We need Medicare reform, but co-payment 3.0 is the wrong place to start

This article by Stephen Duckett from the Grattan Institute sees a greater role for pharmacists in keeping the health budget under control.

Originally published at The Conversation.

By Stephen Duckett, Grattan Institute

The primary care reform debate of the last 15 months got off on the wrong foot. It was framed in terms of cutting government spending, with an overlay that consumers needed to bear the brunt of system reform. Although no one can deny the importance of money, nor the importance of consumers as being part of reform, the framing led policy makers down the path to perdition.

In response, both policy experts and medical professionals denounced co-payments as inequitable and, potentially inefficient.

A second frame was that Medicare was unsustainable. Again, this assumption was challenged and shown to be a myth.

Consider what the reaction of the public and the medical profession would have been if the frame was: how do we improve the quality of primary care? Or, what steps will keep growth in primary care spending in line with population growth while protecting access and quality?

Medicare reform must focus on increasing value, not just cutting costs. This means changing how things are done and what gets done, not just who pays for it. Policymakers can learn from patients about what is wrong with the system.

Reduce duplication

One area for savings is through reducing duplication. Extracting savings from duplication will be neither easy nor quick, but eliminating duplication can increase the speed of diagnosis and patient convenience while cutting costs.

In a 2013 survey of 1,500 Australians conducted by the New York-based Commonwealth Fund, 7.9% of respondents said that in the past two years their doctor had ordered a medical test that the patient felt was unnecessary because the test had already been done.

One in eight has experienced a situation where information, including test results, was not available at a consultation when required.

At present, a general practitioner or a specialist might order a pathology test not knowing that the same test was ordered by someone else a week before. But what if all pathology tests had to be ordered electronically and results uploaded to a secure site?

If a duplicate test was ordered, a real-time message could tell the doctor and ask for confirmation that another test was necessary. The technology to do this is available now and has been for a decade at least. What is required is getting that technology onto the desktops of clinicians.

Patients would be happier not having the inconvenience of having to present for multiple tests. Clinical care would be improved by quicker diagnosis. Savings to the taxpayer would automatically flow. A win-win-win situation.

Get the right person doing the right task

Previous Grattan Institute work has shown that almost 20% of general practitioner visits were “less complex”. This means they only involve one problem, with only one or two medications prescribed. They don’t involve referrals to specialists or allied health services, ordering of tests and investigation, conducting procedures or providing other treatment.

A significant proportion of these visits could reasonably and safely be handled by other professionals: physician assistants, pharmacists and practice nurses.

Physician assistants could work under the direction of general practitioners to examine, diagnose and treat patients. Physician assistants are an established part of the health-care team in several countries and their patients report high levels of satisfaction. Physician assistants aren’t widely employed in Australia because they are not authorised to write PBS-subsidised prescriptions or offer Medicare rebates for consultations.

Pharmacists could work in collaboration with general practitioners to issue repeat prescriptions. Pharmacists have four years of drug training and can safely dispense drugs and provide advice on medicines. Pharmacists in the United Kingdom, United States, Canada and New Zealand already deliver a wider range of primary care services and Australian pharmacists should follow suit.

Non-doctor providers can safely perform a range of health services.
Christiana Care/Flickr, CC BY-NC-SA

Practice nurses could take a greater role in management of chronic illness. They could be responsible for monitoring patients and coaching them about how to manage their illness.

The expected annual remuneration for all these professions is up to two-thirds that of general practitioners. Developing models which involve a shift of care from general practitioners, freeing them up to perform the more complex care that fully uses their skills, would be a move in the right direction and would add to their work satisfaction.

Again, as well as improving the health system financial bottom line patients would get quicker access to care.

The challenge for policymakers will be ensuring that those other professionals are true substitutes and not additive.

Next steps

The two proposals outlined here are just the tip of a reform iceberg. Money is to be saved in improving prescribing and in improving referral pathways too.

None of the options described here will deliver savings within six months, but then again, neither did Co-payment Policy 1.0 or 2.0. All these changes are difficult. They require shifting a complex system, managing implementation and often taking on vested interests.

Making the system work better is hard, but the government is learning that not doing it, and passing the buck to patients, might be even harder.

The Conversation

This article was originally published on The Conversation.
Read the original article.

Rebuilding Papulankutja Art Centre

Robert Woods dancing as they mourn the loss of their art centre
Robert Woods dancing as they mourn the loss of their art centre

In the early part of October on a windy hot day a grass fire burnt down the store room and gallery of the Papulankutja Art Centre. The fire destroyed all stock waiting to be sold to give the artists earnings and to pay for the running of the art centre. This included paintings, artefacts, bush soap and important works from artists who have since passed away. The loss of stock has been estimated at over $200,000

Papulankutja (also known as Blackstone) is about 80km west of the tristate (SA, WA, NT) border in the Ngaanyatjarra lands. Give yourself about 9-10 hours to drive into the closest major centre, Alice Springs.

They need help to rebuild and to assist with this they have started a crowd funding campaign to raise just over $37000 to assist with obtaining a new portable unit. There are some beautiful gifts for donating from $25 to $5000.

You can also buy in their Christmas sale with the artists giving 10% of all sales from new paintings since the fire to help rebuild their art centre.

Papulankutja Artists Crowdfunding Campaign from DRAMA on Vimeo.

Watch the video, go to their fund raising campaign and donate, head to their online gallery to purchase a product and follow them on Facebook.

Noel Pearson’s eulogy for Gough Whitlam

Everyone has a view on Noel Pearson. But you would have to agree that he is one good orator. His eulogy for “this old man” Gough Whitlam is being called one of the great Australian speeches.

Only those who have known discrimination truly know its evil. Only those who have never experienced prejudice can discount the importance of the Racial Discrimination Act. This old man was one of those rare people who never suffered discrimination but understood the importance of protection from its malice.

Over at The Conversation they have taken a closer look at the eulogy.

Below is both a video and a text of the eulogy.

The Eulogy

Paul Keating said the reward for public life is public progress.

For one born estranged from the nation’s citizenship, into a humble family of a marginal people striving in the teeth of poverty and discrimination – today it is assuredly no longer the case: this because of the equalities of opportunities afforded by the Whitlam program.

Raised next to the wood heap of the nation’s democracy, bequeathed no allegiance to any political party, I speak to this old man’s legacy with no partisan brief.

Rather my signal honour today, on behalf of more people than I could ever know, is to express our immense gratitude for the public service of this old man.

I once took him on a tour to my village and we spoke about the history of the mission and my youth under the government of his nemesis: Queensland Premier Joh Bjelke-Petersen.

My home was an Aboriginal Reserve under a succession of Queensland laws commencing in 1897. These laws were notoriously discriminatory and the bureaucratic apparatus controlling the reserves maintained vigil over the smallest details concerning its charges. Superintendents held vast powers and a cold and capricious bureaucracy presided over this system for too long in the twentieth century.

In June 1975 the Whitlam government enacted the Aboriginal and Torres Strait Islanders (Queensland Discriminatory Laws) Act 1975 (Cth).

The law put to purpose the power conferred upon the Commonwealth Parliament by the 1967 referendum: finally outlawing the discrimination my father and his father lived under since my grandfather was removed to the mission as a boy, and to which I was subject the first 10 years of my life.

Powers regulating residency on reserves without a permit; the power of reserve managers to enter private premises without the consent of the householder; legal representation and appeal from court decisions; the power of reserve managers to arbitrarily direct people to work; and the terms and conditions of employment – were now required to treat Aboriginal Queenslanders on the same footing as other Australians.

We were at last free from those discriminations that humiliated and degraded our people.

The companion to this enactment, which would form the architecture of indigenous human rights akin to the Civil Rights Act 1965 in the United States, was the Racial Discrimination Act 1975.

It was in Queensland, under Bjelke-Petersen, that its importance became clear. In 1976 a Wik man from Aurukun on western Cape York Peninsula, John Koowarta, sought to purchase the Archer Bend Pastoral Lease from its white owner. The Queensland Government refused the sale.

The High Court’s decision in Koowarta v Bjelke-Petersen upheld the Racial Discrimination Act as a valid exercise of the external affairs power of the Commonwealth. However in an act of spite the Queensland Government converted the pastoral lease into the Archer Bend National Park.

Old man Koowarta died a broken man. The winner of a landmark High Court precedent, but the victim of an appalling discrimination.

The Racial Discrimination Act was again crucial in 1982 when a group of Murray Islanders, led by Eddie Mabo, claimed title under the common law to their traditional homelands in the Torres Strait. In 1985 Bjelke-Petersen sought to kill the Murray Islanders’ case by enacting a retrospective extinguishment of any such title.

There was no political or media uproar against Bjelke-Petersen’s law. There was no public condemnation of the state’s manoeuvre. There was no redress anywhere in the democratic forums or procedures of the state or the nation.

If there were no Racial Discrimination Act, that would have been the end of it. Land rights would have been dead. There would never have been a Mabo Case in 1992. There would have been no Native Title Act under Prime Minister Keating in 1993.

Without this old man the land and human rights of our people would never have seen the light of day. The importance of Mabo to the history of Australia would have been lost without the Whitlam program.

Only those who have known discrimination truly know its evil. Only those who have never experienced prejudice can discount the importance of the Racial Discrimination Act. This old man was one of those rare people who never suffered discrimination but understood the importance of protection from its malice.

On this day we well recall the repossession of the Gurindji of Wave Hill when the prime minister said:

Vincent Lingiari, I solemnly hand to you these deeds as proof, in Australian law, that these lands belong to the Gurindji people, and I put into your hands this piece of earth itself as a sign that we restore them to you and your children forever.

It was this old man’s initiative with the Woodward Royal Commission that led to Prime Minister Fraser’s enactment of the Aboriginal Land Rights (Northern Territory) Act 1976 (Cth), legislation that would see more than half of the territory returned to its traditional owners.

Of course recalling the Whitlam government’s legacy has been for the past 39 years since the dismissal, a fraught and partisan business. Assessments of those three highly charged years and their aftermath, divide between the nostalgia and fierce pride of the faithful, and the equally vociferous opinion that the Whitlam years represented the nadir of national government in Australia.

Let me venture a perspective.

The Whitlam government is the textbook case of reform trumping management. In less than three years an astonishing reform agenda leapt off the policy platform and into legislation and the machinery and programs of government. The country would change forever. The modern, cosmopolitan Australia finally emerged like a Technicolor butterfly from its long-dormant chrysalis.

Thirty-eight years later we are like John Cleese, Eric Idle and Michael Palin’s Jewish insurgents ranting against the despotic rule of Rome, defiantly demanding “and what did the Romans ever do for us anyway?”

    Apart from Medibank?
    and the Trade Practices Act 1974?
    cutting tariff protections?
    and no-fault divorce and the Family Law Act 1975?
    the Australia Council?
    the Federal Court?
    the Order of Australia?
    federal legal aid?
    the Racial Discrimination Act 1975?
    needs-based schools funding?
    the recognition of China?
    the Law Reform Commission?
    the abolition of conscription?
    student financial assistance?
    FM radio and the Heritage Commission?
    non-discriminatory immigration rules?
    community health clinics?
    Aboriginal land rights?
    paid maternity leave for public servants?
    lowering the minimum voting age to 18 years?
    fair electoral boundaries and Senate representation for the Territories?

Apart from all of this, what did this Roman ever do for us?

And the prime minister with that classical Roman mien, one who would have been as naturally garbed in a toga as a safari suit, stands imperiously with twinkling eyes and that slight self-mocking smile playing around his mouth – in turn infuriating his enemies and delighting his followers.

There is no need for nostalgia and yearning for what might have been. The achievements of this old man are present in the institutions we today take for granted, and played no small part in the progress of modern Australia.

There is no need to regret three years was too short. Was any more time needed? The breadth and depth of the reforms secured in that short and tumultuous period were unprecedented and will likely never again be repeated. The Devil may care attitude to management as opposed to reform is unlikely to be seen again by governments whose priorities are to retain power rather than reform.

The Whitlam program as laid out in the 1972 election platform, consisted three objectives:

    to promote equality;
    to involve the people of Australia in the decision-making processes of our land; and
    to liberate the talents and uplift the horizons of the Australian people

This program is as fresh as it was when first conceived. It could scarcely be better articulated today. Who would not say the vitality of our democracy is a proper mission of government, and should not be renewed and invigorated? Who can say that liberating the talents and uplifting the horizons of Australians is not a worthy charter for national leadership?

It remains to mention the idea of promoting equality.

My chances in this nation were a result of the Whitlam program. My grandparents and parents could never have imagined the doors that opened to me which were closed to them. I share this consciousness with millions of my fellow Australians whose experiences speak in some way or another to the great power of distributed opportunity.

I don’t know why someone with this old man’s upper middle-class background, could carry such a burning conviction that the barriers of class and race of the Australia of his upbringing and maturation, should be torn down and replaced with the unapologetic principle of equality. I can scarcely point to any white Australian political leader of his vintage and of generations following of whom it could be said without a shadow of doubt he harboured not a bone of racial, ethnic or gender prejudice in his body. This was more than urbane liberalism disguising human equivocation and private failings. It was a modernity that was so before its time as to be utterly anachronistic.

For people like me who had no chance if left to the means of our families, we could not be more indebted to this old man’s foresight and moral vision for universal opportunity.

Only those born bereft truly know the power of opportunity. Only those accustomed to its consolations can deprecate a public life dedicated to its furtherance and renewal. This old man never wanted for opportunity himself but he possessed the keenest conviction in its importance.

For it behoves the good society through its government to ensure everyone has chance and opportunity. This is where the policy convictions of Prime Minister Whitlam were so germane to the uplift of many millions of Australians.

We salute this old man for his great love and dedication to his country and to the Australian people. When he breathed he truly was Australia’s greatest white elder and friend without peer of Indigenous Australians.

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