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.

Are We Accepting the Death of Private Obstetrics?

Are you losing count of the closures of private maternity units in recent years? It seems that we can’t go two months without hearing about another case of private unit closure and subsequent crisis in the already overwhelmed public system.

NASOG’s fight in Cairns has current media attention, but this is not a Queensland specific issue. We have also seen announcements related to closures in Victoria, Tasmania and NSW.

Are we quietly sitting by and accepting the death of our chosen specialty’s private practice?

Have we made an unconscious decision to hand over the care of Australia’s future mothers to an overstretched and underfunded public sector?

Do we actually believe that obstetric care is only necessary in 5-10% of cases so under resourcing in rural and regional areas is fine?

And if the majority of our colleagues are sitting on the sidelines, why?

I know that private obstetric practice is getting tougher, I’ve been saying it for years and the numbers are there to back it up.

BUT the numbers also show that Australian women still want to choose the style of care that suits them. Our own review of the MBS data shows that the number of patients seeking an initial appointment with a private obstetrician have barely changed since 2012. But what has changed dramatically is the number who then continue with private care.

In the seven years to 2016/17, on average only 12% of women who had an initial consultation with a specialist obstetrician did not pursue private obstetric care. 

By 2019/20 this had percentage increased to 46%.

And by 2021/22, increased further to 52.5%*


Because Medicare and Private Health Insurance patient rebates have not kept up with the real costs of practice. More families just can’t afford to pay all of the out-of-pocket costs on top of their, already high, private health insurance premiums.

The public sector felt the pressure of those families decisions to the tune of approximately 55,155 additional maternity patients in 2022.

Those costs are borne by the States, but the solution lies with the Federal Government.

The public maternity system needs a robust private sector so that patient care can be delivered to the level that Australian women want and deserve. This can only be achieved if Federal and States Governments work together with the profession to find a meaningful solution.

The Federal Government needs to increase the Medicare rebates for patients and remove the private health insurance premium discrimination against women’s reproductive health.

NASOG has not wavered from these points since first putting our proposal to Government in 2021. We are determined to bring balance back into the system before there are serious costs for mothers and babies.

In the past week, NASOG annual membership renewals have been sent. If you believe that specialist private practice is worth fighting for, make sure you renew by 30 June.

If you are not a member, I urge you to sign up now.

We need to show the decision makers that we are a united specialty and will keep fighting until we have a revived private sector.

NOW is the time to back NASOG in the fight for our speciality!

Otherwise, we will see the death of private obstetric practice in Australia, not with a bang, but a whimper.

A/Prof Gino Pecoraro OAM
(with apologies to TS Eliot)

*Calculated from MBS data obtained from medicarestatistics.human.services.gov.au.  The number of claims for item 16404 (subsequent attendance) was subtracted from the number of claims for item 16401 (initial consultation).

No Risk Births?

As the regional maternity crisis continues to roll out across the country, Queensland Health bureaucrats are attempting to address the high-profile maternity bypass at Gladstone Hospital by enabling ‘No Risk Births’ to take place there.

Superficially, this may appear to be good news for the expectant mothers of the Gladstone district. However, NASOG has a number of significant concerns that I’m sure are shared by many.

What exactly is the definition of a “No Risk Birth”. It is certainly not a medically recognised concept and does not appear in any textbook of Obstetrics and Gynaecology. While thorough history taking can identify a number of known risk factors and therefore presumably find a group of women with “lower risk”, no delivery can be classified as having no risks attributed to it at all.

A/Prof Gino Pecoraro on 10 News, Brisbane, 12 April 2023

As all obstetricians know well, pregnancies and deliveries are normal until they aren’t. The change from normal to ultra-high risk can happen in the blink of an eye and place both mother and baby at risk of losing their lives or permanent disability.

A number of studies looking at lower risk pregnancies managed in a number of different midwifery led settings without automatic oversight by an obstetrician, quote varying rates of up to 50% ultimately needing the input of an obstetrically trained doctor to effect safe delivery of the baby.

Statistics such as these should be of great concern to the people of Gladstone who are living with the prospect of having a baby at a unit without access to emergency lifesaving obstetric input.

These figures should also encourage caution on behalf of the department when making announcements to the public without the necessary contingencies in place to handle emergencies when they inevitably occur.

While everybody is understandably incredibly keen and anxious for maternity care to be delivered once more from Gladstone Hospital, it is imperative that such care is safe for both mothers and babies who are at a particularly vulnerable time in their lives.

This safety must not be sacrificed for expediency or to dampen adverse political recriminations.

Members of NASOG know that reinvigorating private obstetric practice and removing the discrimination in access to Gold level Private Health Insurance will make a genuine difference to the provision of maternity services throughout the country.

NASOG has been highly vocal in the Queensland media and actively meeting with stakeholders at State and Federal level to encourage my home state to work with the Federal Government on policy decisions that will return full maternity services to our regions.

The same approach needs to happen across the country before we see more regional hospitals turning to a ‘No Risk Birth’ model.

LISTEN: A/Prof Gino Pecoraro on 4BC, 13 April 2023

Canberra. We Have A Problem.

Since I became NASOG President in 2019, I have used the word ‘Crisis’ in relation to obstetric services in almost every article, interview and meeting I have been involved in.

This is not an overstatement and far from being sensationalist,  the situation is worsening and demands our attention if we are to safeguard obstetric services into the future.

The current recruitment and retention difficulties we are currently seeing, particularly in regional Australia are every bit as dire as the previous indemnity crisis that saw the viability of our specialty seriously questioned.

As 2023 unfolds, it is clear that the delays in action on the issues around maternity services generally have become just as serious as predicted by NASOG, if not more so.

In late 2019, the previous Federal Government started some work through the Department of Health on the ‘Future of Private Obstetrics’. This project was prompted by the significant drop in patients using private obstetric care, the increase (at the time) in fixed price private birthing models, and the assumption that public hospitals would be unable to cope if private obstetrics continued to fall.

Unfortunately, the project fell by the wayside due to the public health emergency of the COVID-19 Pandemic.

Which meant that over the past 3 years, the situation in obstetrics has quietly continued to worsen.

NASOG’s own review of the publicly available data on MBS item numbers 16401 (Initial Consultation) and 16404 (Subsequent Attendance) shows the situation in stark relief.

In the seven years to 2016/17, an average of 12% of women who had an initial consultation with a specialist obstetrician did not pursue private obstetric care. 

In 2019/20 this percentage had increased to 46%.

And, by 2021/22, over 52% of patients attending an initial consultation with a specialist obstetrician, did not attend a subsequent appointment.

Meaning that in the past year alone, approximately 55,155 women did not pursue the private care they had been considering and were instead cared for by public hospitals.

We know what this means in practical terms for our specialty and the patients we care for:

  • Private specialist O&Gs are opting out of obstetric work and working in gynaecology and fertility only.
  • Specialist O&Gs are pulling out of regional areas as without private work it is uneconomical to stay in practice.
  • More patients are attending under-resourced public hospitals causing some of them to struggle to retain trained staff and leading to mass walk outs and even closure of public units . All the while private hospitals have empty wards and continue to close due to under utilisation and loss making.
  • The career path for trainee O&Gs is narrowing, making the specialty overall less attractive.
  • There is too much pressure on rural GP Obstetricians when they lack any specialist back up, making their sub-specialty less attractive.

Despite this issue having been recognised and briefly addressed at a Federal level, the disastrous repercussions are being felt by the States.

Private maternity wards closed in Gladstone, QLD in 2018. By June 2022 the public hospital was in a workforce crisis and on bypass for maternity. The QLD health department’s solution of telling women to drive to Rockhampton to have their babies, resulted in added pressure on the Rockhampton Hospital, the subsequent resignation of overworked staff and a further reduction in access for women in the district.

Tamworth, NSW lost their private maternity hospital in 2012. O&G care at the Tamworth Public Hospital is now provided largely by locums, meaning patients have no continuity of care and the risk of associated adverse outcomes increased unnecessarily.

Everyone surveyed agrees that a continuity of career model led by trained obstetricians, offers the best outcomes for women and only an obstetrician is able to safely effect delivery in ALL situations.

Blacktown Hospital in NSW became so overwhelmed by the number of patients they could not always provide timely emergency care with tragic results, a staff walkout and national media attention.

In Geelong, VIC, the Epworth has recently announced the closure of their maternity unit, citing workforce shortages. Once again forcing more women to deliver in the public system.

NASOG developed a plan in 2021 to increase the MBS Rebate for Item 16590 (pregnancy management fee) to significantly reduce out of pocket costs for patients and encourage more people back into the private system.

Private insurers also need to better support Australian women. Ideally, pregnancy cover should be included in all policies or at the very least, an option similar to mental health inclusions should be adopted so women can raise level of cover once in their lives by waiving the waiting period.

We continue lobby hard for the removal of the blatant discrimination in Private Health Insurance premiums for reproductive health that our federal government allows to continue unchallenged..

These are solutions that only the Federal Government can implement. While they continue to do nothing, the States are floundering about with alternative workforce ‘solutions’ that at this stage, can be nothing more than a short-term fix.

Members already know that NASOG plays a vital role in political advocacy for profession. At the heart of what we do are some core principles;

  • Maintain access and affordability for patients to all levels of O&G services in Australia.
  • Ensure the survival and success of O&G as a specialty into the future.

The NASOG Council is unanimous in the belief that we must use every endeavour and all our available resources to fight for these principles.

You can support our fight to have this crisis addressed at a Federal level. You can lobby your local Federal Members and Senators (contact admin@nasog.org.au for material), you can become a NASOG member or you can contribute to NASOG’s fighting fund to help us keep the pressure on (find more details at www.nasog.org.au)

It is essential that the Federal Government addresses the Obstetric Crisis with all the tools available and does not abandon the States, our profession and Australian families.

A/Prof Gino Pecoraro
NASOG President

Keeping the Pressure On!

Since 2019, NASOG has been warning State and Federal Governments that without support to increase the use of private obstetrics, public obstetric units would start to collapse. Today we are reading a new story in the media almost daily about another hospital somewhere in the country (usually regional areas) that is closing its maternity unit. The crisis in Queensland has been particularly obvious and NASOG President, A/Prof Gino Pecoraro has not held back in the media about the many challenges facing maternity care. His opinion piece, shared below, highlights just some of the challenges facing young doctors considering obstetric roles in regional areas.

We call on all NASOG members to be vocal about the crisis within our profession and the risks it places on Australian Mothers and Babies.

If you know of a media or political opportunity, contact NASOG for assistance or comment.

The Sunday Mail (Qld): February 12, 2023

Opinion: Health Minister’s insulting comments inaccurate

The Queensland Health Minister’s disparaging comments about obstetricians do nothing to help the crisis facing the state, writes Gino Pecoraro.

The obstetrics crisis is far from resolved.

Fed-up obstetrics doctors in regional and rural areas are sharing their personal stories explaining why they are leaving maternity care altogether and fear young doctors are unlikely to be attracted to working in what they say are toxic environments.

Most are afraid to speak out for fear of reprisals. But the National Association of Specialist Obstetricians and Gynaecologists has seen an email circulating explaining their concerns. Alarmingly, many of these statements come from young doctors who have not chosen their specialty area yet, but they know they will not be pursuing obstetrics based on their experiences.

The issue is not simply one of remuneration, but how maternity units function and how obstetrics team members are perceived and treated within their hospitals and by the health department.

The women and families of Queensland deserve better, writes Associate Professor Gino Pecoraro.

Unfortunately, Queensland’s Health Minister has publicly made disparaging comments, saying obstetricians aren’t really needed in most cases and only contribute in 5-10 per cent of cases. Inaccurate comments like these contribute to obstetricians feeling undervalued and as though they are only employed to provide an “ambulance at the bottom of the cliff” service as well as being a scapegoat with an insurance policy should things go wrong in what has increasingly become a midwifery-centric model.

Unless something is urgently done to make training in obstetrics more palatable, we will face a national shortfall of obstetrics doctors at both GP and specialist levels in both public and private sectors.

This situation was accurately predicted by NASOG and its concerns expressed to federal and state health departments and politicians from both sides.

The recruitment and retention crisis looks every bit as dire as the indemnity crisis which saw many obstetricians give up practising in the highly litigious field.

That crisis needed federal legislation.

The current situation also needs federal intervention.

Something beyond political announcements needs to be done.

Our women and families deserve so much better!

Associate Professor Gino Pecoraro is the President NASOG and an obstetrician and gynaecologist.

Collaborating for Safe and Happy Births

A disturbing story appeared in the Courier Mail on Sunday 29 May 2022. Entitled Doctors slammed for ‘sticky beaking’ into births, it suggested that the human rights of birthing mothers in Queensland public hospitals were being breached by obstetricians entering the room and speaking with the labouring women.

At a time when public maternity units are filled past capacity and struggling to meet the demand, the content of the article showed a fundamental misunderstanding of the realities of public healthcare and belittled the crucial role of our Registrars in the care of mothers and babies.

Many women in our public units are being discharged only a few hours after a vaginal delivery and 24 hours after an elective c section. Seeing an obstetrician during pregnancy and labour is not guaranteed and many women are cared for solely by midwives throughout their entire pregnancy and delivery journey.

This is not the case for women having babies in the private sector, where their chosen specialist obstetrician liaises with their labour ward midwife during labour and is on call for them specifically. Private obstetricians rarely have to care for more than 1 labouring woman at a time. However, private maternity units are closing at an increasing rate as many families can no longer afford to pay the out-of-pocket costs caused by stagnant and woefully inadequate Medicare and private health insurance rebates.

As a result, our large public hospitals can have as many as 20 women labouring at a time. The Registrar is responsible for overseeing the well-being of EACH of these women and their babies, even if the woman is deemed “low risk” and is being cared for by her midwife. Registrars rely on the midwives they work with to be able to pick up complications early and notify them of any concerns.

It is imperative that the Registrar knows what is going on in each room at all times, in case an emergency develops with one or more women.

The Registrar introducing themselves to the labouring woman is trying to make sure that, should they have to administer obstetric treatment, it is not at the hands of a complete stranger and someone they are first meeting in an even more anxious and tense time.

The Registrar needs to be able to prioritise the labour ward demand for their attention so that if 2 or women need obstetric assistance at the same time, the best use of their time and access to operating theatres etc can be made so that the most urgent woman receives care first. This can only be done if the registrar (who is the person who makes the decision that emergency obstetric care is needed) is fully across all that is happening in the entire labour ward.

Everyone involved with looking after patients would, I trust, be respectful in their dealings and knock before entering a room and introduce themselves by name and position. If that is not the case then it certainly needs to be addressed, but the article and commentators have not said that this was the issue.

A career in obstetrics is hard enough as it is. Not only is it one of the longest medical training programs at 6 years; anxiety and stress levels are high, working shifts around the clock is the norm and the constant threat of career ending litigation is never far from trainees’ minds.

Once they finish this arduous training program, positions in the public sector for fully trained specialists are minimal and private obstetrics is in real danger of collapsing under affordability issues with sky rocketing insurance and practice costs at a time when private health insurance for patients is simply too expensive and does not cover the cost of providing the service.

Unless changes occur in the near future, obstetrics, like general practice, will simply cease to be an attractive proposition for junior doctors to train in when so many other specialties offer more family friendly hours, shorter training times, much lower risk of litigation and lucrative private practice options.

Continuing to apply unnecessary pressure on this dedicated group of medical professionals just trying to do the best for the women in their care, certainly will not increase the numbers of doctors wanting to go into the specialty and will ultimately lead to women having babies experiencing less access to this mother and baby lifesaving specialty, with more units, both public and private, closing as staffing them becomes even more difficult.

Obstetricians have higher than the average doctor suicide rates. This tragedy needs to be addressed and while we all need to do a better job at looking after ourselves and our colleagues, it is important that as a nation we do our best to weed out toxic work environments and ensure every staff member feels valued, supported and appreciated.

So instead of devaluing the input of our junior obstetric colleagues in labour ward, perhaps acknowledging that everyone involved in caring for labouring women is doing their best to ensure a happy and safe birth for both mother and child would be the better way to go.

New Government. New Opportunities.

The Federal Election is now only 24 hours away and a close result is anticipated. The neglect by all parties of healthcare overall, but women’s health particularly, throughout the election campaign is utterly disappointing. NASOG has been regularly forwarding information about the maternity crisis in Australia and our proposed solutions to candidates from all sides of politics. The challenges of accessing women’s and family healthcare in regional areas has been a particular focus, highlighting the inequality in women’s health funding generally. Continued mention has been made of the gender inequity in private health insurance rebates and we hope that this is gaining momentum.

NASOG Councillors have also been individually contacting their local candidates to raise awareness of the challenges and I hope that all members have taken the opportunity to do the same.

Although there have been no big policy announcements to impact voter behaviour, our efforts do seem to be paying off, at least with Labor candidates, with recognition in all of their return communications of the challenges facing womens health and a commitment to meet with NASOG following the Election, should they win power. At some local levels, particularly in Queensland, key Liberal candidates have responded positively and are eager to continue working with us to address these health inequities,

We have recently started working more closely with the Australian Birth Trauma Association with the goal of increasing public recognition of adverse maternal outcomes, which we are linking to inadequate investment in maternity care. The economic and social impacts of the ongoing gynaecological and allied health support needed by mothers who have endured Birth Trauma have long gone unacknowledged but form a crucial part of the whole story around the survival of private obstetrics.

As members are all aware, the new MBS Item numbers for Gynaecology came into use on 30 March this year. I would like to thank all those who have taken the time to forward through their problems with implementing the new numbers. Please continue to send comments through to NASOG as we have committed to send them on to the Department until we receive a reasonable response and action to correct the issues raised.

We have also been in discussion with other gynaecological interest groups about the item number changes with the intention that a united front will have more impact in dealing with the Department of Health once the new Government is in place.

Members will remember the proposal from Honeysuckle Health and nib last year to establish what is essentially a managed care operation in Australia. This was allowed to go ahead by the ACCC under strict conditions. The group has now appealed for those conditions to be significantly loosened. NASOG has been invited to provide comment on the new proposal in a very tight timeframe. As there isn’t sufficient time for us to seek legal advice, we are supporting the responses put forward by the Federal AMA.

Representing private O&G practice is a priority for NASOG. In addition to taking our voice to our national decision makers, we are asking College for clearer and more specific recognition of private practice. This includes an identified private practice representative on the Board and key Committees. This will ensure equity in the representation of the various areas of our specialty and help in decision making for the future. If you have an opportunity to raise the profile of private practice within your College activities, we encourage you to actively do so.

Active representation of our practice by every individual is becoming more and more important. Around the world and in our region in particular, membership organisations representing the interests of specific groups are facing a watershed moment.

Recent news that the New Zealand Medical Association has been put into receivership should strike fear into the heart of doctors across our nation. It is disappointing that our industry associations appear to be taken for granted, there seems to be a general perception that you don’t need to be a member as you will benefit from their work regardless of your membership status.

Unfortunately, dwindling membership bases mean that financial resources also diminish and the funds needed to fight for specialty related rights and remuneration are no longer there. With the ultimate result that those who were previously represented lose their voice and it won’t take long before they have also lost their income and choices in how and where they practice.

It is imperative that NASOG continues to have sufficient members to do our incredibly vital work as no other organisation represents the specific interests of specialist obstetricians and gynaecologists in Australia.

Our membership notices will be going out shortly. Annual subscription rates have been held at the same level as 2019 to keep them affordable for all.

If you are reviewing your membership and feel that NASOG isn’t doing quite what you signed up for, approach your state NASOG Councillor and tell them. Or even stand for Council yourself and bring change from within. Encourage your colleagues to get involved and communicate with us on the practice issues that will make the most difference to you. Be active, think and talk about the future of your practice and how important it is in the Australian health landscape.

We appreciate that priorities change with generations, as does the way that we work and interact. However, it is essential that our association stays relevant for members so that we can continue to be the voice of the profession at the political table and ensure that the private sector survives and thrives so that the public sector can also improve the services it delivers to Australian women.

I’m looking forward to negotiating with the incoming Federal Government and starting to see some real change in the affordability and access to women’s health in our county. I hope you will all join me.

More C Sections in Private Obstetric Care – But What’s the Full Story?

On 14 March 2022, The Conversation published a story titled More c-sections in private obstetric care

The article references a study which showed an increased likelihood for an unplanned caesarean birth in a private hospital setting.

NASOG President, A/Prof Gino Pecoraro commented on the article on Twitter and in a response to Medical Republic.

Articles like this play a key role in raising the profile of private healthcare in Australia, but rarely in a positive light and often without consideration of the range of individual circumstances that impact the decisions made by specialist obstetricians with each and every one of their patients.

Key to NASOG’s role is promoting the full perspective of private practice and encouraging government and community to consider all sides to the story. We strongly encourage members and supporters  keep doing the same.

A/Prof Pecoraro’s article is shown below. If you feel strongly about this issue, add your comments on the original article.

While this study is interesting and an import focus for discussion, it does not tell the whole story. All obstetric outcomes are important, including patient satisfaction data, rates of “birth trauma” and long term effects of childbirth on women, not just the mode of delivery.

Other studies, from Melbourne and Brisbane , suggest private obstetric patients when matched for complexity, maternal age and co-morbidities etc, have some beneficial outcomes when compared with their public sisters.

Tudehope in his 2017 Brisbane paper, reports a decrease in the perinatal mortality rate for mothers delivering in the private sector and concluded “differences in clinical practices seem to be partly responsible.” There are similarly lower reported rates of 3rd and 4th degree tears in private obstetric patients which might also be as a result of differing practise between the 2 systems.

As with all retrospective data analysis, potential confounders can exist and the authors admit that an RCT to get a definitive answer would be unethical to undertake so this type of research is what we must rely on .

I believe it is an oversimplification to suggest that the method of remuneration in the different sectors is the major or only incentive to offer obstetric treatment – the use of the word “intervention” to describe obstetric treatment is perjorative and plays into the emotive nature of this conversation.

In fact the continuity of care that private obstetrics offers women means that 1 doctor is responsible for her care and outcomes rather than a team of obstetricians and this in itself may change the risk acceptability for both woman and obstetrician.

As briefly alluded to in your article, the litigation burden carried by private obstetricians might be what drives the higher section rate and this could be minimised by having private obstetrician indemnity insurance premiums capped or kept at the same rate as public hospital obstetricians and midwives.

Another issue to consider is the effect of the NSW public health policy “Towards Normal Birth” which was in place during at least part of the study period. This government policy affected women’s choice and precluded publically treated women from accessing an elective c section in public hospitals without a “medical indication” .

Many women considering an elective c section (or just wanting the option) during this time, opted out of the public sector. While the authors report that women definitely wanting elective sections were excluded from the data, this data can be difficult to analyse and tease apart. It would not be unreasonable to assume that these women had a lower tolerance for some procedures like operative vaginal delivery or risk generally and this may have affected the rates of c section that were performed.

While this is an interesting study and rightly should promote discussion and reflection, it is by no means the entire story. Sensational headlines aside, Australia depends on both public and private maternity systems to survive and thrive if we are going to meet the obstetric needs of our population both now and into the future.

“Perinatal mortality disparities between public care and private obstetrician led care- a propensity score analysis” Adams, Tudehope et al BJOG 2018 Jan;125 (2) : 149-158

“Pregnancy outcome at term in low risk population: Study at a tertiary Obstetric Hospital” Permezel et al J. Obstet Gynecol Res Vol 41, No 8, 1171- 1177 August 2015

Responding to the Shadow of Managed Care

Honeysuckle is a glorious and fragrant climbing plant. It is a traditional favourite of many cottage gardens, filling the early days of spring with its beautiful scent and seeming to herald long and happy summer days ahead….

It is also highly invasive and aggressive and now classified as an environmental weed throughout Australia. It spreads quickly, smothering trees and shrubs and pulling down the fences and buildings it scrambles over.

Honeysuckle Health is a joint venture between private health insurer nib and US Managed Care giant, Cigna.

The Australian Competition and Consumer Commission (ACCC) recently released a draft determination that would allow Honeysuckle Health and nib to form and operate a buying group to collectively negotiate and manage contracts with healthcare providers on behalf of health and medical insurance providers and other payers of healthcare services.

You can see the details of the case including all submissions made here

To believe that a corporate entity wouldn’t put profits ahead of best patient outcomes is naive. And when this entity plans to work on behalf of the majority of private health insurers in the country, the potential repercussions for our healthcare system are significant. The scope for quality private practice work is likely to diminish, limiting future career options for trainees and pricing many senior specialists out of practice altogether as they will be unable to compete with the prices of many of those on contracts.

Australia does not need another type of invasive honeysuckle that threatens to smother our healthcare system.

NASOG’s submission on the draft determination is below. If you would like to add your voice to this issue, you can email a letter, referring to case AA1000542, to exemptions@accc.gov.au by 11 June 2021.


The National Assocation of Specialist Obstetricians and Gynaecologists (NASOG) opposes the ACCC draft determination in relation to the proposed health services buying group, Honeysuckle Health.

Colleagues in other specialty groups have already emphasised the negative impact of the managed care model in the United States which this model approximates. Particularly in relation to a corporate entity placing profitability ahead of patient rights and preferences and clinician expertise.

Unlike the USA, Australia has a well established public health system, delivering a high standard of care. Australian patients expect that they are going to receive the best and most appropriate treatment, whether they are in the private or public sector.

Experience in Obstetrics tells us that if this model gains a foothold, there will be wider impacts on our health services. Over several years, Private Health Insurers have tried iterations of no-gap maternity programs. Despite locking hospitals and doctors into tight contracts, the anticipated uptake and profits have not been seen, so insurer investment in these programs is diminishing. Obstetric patients are increasingly turning to the public sector, which is not resourced to manage the volume, resulting in high-profile media stories about infant deaths and maternal damage.

In the ACCC’s final deliberation, it must be considered that Honeysuckle Health’s proposed model could result in patient dissatisfaction with the options for their care. Either through limitations on which doctors they can see, the treatment options available or which hospital to attend. Coupled with any restrictions placed on the doctor by their contract, the result will be increased numbers returning to an under-resourced public sector and significant cost burdens and pressure placed on the state and federal governments.

Finally, NASOG queries the value of adding another level of administration to our healthcare system. While Honeysuckle Health will draw an income from the contracting and management arrangements, it is challenging to see how adding an additional layer into government schemes, indemnity providers, hospitals, clinicians and patients will improve efficiencies in healthcare delivery and patient care.

We believe there is no justifiable reason to negatively impact the way Australians access their healthcare through the implementation of a foreign style, managed care structure.

If You’re a Specialist O&G, Now is the Time to be a NASOG Member.

The annual renewal period for many professional memberships is upon us, including NASOG membership which is due for renewal by 30 June 2021.

A key focus of NASOG’s work is ensuring the survival and success of independent, private obstetric and gynaecology services in Australia.

We do this by:

  • 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.
  • Ongoing meetings with the Department of Health executive on how to improve access and affordability for women to private obstetric care.
  • Raising the profile of the crisis in private O&G with the media nationally.

During 2020 we all saw that it is possible for our healthcare system to be responsive to immediate need and show initiative. Over the past 6 months particularly, national political and community attention has turned to the overwhelmed and rapidly failing, public maternity system. Reports of baby deaths have become all too regular, clearly illustrating the pressure the public system is under.

It is past time for some change to occur within the system to prevent more avoidable deaths and other poor outcomes. This is acknowledged by all stakeholders. As is the ability for the system to change when circumstances demand it.

NASOG has taken leadership on the issue over the past year and successfully raised a proposal with Government to address patient out-of-pocket costs for maternity care. The aim is to enable more insured mothers to access the underutilised private sector. Work is ongoing on the details around implementation.

But a success in improving access and affordability for private maternity care will be wasted if Australia’s healthcare system falls prey to US style insurer driven managed care.

The fight to prevent that structure gaining a foothold in Australia has reached a new level with the recent ACCC decision to allow US firm CIGNA to operate in a joint venture with NIB through NSW based Honeysuckle Health.

NASOG is joining other specialist groups in speaking out about this real threat to the rights of both patients and doctors to determine what care is given and how it is delivered.

The issues of access and independence are central to our ability as medical practitioners to deliver quality care now and in the future.

We believe that a strong and independent private sector in O&G is crucial to ensure a future career for current and future RANZCOG trainees. They should be confident that they will find personally satisfying work in a stable and sustainable healthcare system which balances public and private sector services and capacities.

To deliver successful outcomes, it is vital that NASOG continues to receive financial support from all O&Gs as full members or supporters so that we can secure our ability to:

  • Ensure the voice of the obstetrics and gynaecology profession continues to be heard in negotiations to improve affordable access to care in the private sector for Australian women.
  • Expand mutually beneficial relationships with other associations and societies, both medical and consumer.
  • Continue to escalate the importance of our independent and high quality private health system through Parliamentary and bureaucratic networks.
  • Work towards a successful career future for all trainees in O&G.

We appreciate that annual membership of several representative organisations can be a financial burden when your practice income is under pressure. So, this year we have held the standard NASOG membership subscription at $600 and maintained membership savings for those who are AGES members, retired from practice and trainees.

Renewing your NASOG membership means your association continues to have the resources to represent you and the future of your practice.

With such big issues circling around our specialty, now is also the perfect time to add your voice and become a NASOG member or contribute as a supporter at www.nasog.org.au

In 2021 we will build our capacity to represent you, and 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

Lets Save Our Collapsing Health System

We are now hearing daily stories of the effects of our collapsing health system. Increasingly, delays spent waiting in ramped ambulances in our public hospital driveways are leading to unnecessary suffering and in some cases, death.

The response from our politicians is to shift blame between the Prime Minister and Premiers over whose fault it is and the taxpayer is caught in the middle, believing that our public hospital system will protect them and offer them what they need in their time of need.

The problem is not new, multiple reviews have been arranged and yet no solution seems forthcoming. In addition, it should have been predicted and planned for. In my home state of Queensland, we are told that everyone wants to move here and it’s a positive that our population is growing. But while the numbers are increasing, so too is the age of the population and this brings with it an increase in the burden of chronic disease as well as demand for health services.

It is lamentable that previous State Governments felt that pulling down older public hospitals and replacing them with new ones that had fewer beds was a good thing to do (despite the protestations from numerous professional groups saying this was a mistake). But this cannot be undone so we must learn from our mistakes and make sure no future government does a similar thing in a misguided attempt to try and rationalise the provision of an essential service.

Like with everything else, there are two sides to the health equation, supply and demand.

The most obvious solutions are expensive. Increase supply is to build new hospitals which are fully staffed and provide added beds to meet the need. Other supply can be added by increasing capacity and the type of service offered at existing hospitals. Freeing up supply by better use of hospital beds, such as getting aged care patients into aged care facilities rather than in acute stay beds, is also an option.

Overseas experience tells us innovation and technology can increase the amount of treatment that can be provided as an outpatient in suburban hubs or in people’s own homes. This is useful but data also exists to show this has a finite limit before early discharge can result in inadequate treatment leading to re-admission.

Increasing demand is the other part of the equation. Where possible this increased demand needs to be managed as we know that in a “free” government funded system, demand will always rise to and usually exceed supply.

We have seen the TV commercials advising us to only use the emergency department for true emergencies rather than issues able to be handled by our GP and this is a valid point. There are studies suggesting that as many as 30% of emergency department presentations are non-emergencies, but our frontline doctors also report that this may be exaggerated and the vast majority of people presenting, need to be there. How can we make sure we achieve the best usage of our emergency departments?

Firstly, if we want people who are suitable for out of hospital treatment to use those facilities, then something urgently needs to be done to make accessing general practitioner appointments both affordable and available. This is the purview of the Federal Government and the Prime Minister needs to acknowledge the problem and start offering solutions.

It is no secret that Medicare rebates have not kept up to date with inflation nor the cost of providing medical services and this runs across the entire gamut of service providers. For some people, the cost of going to see a general practitioner, even if they can get an appointment in a timely manner, is such that they prefer to present to the local public hospital and wait, knowing that any blood tests, scans visits or referrals to other specialists will be “free” without needing to pay any extra. This situation needs to be addressed.

Whether it is by changing the Medicare rebate system, opening out-of-hospital treatments to receive some form of rebate from private health insurance or subsidising general practitioner clinics to provide service to those most in need and without the ability to pay at a subsidised rate, something needs to be done. The public hospital system as it currently stands, simply cannot meet the needs of every Australian, even though as taxpayers we are entitled to free treatment in our public hospitals.

While the public system is struggling, there are reports private facilities are being underutilised or even sitting idle. Notably, a number of private maternity units have seen such a decrease in utilisation that they have closed while the public units in the same areas continue to struggle to meet demand.

Surely it is time for the Federal Government to bite the bullet and effect real change to bring affordability back to the private health insurance industry.

Private health insurance used to be comprehensive like car insurance. If you had insurance it covered everything, there were very few products available but people were reassured that if they had private health insurance and needed to use it, their condition would be covered and the rebates paid by the insurance policy would be enough to cover the cost of accessing the service.

Today, not only do 75% of the policies sold specifically exclude a number of conditions, but the rebates have also not been indexed to the recommended retail fee charged by most providers leaving consumers trying to access the private insurance policies with large out-of-pocket expenses.

This is further complicated by some medical providers charging way above the industry standard (Australian Medical Association recommended pricing) meaning it is difficult for patients to make an informed decision about how much their insurance will cover.

A coordinated effort and real cooperation between State and Federal Governments is needed.

A total overhaul of how we pay for our health system is needed.

Until these issues are resolved, families will continue to needlessly suffer, standards further erode and the morale of the dedicated staff working in the health sector further fall.

If nothing is done, it will surely only be a matter of time until someone utters the most feared of all words “means testing” and our universal healthcare system, which is the envy of the rest of the world, becomes just a beautiful distant memory.