First published: Sunday, April 29, 2012

The consequences of over diagnosis, over investigation, and over treatment in health care systems has dire consequences not only for those individuals subjected to such treatment, but to the rest of the population who look to their health care system for appropriate treatment or management. Thus, as has been said by others, instead of rational use of resources, many are subjected to rationing because politics limits the amount of public funding available and income levels prevent many accessing private care. As one would expect, rationing predominantly affects those who are not rich enough to use the private system or travel from areas of workforce shortage to areas of oversupply.

One could look at the bright side of rationing. If you have to wait 2 years for a knee arthroscopy in the public system the problem may well have settled down and you have avoided the small but definite risks of an arthroscopy. If it takes 3 months to see the urologist about your modestly elevated PSA (a disputed screening test for prostate cancer), the repeat test may show the level is lower and you may avoid immediate consideration of potentially dangerous interventions.

The dark side however is that patients face copayments they can’t afford or they simply can’t find the health care provider they need in their location. The Commonwealth Fund survey from 2010 found that 22% of Australians didn’t see their doctor when ill or didn’t do tests recommended or skipped drugs or didn’t fill out prescriptions because it cost too much.  They also face waiting times of years to access public hospitals for elective surgery eg hip replacement.

One issue this raises is the possibility of addressing the wasteful and dangerous over utilisation of resources and directing them appropriately to deal with these equity issues. That really depends upon how the issue of over utilisation is addressed.

Over utilisation takes many forms. There is the medicalisation of the normal range of human behaviour which then requires treatment. Although there are some examples of this being due to a non profit based genuine scientific and human interest in improving health, it is seldom the whole story and even when that is the basis for such interest it is frequently consumed by financial interest. To arrest that process requires arresting the profit motive in health servicing. A tall order in societies which are increasingly accepting that health servicing is an industry rather than a system for delivering health care as needed.

There is however another form which is prominent in overutlisation. It is a belief that one must be able to act to improve the situation. It includes a belief that as a highly trained professional, the skills one has should be able to offer something to address the problem with which the patient presents. Thus, a doctor trained to prescribe a medication for most problems may expect to do just that for problems for which medication is inappropriate. A surgeon trained to do an operation for most knee problems he sees will look to do just that even in the face of suggestive evidence that it won’t help in the long term.

It includes a conscious and unconscious link to the profit motive. But such a link is often not apparent. It involves providers, doctors and others, who work long hours responding to needs, expecting to be well remunerated, but often too dedicated to doing their work to enjoy the financial rewards, believing that what they are doing is what is required for the benefit of their patients. Some may question their own practices but when surrounded by other doctors who are much more interventionist, they feel they are demonstrating restraint. The ever present uncertainty of data and the difficulty in interpretation of data means that clinical practice cannot be determined by the science. The science is a guide only. Every day doctors who look very critically at the data are faced by patients who do not fit into the clinical trial data which guides them. Extrapolating from clinical trials is inevitable for specialists despite a wish to rely on good data. We check with colleagues. What would you do in this situation? Teenagers are not the only group in our society who are subject to peer influence.

For those who don’t have expertise in a particular area and rely on experts to guide their management, another layer of uncertainty descends. How independent is the expert? How much does the expert’s involvement with the drug or device industry affect his/her opinion? How much does the expert’s own research efforts influence his/her opinion?  For most doctors the answer to that question is often just a matter of judgement based on personality, beliefs, and perceptions. Drug companies seek out convincing key opinion leaders to influence this process.

This is not a problem of profit driven doctors. It is a system problem. If health care is an industry, profit will dictate its processes and outcomes. If health care is an industry with very large players, patients will suffer from over and under servicing. If healthcare is an industry of small businesses (which has been the case previously in Australia), it has some chance of avoiding such problems because providers have some control but can still be heavily influenced by external forces such as pharmaceutical companies and key opinion leaders.   If health care is a service which is centred on patients, it promotes the aspirations of the majority of health care professionals to provide a service rather than succumb to the necessities of the business ethic.

Until it is recognised and accepted that health care as an industry will drive over utilisation to the detriment of all except the providers, only minor control of this problem can occur. Until it is accepted that fee for service funding is a barrier to team based care and consumer participation the scene is set for a continuation of over utilisation in its various forms.  Education can help to a limited extent but works so slowly as evidenced by the lag time between the recognition that antibiotics are not needed for most ‘colds’ or that tonsillectomies were not needed in most 4-6 year olds and the appropriate change in practice to limit antibiotics for the former and stop dangerous surgery for the latter.

Experience in the United States that health care costs can be controlled by moving to a team based salaried workforce eg Mayo Clinic, Kaiser Permanente, without any evidence of decline in quality and indeed suggestions of better outcomes, is supportive of the concept of moving away from fee for service provision of services. The question of private versus public funding becomes important when looking at the accessibility of services. In Australia, the debate is very different because funding remains predominantly public but team based salaried approaches are largely restricted to the public sector where hospitals are the prime example.

If such resistance to team based salaried service were overcome, the potential exists for a reduction in over utilisation. The additional benefits would be huge. Patient/ consumer involvement would be facilitated by such structural change. If funded publicly, such services could be funded on the basis of measured need, thus addressing the gross inequity of access which currently exists. Savings from over utilisation could be used to build such services. Team based service providers would be in a position to advocate around the social determinants of health, especially as it would become more apparent that inequalities in health outcomes cannot simply be addressed by ensuring access to services.

The increasing awareness of and education about overutilization is welcome and necessary, but without structural change to how services are delivere
d and funded, its impact will be small and gradual.

Tim Woodruff

Vice president

Doctors Reform Society

First published: Saturday, September 17, 2005

ONGOING education is a vital part of being a doctor – very little in medicine being still the same as when most of us left university. If you don’t keep up to date both you and your patients are in big trouble.

But recent criticisms of the postgraduate education system, Continuing Professional Development (CPD), is somewhat misplaced. Some doctors may be rorting the system – but most take it very seriously.

The real problem is that the ongoing medical education system has been taken over by the big pharmaceutical companies, as has our medical science.

The interaction between big pharma and the doctors has intensified over the last 20 years and is driven by the enormous profits made by the pharmaceutical industry. It is said that the drug companies spend on average $30,000 per year on each Australian doctor – about $1 billion per year on doctor interaction and “education”. By way of contrast the federal Government spends a paltry $15 million, and is said to save at least three times this amount in the better prescribing by doctors that results.

By leaving the doctors’ ongoing education system to the drug companies it is government, more than the doctors, that ends up with the “free lunch”.

The rules state that drug company gifts to doctors can’t be valued at more than $10. The result is, in addition to the many drug company “educational” dinners, the less frequent weekends away at a luxury resort and the endless stream of drug company sales representatives, known as drug reps, in our surgeries, doctors are being enticed with the latest array of plastic gadgetry from China.

The problem is of course much bigger than the drug reps. Postgraduate education and medical research is now so heavily funded by pharmaceutical companies as to have created an environment where nobody can retain objectivity and most medical research has inherent bias.

There is enormous pressure on the “independent medical speaker” at drug company-sponsored educational dinners to mention products by name, and speakers often oblige. The talks are often on subjects chosen by the drug companies that highlight their products. Thus doctors are given endless “educationals” on medications that lower cholesterol in the blood (called lipid-lowering medicines), drugs for impotence, and for newly manufactured diseases that are for most people part of the natural ageing process – such as osteoporosis or dementia.

To make sure the doctors keep coming back for more such talks are often held at more salubrious restaurants and locations – such as luxury resorts on weekends away.

At yet another educational on lipid-lowering drugs, I went along mainly to ask the cardiologist about the benefits of fish oil and other supplements in managing my patients. He admitted that he used the supplements in his own cardiology practice but had not mentioned them, or other alternatives to statins (a class of lipid-lowering drug), “because he had only been asked to speak about the drug company’s product”.

At some of these educational dinners the drug reps can almost outnumber the doctors. Sometimes the drug reps cannot resist a promo of their drug product before and after – especially if their state manager is in attendance and they have a captive audience.

In such a situation it is difficult for doctors to have a free and open discussion. If a doctor has a differing point of view, or even an independent question, most of us now wait in silence until after the talk has concluded and hope to corner the speaker – often one of our trusted specialist colleagues – and furtively ask our questions in private.

Getting medical scientific knowledge or education untainted by commerce is becoming increasingly difficult – even if doctors had the time to do the research. Manufacturers of drugs and medical products fund 70 per cent of current clinical research. Studies show that findings published by researchers with company connections are almost four times more likely to favour industry products than research done independently.

An article published in Journal of the American Medical Association (2003;289:454-65) reviewed studies on the extent, impact and management of financial conflicts of interest in biomedical research. The conclusion was that financial relationships amongst industry, scientific investigators, and academic institutions are widespread.

Another study published in the British Medical Journal in May 2003 concluded “systematic bias favours products which are made by the company funding the research”. Such widespread bias has serious implications.

It is known that 30 per cent of the conclusions of the Cochrane Review – considered the most authoritative source of medical evidence – contain errors where conclusions are not supported by the evidence under review. This is now being addressed but there is compounding of the errors due to commercial bias – a bias always in favour of the drug companies.

This is because drug companies do not reveal all of their data – especially data which is negative for their product, or against using the drug. This then affects the systematic review, which is only as good as the studies that are published. It may not be such a bad thing that doctors are falling asleep during their post-graduate ongoing education sessions – or that doctors are preferring educational sessions on wealth creation rather than patient management. At least these sessions contain less bias, the information is less selective and you can ask any question you like of the speaker – and in full view of your colleagues and the drug reps.

Con Costa is a Sydney GP and qualified physician, and vice-president of the Doctors’ Reform Society.

First published: Friday, October 7, 2005

I only ever knew one of my grandfathers. He was, among other things, a Queensland Lightweight Boxing Champion and a disabled Gallipoli veteran. At about the age of eight, I remember accidentally bouncing a beach ball on his head. I floored him.

This taught me to be careful with Grandad. I’d known about his mangled arm but hadn’t realised bits of his skull were still in the Middle East.

But it could have been worse. One long-dead uncle was never the same after being buried alive for 36 hours. His official diagnosis was shell shock. These days we’d call it post-traumatic stress disorder, although it could also be known as thinking too much.

My uncle wrote a memoir while trapped in the foxhole. I’m told it’s almost unreadable – not because it’s illegible but because the contents are deeply disturbing. The memoir’s elderly keeper seems reluctant to let others view it, perhaps fearing that readers will be possessed by the same demons. I expect it will one day be buried. May the demons rest in peace.

My father served in New Guinea during The-War-Straight-After-The-War-To-End-All-Wars. It wasn’t an experience he’d talk about. As a child, I would no doubt have been thrilled by tales of glorious heroics in defence of the homeland. I didn’t get them.

It’s said that those who don’t learn from the past are condemned to repeat it. Perhaps my Dad tried to teach me a thing or two.

When I was in primary school, during the Vietnam War, I was given a T-shirt that read “War is not healthy for children and other living things”. A more obviously true statement there never could be.

Over the years, I’ve also seen T-shirts that assert another truism “Shit happens”.

Everyone knows it’s happening in Iraq.

Recently, it’s happened in London too. There have been many deaths, including a sort-of-Islamic-looking man executed by sort-of-civilian-looking police. He was collateral damage in The War Against Terror.

Perhaps I’m getting old, but fighting terror with terror seems absurdly Orwellian.

We’re told that young Muslim guys are blowing themselves up to get their hands on 72 virgins or, according to some Islamic scholars, 72 raisins. I don’t get that, but it’s no weirder than lots of stuff in the Bible. If al-Qaeda provide an email address, in the interests of world peace I’ll happily forward every spammed offer I receive of virgins or dried grapes.

Of course, in reality, suicide bombings can’t be statements of lust or gluttony. They are statements of anger and anger is always based on a perception, whether valid or not, of injustice.

People can get angry about injustices either to themselves or to others. In general, getting constantly angry about injustices to yourself means you’re a pain in the butt. In contrast, getting angry at injustices to others can make you a hero… or a monster.

Contrary to common intuition, research suggests that suicide bombers are not particularly poor, uneducated, miserable or psychopathic. They’re vulnerable, and the kind of people who, once they make a commitment to their group, must fulfil it. Suicide bombers might be stirred to anger, but they’re too compliant to consider telling a power-tripping cleric where he can stick his dynamite. Like Samson collapsing the Philistine temple, they’ll fight perceived injustice, whatever the consequences.

Many children have an instinctive dislike of goodie-goodies. Humans want social stability but don’t want the power of their rulers like childhood school teachers to be too overwhelming. Suicide bombers are the ultimate goodie-goodies. That’s why rebellious thrill-seekers might sometimes be dangerous, but aren’t suicide bomber material. David Hicks, the Australian detainee at Guantanamo Bay, could well fit into this category.

Meanwhile, our leaders play their own games.

Half a millennium ago, a remarkable little book was written on political psychology. Its author is to power-brokers as Randi the Magician is to spoonbenders. Revealing the tricks of a trade is no recipe for popularity.

Machiavelli wrote that rulers could control their subjects with either love or fear but fear was simpler. This means the switch never gets flicked to vaudeville.

So here’s a survival tip for our species: when you look in the mirror, see the chimp. And don’t be afraid.

First published: Thursday, March 16, 2006

For how much longer can Australians take readily available good health care for granted? Even urban areas are experiencing shortages of doctors and hospital beds. Will it get worse? What are the solutions?

How good is our health system? Figures from the OECD from 2003 show we have a life expectancy at birth of 80.3 years, fifth in the world.1 It has increased from 77 years in 1990, and the increase is on a par with that of most comparable countries. We are sixteenth in terms of infant mortality, 5.2 (per 1000 live births) compared to Iceland’s 3.0. We have managed this whilst spending US $2699 per capita on health which is the twelfth highest in the world, and as a percentage of GDP our spending is also twelfth at 9.3%. Public spending constitutes 67.5 % of our health spending. The four countries whose public spending is less than 52% all have life expectancies at least 2 years less than us and infant mortality over 6.1. and the United States is one of these countries. Thus, compared to other countries our health system delivers good outcomes and spends the money efficiently. One might conclude therefore that with a system working this well, we shouldn’t be too worried about changes.

There are other ways of looking at available statistics however. Figures from the Australian Institute of Health and Welfare show that ‘health gains have not been equally shared across all sections of the population’.2 Thus, although mortality rates are declining in all age groups at all levels of socio-economic status, the relative mortality rates in the most socio-economically deprived groups compared to the most advantaged group are increasing. For example, in 1985-7, the mortality rate in males from the most disadvantaged aged 25-64 was 65% higher than the most advantaged but by 1998-2000 that figure had risen to 75%.

When one looks at the more regular users of the health system, there is evidence to suggest that many do not take for granted the ready availability of good health care. The Commonwealth Fund, a Harvard based international health research institute, performs surveys in various countries every few years. In 2005, an in depth telephone survey of 750 Australians with some evidence of chronic use of the health system in the community showed that 34% did not access health care because of cost. Forty six percent who needed a specialist consultation waited more than 4 weeks for the appointment, 19% waited more than 4 months for elective surgery, and 17% waited more than 4 hours waiting to be seen in an emergency department.3 It would appear therefore that many Australians who use the health system regularly already do not take access for granted. The question is ‘will it get worse?’

For those who have sufficient money, little will change as is always the case. For most of those who already have problems with accessing the system, the answer is almost certainly yes, it will get worse. The reason is not the workforce crisis. That is just one very significant contributing factor. The direction our health care system is taking however, is the major factor which will lead to increasing inequity and increasing inefficiency.

From 1974, when Medibank (succeeded by Medicare) was introduced, until 1996, the Australian health system had been characterised by a very large public health insurance scheme which had aimed to provide universal affordable access to basic health care in an efficient and cost effective manner. The small pre-existing private health insurance system continued to supplement the public system.

In 1996, the direction changed. No longer was the aim to maintain and improve the public health insurance scheme. Instead, ‘choice’ had to be championed and the private system expanded whilst maintaining a public system for those who were unable to afford the private fees. The publicly funded component of the system had to be seen as predominantly a ‘safety net’ for those who were unable to afford the private system.

This change of direction however, has been gradual. Any abrupt change in direction would have been politically too dangerous. The benefits of private health care and choice needed to be sold to enough of the population with a mixture of carrots and sticks. Sufficient Australians needed to be convinced that the public system should be the ‘safety net’. Despite setbacks, the agenda continues, and we can expect to see an expansion of private health insurance cover to such things as private emergency departments, radiotherapy, dialysis, prescription drugs, and eventually everything.

One of the temporary setbacks to the agenda has been the issue of ‘safety nets’. The iron clad guarantee underpinning the Medicare safety net rusted very quickly, but much less publicized is the legislated guarantee that for the next 4 years the Pharmaceutical Benefits Scheme safety net will become harder to access each year. That’s the problem even with the very obvious ‘safety nets’, they are never safe from the Treasury’s knife. But more important is to understand that the whole of the public health system will increasingly be seen as a ‘safety net’, as private fees become ever increasing components of medical services, and private health insurance is permitted and encouraged to step in to cover an increased range of services.

Inevitably, the privatization of our health system and the transformation of the public system into the ‘safety net’ will mean increasing inequity. Those who currently face barriers to access will find the barriers greater, and many who now manage will struggle as the financial bar is raised. Failure to pay medical bills is the single most common reason for personal bankruptcy in the privatized United States health system. That is the direction in which we are heading.

Workforce issues will be even more of an issue as privatization increases. Already, despite very definite evidence of increasing workforce shortages across Australia, there are seldom significant delays even for elective surgery in private hospitals in major metropolitan centres. Next door in the co-located public institution, workforce shortages are usually one of many factors contributing to the delayed service.

But the privatization agenda, the Americanisation of our health system, is not just a disaster in terms of equity. It is the most expensive and inefficient way to fund our health system. Spending on health care in the United States is US $ 5635 per person per year. In Australia, we spend US $ 2699. We live longer and our infant mortality is better. An increasing reliance on a poorly regulated private health sector is a recipe for increasing inequity and inefficiency.

Private health care is much more expensive than public care, for at least two reasons. Firstly, the charges are much higher. In 2001 a study in the Medical Journal of Australia showed that the charges for having the coronary arteries investigated in a private hospital after a heart attack were twice that of the costs in the co-located public institution, using the same facilities.4 The only constraint on costs in the private system is the capacity of individuals or the health fund to pay. Patients are seldom in a position to question costs. But despite the costs there is no evidence that medical outcomes are any better, and most specialists will tell you that if you are really sick, the best place to be is in the public system because the level of care is better.

Secondly, there is very suggestive evidence of overservicing in the private sector. For example, the rate of expensive investigation of the coronary arteries after heart attack was assessed in Victorian public and private hospitals in 1999.5 The rate in private hospitals was twice that in public hospitals. This could be all due to underservicing in public hospitals but the more credible explanation is that it
indicates a mixture of overservicing in private and underservicing in public. Doctors like to help, and when confronted by a problem, they like to use their expertise and when it is procedural expertise there is an inevitable tendency to use that expertise. In private, no one questions an individual doctor’s decisions. In public there are many constraints. Huge discrepancies in the rates of a whole range of procedures have been documented previously. The inverse care law “the availability of good medical care tends to vary inversely with the need for it in the population served.”, coined by Tudor Hart in 1971 still applies.6 Thus overservicing, combined with increased charges in a privatized system leads to a much more expensive health system with no evidence to suggest better outcomes, and the distinct possibility of worse outcomes in patients inappropriately subjected to unjustified low risk procedures.

So what can be done to improve our health system, to increase the likelihood that more Australians can take for granted the availability of quality health care?

Firstly we need to reverse the direction in which our health system is heading, away from a privatized system with targeted ‘safety nets’ which are being eroded as you read this, back to a public health insurance scheme of some kind which aims for universal access. That universal access must be to quality health care, not, as is currently the case, to an inadequate Medicare rebate especially for specialists, increased copayments for pharmaceuticals, year long waiting lists for surgery, and 4 hour waits in emergency departments.

But more is needed. Medicare as it was, was far from perfect. The emphasis of our health system has been on hospital care, and the approach to non-hospital care has been directed to doctors on an inefficient fee for service basis. Especially as the burden of disease is increasingly related to chronic diseases, we need to move the emphasis to primary care and to preventive care. The current rhetoric even supports such a change in emphasis, but significant political financial and organizational commitment is still lacking. Without such commitment, the poorly integrated primary care sector, attempting to cope with funding from 3 different levels of government, and multiple sources within each government, will remain an inefficient mess. Without a whole of government approach which involves, for example, departments of welfare and of housing, the mental health crisis will be re-documented, unchanged or worse, in 5 years.

In addition, it’s time to engage the community to determine what they want most from the health system. To date the priorities of the system have been determined predominantly by the medical profession and politicians, with the media having a huge influence on the latter. Thus, hospital care, the lack of which always makes a good story, has led the priority list for funding. But already there are examples in Australia of governments and health authorities engaging the community to help to determine priorities and successfully move away from the stereotypic ‘you can’t close that’ response to a reallocation of resources.7 In that context it was disturbing to note the very negative response of Health Minister Abbott to the concept of citizen engagement as expressed at a meeting of the Australian Health Care Alliance in November 2005.

Despite such negative responses, there must be something positive happening. For some years now there has been a gradual increase in the component of GP income which is derived from sources other than fee for service rebates. It remains small and for specialists the issue has been ignored, despite even the conservative AMA acknowledging that specialist fee for service rebates for many procedures are inappropriate. The recognition that allied health is a part of the health system and the introduction of taxpayer funds, albeit very limited, for that purpose, is to be applauded.

The recent Council of Australian Governments meeting committed $1.1 billion to health sounded impressive but when one recognizes that the this amount is over 4 years and is only one tenth the amount of taxes spent on propping up the inefficient and inequitable private health industry, it is a sad reflection of government priorities. The fact that the State and Federal Governments managed to commit together to some small improvements in the health system, such as getting young people with disabilities out of nursing homes, should be considered a positive step, but when one sees that the future direction for our health system remains unchanged, such commitment is not encouraging, Indeed, with the Queensland Premier talking about means tested access to public hospitals, and leading the country in enrolling private fee paying medical students, this new found co-operation between State and Federal Governments may indicate that all we will see are some minor efficiency gains, some more targeted programs, but a health system destined to rival the United States in its inequity and inefficiency as State Labor Governments accept and adopt the conservative privatization agenda.

First published: Friday, November 21, 2008

Are doctors the cornerstones of primary health care? If they are currently, they shouldn’t be. Patients should be. The fact that we have in this country a health system which uses a funding system for primary care centred around funding providers – not patients, not need – is a sad reflection that patients are no longer the cornerstone of primary care.

However I think I’m correct in saying that the debate today is about how GPs and other health professionals fit into the primary health care system. Technically we’re really talking about what many call “primary care” as the term “primary health care” is often used to mean the broader picture – including population health over which primary care professionals have little impact.

The current situation is such that the GP is central to care in the majority of situations – but there are an increasing number of situations in which the role of the GP is not central. For example, patients with clearly traumatic musculoskeletal problems will visit a physiotherapist, chiropractor, osteopath, or podiatrist; those with weight problems visit a dietician or exercise physiologist; and those with psychological problems visit psychologist and counsellors. If a patient can afford to access private allied health or dental care, then this occurs with taxpayer support and without any contact with a GP.

For those who cannot afford such access, the access to such practitioners is limited. This is so firstly because GP referral is generally required, secondly because funding is an issue, and thirdly because access to a GP can also be a problem. Thus, government currently funds one system which requires GPs to be the cornerstone and another system which bypasses GPs entirely, the difference being largely the socio-economic status of the patient. Optometry, it should be noted, is a little unusual in that government funds the bypassing of GPs for all and clearly relies on the expertise of the optometrist to recognise those conditions for which specific GP or specialist care is required.

So is there a problem with patients bypassing GPs? When AMA President Dr Rosana Capolingua addressed the National Press Club a few months ago, she raised the example of a patient with Cushings disease, a tumour of the pituitary gland which may present with obesity. Her concern was that this patient may be seen by a dietician and the diagnosis missed. Her example was raised in relation to a dietician in a Superclinic: the patient was seeing the dietician because a receptionist had suggested she didn’t need to see a GP first.

Dr Capolingua continued, “Patients directly access allied health providers now and should be able to continue to do so.” I agree. But rather than patients seeing such professionals in a fee-for-service small business environment, – if they can afford it – I think these professionals should be seen in an integrated primary health centre where finance is not a barrier to access and where it is much more likely that whoever they see will easily and comfortably ask formally or informally for input from other members of the team as necessary.

There is no doubt in my mind that GPs are the best trained health professionals to perform a detailed assessment and diagnosis of a patient with a complex medical problem. There is also no doubt in my mind that a physiotherapist may be better than many GPs in assessing and treating a sprained ankle. GPs have possibly the most difficult task in medicine – certainly much more difficult than a specialist. They are expected to know enough about everything to enable them to know when they are out of their depth and need further advice and to provide treatment for almost any problem.

What is desperately needed is a collaborative approach to the assessment and treatment of patients: “teamwork” is the buzz word. There are several requirements for teams to function optimally. Firstly, co-location, – as in the Victorian community health centre model or the Superclinic model – must make teamwork more likely. It’s often more convenient for patients. But geography and numbers may make it impractical. Secondly, the funding model needs to be one which promotes co-operation and avoids perverse incentives. Having all staff funded in a similar way would be a start: fee-for-service for GPs and salaried service for other providers works against fostering teamwork. Thirdly, funding for professional development is required. It would entail all the relevant members of the team learning together – rather than have doctors learning at a drug company funded dinner whilst allied health professionals go to their own less salubrious meeting. Fourthly, simplifying the funding is necessary to streamline the multiple sources of funds and multiple accountability measures so that money is directed towards patients rather than programs. Finally, consumer and citizen input on how the team works and how it determines its priorities is also essential given my central proposition that patients are the cornerstone of primary health care.

When such a team is the norm, the likelihood of referral to the most appropriate person will increase because all parties are used to working together. Those patients who self-refer to a dietician with their obesity will see a professional who will be much more likely to pick something not quite right about the patient and refer to the GP down the corridor.

Back to the front desk. Who should decide what to do with the patient when they arrive at a primary health care centre? A receptionist? A nurse practitioner? Or should they all go to the doctor? That’s something which needs ongoing assessment as different models of triaging are implemented. Appropriate training is the key to the most efficient method of triaging. Where patients aren’t all seen by the doctor, it’s imperative that the outcome of such practice is assessed, given the many different possible models. But given that we already have a system which allows and indeed finances patients to see professionals other than GPs as first contact and patients are often happy with that, it seems conservative to suggest we can’t improve on that rather than waste the time of the most highly trained professional seeing patients that don’t require their expertise.

Nurse practitioner lead clinics in the UK have had mixed results, with reports of better patient satisfaction but increased costs because more patients end up seeing both a nurse practitioner and a doctor. But nurse practitioners working with increased responsibility in a team with a doctor, permitting the doctor to concentrate on the most highly skilled aspects of care would seem to be a sensible option. The scope for such an option is limited however, by the workforce shortage which affects all health professionals. In places of doctor shortage in Australia other health professionals are the first contact, and sometimes the only contact for the patient. There is nothing optimal about that. Better training for such people is appropriate but it is second best to having adequate distribution of doctors who remain the most highly trained health professional on the frontline of primary care.

This is an edited version of an
address delivered by Tim Woodruff to the Victorian Healthcare Association
Annual Conference on 16^th October 2008.

First published: Tuesday, July 3, 2012

Recently a patient came to me for treatment of her rheumatoid arthritis. She’s 42, a single mum with 2 kids, surviving on a pension which she is about to lose as her youngest is 8 years old and budget changes mean she has to work or go on Newstart. Her teeth are terrible. For the last 3 years she has required antibiotics for tooth infections about every 6 months. I can treat her arthritis and there’s a good chance I can get her well enough to go to work, but only a modest chance I can return her to a pain free existence (and that will be with prescription drugs for years). She is one of the 400,000 people on waiting lists for public dental care. Because of her serious dental disease her risk of heart disease may be up to twice normal. There’s even weak evidence suggesting dental disease may play a role in causing her rheumatoid arthritis. Now that she has a chronic disease she can get $4000 of dental work done under the Chronic Disease Dental Scheme (CDDS). Better late than never. Even without that she may be one of those set to benefit from the recent Federal budget announcement of a $350 million package over 3 years to address the appalling waiting list for public dental care.

Sadly, that’s almost all there was in the budget to address the parlous dental state of our nation. At least one third of Australians don’t see or delay seeing a dentist because of cost. Dental problems are one of the commonest preventable causes of admission to public hospitals. But there is no vision yet from this Federal Government about how we address this problem. The best offered so far is like ‘cake from the rich man’s table’.  The previously mentioned CDDS is a $1 billion a year program introduced by the Howard Government and has been a godsend for some desperate patients but is poorly targeted and structured in such a way that it is easily rorted. The Federal Government wants to stop it but can’t do so without the support of the Greens who are resisting because they want whatever replaces it to be a substantial improvement.

The problem of affordable access to dental care for all is not new. It was well documented by the Government’s own National Health and Hospitals Reform Commission which in 2009 recommended a scheme which would have cost an extra $4 billion per year to implement. This was ignored in the great health reform plan of 2011. Instead yet another committee, the National Advisory Council on Dental Health, was formed last year to suggest options. Basically it said that a capped Medicare style system to cover low income adults and all children would cost $8 billion per year and a capped public system provision for the same groups would cost $2.5 billion per year. Either proposal would be a large safety net aimed at addressing the needs of the most vulnerable. From these figures it would appear that funding dental through a Medicare style rebate system is vastly more expensive than funding through a major expansion of the public system. The public option suggested would essentially fund the states which could use a mixture of private and public dentists. One might expect Treasury to favour the cheaper option.

Unfortunately  the current negotiations between the government and the Greens are not about a universal access scheme for dental care. It’s much less than that. Essentially, it is about the size of the safety net.  The government did not request the Advisory Council to look at a universal access scheme and nor has the government expressed any vision for such a scheme.  Whilst we can expect the Greens to demand a large safety net, this is an opportunity to begin to implement a universal access dental scheme based on need. We know from our experience with Medicare that a rebate style, fee for service system fails to deliver universal access either because patients can’t afford copayments or can’t find a doctor. If we are to have dental care for those who need it, now is the time to set in train a process to deliver such a scheme. The cheaper public option could form the basis for a universal access scheme. The more expensive Medicare style option will not.

This is an opportunity for the Federal Government to demonstrate a vision of a dental system which encompasses the principles of equity and efficiency. It could borrow from the Gonski review of education which recommended a needs based funding model for school education to ensure that access to funds would not be a barrier to equity in education. A needs based funding model could be introduced for dental care. Such funding could be distributed to regions, based in the new regional structures the government has introduced known as Medicare Locals.  These are currently in development and thus incapable of immediately taking on the task of organising the regional use of such funds but the potential exists if the government would only return to its previously stated vision of ‘central funding and local control’.  As an interim measure the government could adopt the public funding model recommended by its own Advisory Council.

Will the Federal Government waste another opportunity to demonstrate it has a vision for equity and a strategy to achieve such a vision?

Tim Woodruff

Vice president

Doctors Reform Society

First published: Tuesday, December 31, 2013

Making patients pay out-of-pocket for visits to the doctor is cruel and discriminatory, having most effect on the disadvantaged, writes Tim Woodruff.

A proposal being considered by the Abbott Government to introduce copayments for GP visits is economically dumb in addition to being heartless.

The stated aim of such copayments is to save money and to stop overuse so that there is more money for those who need care. But the likely success of such a proposal is highly questionable.

There is little doubt that such copayments would reduce GP visits and thus reduce the cost of rebates to GPs. But some of that reduction would be for visits to the doctor that are very appropriate.

Imagine a single mum with three young children, all of whom have asthma. One is unwell so she attends the GP: $5. Day two, and another one is unwell, and the first is no better: $10. Day three, the third has the same symptoms and the others are unchanged, so she looks at the wallet for $15. She’s short on money as the fridge broke down last week and cost $150. She hopes things will settle. Night-time, and her third child gets worse, gasping. What follows is fear, an ambulance trip, an emergency admission overnight, and taxpayers paying $1,000+ for the treatment.

Imagine the young man with a mental illness, who is depressed, unemployed, and on medication but not taking it regularly. He gets desperate, considers seeing a GP, but is broke. He postpones the visit. He drifts into psychosis, and is taken to emergency. Where is the cost saving?

Then there are all the patients who we encourage to be screened for diabetes, blood pressure, and cancer. They see the ads, reluctantly think perhaps they should get screened, and are then confronted by a copayment.

It is dumb policy.

Of course, the copayment could be introduced in a variety of ways. It might just target those who don’t have a pension or health care card. It might allow a dozen visits bulk-billed and then charge, or charge a copayment for the first dozen visits and then stop, much like the Pharmaceutical Benefits Scheme.

One might argue that those not on a health care card can easily afford a copayment. The theory might be correct, but then there is reality. Low wage earners just above eligibility for pensions have to budget for everything, sometimes paying other out-of-pocket costs for a sick spouse who can’t get a pension because there is a wage earner in the family. The single-mum mentioned above could be working, earning just enough not to qualify for a pension, as well as supporting a sick unemployable husband and the three kids. Money is short. Another excuse to put off the Pap smear to pick her cervical cancer early, and so taxpayers bear the cost of her completely preventable cancer treatment.

The Pharmaceutical Benefits Scheme (PBS) has copayments of $5.90 for pensioners and health care card holders and $36.10 for the rest, and there is a safety net which cuts in after a certain amount is spent. Thus patients must find the money early in the year or go without. For years the Commonwealth Fund has demonstrated that about 20 per cent of Australians avoid filling out prescriptions because of costs. All doctors know that getting patients to take their medication appropriately is a constant challenge. But the Government puts a barrier in our way. Copayments for GP visits will have the same effect, even if introduced in the same way as the PBS.

The further concern with copayment policy proposals is the signal it gives for the future. The PBS in 1971 was $1. By 1979 it was $2.75. It is now $36.10. This is a fourfold increase in constant dollars (allowing for inflation). The introduction of PBS copayments was the thin end of the wedge. The introduction of GP copayments is the thin end of another wedge. Copayments will rise and Medicare as we know it will die. This proposal is designed to relegate our public provision of health care to an inadequate safety net for the poor. The rest will pay, and the rich will get the most expensive.

While touted as economically positive, this policy proposal, seen in the broad context of the total cost, is economically dumb. It is also cruel and discriminatory, having most effect on those least able to deal with illness. Copayments kill, but they don’t affect the rich and capable.

First published: Tuesday, January 7, 2014

Healthcare: GP co-payments not the real answer – there are far better ways to put budget back in shape
By: Tim Woodruff

The recent proposal to introduce a co-payment for GP visits has ignited debate about the financing of – and principles underlying – the health system.

The unambiguous aim of the proposal, prepared by a previous adviser to then health minister Tony Abbott, is to reduce or significantly slow the growth in medical benefit schedule outlays.

Despite targeting only GP visits, no mention is made of the fact that GP Medicare rebates constitute less than one third of such rebates, the rest being for specialist and other services. Rebates for specialist services have increased at least as fast as GP services since 2007 and cost about the same but have been ignored in the proposal. The estimated savings are less than $200 million a year.

If the real aim of the proposal is to save money from an ever expanding health budget, perhaps a more comprehensive approach to cost drivers and wastage is required. An easy first start would be to begin paying world market prices for generic drugs. This would save $1.3 billion a year, a Grattan Institute report says.

A second move, more complicated but financially rewarding, would be to respond positively to the multi-party recommendations from the Senate report of May last year, on the social determinants of health – those factors outside the health system that cost money by producing poor health.

The report noted estimates from the National Centre for Social and Economic Modelling, which suggested that $2.7 billion of savings in the health system, $2 billion to $3 billion of savings in income and welfare support, and $6 billion in extra earnings could be achieved annually through increased work participation and productivity if the issues identified were addressed.

Primary healthcare, that is, the first contact care in the community along with health promotion, illness prevention, community development and advocacy and rehabilitation, is widely regarded as central to efficient and equitable healthcare systems. We have first-class GPs and allied health professionals. But it is often a logistic and financial nightmare for patients to negotiate the complex care required for chronic diseases such as diabetes.

Co-ordination and simpler funding models are crucial to maximise the skills of these professionals. Investment in co-ordination through the development of regional health organisations of some form such as Medicare Locals can save money and lives. The funding model of fee-for-service and optional co-payments, however, stands in the way of optimum co-ordination and leaves many unable to afford the best care. It is time to revisit how we fund and organise primary healthcare in the interests of efficiency and equity.

The National Health Performance Authority says 7 per cent of public hospital admissions were preventable in 2012. These admissions were for conditions that needed better primary healthcare. Increased access to palliative care, advance care planning and home visits (including to aged care facilities) could reduce costs from over-servicing and hospitalisations.

Public hospitals cost $40 billion a year. Savings are there for the taking as decreased preventable admissions would help those on waiting lists to get treated early and return to the productive workforce or stop being a major drain on family and community as they wait for their necessary procedure.

A recent report in theHeraldshowed that $20 billion a year was being spent on low-value medical procedures. Even accepting that perhaps only one quarter of this can be saved, it still means $5 billion a year. But to do that requires a rethink about primary healthcare – which, when of high quality, leads to fewer referrals to specialists who perform most of these procedures – and fee-for-service funding of such procedures whether done in publicly subsidised private care (the doctor still gets a taxpayer-funded rebate) or in public care.

Then there is the $5.6 billion private health insurance rebate. It is a grossly inefficient way to fund healthcare, passing the money through private insurance companies, which then finance more expensive private hospital care.

Take your pick. There are many ways to improve the budget bottom line and the health of all Australians. The financial gains of a $5 co-payment, even ignoring the likely financial losses from patients not seeing doctors when they should, pale into insignificance when seen against these options.

This proposal would appear to be more part of an ideological crusade against a universal access health system and for a user-pays two-tiered system with an inadequate second rate safety net for the most deserving disadvantaged. It fits well with the Prime Minister’s previous agenda as health minister, when he supported the rise of the private health industry, let the federal contribution to public hospital funding decline from 50 per cent to 39 per cent, and presided over a fall in bulk billing rates to 69 per cent, only to belatedly realise that people liked bulk billing, which at least led to a backflip on that issue.

Perhaps he and the wiser heads in government can try another backflip and be economically rational. It could lead to better health for all.

Tim Woodruff is vice-president of the Doctors Reform Society.

First published: Wednesday, August 29, 2012

Dental Health: Roadblocks to Progress

A four-point plan for advancing equitable dental reform

The recent one day Oral Health Policy Forum in Canberra gathered together a variety of oral health professionals along with members and representatives from a variety of professional and consumer groups with a strong interest in improving oral health. The hope was that this would be an opportunity to find common ground and explore ways of advocating for the necessary changes to address the appalling state of oral health throughout the country and the grossly inequitable access to oral health services due to both geographical and financial barriers.

The question raised was ` Why has dental health been getting the brush off?’

One might argue that in a cost constrained world it is just too expensive. Then one has to ask how it is that the first steps towards a very expensive National Disability Insurance Scheme (NDIS) have been taken. It’s a long road to implementation but the commitment is there. In addition the cost of not having a comprehensive oral health system tends to be ignored in such arguments. Lastly it’s worth considering that according to the Henry Tax Review, “Australia is a low tax country by OECD standards” and we have the 3^rd lowest spending to GDP ratio of all 30 OECD countries. It is a myth that we can’t afford the NDIS and another myth that we can’t afford proper dental care. It requires political will and leadership.

But the Canberra forum demonstrated another major obstacle to dental reform. Many of those present are seeking a commitment to a universal access dental scheme. One group which believes that a universal access scheme will not work is the Australian Dental Association (ADA). It raises quite reasonable concerns about the failure of various Medicare add on schemes to prevent the perpetuation of the inverse care law ie that those who need the most get the least and those who need the least get the most.  It does not recognise that Medicare itself is plagued by that same rule and that a fee for service dental scheme with copayments would like Medicare, fall into the same trap.  Instead it proposes a targeted approach to disadvantaged Australians complete with a cap on how much government funding is permitted each year, supplemented by private insurance and copayments `as a means to have people appreciate that there are significant costs associated with their treatment, ‘(1)  and that use of such copayments be determined by the dentist.

This should all sound familiar. It is like Medicare but even more restricted. At least with Medicare  there is no yearly cap on expenditure and one doesn’t have to fit an arbitrary criteria of disadvantage to qualify.  Medicare has been fantastic for improving access to health services but after 25 years of fiddling around the edges with safety nets and programs, it remains characterised by significant financial and geographical barriers to access. There are many contributing reasons for geographical barriers but the reason for financial barriers is simple. They are permitted, and in the case of access to pharmaceuticals, they are mandated by the Federal Government despite the evidence that they reduce access to care by the most needy.  Copayments for dental care will be no different, whether they are those envisaged by the ADA’s plan or optional copayments under a fee for service Denticare as promoted by some of those hoping for a universal access scheme.

In 1975 Medibank was introduced by the Labor Party despite the vehement opposition of the Australian Medical Association (AMA). A universal access scheme was regarded by that organisation as anathema partly because it was perceived to threaten the control and power of the doctor by making him (usually) dependent on government funding.  They have fought ever since to maintain their power to determine who will be bulk billed, who will pay a copayment, and how big that copayment is.

The ADA is more subtle but their alternate proposal demonstrates that this is mainly about the threat to the independence of the profession. Capping access to funds and requiring copayments does not give the impression that the patient is the main concern.

To move oral health policy forward towards a universal access scheme, we need to recognise that the ADA will put its members’ interests first.  Individual practitioners will continue to provide great and generous service to individual patients. The ADA’s primary interests however, concern the maintenance of income, independence and power and it will not support a system which threatens those interests.

The National Advisory Council on Dental Health set out short term options for the Government. The public option covers children and a capped means tested adult service for $2.5 billion per year. The fee for service option covering the same groups costs $8 billion. The public option sets the scene for the development of a universal access scheme. The fee for service option sets the scene for a Medicare style dental scheme with all its financial and geographical barriers to equity.

To move forward we need to

1. challenge the perception of inadequate funds,

2. encourage political leadership,

3. recognise the ADA as primarily protective of its own interests just as reformers since 1975 have regarded the AMA,

4. plan a system with an emphasis on salaried public service free of the financial and geographical barriers so evident in Medicare.

Tim Woodruff

Vice president

Doctors Reform Society

1.  “Dental Access” Proposal:  Proposal to the Australian government for a Scheme to assist disadvantaged Australians obtain improved access to dental care. 20 November 2009 http://www.ada.org.au/App_CmsLib/Media/Lib/1108/M329081_v1_Dental%20Access%20Proposal.pdf

First published: Thursday, June 12, 2014

Killer copayments and murder of Medicare