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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.

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
President

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
President

Elective Surgery Resumes

Slated to recommence on 27 April, elective surgery bans have been eased and elective surgery will be reintroduced in a staged manner according to the federal health Minister Greg Hunt.

But it’s not an immediate return to business as usual.

Category 1 patients continue to be allowed and focus been turned to the reintroduction of surgery for category 2 and more urgent category 3 cases.

The Federal Health Minister has released the following information giving guidance to which added procedures can be considered.

“Reintroduction of elective surgery will be done using a staged and controlled process which balances the ongoing need for the capacity to treat COVID-19 patients, while allowing our hospitals to treat elective surgery patients.

The selection of patients to undergo elective surgery will ultimately be a clinical one, guided by the following principles, recommended by the Australian Health Protection Principal Committee (AHPPC) and endorsed by National Cabinet:

  • Procedures representing low risk, high value care as determined by specialist societies
  • Selection of patients who are at low risk of post-operative deterioration
  • Children whose procedures have exceeded clinical wait times
  • Assisted reproduction (IVF)
  • Endoscopic procedures
  • Screening programs
  • Critical dental procedures.

This first stage of reinstating elective surgeries will require health administrators to monitor supplies of personal protective equipment (PPE), ICU and bed capacity, while preparing for the next phase.

On the advice of AHPPC, in addition to Category 1 elective surgeries, hospitals will initially recommence one in four closed operating lists, with a focus on Category 2 and some important Category 3. 

In reintroducing elective surgery we acknowledge the safety of patients and healthcare workers is paramount. A thorough risk assessment of patients planned for elective surgery is essential, based on national guidelines.”

READ MORE

NASOG reminds all members to maintain vigilance and stick to recommendations both of the Federal Government and of local hospitals where procedures are undertaken.

In many cases, hospitals are requesting potential theatre cases be discussed with a colleague prior to scheduling, to ensure the proposed procedure is within the current recommendations.

We have been informed that some facilities are using more formal processes with the requirement that proposed theatre lists, with justifications, be submitted to medical advisory committees for approval prior to procedures being able to be booked.

How much elective surgery is performed will of course depend on individual hospitals’ continued availability of personal protective equipment. This is likely to vary both in region and individual institutions so liaison with your specific local hospital is essential.

Bear in mind that the categorisation of patients has been defined by the Office of the Prime Minister:

Category 1 – Needing treatment within 30 days. Has the potential to deteriorate quickly to the point where the patient’s situation may become an emergency

Category 2 – Needing treatment within 90 days. Their condition causes pain, dysfunction or disability. Unlikely to deteriorate quickly and unlikely to become an emergency

Category 3 – Needing treatment at some point in the next year. Their condition causes pain, dysfunction or disability. Unlikely to deteriorate quickly.

READ THE FULL STATEMENT

Obstetrics related theatre cases remain Category 1 and are not subject to any bans. NASOG strongly recommends that COVID-19 drills and simulations continue to be undertaken to ensure all staff maintain readiness and familiarity with processes needed to deal with a potentially infectious case.

This is a significant improvement in elective surgery situation and is important we continue to monitor how the rollback of restrictions is progressing. Please feel free to contact NASOG and let us know of any concern so we can continue to inform the appropriate authorities.

Finally, continue to look after yourselves and your colleagues to make sure health worker and patient safety remains the top priority.

A/Prof Gino Pecoraro
President

NASOG eNews: 9 April 2020

I am committed to keeping all NASOG members up to date as the Australian healthcare landscape changes rapidly during the COVID-19 emergency.

If there is something your association can help you with, don’t hesitate to get in touch.

If you are not currently a member, rejoin today to support our work.

A/Prof Gino Pecoraro, NASOG President
Contact me: president@nasog.org.au

1. Agreements with Private Hospitals: Check Before You Sign.

Since the initial announcement of the Federal Governments guarantee for private hospitals there has been a scramble of activity at State and Territory level to implement agreements with private hospital operators.

Each hospital will then implement their own contractual arrangements with individual doctors.

This is an important and high-risk time for doctors. We are managing an unprecedented emergency situation, and the opportunity offered to however, the repercussions within the healthcare system are likely to be long term.

Before you sign a new contract with a private hospital as part of the guarantee arrangements, check through the following:

  • How will you be indemnified for the work?
    • Employer Indemnity or will you need full cover?
    • Will your regular insurer require any additional fees or information?
  • What is the length of the contract?
    • Bear in mind projections for the ongoing impact of COVID-19.
    • Is there a definite end date or time when it will be reassessed? Be aware – an open contract leaves the door open for managed care type contracts in the longer term.
  • What are the remuneration rates?
    • And how do they compare with other private hospitals in your city, state and the rest of the country.
    • Is the structure Fee for Service or wages?
  • If you are working across several hospitals, are the terms and conditions of the contracts offered consistent?
    • Are you a contracter or employee?
    • Will there be any workers compensation arrangements within the contract?
    • Will all doctors be offered equal access opportunity?
    • What happens with regards to sick leave if you become unwell while doing this work, will the state government or private hospital provide sick leave?
    • In the unfortunate event of a workplace related death due to work acquired infection, what support and payments are available for family?

NASOG strongly recommends that you do not sign a contract until you have taken the time to get a good understanding of the terms of the document and had it reviewed on your behalf. If you are an AMA member, get in touch with your state AMA to assist or ask if your MDO offers a service to review the proposed contract.

2. Assisting with the COVID-19 Workforce

If you are a retired O&G returning to the workforce to assist in some way with the fight against COVID-19, we thank you for your dedication! As you prepare to return to the hospital environment you may be asked to work outside your former specialty area or scope of practice. Even if not working in direct clinical contact with patients we suggest you ensure:

  • You are given full and correct training.
  • Your indemnity cover is appropriate (check with your own indemnifier)
  • You know where to raise concerns if you feel uncomfortable or are placed in an unsafe environment

For more information: https://www.ahpra.gov.au/News/COVID-19.aspx

www.ama.com.au

3. Good News on Indemnity

NASOG raised the issue of indemnity costs during the COVID-19 emergency with Australia’s medical indemnity insurers, The impact on O&Gs is widely acknowledged and Avant are proactively addressing the issue.

They will shortly be sending their O&G members a policy schedule outlining their current policy information, including their category and annualised billings.  

If anything has changed significantly from what is noted in your current policy documents, you should immediately contact Avant to amend your details.

Significant changes to annualised billings could result in a premium adjustment.

See their COVID-19 resource page for more information on Avant’s  response to COVID-19 and related assistance to their members.

4. Looking to the Future

NASOG believes that the future is one of opportunities and risks. We are very much focused on how the healthcare system in Australia emerges from COVID-19. With that in mind we wrote to Minister Hunt on 31 March with a series of proposals for action which will build on the cooperation and goodwill we are seeing during this period and ensure that doctors are appropriately recognised for the work that they undertake.

NASOG has asked that Government consider the following:

  1. Medicare covers 100% of the schedule fee for services provided by GPs, specialists and nurse practitioners with an incentive scheme to encourage doctors to accept this as full payment for a fixed period until the Australian economy gets back on its feet
  2. Continue to support O&Gs providing frontline services to patients through increased MBS funding to minimise out of pocket costs.
  3. Make changes to the Medicare Safety Net to minimise patients costs in accessing healthcare during the pandemic and recovery from it.
  4. Other levers to incentivise patients who can afford it, to help fund their health care by accessing private health insurance and the private sector.

NASOG also requested a review of necessary legislation, or other incentives, to encourage private health insurers to become more responsive to the economic climate.

We took the opportunity to remind government that greater than 50% of all spontaneous pregnancies in Australia are unplanned so deserve to be covered like other accidents by private health insurance policies. By allowing a single waiver of waiting period in a woman’s life, women and families with private health insurance would be able to access obstetric care in the private sector, further freeing up public capacity.

We look forward to further discussing our proposals with Government and working together to help ensure that both public and private sectors continue to survive and can meet the expected increase in healthcare demands from our population.

Pandemic Information: Check the Sources and Stay Kind

Article written for the Courier Mail by A/Prof Gino Pecoraro

The Covid 19 pandemic continues to affect the lives of everyday Australians in ways we had not previously imagined. The world is different now. There are changes this virus has caused to not only our health but also our social, political and economic systems.

In times of national emergency such as these, it is generally best to have one trusted reliable and accurate source of information. This information service should provide timely and simple instructions to the general public on how to best protect themselves. Traditionally, this voice belongs to the government of the day, acting in the best interests of the nation and all of its inhabitants.  The messages put out are informed by healthcare experts including public health physicians, infectious disease physicians, biologists and emergency physicians as well as those government agencies whose job it is to plan for and deal with national and global emergencies.

These experts have been trained in disaster management and how best to calmly and efficiently deal with large numbers of casualties while maintaining order in our communities.

Some well-meaning doctors and other experts have taken to social media to try and promote alternative health messages, frequently critical of current planning and measures taken to control the virus. In this situation, my view is that we need ordered and calm responses. While a particular state or territory’s management of border control, self isolation or elective surgery management plan might not be to everyone’s liking, it is important that all members of society can get behind a common plan and work together to achieve the best outcome.

Now is not the time for political leaders to try to point score against each other or for journalists to look for “gotcha moments” when leaders are explaining economic and health rescue packages to minimise the devastation.

Moreover, the general public needs to be aware of what we can do to help each other during this time. Follow the advice with regards to physical distancing, make sure that hygiene measures like washing hands are undertaken regularly and stay at home unless absolutely necessary.

For people with symptoms that may be COVID-19 related, please ring ahead to your local doctor and let them know of your concerns rather than just turning up at the surgery and potentially infecting other people. The government has announced earlier this week the release of this year’s seasonal flu vaccine which will be available at no cost to seniors, pregnant women, indigenous Australians, children between the ages of six months and five years and those with medical risk. People in these categories should make sure they get the flu vaccine to decrease the possibility of infection which could further worsen the pandemic.

Now is not the time to ignore other chronic health conditions and making sure that disease plans for conditions like asthma, diabetes, high blood pressure and others are adhered to remains vitally important. Health screening tests may need to be delayed for a period of time but it is important to make sure that once the pandemic is controlled, the usual screens like smears, mammograms, bowel and diabetes tests aren’t forgotten.

Make a note in your phone to remind you to revisit these important health tests in say 3-6 months. Forgetting them could potentially be disastrous.

Finally, the pandemic provides an opportunity for us all to remember we are part of a community and we need to look after each other. Check on neighbours, offer to provide meals which can be left at the door for people undergoing self isolation, ring up an elderly person who may be feeling particularly afraid or alone and just be nice to each other.

Together we will all get through this and may just come out of it with a stronger sense of community.

COVID-19 Update

The COVID 19 pandemic is rapidly evolving and NASOG is committed to making sure its members have accurate information to best guide both clinical and commercial practice.

Advice around how best to manage the situation is unfortunately being received in a fragmented nature and can be conflicting. State and Commonwealth health departments are not always consistent in their advice around how best to manage elective surgery, and on when and whom to provide testing and quarantining without unnecessarily creating anxiety in vulnerable populations.

In order to try and simplify the situation and help guide obstetricians and gynaecologists in the management of their patients, how to keep themselves and staff safe and maintain a practice, NASOG has  been in regular communication with health departments, other associations and colleges, medical indemnity providers, the AMA and the Private Hospitals Association.

We have linked below a number of websites which are regularly updated providing information from multiple sources around what precautions need to be taken, what advice to give patients with regards to testing and quarantining as well as doctors’ obligations in running their practices.

We will continue to keep in contact with these key organisations and will link any new information received on our website and help disseminate it through our Facebook and Twitter feeds.

As the pandemic continues, we remind doctors to make sure that they continue to look after their staff as well as their own family and personal health needs.

A/Prof Gino Pecoraro
President
Contact me: president@nasog.org.au

Useful Resources

Several organisations are constantly updating online information in response to the evolving COVID-19 situation. Refer to these in the first instance and contact us if the information you seek is not available.

Medico-legal Advice
Wide range of issues including telehealth, elective surgery and patient management
https://www.avant.org.au/Resources/Public/Coronavirus/
https://www.mdanational.com.au/mda-national-coronavirus-advice

Patient Alert Posters
https://www.racgp.org.au/coronavirus

Federal, State and Territory Departments of Health: Advice and Actions
Federal
ACT
NSW
NT
QLD
SA
TAS
VIC
WA

Australian Health Sector Emergency Response Plan for COVID-19

MBS Online Coronavirus Items Factsheet

If you have a query relating to interpretation of the Schedule, you should email askMBS@health.gov.au.

College Updates
RANZCOG

Elective Surgery

At the time of writing there are ongoing discussions about elective surgery in a variety of jurisdictions. There is currently a lack of consistent approach so we are working with other groups towards a resolution. At this stage, keep up to date with your hospital’s requirements.

MDA National mentions some things you may wish to consider around elective surgery and COVID-19 HERE