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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.

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.

SUBMISSION TO THE ACCC: HONEYSUCKLE HEALTH DRAFT DETERMINATION (21 MAY 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
President

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.

Key women’s health issue left out of the Budget

NASOG welcomes the investment in women’s health areas being made by the Australian Government through the 2021-22 Budget.

The funding boosts for the range of gynaecological items and support for the mental health of new and expectant parents are particularly positive and strongly backed by NASOG members.

However, we were disappointed that funding to support greater access to private obstetric care for Australian families was not included.

With costs for pregnancy management and birth through the private system perceived as high, women’s choices of care for themselves and their babies are limited to the services available in over-stretched public systems.

Without a significant funding boost, the limited clinical staff in public maternity units continue to face the challenge of increasing patient numbers.

And we will continue to see delayed treatment for emergency cases and the ongoing tragedy of baby deaths and maternal injury.

NASOG President, A/Prof Gino Pecoraro urges the Government to look into suggestions for improving access to private obstetric care, to ease the pressure on the public system and give choice back to Australian women.

COLLABORATION IS ADDRESSING OUT-OF-POCKET COSTS

During this past week a number of key stakeholder groups were brought together by the Department of Health to reignite the discussions around the Future of Private Obstetrics in Australia.

From the Government perspective there is a strong need to take increasing pressure off the public health maternity units by facilitating women’s access to the private system.

Aside from the Government representatives, attendees included NASOG, RANZCOG, the AMA and other representative doctors’ groups as well as Private Healthcare Australia and the Australian Private Hospitals Association. Importantly, the direction of the meeting was one of collaboration and a determination by all parties to reinstate the sustainability of the private obstetrics system in Australia.

NASOG’s proposal to restructure MBS rebates to help direct more women back to the private system was the key topic of discussion at the meeting.

The approach is aimed at directly targeting those 46% of women who have an initial consultation with an obstetrician but then decide not to proceed with private obstetric care.

Our proposed solution places no obligation on any individual practitioner to change the way they practice or bill patients, unless they choose to do so.

For those who are seeing falling numbers of patients, or are located in an area where more patients are attending public maternity units, the potential to attract more women to your practice is significant. In concept, by initiating the proposed system, doctors would charge a fee that would attract larger rebates leading, ideally, to little or no patient out of pocket costs.

But if you are satisfied with the status quo and feel the current system is working well for you and your patients, there is no need to make any change to the way you practice.

A key part of the NASOG proposal is that it does not involve signing contracts with health funds or hospitals and your autonomy would be preserved at all times.

This week’s meeting finished very favourably, with all stakeholders committing to working together and coming back to the group with additional feedback and data if they are able to provide it.

All parties acknowledge that we are facing a genuine crisis in private obstetrics, and if it is not addressed, there is significant potential to for things to spiral over time into a broader crisis in the provision of women’s health nationally.

NASOG is determined to make a real difference to private obstetrics in Australia and secure a sustainable career for existing and future members.

This a key time to gather the support of the profession so please let your colleagues know that they can help by becoming a full member or supporter of NASOG. The more members we have, the louder our voice becomes and the more impact we can have on policy outcomes.

A/Prof Gino Pecoraro
President

The Future of Private Obstetrics: A Work in Progress

Dear Colleagues,

We are now well into 2021 and our energies so far have been focussed on the emerging threat of managed care in medicine generally but in obstetrics particularly and the current parlous state of the entire private obstetric sector.

The Federal Government has resumed work in this important area and reaffirmed their commitment to working with the profession on boosting the number of women accessing private obstetric care and keeping the sector alive.

In late December 2020, the Department of Health requested further follow up to the Discussion Paper circulated in July and a Stakeholder meeting is now scheduled for early March.

It is important to appreciate that the Government motivation is very much to take increasing pressure off the public health maternity units and to facilitate this by encouraging women back into the private system.  In addition, it is in the department’s interests to ensure emerging generations of doctors see obstetrics as a viable career and continue to apply to become registrars who are the backbone of the public hospital workforce in meeting service delivery demands.

College data suggests that greater than 70% of fellows work in the private sector once they have finished training and if this sector continues to shrink, there will be fewer places for fellows to go and ultimately this will result in fewer doctors choosing obstetrics as a career leading to worsening shortages, not just maldistribution. 

MBS data shows that in 2019/20, 46% of women who had an initial consultation with an obstetrician did not pursue private obstetric care. This is a significant increase from the seven years to 2016/17, where on average 12% of women did not pursue care with a private obstetrician.

It is acknowledged that their reasons have not been surveyed, but it is widely assumed that  the impact of perceived (or real) Out-of-Pocket costs for a private birth has driven more women into the public system, even if they carry Gold level private health insurance.

NASOG has taken the lead in trying to provide a workable solution to this dilemma and is representing the profession in discussions with the appropriate department decision makers.

Taking into consideration feedback from our member survey in mid-2020, as well as the MBS data, we have sent an initial proposal to Government that would see (directly or indirectly) an increase in MBS rebates or other methods to reimburse patient costs. The approach is aimed at directly targeting those 46% of women who are currently deciding not to proceed with private obstetric care.

A key component of our proposed solution is that it places no obligation on any individual practitioner to change the way they practice or undertake their billing, unless they choose to do so.

This means that those doctors who are satisfied with the status quo and feel the system is working well with their current patient levels and income can stay as they are but those who for whatever reason want to, have the ability for their patients to access a new range of rebates.

By agreeing to use this system, doctors would charge a fee that would attract larger rebates leading ideally, to little or no patient  out of pocket costs.

It is important to point out that this would not involve signing contracts with health funds or hospitals and the doctor’s autonomy would be preserved.

It is still early days and there is considerable work to do before a workable solution that satisfies all parties is put in place. The Government appears to have a genuine commitment to address the crisis in private obstetrics and the Department of Health is working with NASOG in a true spirit of cooperation, looking for a mutually acceptable solution.

NASOG is determined to make a real difference to private obstetrics in Australia and secure a future career for existing and future members. This a key time to gather the support of the profession so please let your colleagues know that they can help by becoming a full member or supporter of NASOG. The more members we have, the louder our voice becomes and the more impact we can have on policy outcomes.

A/Prof Gino Pecoraro, President

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.

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