President Michael Aizen – Health Reform the biggest issue
"It is an honour to become president of AMA Tasmania once more. The organization is in good shape thanks to the hard work of my predecessor, Dr. Chris Middleton, and our CEO, Tony Steven.
We are in the midst of a truly once in a lifetime event, namely the new Commonwealth - State funding arrangements and a move to local governance of our hospitals. In our submission to the Legislative Council Committee of Inquiry into Public Hospitals last year we called for, amongst other things, more local governance and greater medical practitioner input into developing, overseeing and reviewing hospital service policy for our patients. The State Government is in the process of developing the number and nature of Local Hospital Networks. We look forward to your participation in a forum on this very important matter on June 18 in order for us to present a consensus position to the Minister for Health.
See www.amatas.com.au/issues for a copy of our submission.
AMA Tasmania is also developing a Council for General Practice to guide us, and Federal AMA, on matters related to that specialty. All GPs will receive an invitation to join this very important policy development group. The matter of Primary Health Care Organizations is but one matter that requires policy development, in particular how they relate to Local Hospital Networks and the Aged Care sector.
Let me close by encouraging all members to engage with the AMA on the above issues and talk to your colleagues about membership. We are the most heard voice in Canberra and we need your input.
Dr. Michael Aizen.
Tony Steven - AMA CEO
National Conference:
The Federal Government’s health reform agenda was the main topic at the AMA National Conference held in the last week of May in Sydney. Over 200 doctors from all sections of the profession and every corner of the country assembled to contribute to the debate and hear the Prime Minister address the conference. Health Minister Nicola Roxon and Shadow Health Minister Peter Dutton debated the issues as well later in the day. Dr. Andrew Pesce was re-elected National President for second term.
Division activity:
I am very pleased to be able to say all three Divisions of the AMA Tasmanian Branch are now active, up and running. We now have three Division assistants being Rosemary Armitage in the North, who’s been with us for more than 10 years, Ngairi Pirere in the South and now Justine McCarthy looking after the North West Division. The Divisional meetings occur every month in your area and I strongly suggest you attend and make sure your voice is heard and support your fellow members.
Membership is important to AMA Tasmania:
Our membership numbers are up and on last year but we still need to reach our target for 2010, so if you are talking to your colleagues, suggest to them that they should join the AMA for two main reasons, firstly that they are considered leaders in the Tasmanian community and as such should take on that responsibility and contribute to the debate either directly or just by being a member,
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and secondly there are a large range of benefits through our supporters like Dell, Aequis, Caltex, VW and TasTel Community Telco. We also have our Divisional meetings every month which have become the ideal place to catch up with friends.
National Registration and Accreditation Scheme:
We are talking in detail with the Government and Upper House Members on the introduction of the enabling Bill in the Tasmanian Parliament. The main points we need amendments on are Mandatory Reporting Exemptions, namely for Doctors treating Doctors, Spouses and the Peer support programme. The main reason for this is to ensure doctors are not discouraged from seeking treatment and assistance.
Also protection of titles such as Physician, Doctor and Surgeon, (accept for Dental surgeon). These should only be able to be used in a Clinical setting by Medical staff that are qualified in Medicine or dentistry as indicated above, we need the Tasmanian Bill need to outline this.
A third issue is the requirement for a Public Interest Test before Ministers can make recommendations to Ministerial Council. All State and Federal Ministers should be subject to a Public Interest Test when making recommendations to the Ministerial Council on standards for allocation of doctors to regions based on workplace distributions.
States Rights is also an issue; the Tasmanian Parliament should have to ratify any amendment to the Queensland Bill before it applies to Tasmania. This is not the case under the current Bill.
Our Website:
Keep a close eye on our website; it is constantly being updated with information that will keep you informed.
Representations:
On the Website I have a list of representations we make to many different committees, forums and groups, both inside and outside Government. I ask all members to take a look and consider being part of one of these. Many organisations would like to have a doctor as a member of their consultation group or even on their Board. Please contact me to discuss these opportunities.
In closing I remind you the main thrust of this issues report is “get involved”, see you around.
Tony Steven
Coffee with Kevin - Ray Lowenthal
When the call came to my iPhone from a blocked number I diverted it rather than have it interrupt the Wednesday morning ward round. A few minutes later came the unexpected message “Please call Corri in the Prime Minister’s office”. So I called several times only to be asked to leave a message. Frustrating. Then Corri called back to tell me that the PM would be in Hobart that evening and wanted to meet some AMA office bearers. Would I be available to have coffee with him at 5 pm? Would I what?
Some quick phone calls to reorganise my afternoon private rooms patient list, a call to Michael Aizen to ask him to join me in his role as President-elect, a quick lunch, start on the patients who remained on the list, then a call from another of the PM’s minders that the PM was running a bit late and would 6 pm still be OK? Well at least the pressure was off for the waiting patients. The meeting would be in a small coffee shop in Salamanca Square, there would just be four of us, Michael and myself, the PM and his health adviser.
5.30 and I meet up with the minder. ‘the PM is still a little late”. Where is he now? In the air! He will be coming straight from the airport. So Michael and I sit at a window table in Cuicci’s discussing tactics. Intriguingly when informed by us who is coming, it turns out that none of the waiting staff of the coffee shop had been warned.
A few minutes after 6 and the PM walks in, a quick introduction, we sit down and immediately he is chatting about the last few days of intense negotiation with the state and territory leaders about his health plan. He is very fired up and keen to explain it to us. The AMA is very important, he has a lot of respect for the AMA he says. Clearly he wants us on side.
There really are only 4 of us. A young man comes and takes our coffee orders. The PM drinks ordinary tea using a tea strainer. I have a chai. We are offered the dinner menu but the PM says ‘we’re not eating’. The menus are removed.
Michael and I put a number of matters of concern to him. Doesn’t his new system run the risk of increasing rather than decreasing the bureaucracy by adding a third layer, the networks? Will the new system really stop the blame game? You know what, he says, ‘the buck stops with muggins here’. Then he draws some diagrams with lots of boxes and arrows showing how the money will quickly pass from Canberra through a new independent (non-political) body that will disburse the funds, to the point of need.
Activity based funding has been tried before, there was lots of fudging the figures we say. ‘Gaming’ says the PM, showing his awareness of the jargon. We are awake up to that. And so on and so forth. Some important issues but have been little mentioned in the last few days, we say, indigenous health, research, e-health. They are all important says the PM and will be attended to, assuring us for example that Nicola is a ‘zealot’ for e-health. He certainly has a good understanding of the issues, you can’t take that away from him.
Part way through Rudd takes out his mobile phone (was it an iPhone? – I couldn’t quite tell) and says he has to send a text to his wife.
The 5 or 6 young ladies at the next table, arriving one by one for some kind of celebratory meal, don’t even seem to notice who is there, or if they do they are very discrete about it. I recall that just up the road the satirical revue “Pennies from Kevin” is playing at the Theatre Royal starring a Kevin Rudd look-alike. According to the photo in the Mercury the following morning, the resemblance is uncanny. Perhaps the young ladies think it’s the look-alike having coffee with 3 of his mates and not the real thing.
At 7 pm the PM and his adviser leave quickly. When they get into the Square I note, only then, a couple of people appearing out of the shadows, presumably security, discretely in attendance. Somewhere along the line someone must have paid for our coffees but I didn’t notice. No one asked me to pay anyhow! I muse that Australia really is a lucky country. In how many others would the country’s leader drop into a provincial city for a coffee, just two on two, for 45 minutes, with two of his constituents, with no security in sight, ordinary people coming and going, passing right by.
On the other hand, maybe it was the Rudd look-alike we were talking to, after all.
Ray Lowenthal
AMA Collection - Dr. Philip Thomson
NEW: Over the past years Dr. Philip Thomson of South Hobart has dedicated many hours to the development of a Medical Collection which for a while was housed at the AMA. The time has now come to house and manage this priceless asset and ensure its safe keeping for future generations. This is an account of the past and present state of play by Dr. Thomson.
EXISTING: The many items in the collection have been in storage for the past 5 years. Packed up prior to the sale of the Gore Street building, the collection has lived at Vaucluse Gardens Nursing Home and over the past year at St John’s Hospital in the old Eye Clinic building in South Hobart. This is a rent-free temporary arrangement with Calvary
The many items in the collection have been in storage for the past 5 years. Packed up prior to the sale of the Gore Street building, the collection has lived at Vaucluse Gardens Nursing Home and over the past year at St John’s Hospital in the old Eye Clinic building in South Hobart. This is a rent-free temporary arrangement with Calvary Health Care. The building is in poor repair and faces an uncertain future.
We are looking for a building to house the AMA Collection and the RHH Nurses Collection which also is in storage. In addition, we would like any AMA members interested in helping manage the Collection to contact me or Tony Steven.
Despite the precarious circumstances under which the Collection currently lives, donations are still being received. Recently the family of Reg Lewis donated some items. Reg was a pioneer Hobart anesthetist and kept many pieces of equipment. Mike Hodgson arranged for some of these to be sent to the College of Anaesthetists museum. These latest items tell an interesting story, they include a microscope and cardboard boxed set of teaching microscope slides from the 1930's. In addition there are two Victorian wooden boxed sets of slides with glass jars for staining specimens. These represent the style of medical practice early in the 20th Century where medical practitioners frequently prepared their own slides and used their own microscope with reference collection to identify anatomical and pathological specimens. These days of course, most medical graduates do not have a microscope and it is many years since we had our own set of slides.
I would appreciate hearing from anyone who has suggestions about an available building or who would like to help looking after the Collection.
Dr. Philip Thomson
Sit up and take interest - Doug Davey, Aequis
Like many people, I enjoy The Mercury’s Real Estate Guide. Even though I have no intention of moving house, I nevertheless find myself, week after week, trawling through the pages with eager interest. As a die-hard fan, I’ve read and re-read the Guide’s many articles on home loan interest rates, and it seems I’m not alone.
Several clients have approached Aequis after reading these articles, wondering whether they should fix the interest on some, or all, of their home or commercial loans.
Firstly, it’s important to understand that these articles are normally sourced from the Real Estate Institute—after all, the Real Estate Guide is their publication. So, for an objective answer to the question of whether to fix your loans, you should also seek advice from your financial adviser before making a decision.
Adding fuel to this particular fire is recent speculation that interest rates will continue to rise, possibly reaching double-digits. This prospect could make the most financially responsible person break out in a sweat.
While there is no doubt that interest rates will continue to rise, according to the Governor of the Reserve Bank of Australia, Glenn Stevens, rates are moving towards the average. This could suggest that the pace of rate hikes may now begin to slow.
When considering the variable-versus-fixed interest conundrum, one must always remember that if we mere mortals expect interest rates to rise, then the banks have certainly already factored this forecast into the fixed interest rates they offer to their customers.
When discussing the pros and cons of fixed rates with our clients, we look at the term of the fixed rate versus the amount of times the variable rate needs to rise to ‘break even’.
For example, if you fix your rate for three years, and you need at least four-to-six interest rate hikes (at .25 percent) for the variable rate to match your fixed rate, it could be 18 months before your interest rate is the same as the variable. Then of course it will take time for you to recoup the additional interest you have paid to break even—possibly at the point your rate becomes due.
Having said that, fixed interest rates most definitely have their place in the market. Many people have fixed their home loan rate with positive results, while others simply can’t afford to meet increases in the variable rate without significantly impacting their cash flow. In general terms though, if you are fixing your interest in an attempt to ‘better the bank’, you may be in for a surprise.
There’s more than one way to save money and trim time off your home loan. I encourage my clients to look, not only at the fixed-versus-variable debate, but at the way their loan operates. Do they have an offset account attached to their loan? Are they making fortnightly repayments (at least) to the loan?
The message is—you don’t have to settle for a 30-year home loan. You can repay your home loan faster with the same amount of dollars, just by applying a few simple changes to the way you make your repayments.
*Doug Davey and Aequis Pty Ltd are Authorised Representatives of GWM Adviser Services Limited ABN 96 002 071 749 Australian Financial Services Licensee Registered Office at 105 – 153 Miller Street North Sydney NSW 2060. GWM Adviser Services Limited is a Principal member of the Financial Planning Association.
CALL FOR PREGNANT, BREASTFEEDING WOMEN TO BOOST IODINE INTAKE
Tasmanian women who are pregnant or breastfeeding have been advised by health experts that they need to take iodine supplements to safeguard the normal development of their babies.
Chair of the Tasmanian Ministerial Thyroid Advisory Committee Dr
John Burgess and Director of Public Health Dr Roscoe Taylor said there was evidence that Tasmanian women who were pregnant or lactating were not getting enough iodine in their diet.
Drs Burgess and Taylor said recent findings from the National Iodine
Nutrition Survey showed that Tasmanian women were not alone, with much of the Australian population also being mildly iodine deficient.
However, Drs Burgess and Taylor warned that the health consequences of iodine deficiency were greater for pregnant and breastfeeding women and their babies.
They said that iodine was an essential nutrient to ensure normal
development of the brain and nervous system in babies and young
children.
And they said that iodine deficiency during pregnancy and breastfeeding could have a negative affect on the brain and nervous system of infants and children and result in a lower IQ.
Drs Taylor and Burgess said that, for this reason, the National Health and Medical Research Council (NH&MRC) was recommending that all women who are pregnant, breastfeeding, or considering pregnancy, take an iodine supplement of 150 micrograms each day.
“That is why we have written to all Tasmanian health professionals who come into contact with these women, bringing the NH&MRC guideline to their attention so they can make it a part of their case management of the women we need to target,” Dr Taylor said.
He said existing measures such as the mandatory iodine fortification of bread were excellent for the general population, but did not provide enough iodine for pregnant and breastfeeding women.
“Most foods in Australia contain only small amounts of iodine, making it difficult for pregnant and breastfeeding women to get enough iodine through food alone.”
Dr Burgess said that while bread fortification did increase iodine intake in the general population, the iodine requirements during pregnancy and lactation to support the neuropsychological development of the foetus and baby required additional iodine intake.
“Therefore, it is recommended that pregnant and lactating women take a daily 150 microgram iodine supplement,” he said.
“This is recommended under national guidelines and is considered
effective for pregnant and breastfeeding women, promoting the health of their babies.
“The main concern is that if iodine intake falls below this recommended level, the thyroid cannot produce enough thyroid hormone and this is when deficiency disorders can occur”.
“This is of particular concern during pregnancy because abnormal
function of the mother’s thyroid has a negative impact on development of the nervous system of the unborn baby.”
Dr Burgess said that women with pre-existing thyroid conditions should seek advice from their medical practitioner prior to taking a supplement.
Drs Burgess and Taylor said that reasons suggested for the recurrence of iodine deficiency in Australia included reduced use of iodine-based cleaning products by the dairy industry and less household use of iodised salt (caused by a gradual increase in consumption of commercially processed foods containing non-iodised salt).
New NHMRC Recommendation: Iodine Supplementation Essential For Pregnant and Breastfeeding Women
The National Health and Medical Research Council (NHMRC) has released a new statement recommending that all pregnant and breastfeeding women take iodine supplements to help make sure that a baby’s brain and nervous system develop normally.
Iodine is an essential nutrient required for thyroid hormone synthesis, which is vital to ensure normal development of the brain and nervous system before birth, in babies and young children.
Insufficient iodine can cause learning problems for babies and young children, result in reduced intelligent quotient (IQ), affect their physical development and hearing.
It is therefore very important that pregnant and breastfeeding women get enough iodine.
The NHMRC has released a new statement recommending all women who are pregnant, breastfeeding or considering pregnancy, take an iodine supplement of 150 micrograms (μg) each day.
Supplements of 150μg/d of iodine are safe and effective for pregnant and breastfeeding women.
The National Iodine Nutrition Survey (2006) results suggest that Australians do not get enough iodine.
While measures such as the mandatory fortification of bread do increase iodine intake in the general population, iodine requirements during pregnancy and lactation to support the neuropsychological development of the foetus and baby are substantially greater.
Evidence from recent Tasmanian research has confirmed that iodine fortification of bread is insufficient to meet the needs of pregnant women.*
The Tasmanian Thyroid Advisory Committee and Population Health (Department of Health and Human Services) want to ensure that all health professionals in Tasmania are aware of the need for pregnant and breastfeeding women to take iodine supplements in accordance with NHMRC advice.
Currently there are no specific commercial iodine supplements on the market. However, there are a number of commercial vitamin and mineral supplements designed for pregnancy and lactation that have the recommended amount (or close to) of iodine. It is hoped that increased demand for an iodine only supplement will lead to increased availability over time.
Further information including a literature review can be viewed on the NHMRC website by using the link below: http://www.nhmrc.gov.au/publications/synopses/new45_syn.htm.
For further information about this matter please do not hesitate to contact Judy Seal, Principal Advisor, Public Health Nutrition on 6222 7731 or via email judy.seal@dhhs.tas.gov.au.
THE BEGINNING OF THE END FOR MEDICARE?
General practitioners face an unprecedented performance shake-up under the Federal Government’s National Health and Hospitals Network with the introduction of performance payments for keeping chronically ill patients out of hospital and the prospect of primary care league tables.
Last month’s Federal Budget confirmed the introduction of the voluntary enrolment scheme for patients with diabetes. From 2012 patients will be invited to sign up with a medical clinic of their choice. Practices will be paid up to $1200 annually for each diabetic patient they sign up, plus an initial $1500 practice sweetener.
The practice will then become responsible for managing the patient’s care and will be eligible for annual payments worth up to $10,800, depending on the number of patients they enrol and, in part, on the basis of their performance in keeping chronically-ill patients out of hospital.
For the first time since 1 February 1984 some Australians will be seeing their family doctor without the right to a Medicare rebate. After 26 years, this universal aspect of Medicare is being eroded in favour of patient registration and paying for performance.
The government’s proposal, as it stands, just covers people with diabetes but the Prime Minister and Health Minister have indicated this is a pilot program likely be expanded to encompass other chronic conditions in future.
“We have outlined our plan to start paying for better health outcomes rather than just one-off visits to doctors and specialists for patients with diabetes,” said Ms Roxon at the Australian Practice Nurse Association Conference in Melbourne last month. “I am pleased that we’ll have more to say on our other directions in primary care very soon, which will build on these significant reforms.”
The National Health and Hospitals Network’s performance framework will be monitored by the yet-to-be-established National Performance Authority, which will also oversee hospital performance. The primary care data will be used to produce performance reports called Healthy Communities Reports, but the government is yet to reveal how details of how the reporting system will work.
The Healthy Communities Reports will include coordination measurements, such as the number of avoidable hospital admissions, prevention trends, local and regional information on preventive risk factors, access to GP services, and after-hours care. The government says the details of what will be measured and how it will be reported are yet to be developed but will be done in consultation with doctors and other health professionals.
It is unclear what role the recently announced Medicare local primary health care organisations will play, or even if the reports will be made public. Minister Roxon has not ruled out the possibility of creating regional or practice-based league tables.
Pay for performance is not a new concept for Australian GPs. The General Practice Immunisation Incentive Scheme (GPII) was introduced in 1997 to reward GPs with bonus payments for promoting, providing and monitoring childhood immunisation service. Since 1998, Medicare’s Practice Incentives Program (PIP) has been paying practice bonuses to thousands of Australian practices for meeting, or working towards, practice accreditation standards.
The difference between the existing programs and the diabetes plan is that under GPII and PIP, GPs are paid for providing services. Under the diabetes plan, the government wants to pay for patient outcomes, which won’t always reflect the quality of GP care.
Proponents of performance payments argue that the end result is the key. The object of health care is to make people healthier, so doctors should be paid for results. This was reportedly taken to the extreme by Arabian royalty in the middle ages, where the princes only paid their doctor when they were well. If they were sick, the doctor was not doing their job well enough to deserve reward.
Critics of paying for performance outcomes make the point that a doctor can recommend a course of action, but successful outcomes rely on the patient. For example, doctors are likely to recommend that all of their patients quit smoking, yet one in six adults still use tobacco on a daily basis.
There have been analyses of pay for performance regimes that have noted other possible deleterious effects. Pay for performance has been cited as:
• Encouraging doctors to avoid sicker patients who are less likely to achieve the outcomes — often the neediest people in the community.
• Causing doctors to neglect the types of care for which there are no reward. This is a common complaint about KPIs in the Victorian hospital system — what gets measured gets done.
• Increasing red tape, as reporting on performance takes time away from patient care.
• Decreasing internal motivation, as external motivation is imposed by the performance targets.
Design is key for pay for performance regimes. Victorian hospitals have already seen scandals and data manipulation by hospitals overzealous to meet KPIs, which have actually resulted in poorer patient outcomes.
While general practice does not have armies of administrators putting pressure on clinical staff, there is still the potential for pay for performance to do more harm than good.
The AMA has put an alternative proposal for chronic disease management to the Federal Government based on the existing MBS structure and some key improvements. Under the plan, patients with chronic conditions would have access to a broader range of MBS-subsidised allied health services, and excesses of MBS red tape would be reduced.
“Our plan ensures that patients do not lose their entitlement to a Medicare rebate and that funding arrangements do not interfere in the doctor-patient relationship,” AMA Vice President, Dr Steve Hambleton says. “It means that patients would have more choice and greater control over decisions about their health care, and it provides patients who have multiple conditions with improved access to GP-coordinated care services.
Dr Hambleton says unlike the government’s diabetes plan, the AMA alternative would allow patients to receive care based on their clinical needs rather than a predetermined capped budget.
“The AMA plan means that patients would have more choice and greater control over decisions about their health care. It targets the sickest patients with multiple co-morbidities, allowing them improved access to a range of health services,” he says.
Pay for performance in the United Kingdom
The UK government introduced the Quality and Outcomes Framework pay for performance scheme for GPs in 2004. Despite the program being voluntary, 99.6 per cent of GPs participate in it, gaining around 25 per cent of their income from the performance payments.
The UK government invested heavily in the program, with funding for primary care increasing by 20 per cent over previous levels, allowing practices to invest in technology and extra staff. Early studies show GP income increased by an average of $40,000.
Of the 146 Quality and Outcomes Framework performance indicators, ten relate to GP management of chronic diseases. The program delivered initial results for patients with asthma and diabetes, but these gains soon dropped off. Three years into the program the rate of improvement had slowed and the quality of aspects of care not associated with an incentive declined for patients with asthma and heart disease.
