Pharmacy prescribing puts politics above patients

Pharmacy prescribing is a disturbing trend that may herald the further degradation of quality health care in the future. Substituting core roles of our highly trained medical workforce to other healthcare professionals, not specifically trained in the area, seems to be a favourite way for government to try and cut costs.

Unfortunately, it devalues primary are disturbs the continuity and totality of care provided by our general practitioners and further lessens the opportunity for preventative health care which is repeatedly quoted by all levels of government as being vital to not only improve the health of all Australians, but manage costs by intervening early and decreasing the need for in-hospital treatment .

We have seen government substitute nurse practitioners for doctors to perform surgical procedures, pharmacists with commercial vested interests deliver immunisations and there is talk of non-medically trained personnel giving anaesthetics.

Queensland Health Minister Steven Miles, supported by Premier enabled pharmacists to prescribe and dispense the oral contraceptive pill for women already using this method of contraception, without having to be seen, assessed and evaluated by their general practitioner or gynaecologist. This is a clear departure for Pharmacists in their role and is one for Which they are inadequately prepared and trained.

While pharmacists are a valued and important part of our health system, drug s. Whether it be how a drug works, how best to deliver or take the drug and what interactions a particular medication may have with other treatments that a patient is already on, a pharmacist is an expert in this field. They are not however, trained in how to diagnose or treat a particular medical condition. Moreover, they are unable to clinically examine the patient or request the appropriate investigations that lead to a definitive diagnosis being made prior to undertaking any therapeutic options.

Pharmacist prescribing has been extensively marketed by politicians as having a significant convenience factor for women who are described as time-poor and finding it difficult to schedule regular appointments to see their general practitioner to manage their contraceptive needs.

A standard pill pack contains four with two repeats able to be given, it means a woman need only see a doctor once a year to manage her contraceptive needs.

The World Health Organisation (WHO) is already on the record as saying that Australians are far too reliant on oral contraceptives and that these older methods should be replaced by newer long-acting reversible contraceptives (LARCs) such as implants and intrauterine devices. Importantly, LARCs are cheap! A single implant can last between three and 10 years, is covered review. In addition, they are associated with a significantly lower rate of unplanned pregnancies and method failures meaning fewer abortions.

In this election year, any government wanting to help women with their contraceptive options and save both individuals and the health system significant amounts of money would do well to encourage them to see their GP or gynaecologist to discuss and update their contraceptive choice.

Instead of having medically untrained pharmacists continue to dole out old fashioned treatment without review, perhaps we could look at government funding for contraceptive clinics being reintroduced or allowing gynaecology outpatient departments to see women again for contraceptive advice.

A Reflection on 2020

As this year draws to a close, I would like to thank you all for your support of NASOG throughout 2020 and acknowledge the challenges we have all faced and dealt with during this unique time.

As demonstrated by the number and content of the “president’s articles this year, NASOG has been tirelessly working to bring attention to the issues that are impacting Obstetric and Gynaecology practice in Australia today. Our aim is to inform both members of the profession, the community and decision makers in government so that where needed, improvements can be made to the service we can offer to our patients and ensure that women have choice in accessing their care

In February, NASOG was an integral part of a body of work with the Federal Department of Health bringing together a wide range of stakeholders to start work on a solution to increase the viability of private obstetrics. While there was a lot of momentum behind this, the project has been slow to progress as a result of COVID-19 but we fully intend to keep the minister and the department’s collective minds focussed on this very important issue.

Our response to the Department’s ‘Future of Private Obstetrics’ discussion paper was widely circulated and supported mid-year forming the basis of submissions from various other groups including some private hospitals and College., demonstrating NASOGs leadership position on issues that relate directly to our members ability to continue in practice.

With an increasing number of private obstetric units closing across the country, in 2021 we will continue to press the Government to reconvene the stakeholder group and make some real strides in supporting private obstetrics. Our discussion paper is available to all members on request.

A key part in bringing patients back is the uptake of private health insurance. I was heartened to read recently that a positive outcome of the COVID-19 pandemic is the increase in new private health insurance policies. This is great news particularly for elective surgery lists across the board and should have a positive impact on workload for gynaecology.

We would hope that the increased number of policies are at Gold level and therefore more women will be looking for private obstetric care. The ability to make their own informed choices around birth is a key factor for many women and something NASOG strongly supports. The moves in New Zealand to require psychiatric consultations before choosing an elective caesarean section are restrictive and, I believe, cruel. NASOG will use all our resources to ensure such an approach never takes hold in Australia.

In the gynaecology area, the MBS Review is complete, and you will now be working with the revised item numbers. Don’t hesitate to contact NASOG if you have any problems so that we can take them up for you.

I have been hearing recently that some private hospitals have been placing increasing compliance demands on O&Gs. This could make it much harder to run your practice as you would like to as your systems must align with the hospital. We would like to know if this is another emerging trend and whether members feel it is another move towards a type of managed care in Australia.

Managed care has been another big topic for work in 2020. With apparent increased pressure from some health insurers and private hospitals to sign tight integrated contracts around remuneration and systems, the AMA has shown more interest in addressing the threat of managed care on our healthcare system and is planning a summit for 2021.

To contribute to the discussion, NASOG surveyed our database on their impressions of remuneration and a managed care structure. We were pleased to find that length of time in practice, percentage of private work and gender made little difference to thoughts around how O&Gs should be remunerated. The vast majority of respondents felt that signing contracts with Private Health Insurers and Hospitals, and allowing these entities to set fees (and rebates) was only marginally better than doctors accepting the established Medicare rebates as full payment for any service that is provided.

We are looking forward to working with our AMA and specialist society colleagues in 2021 to develop a united approach on managed care.

On a more administrative note, we are pleased to have stabilised our financial position this year but we still need to significantly improve our reserves to put in place greater advocacy resources on your behalf and enable a renewed focus on resources and content for trainees who are seeking to find out more about establishing their career in private practice. If you are not a current member of NASOG, I would encourage you to join and support our work through your subscription payment, the more members we have, the more we can achieve on your behalf.

As this unusual year draws to a close, thank you again for your support and I wish you all a Merry and safe, Christmas and Happy New Year.

Blacktown Hospital and the Evolving Crisis in Obstetric Care

The recent coverage of the tragic newborn deaths at Blacktown Hospital in outer Sydney brings the evolving crisis in obstetric care in Australia into sharp relief.

Pressures on the capacity of this hospital to manage the numbers and complexities of maternity patients in the district could soon be seen in every public hospital throughout the country.

The issue of adequate resourcing for maternity services in Australia is far reaching and clearly demonstrates the effects of long standing undervaluing and resourcing of women’s health services by  the Federal Government and the follow on effect this has in overstretched public hospitals.

Inadequate, frozen and non indexed Medicare rebates have affected access to specialist women’s health services in the community. In addition, rising private health insurance premiums have seen many patients opt out of cover and pregnancy is excluded in all but the most expensive of policies. Up to 50% of spontaneous pregnancies in Australia are unplanned, and this all adds up to less and less expectant mothers going outside the ‘free’ public system.

This puts enormous pressure on a public system that was not designed nor properly funded to manage this volume of patients.

Private hospitals are closing down maternity services, consultant obstetricans are no longer able to support regional and rural areas, and more and more mothers are trying to access limited services. This is placing more young lives at risk.

The only factor preventing more women accessing private obstetric care is the underfunding of women’s health, due to long term inadequate rebates from both Medicare and private health insurance funds.

Australia needs BOTH public and private obstetric sectors , adequately funded, to survive and thrive. It should be a balanced partnership that meets the burden of care provision for our current population and into the future.

NASOG has provided feedback and suggestions to the Federal Government on the support needed to ensure the future of well supported obstetric care in Australia.

We ask Minister Hunt, his State colleagues and the private health insurers to waste no more time and address the funding of all maternity services so there are no more avoidable tragedies.

We’re All in This Together

The week of 6-11 September was Women’s Health Week, a nation-wide campaign centred on improving women’s health and helping them to make healthier choices across all aspects of their lives. Women’s Health Week attracts the support of organisations, high profile ambassadors, businesses, community, sporting and media groups across the country and draws attention to all areas of Women’s Health. Importantly, it also acts as a timely reminder for women to maintain their regular health checks with GPs and gynaecologists.

This year, the same week also marked Birth Trauma Awareness Week, reminding Australians that not every childbirth experience is pleasant and straightforward for a woman, nor necessarily what she had planned or wanted.

Research over many decades has repeatedly shown that continuity of care (seeing the same person throughout the antenatal, intrapartum and post-natal period) is reported to have the highest patient satisfaction scores as well as being an important driver in avoiding  birth trauma, both physical and psychological.

Pregnancy and labour care delivered by a private obstetrician gives the greatest chance of continuity of care as only an obstetrician can manage all forms of labour and delivery from normal to complex and include all delivery methods including spontaneous vaginal, assisted vaginal and caesarean delivery.

A Sydney based study published in January this year in the International Urogynecology Journal found that so-called “passive”  management of labour, a model of labour care instituted in Sydney public hospitals by a government directive in 2010, seems to be associated with a significantly higher rate of obstetric anal sphincter injuries (OASIS) than was observed in adjacent private hospitals where more “traditional” labour and birth management was undertaken by specialist Obstetricians. (https://link.springer.com/article/10.1007/s00192-019-04183-6)

It is common knowledge that in recent years, fewer Australian mothers have been giving birth in the private system. The reasons for this are complex and varied but include affordability issues associated with inadequate and non-indexed patient rebates from both medicare and private health insurance. In addition, many women find out that their insurance policy does not cover, what is for many Australian families, their first foray into the private medical system. What may have originally seemed like a sensible saving on health insurance can turn out to be a nightmare as women find that pregnancy care is currently excluded in all but the most expensive “gold” polices.

This anomaly unfairly punishes women who become pregnant and is a source of ongoing lobbying by NASOG to both the federal government and the private health insurance industry.

Because of these reasons, many women and their partners can find it difficult to navigate private health insurance when planning a family. Some couples start with the assumption that the Out of Pocket costs will be prohibitive and go no further. A significant number start the process with a private obstetrician but do not progress past the first visit.

Lack of public awareness around birth trauma may also contribute to decision making about private obstetric management, with an assumption by many that they can expect a normal vaginal delivery and will be home within 24 hours, to focus 100% on their new baby.

As specialist obstetricians and gynaecologists, we know that this is not always the case and for some women, the birthing experience is neither pleasant nor what they were expecting and this can be the cause of ongoing distress and trauma both physical and psychological.

NASOG believes that Australian women deserve the right to easily make a choice about their birthing experience when they are planning their family. In fact, even if they are one of the more than 50% of women whose spontaneous pregnancy was not specifically planned, deciding on and arranging pregnancy care should be simpler than it currently is.

Everyone deserves clear and complete information about the features and benefits a of all available models of care, so that they can make an informed choice about which model best suits them as individuals and their family situation.

Women and their families, need consistency in the rebates they receive, independent of which fund they are a member of, or in which Australian state or territory they reside in.

The many urban myths surrounding the cost and experience of private obstetric care, have resulted in increasing birth numbers in the already crowded and under resourced public system.

While families may have saved the out of pocket costs related to the 12 months around their pregnancy and the birth of their child, a birth related trauma requiring surgery, physiotherapy and ongoing psychological care, can generate many more unexpected costs.

NASOG is determined to restore the private/public balance to maternity care in Australia for the benefit of women and their families and is working with many stakeholders to bring that about.

Improving community understanding of all of the benefits of private obstetric care is one of the most important aspects of boosting patient engagement with private obstetrics.

The Future of Private Obstetrics

It is common knowledge that in recent years, fewer Australian mothers have been giving birth in the private system. This is obviously having a significant impact on the work of many NASOG members and is a priority area for our advocacy.

Since mid February 2020, NASOG and a number of other stakeholders have been working with the Federal Department of Health on strategies to improve the rates of use of private obstetrics.

In the months since, the Department has developed a Discussion Paper which outlines their impression of current situations, provides an outline of relevant data, and raises some options for moving forward.

We believe that the future of private obstetrics is dependent on developing well founded policy options with three higher order objectives:

  • Make PHI for private births affordable.
  • Limit expansion and contraction of out of pocket costs caused by arbitrary decisions about benefit levels by government and private health insurers.
  • Help consumers to better understand and navigate private obstetric care, benefits and insurance arrangements.

To successfully achieve these objectives, some key aspects need to be more clearly articulated and understood. It is critical that there is cooperation to undertake a thorough review and analysis of all medical specialist fees charged in relation to obstetric care. This will objectively identify an appropriate policy outcome and show where efforts need to be focused.

Maintaining a consistent financial experience for patients will be key to increasing the uptake of private obstetric services. We suggest that a mechanism that benchmarks fees, MBS rebates, PHI benefits and appropriate indexation could be established to provide that consistency.

In terms of PHI, NASOG believes this particular discussion should focus on policies designed to increase the number of women holding policies that cover private obstetric care. Data analysis of the number of women who have held cover for obstetric services and how they have used it would inform development of policy and help provide incentives for women to hold PHI for obstetric services.

Any policy options around PHI need to be informed by data about which policies have been used to cover women for private obstetric care, and which have been dropped.

Finally, there is no doubt that women and their partners currently find it difficult to navigate private health insurance when planning a family. Many start with an assumption that the Out of Pocket costs will be prohibitive and go no further. A significant number start the process with a private obstetrician but do not progress past the first visit.

A specific communication package for patients should be developed that provides a guide to the current funding arrangements for private obstetrics and the reasons for choosing private care, how to make choices about doctors, hospitals and insurers, and what to expect along the way. This will help counteract the ‘urban myths’ around private obstetric care and is a starting point for improving patient engagement with private obstetrics.

I strongly encourage all Members to review NASOG’s full submission, discuss it with your colleagues and work with them and your hospitals to prepare your own submission supporting NASOG’s position.

This will guide the Future of Private Obstetrics.

Submissions are due with the Department by 30 August 2020 however, you can contact SurgicalServices@health.gov.au to request a later submission date.

*Current NASOG members have been sent login details. To renew your NASOG membership and support our work, click HERE

It’s All About What Comes Out of the Pocket.

There is no doubt that the promise of No Gap Maternity services is appealing to patients who are suffering under increasing insurance premiums coupled with static medicare and insurance fund rebates to cover escalating medical costs.

Similarly, obstetricians also need a reliable regular income to ensure a sustainable practice in these times of high overheads and falling private insurance coverage among pregnant women.

As you are hopefully aware, several groups are looking right now at finding solutions to this affordability and sustainability problem in obstetric care in Australia. The solutions being explored vary in structure and level of engagement of the profession but they all ultimately aim to achieve an increase in the number of women accessing private obstetric care in private hospitals.

You’ve heard a lot from me recently about where some of these programs might lead for doctors and patients in the longer term and of potential risks to the future of the profession if we get this next step wrong.

A viable private obstetric service in Australia is crucial to everyone. Not only must women maintain their hard fought for right to chose their maternity care giver, we also need to make sure that there will be sufficient interest from the next generation of doctors to meet the future needs of the families of Australia and undertake the long and arduous training needed to become a specialist Obstetrician and Gynaecologist.

If we can’t make private obstetric practice (where the vast majority of qualified obstetricians and gynaecologists will ultimately work) both attractive and economically viable for our trainees, the system will fall over. Without enough junior staff available to work safe hours, public services will also fall over.

Failure to sort out the problem is simply not an option and I am convinced that with genuine desire to reach a mutually satisfactory and sustainable solution, we can fix the problem.

Now, it is time to hear from you, our members and supporters, to make sure we have all the information we need to formulate the best approach on managing out of pocket costs

Please complete our quick survey to give us a snapshot of the opinion of Australia’s obstetricians on the way forward.

Other representative organisations are also gathering infomation on specific programs and I encourage you to also respond to their requests so that these surveys are truly representative.

Thank you for taking the time to help NASOG continue to develop our policy and advocacy approach on the issue of Out of Pocket Expenses for Obstetrics. If you have any queries or wish to discuss further, please contact us at ceo@nasog.org.au

A/Prof Gino Pecoraro, President

This is Not a Drill…

I have been writing a lot about Managed Care lately, reminding Australian obstetricians to be wary of the apparent promises made in relation to No Gap Obstetric Models. I’ve also asked you to support NASOG find alternative ways to maintain an affordable and economically viable private obstetric service to the women of Australia where their choice of service provider is protected and defended.

So too, doctors deserve to have the choice to refer to other specialists they believe to be the best provider for their patients, not be forced to refer based on a low-cost contract held by an insurer or hospital.

In the past 24 hours, emails have been sent from a large national private hospital chain in multiple states, giving recipients a two-day time frame to express interest to participate in an HCF and Hospital No Gap Obstetric Model.

Although correspondence from the corporate entity states that it was not their intention to intimidate or force decision making, this tight time frame feels like it has been set to place pressure on doctors and encourage a fear of missing out on any deal on offer. Considered discussion with advisors and colleagues is effectively stifled, leaving doctors forced to make concessions that may have a long-term impact on their career.

Is it essential to be aware that while doctors will be forced to accept cuts in remuneration under these type of arrangements, health funds will continue to implement waiting periods and charge high premiums to cover obstetrics. We have previously argued that obstetrics should be considered a basic component of all health insurance policies, or enjoy the flexibility of psychiatric services, where a patient can upgrade to a policy to include psychiatric admission without a waiting period, on 1 occasion in their lifetime.

It is not clear yet whether private hospitals are taking a cut in bed or theatre fees for this “no gap” product but they will stand to benefit from increased bed occupancy rates and the goodwill that we know private obstetric treatment engenders in women. These happy mothers are frequently the decision makers in how and where to spend the family’s future health dollars.

Obstetric service rebates are not proposed to be indexed to CPI (or other measure) and nor are any proposed additional obstetrician payments, to encourage taking up of these offers, guaranteed to increase in line with escalating costs.

The doctors are not however the only losers with a No Gap Obstetric model.

PATIENTS LOSE CHOICE – the central tenant of private medicine.

We obstetricians and gynaecologists are not alone, craft groups beyond obstetrics are included in the model. Once signed up, you MUST use the IMAGING, PATHOLOGY, ANAESTHETIC and PAEDIATRIC providers that the fund and hospital have decided on.

This means that, like your patients, you have been DENIED CHOICE in providers.

Meanwhile, the health funds and hospitals will continue to maintain profits and run a “business as usual” model. Any perceived savings for patients come through clinicians receiving decreased remuneration for their services and loss of choice in referrals to other specialists.

If obstetricians sign on to these models, our specialty will effectively be sidelined in the discussions on how to really solve the complex problem of affordable private obstetric care. A problem that has arisen over time through inadequate and non-indexed patient rebates from both government and health funds.

We must stand together with our anaesthetic and paediatric colleagues as well as imaging and pathology providers to fight against this intrusion of managed care into our Australian health care system!!!

MAKE NO MISTAKE – this No Gap Obstetric model represents an existential threat to viability and choice of obstetric care in this country.

If you have received one of these emails from a hospital you work with and are making your decision, I urge you to CAREFULLY CONSIDER, not only the future of your craft group but also the larger implications of a financially driven third party influencing patient choice, clinical autonomy and ultimately the entire therapeutic process.

This threat is no longer an emerging risk. It is real and happening in a hospital near you TODAY.

NASOG asks you to keep us informed of any similar incursions into this space. We are maintaining communication with private hospital groups and working closely with other representative associations to find a mutually satisfactory way forward for the profession.

A/Prof Gino Pecoraro

Why NASOG is the Voice of Your Profession

Have you renewed your membership of NASOG for this year? If not, I want to ask you to seriously consider rejoining the association at this crucial time in the evolution of our specialty.

Obstetrics and gynaecology as we know it, is under threat.

The spectre of managed care has never been a more obvious or prominent threat to Australia’s health system and moves are underway by a number of private health insurers and private hospitals to implement this failed American model in Australia.

The Federal Government has long undervalued the cost of providing specialist women’s health services. The Medicare rebate freeze, as well as longstanding lack of indexation, means that for many women, private medicine is simply becoming too expensive.

Enter the managed care providers with promises of no out of pocket costs to patients and full hospital wards to private hospitals. But delivering only clinical interference, loss of choice for patients and indentured servitude for doctors.

Overseas experience shows that after a grace period, managed care also stops providing cost containment and certainty, leading instead to unsustainable increases in the cost of providing health care.

While this may appear to be an issue initially only affecting private medicine, this scenario can (and will if allowed to continue) impact the public sector as well.

More than 70% of Australian trainees will have to find work in the private sector when they finish their training. If private O&G ceases to become a viable employment model, junior doctors will realise their post training options are limited and stop applying for one of the longest training programs in medicine.

This will eventually lead to community shortages (beyond our current maldistribution with oversupply in urban areas) and increased closure of regional and rural units as GP obstetricians will be unable to attract consultant back up.

The reduction of O&G services in regional areas will mean women travelling long distances to large urban units to receive specialist care.

To date, Government has been reluctant to assist and our role is to help them understand why more needs to be done to protect O&G as a specialty. The provider of women’s healthcare.

NASOG is continuing to lobby on the profession’s behalf to look at alternative funding models to help keep private obstetrics alive as well as providing input into the gynaecology item number debate. Prior to COVID, discussions with the Chief Medical Officer finally reached agreement that unless something substantial was done soon, private obstetrics would go under. Leaving the women of Australia without choice and an already overburdened public sector dangerously stretched.

Another challenge is the ongoing task substitution agenda, with the mistaken thinking that pharmacists, nurses, midwives, paramedics and physiotherapists can diagnose and prescribe without appropriate training. We all know that this solution will only make running a specialist practice less sustainable and more costly, acting as a disincentive to specialist Obstetricians and Gynaecologists and ultimately leave the women of Australia at risk because of less skilled service providers.

The College has safety, standards and training as its central purpose and the AMA looks after issues as they apply to the entire medical profession. Only NASOG can specifically and solely look after the best interests of Obstetricians and Gynaecologists in Australia. NASOG liaises closely with these organisations but remains the main body in the advocacy space for O&G’s and their patients.

There has never been a more important time to be a financial member of NASOG. Your fees give us the resources we need to continue fighting for your rights.

If you have not already done so, please click on the link and rejoin today.


A/Prof Gino Pecoraro

Being Part of NASOG has Never Been So Important!

The end of the financial year often marks renewal time for association memberships and NASOG is no different. This year we are working pro-actively on a number of issues that impact our profession. If you are not already a NASOG member, I encourage you to join now and add your voice to our advocacy.

The Issues

Over recent years the issue of large out of pocket costs due to inadequate rebates from Medicare and health funds as well as lack of indexation, has seen the erosion of the private sector in Australia especially affecting the area of women’s health.

We are at a watershed point now, and ongoing insufficient funding of women’s health by successive governments, is causing an existential threat to the viability of Australian women being able to choose private services.

An area of real concern is the spectre of managed care, which needs a strong and united front across all medical specialities. If the health funds are able to get managed care off the ground for maternity, it will only be a matter of time until all areas of healthcare are affected. Once again in medical politics, obstetrics and gynaecology is the canary in the mine and where future political problems first show their face.

NASOG is committed to ensuring the survival and success of independent, private obstetrics and gynaecology services in Australia. We aim to capitalise on the ability of our healthcare system to be responsive to need and show initiative, as seen during the COVID-19 pandemic.

Our Actions

In November 2019, a new leadership team took over at NASOG. We have been working hard since then to establish new approaches, partners and benefits for the association.

In the past 6 months we have directed activity toward:

  • Collaboration with key medical representative organisations to oppose and stem the frightening prospect of obstetric Managed Care models being rolled out in Australian private hospitals.
  • Regular communication with both the Health Minister and the Shadow Health Minister’s offices as well as Government and opposition Parliamentarians.
  • Meetings with Chief Medical Officer and the department on how best to improve affordability and survival of women’s access to private obstetric care.
  • Signing an MOU with RANZCOG to officially recognize and embed the crucial roles our organisations have in maintaining and strengthening our profession.

Your Support is Important

In the next 12 months, it is vital that NASOG receives the ongoing support of the profession so that we can put in place a full-time CEO and Secretariat support to further our ability to:

  • Ensure the voice of the obstetrics and gynaecology profession is heard in negotiations that aim ultimately to improve for the women of Australia, an affordable way of accessing care in the private sector.
  • Expand mutually beneficial relationships with other associations and societies, both medical and consumer.
  • Build capacity through our networks to help members with specific practice challenges.
  • Escalate the issues of access and affordability for private care through Parliamentary and bureaucratic networks.

Membership Subscriptions for 2020/21

We understand that annual membership of several representative organisations can be a financial burden when your practice income is under pressure. This may have caused you to drop NASOG membership in the past.

To relieve some financial pressure, NASOG has lowered the standard membership subscription to $600 per annum (plus GST)

We have also introduced further membership savings if you are an AGES member, retired from practice or just wish to contribute to our work without accessing any member rights or benefits.

In Conclusion


We need to build our capacity, the more members we have, the more we can drive the future of our profession.

A/Prof Gino Pecoraro

Contact me: president@nasog.org.au

The True Cost of So-Called Fixed Cost Obstetric Services.

In recent years we have seen the emergence of a number of programs offering patients “low” cost, or “no out of pocket” cost, private maternity care. Established by or in partnership with, private health insurers, these programs initially look like a wonderful solution to prospective parents who may otherwise be unable to afford the out of pocket expenses related to having a family.

BUT, these models, raise the possibility that the insurer may eventually dictate to both medical specialists and patients, the care that can be offered and who can provide it.

Is it the start of Managed Care in Australia?

It’s no news to NASOG members that private obstetric practice has been under pressure for some time. Rising private health insurance premiums have seen many patients opt out of cover altogether. Coupled with the mandatory waiting periods before women can access private obstetric cover (despite over 50% of all spontaneous pregnancies in Australia being unplanned), there are less and less expectant mothers going outside the “free” public hospital system. This puts enormous pressure on a public system that was not designed to manage this volume of patients.

In addition, a number of studies conducted in Australia, report the highest levels of patient satisfaction are achieved when women can access continuous care with the obstetrician of their choice such as is available in the private obstetric setting.

The only factor preventing women accessing this model of care the underfunding of women’s health due to long term inadequate rebates from both Medicare and private health insurance funds. This underinvestment making private obstetric care unaffordable for many women and families.

Australia needs BOTH public and private obstetric sectors to survive and thrive. It should be a balanced partnership that meets the burden of care provision for our current population and into the future.

We need to ensure that sufficient numbers of junior doctors see the potential for a satisfying career in obstetrics and are incentivised to undergo the long and vigorous training program needed to staff the obstetric units of the future.

The possible curtailing of private practice options and limiting career paths available to only the public system may see fewer medical graduates choosing to train in obstetrics. This will have repercussions with ultimately less capacity available across the whole healthcare system- both public and private.

At least in the short term, the appeal of the fixed price model is clear. Private obstetricians are assured of patients and women receive certainty around their care.

But ultimately, there is a third party at play. Insurers will potentially be able to influence decisions that can be made around the medical care that is delivered and removing control from the doctors and placing it squarely in the hands of large often multinational corporations running the health insurance funds.

Contracts will define where a specialist’s role starts and ends in relation to their remuneration. Policy clauses define the limits of care a patient will receive for the premium they have paid. Only providers contracted to the agreement are able to provide services, even if they are not necessarily the best choice when special interests, experience and subspecialty training are taken into account.

In this scenario, what happens when real life circumstances don’t fit the fund contracted definitions?

Fixed price maternity programs represent an existential threat to the future of private obstetrics and the reduction of choice for women in terms of the care they will receive during pregnancy and childbirth.

Important considerations including indexation of rebates to health CPI and addition of necessary new services to be covered, must be taken into account in any health service funding agreement. By having a “fixed” rebate available, and dictating that no further costs can be included, the sustainability of practice in an area where new technology, genetic testing and therapeutic options are rapidly increasing, is severely compromised.

One view could be that these maternity programs are a training exercise for how funds will take control and run a managed care agenda across the whole of the private sector. If they can make these models work to their advantage in obstetrics, it won’t be very long until insurers roll the model out across the entirety of private medicine, resulting in a US styled managed care environment.

The proposed models don’t just target obstetricians. In some proposals, the provision of services from anaesthetists, pathology providers, paediatricians and ultrasound providers (not always at tertiary subspecialist level) are also included. Is it possible that in the future, containment of billings spreads further than the maternity area into those specialty areas more broadly?

The recent rapid response to the major public health challenge of COVID-19 and acceptance of the initiatives put in place for both public and private health systems have demonstrated that our healthcare regulators, administrators, practitioners and patients can adapt and implement change quickly and effectively.

NASOG applauds our state and federal governments for this agility and speed in acting during the crisis. It is now time to apply that same degree of action and proven adaptability to review how the public and private sectors could work together with health insurers to put in place a system that encourages independence, innovation and the highest standards of patient care. A system that will benefit the health of Australian women and families into the future.

NASOG continues to approach Government on the need to address the challenges in obstetric private practice. We are working with the AMA and other specialist groups to address how best to manage the issue of fixed price care while maintaining affordability for patients and independence for doctors.

We are united in our commitment to develop genuine alternative solutions to the challenges facing private medical practice.

Some might continue to argue that a fixed price structure gives assurance in uncertain times. Specialists are assured of income and more patients can access private care, taking some immediate pressure off the public system.

But in the longer term, what will the real cost be to the practice of medicine in Australia?

A/Prof Gino Pecoraro

Are you a member of NASOG? Join today and add your voice to the advocacy for your profession.

If you are a pathologist, imaging provider, anaesthetist or paediatrician who will also be affected by these proposed changes, consider becoming a Supporter of NASOG so your voice in this situation can continue to be heard.

The Post COVID Future…..

With the lifting of some social distancing sanctions this week, NASOG members will hopefully start to notice that their local private hospitals are starting to increase the number of less urgent category two and in time also category three elective surgeries. As there will be a large demand for available theatre time, I urge you to make contact with your local hospital theatre bookings department to discuss prospective cases and make sure they fit the federal government mandated requirements. Also make sure that the hospital has adequate supplies of PPE and fairly allocates available theatre time to all doctors across all disciplines.

NASOG continues to lobby the Federal Government for sensible and fair post COVID-19 management of the health system, which will surely be for ever changed. Now more than ever, the role of private medicine in providing the lion’s share of elective surgery in Australia, must be protected.

It is vital that long standing Medicare and health insurer inadequacies in the funding of women’s health are addressed to ensure the survival of private care. Australian women have had decades of under investment in their healthcare. The underfunding of obstetric services continues to be of major concern, but across the board women need more access and choice for gynaecological care and surgery as well as fertility services, specialised imaging and other sub-specialist women’s health care.

Later this week I will speaking to a group of engaged and enthusiastic young medical students and doctors at the PVOGS virtual meeting about starting a career in obstetrics and gynaecology. I am heartened that our specialty continues to attract young people to enter a training program that is one of the most challenging of all the medical speciality training programs.

It is vital that junior doctors attracted to a career in women’s health do not get forgotten once training is done but that we support and lobby for them to have a satisfying and rewarding long term career.

This is the key role of NASOG – to ensure that doctors working in women’s health can gain access to employment in the field of obstetrics and gynaecology into the future. We need to ensure that the private sector, which will employ over 70% of them, not only survives but thrives and continues to deliver more than two thirds of all elective surgery in Australia. Our patients deserve to have the best care available, delivered by doctors appropriately trained and remunerated sufficiently so they can concentrate on delivering this care rather than how they will keep the practice doors open.

As I write this, I have received information from at least one state where the AMA has strongly recommended doctors do not sign up to the first draft of a contract which has been put out by a state health department. READ MORE HERE

Each state will have its own contract drafted for doctors planning to deal with transfer of public elective patients into the private sector and it is important that you are aware of what is being offered in your particular state and how best to protect your interests. We will continue to update you with information as it becomes available to us.

Similarly, a number of private insurers are exploring contractual agreements with hospitals and providers which run dangerously close to integrated managed care models of healthcare delivery and we ask if approached, please forward details to NASOG, so we can access resources to look at proposals and ensure your interests are protected and rights not lost.

While the COVID-19 crisis continues to evolve, there are a number of signs that things are improving and NASOG will continue to ensure the voice of Australia’s women’s health specialists is heard at the highest level. There is much work to be done and we aim to keep you informed as we work towards the new health world order post COVID.

A/Prof Gino Pecoraro