy must be remembered as we progress our response to the pandemic.
Health
Those in the health field talk about the two major determinants of a healthy community. Firstly, timely affordable access to quality health and preventive care is required. Secondly, we talk about the social determinants of health (SDOH), the conditions in which people are born, grow, live, work and age. Inadequate income, poor education and resulting lack of understanding about illness prevention, domestic violence, homelessness, and discrimination are just some of these important determinants.
The Australian Governments’ Response
The Australian Government’s response to date has resulted in avoidance of the disastrous explosion of cases, which might have overwhelmed our health system. It is to be commended for putting together a team of medical advisors and listening to their advice. That advice has had a strong scientific evidence base despite it requiring assumptions because of the novelty of the virus.
Benefits and Costs
This response has come at a huge economic cost much of which is unavoidable. What has been apparent however is that the Government clearly recognised that the Newstart Allowance was not sufficient to contribute to preventing an even greater economic challenge than we have. The Newstart Allowance was 40% below the poverty line. In the Australian population, 13% currently live in poverty, 17.4% of kids are being raised in poverty, and 40% of children in lone parent families live in poverty (ACOSS 2016). Now most of those fellow Australians receive the Job Seeker payment. It is now a little above the poverty line. No one is saving money on this allowance. Little is wasted. It is being spent and is helping to maintain the economy. Those who have recently lost their jobs will be spending every cent as they try to manage their pre-existing financial commitments.
Future Income Benefits Cuts
From a health perspective, this massive increase in income for our most disadvantaged is overwhelmingly positive. Poverty in rich countries like Australia is very strongly associated with health and social problems (Wilkinson and Pickett). If Job Seeker is reduced to a Newstart level, there will be a return to poverty for the recipients, which will help no one. Whilst in theory the savings might mean we repay the national debt faster than otherwise, recipients will be less healthy, less able to seek work, will spend less, and will place increased demands on health and social services. There may be a net economic loss. There will certainly be a decline in health outcomes.
Alternatives for a More Secure Future: Income Support
The provision of the Job Seeker payment has not surprisingly, been troubled with long queues at Centrelink, inadequate phone response capacity, and major problems for those who have difficulty managing complicated paperwork for whatever reason. How much easier would it have been if we had had a basic income guarantee (BIG)? This is an idea supported across the political spectrum including the conservative capitalist Nobel Prize winning economist Milton Freidman, the Productivity Commission Page 69), and Brian Howe, retired Hawke Government Deputy Prime Minister. No Centrelink queues (with or without physical distancing). No hours on the phone trying to contact Centrelink. No days or weeks waiting for the phone call from Centrelink. No demeaning experience of trying to interact with an organisation with such a focus on stopping rorting that humanity is lost. Even with BIG, huge changes would still have been required. It would however, have been much simpler, faster and less traumatic for all involved.
Alternatives for a More Secure Future: An Integrated Health System
When the trajectory of the pandemic in Australia was upwards there was a major concern regarding the capacity of our health services to cope, both in the community and in hospitals. Some publicly subsidised private hospitals continued to use vital PPEs for elective surgery whilst others were threatening to close for financial reasons despite the real possibility their beds, staff, and equipment might be needed if infection numbers rocketed. Instead, they won a $1.3 billion pay-check from taxpayers before it was clear they would even be needed.
Imagine if instead of using public taxpayer funds to increase the capacity of private hospitals over the last 20 years, we had instead put that money into public hospitals. Sixty percent of elective surgery in now done privately. If most of that was being done in an enlarged public system, we would have a huge increase in bed and ICU capacity easily accessible without any need to pay more money to the private hospital industry.
Imagine if instead of allowing public mental health funding to remain at staggeringly low levels compared to the documented needs, we had used taxpayer funds to develop an integrated community and hospital system of care. The tsunami of increased mental health issues developing as this crisis evolves would at least have been manageable. Despite the commitment of extra funds now to address this crisis, those funds are being spent in a system, which is not a system but a maze of poorly co-ordinated service providers.
Imagine if instead of allowing residential aged care to be subject to market forces and run by Boards with little understanding of health, there had been a health principled base for aged care underwritten by adequate Aged Care Funding Instrument (or other) payments and adequate health informed governance systems. Staff would no longer be on low wages and casual, with perverse incentives to work when they are sick. Residential aged care would no longer be a potential source of infection (all sorts including COVID). Our community would no longer be exposed to agonising decisions about palliative care for the elderly in underserviced environments or in overstretched hospitals not designed or equipped to deal with dementia and aged care. At the moment, either way our senior citizens are likely to die lonely and uncomfortable deaths.
Now is the time to consider an independent single funder for health care tasked with funding and integrating prevention, emergency services, primary health care including dental care, and hospital services using health professionals working in expanded more relevant practices.
Such an organisation must have a remit to fund services which can be demonstrated are effective and which are integrated with other services. Implementing this reform is a long-term project. It could start with controlling all new funding and gathering the data required to establish services based on need across the country and across the health service spectrum. Health service education would be tailored to support this implementation by coordinating education between professions.
Alternatives for a More Secure Future: Essential Medical Supplies and Data
During this crisis, we have been confronted by major challenges relating to supplies of medicines, vaccines, diagnostic testing reagents along with equipment and personal protective equipment. There may be challenges with respect to the equitable distribution of COVID-19 vaccines as they are developed. These problems largely relate to patent laws, which are structured to favour the owners of patents even at the cost of preventable patient suffering and death. The Australian Government has the power to over-ride patents in the interests of public health. It should! (Gleeson and Legge)
In addition, the European Union has put forward a draft resolution for the World Health Assembly for a global pool for rights on data and knowledge that can be of use for the prevention, detection and treatment of COVID-19. The Australian Government should support this measure.
Alternative for a More Secure Future: Telehealth
The advantages of telehealth in this crisis have been very obvious. No more crowded virus loving doctors’ waiting rooms, no unnecessary exposure of patients, medical staff, and medical office workers to rampaging viruses. Patients have frequently found it so much more convenient to address simple issues. Relatives don’t have to take the day off work to bring elderly patients in for a simple quick visit. We already use the technology to enable specialist services to non metropolitan areas.
There are however a variety of concerns.
Sadly there are doctors who are keen to see patients quickly and are not as thorough as we might hope. In general practice these doctors are sometimes identified by the Professional Services Review Board (PSRB) which is able to see Medicare rebate usage. Unfortunately the PSRB is seldom able to identify specialist over-servicing because specialist practice is so varied and the statistics fail to identify outliers.
- Phone and to a lesser extent video calls miss important visual cues.
- Patients clearly sometimes feel the pressure to finish the consult much more than when in person
- Accidental/ incidental issues are less likely to be uncovered than in a face to face consultation
- Fee for service medicine itself is a barrier to the provision of comprehensive integrated care with multiple providers, dealing with patients with multiple morbidities. Doctors and other providers do this every day in public hospitals. On a salary, the decision to ring patients, videoconference them, or ask them in for a face to face consultation is based almost exclusively on what would be in the patients’ best interests. Getting paid doesn’t matter. Telehealth will further entrench fee for service medicine to the detriment of the health system.
What can be done?
We have many salaried doctors and other health professionals. We need more. Aboriginal Controlled Community Health Centres give us one well established model of how this might be done in general practice. Victorian Community Health Centres treating patients generally in more disadvantaged locations provide another model for general practice. Public hospitals, which have been critical to dealing with this pandemic demonstrate that salaried health care can and do provide high quality care without constantly looking to find ways to increase income.
Whilst some might suggest we might limit telehealth to video consultations rather than allowing telephone consultations as has happened with the crisis, such a decision clearly discriminates against those who cannot manage or access the technology. Such people are already the ones who tend to get the least quality health care.
Listening to the Science: Climate Change
It is reassuring that politicians have sought out and accepted scientific advice on how to address the current health crisis. A key lesson to be taken from this response is the importance of evidence and science and the need for greater acceptance of the science of climate change which has the capacity to wreak even more havoc to both our health and our economy over time than this pandemic.
COVID-19: An Opportunity for a Better Future
Hopefully, we will not be going back to a world where welfare recipients are demonised, job seekers are punished, and vulnerable people with a poor education, a mental illness, a drug addiction, or any number of other life challenging conditions/situations are regarded as lazy useless sub-humans. Experience in other countries has shown that it is just these groups which are least equipped to deal with a pandemic. It is these groups which may harbour a resurgence at any time (e.g. migrant workers in Singapore).
It is time to move to a progressive, kinder, caring society which sees every person as valuable, which maximises everyone’s very variable capacity to contribute to society, and which enables rather than hinders the integration of our most vulnerable brothers and sisters.
Jobs need to be secure, not just any job. Income needs to be adequate, not held low in an unsubstantiated belief that that gets people working again in a productive way. Income and wealth disparities need to be reduced. We need to recognise the stark correlation between health and social problems and income.
As we manage our way through this crisis, it is time to think about an integrated, comprehensive, equitable health system. It would be good for the economy. Further, it is time to look at restructuring our society to recognise and address those factors outside the health system, which affect health and therefore affect our economy and our individual well-being.
23rd Oct 2019
Mental Health Productivity Commission draft report: reply
Thank you for the opportunity to respond to your draft report. It is an impressive document with extensive recommendations covering access to appropriate evidence based integrated patient centred care, improved governance, funding models, improved data collection, and other important determinants of optimal care.
This submission is therefore mainly about the gaps in the report recommendations and/or those recommendations with which we disagree or which are insufficient to address the issue. Read more