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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.

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.

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.