MEDICARE 2023: three perspectives

"Australians enjoy access to a world class health system with primary care at its centre. Our vital and valued primary care workforce includes Australia’s hard working general practitioners, allied health professionals, primary care nurses, nurse practitioners and midwives, pharmacists, Aboriginal health workers, practice managers and other practice staff. Primary care provides the foundation for universal health care, working hard to keep all Australians healthy and well in the community, and to deliver care that meets the needs of people and communities at all stages of life, no matter where they live.....

Modernising primary care

Recommendations

• Modernise My Health Record to significantly increase the health information available to individuals and their health care professionals, including by requiring ‘sharing by default’ for private and public practitioners and services, and make it easier for people and their health care teams to use at the point of care.

• Better connect health data across all parts of the health system, underpinned by robust national governance and legislative frameworks, regulation of clinical software and improved technology.

• Invest in better health data for research and evaluation of models of care and to support health system planning. This includes ensuring patients can give informed consent and withdraw it, and ensuring sensitive health information is protected from breach or misuse.

• Provide an uplift in primary care IT infrastructure, and education and support to primary care practices including comparative feedback on their practice, so that they can maximise the benefits of data and digital reforms, mitigate risks and undertake continuous quality improvement.

• Make it easier for all Australians to access, manage, understand and share their own health information and find the right care to keep them healthy for longer through strengthened digital health literacy and navigation." 

[Strengthening Medicare Taskforce Report December 2022, Introduction opening sentences, p.2 & Modernising primary care, one of four recommendation clusters, p.9]

Last week I 'phoned the GP practice I normally attend when I am unwell seeking an appointment.

Rather than the expected two to three week wait for an appointment I was given a choice of appointment dates that week.

When I entered the four-doctor practice it only had two patients sitting in the waiting room and I made a third.

The situation was almost self-explanatory when I read the signs at reception. The practice was now charging fees payable at time of visit.

A Standard Consultation is $84 (which includes a $10 medical centre facility fee). There is a federal government rebate of $39.75 for patients with a Medicare Card – payable electronically after the $84 is handed over.

The Facility Tax For Professional Services also includes as or when required – a medical centre treatment room fee of $20 and a medical centre consumables fee of $20. There may also possibly be a surcharge applied for public holidays.

There is no bulkbilling of DVA Gold Card Holders and Pension Card Holders until they are over 75 years of age.

As the The Australian Government Actuary is currently not expecting the average 67 year-old to live more than somewhere in the vicinity of another 20.1 years, it would appear that a number of GPs are now willing to lock a significant number older patients out of bulk billing for all but the last 12 years of their remaining lifespans.

So is it any wonder that everyone from the prime minister & state premiers to patients are wondering just how far this corporatisation of primary health care will go and, what workable solutions might be found to correct a dysfunctional primary care system.

An excerpt from The Sydney Morning Herald Economics Editor Ross Gittens’ perspective on the recently updated final report of the Strengthening Medicare Taskforce, 8 February 2023:

According to the doctors’ union, the AMA, the reason GPs have become so hard to find is that the federal government isn’t paying them enough. Whereas in the old days half of all medical graduates became GPs, now it’s down to about 15 per cent.

So, pay them more. Problem solved.

What the report’s saying is: sorry, not that simple. It’s true the Coalition government inherited a temporary freeze in Medicare rebates – the amount of a doctor’s bill that’s paid by the feds – in 2013, and continued it until 2018. And although the schedule of rebate payments has been increased annually since then, the increases have been much smaller than inflation.

Why? Partly because the Liberals were trying to prove they could cut taxes without damaging “essential services” such as Medicare.

But also because they knew something was wrong with the way general practice works. They needed to pay GPs differently to do different things. Rather than pay more and more the old way, they’d hold back until they – or some future government – worked up the courage to make changes.

Over the almost 40 years of Medicare, there’s been a big change in the problems people bring to their GPs. Because we’re living longer, healthier lives, much more of our problems are chronic – someone with heart trouble or diabetes has to wrestle with it for the rest of their lives – rather than acute: something that’s easily and quickly fixed.

But the present (subsidised) fee-for-service way of remunerating doctors is designed to suit acute problems, not chronic conditions. It involves waiting for problems to arise, not early diagnosis or stopping chronic conditions getting worse.

It encourages GPs to keep consultations short, avoiding long discussions of multiple problems.

A change no one wants to talk about is the way sole practitioners or partnerships of doctors are giving way to companies owning chains of practices staffed by doctors they employ.

When you separate the person delivering the care from the person watching the bottom line, you increase the likelihood doctors are pressured to keep consultations short and order many tests – a further reason to be cautious about reinforcing GPs’ dependence on fee-for-service.

The report wants to move to “blended” funding, with acute consultations continuing to be fee-for-service, but GPs paid lump sums for developing and managing “care plans” for particular patients with chronic conditions.

While it’s true fewer medical graduates are becoming GPs, it’s not the whole truth. As the Grattan Institute reveals, “Australia has more GPs per person than ever before, more GPs than most wealthy countries, and record numbers of GPs in training”.

How do other countries with good healthcare get by with fewer GPs? By making sure their GPs can’t insist on doing things that could be done by other health workers – nurses, nurse practitioners (nurses trained to do some of the more routine things doctors do), pharmacists and physios.

This is what “co-ordinated, multidisciplinary team-based care” means. Changing GPs’ surgeries into more wide-ranging “primary care clinics” is also about making it easier for patients to move between different kinds of care, with GPs taking more responsibility for the total package, and all the various doctors and paraprofessionals having access to a patient’s medical history.

There’s nothing new about this. Federal governments have been trying to improve the performance of primary care for decades – with little success. Why? Because they’ve had so little co-operation from the premiers and the GPs themselves.

The true message of the latest report is: Medicare reform must not just be about more money to do the same things the same way.

The full 10-page plus cover sheets Strengthening Medicare Taskforce Report can be found at:

https://www.health.gov.au/sites/default/files/2023-02/strengthening-medicare-taskforce-report_0.pdf

The taskforce was formed by the Albanese Labor Government and has 17 members. Its first meeting was held on 29 July 2022 and the taskforce has issued 6 communiques containing meeting minutes.

Tens of thousands of older Australians will now be able to access cheaper healthcare following the relaxation of income tests for the Commonwealth Seniors Healthcare Card

 

SBS News, 4 November 2022:

The Commonwealth Seniors Healthcare Card is changing. Here's what you need to know

HIGHLIGHTS

• The income threshold for senior healthcare cards has been increased to allow more people to access cheaper healthcare

• Singles earning up to $90,000 will now be able to access the scheme, as will couples earning up to $144,000

• The move will benefit an extra 44,000 seniors and cost the federal budget $69.4 million over four years.

Tens of thousands of older Australians will now be able to access cheaper healthcare following the relaxation of income tests for the Commonwealth Seniors Healthcare Card.

The changes were an election promise by the Albanese government, and mean higher income earners will now be able to qualify for subsidised treatment and medicines.

"We want to create a better Australia where no one is left behind and no one is held back, and this is particularly true for older Australians," Social Services Minister Amanda Rishworth said.

Here's what we know.

Who can access the concession card and what are the benefits?

The cards are open to anyone over 66 and six months and not receiving a social security pension or benefit.

Recipients must be living in Australia when they receive the card, and have either Australian citizenship, permanent residency, or a Special Category visa.

Newly arrived residents may face waiting periods of up to four years.

Health card holders can get discounted prescriptions through the Pharmaceutical Benefits Scheme and bigger refunds for health expenses than what's usually offered through Medicare.

GPs are also encouraged to bulk-bill for cardholders……

The seniors health card bill passed the Senate last week, and comes into effect from Friday.

It follows reductions in the cost of medicines, with the government reducing the maximum co-payment under the Pharmaceutical Benefits Scheme (PBS) by $12.50 earlier this year…...

Morrison Coalition Government to reduce or remove Medicare rebates on 900 orthopaedic, heart and general surgery procedures from 1 July 2021

 

Australian Medical Association (AMA) Media Centre, 6 June 2021:

Government in danger of history repeating with Medicare rebate changes

Just weeks before the biggest changes to Medicare in decades, the Federal Government and the private health sector are grappling with the huge number of changes that have only just been released, leading to the potential for chaos for patients.

More than 900 Medicare Benefits Schedule (MBS) items for rebates for private surgery are set to change on 1 July as part of the MBS Review of all 5,700 Medicare rebates.

The latest changes will affect rebates for orthopaedic surgery, general surgery and heart surgery.

“The AMA is concerned that the private healthcare sector – including health funds, hospitals, doctors and patients – will not be ready for the 1 July changes due to poor implementation by the Government,” AMA President, Dr Omar Khorshid, said today.

“Less than one month out from the implementation of these changes, and we still do not have all the information we need to assess and change over our schedules and payment processes to reflect the changes.

“We had enough problems in November 2018 when the first tranche of MBS Review changes resulted in private health insurers, through no fault of their own, not having their schedules updated in time.

“That meant that no-gap arrangements were not possible or were significantly delayed leading to uncertainty for doctor and patient alike.

“Patients were left out of pocket, spinal surgeries were delayed, and doctors couldn’t provide patients with informed financial consent about potential gap fees.

“Those changes involved replacing 70 spinal surgery items with 60 new items.

“The 1 July changes involve expected changes to 594 orthopaedic surgery items, 150 general surgery items, and 188 cardiac surgery items.

“After the spinal surgery debacle, the AMA and the private health sector told the Department of Health that six months’ lead time is needed ahead of MBS changes.

“More than two years later, we are facing the same problems, but with more than ten-fold the volume and complexity.

“This will put significant financial and operational risk on health insurers and private hospitals, and leaves doctors and patients scrambling and confused about what and how to bill against Medicare and private health insurance policies come 1 July. We simply don’t know what the rebates from funds will be, as they haven’t had the time to prepare and release them in advance – including for surgeries already booked for next month.

“The AMA and other medical groups have worked in good faith with the Government and the MBS Review Taskforce since 2015 to ensure that Medicare provides value to patients and taxpayers, and that it continues to be sustainable.

“We have repeatedly reached out to Government and the Department of Health to communicate the needs of the sector to ensure a smooth transition of the MBS changes.

“However, giving the sector just weeks instead of months to change over its entire system to support almost 1000 changes leaves the health system and patients at risk.

"The Government's reminder to doctors to consider patients' circumstances when charging fees misses the point. At the moment there's no way for doctors to know if they are charging a gap due to the chaos caused by the Department's poor implementation."

“The AMA is calling on the Government to urgently commit to changing the process going forward to avoid past problems, and ensure that this massive change to MBS rebates occurs without disruption to patient care.

“We are also calling on the Government and private health insurers to safeguard patient private health insurance rebates, to ensure that they are not worse off financially, for undergoing orthopaedic, general or cardiac surgery after 1 July due to implementation issues with the MBS.”

ENDS

The Advertiser, 6 June 2021:

Patients could find themselves more than $10,000 out of pocket for common surgeries, as radical changes to the Medicare rebate scheme are introduced.

More than 900 procedures – including hip, shoulder, hand, cardiac and other surgeries – will be affected in the overhaul next month, with doctors warning it will create “total chaos”.

In some areas, such as shoulder surgery, one in four of the existing items have disappeared, so there will be no Medicare or health fund rebate – patients will have to either pay the full cost or do without the surgery.

Some tendon procedures for elbow surgeries have also been wiped and, with no Medicare or health fund rebate, could cost patients $7000 to $10,000. As well, fee cuts for hip arthroplasty could deliver a $1200 gap.

Young people and those playing sport are among the worst affected. They are faced with having to fully fund their own microsurgery for an extremely common hip condition. Femoro-acetabular impingement syndrome – where extra bone grows along the hip joint causing an irregular shape and painful rubbing – is no longer allowed as a diagnosis.

The Australian Medical Association said we were now the only medically advanced country not to recognise this diagnosis or treatment through a hip arthroscopy….

The changes are the result of the federal government’s long-running Medicare Benefits Review that was meant to modernise the 38-year-old system.

Doctors said they would continue to charge the fees they do now but many Medicare rebates will go down or disappear, increasing the gap fees patients pay. Health funds have not yet updated their rebate systems and doctors are currently unable to give patients proper informed financial consent about any out-of-pocket fees for surgery they are booking for after July 1.

[my yellow highlighting]

NOTE:

According to the Federal Government Australian Institute of Health and Welfare, as at June 2018 there were 693 public hospitals and 657 private hospitals in Australia supplying 3.9 beds per 1,000 head of population. Depending on urgency level pre-COVID-19 optimum waiting times for surgery at public hospitals ranged from up to est. 30 days to 365 days between diagnosis and surgery. While pre-COVID-19 private hospital waiting times were generally days to weeks. Given the projected additional expense of certain surgeries in private hospitals after 1 July this year, it would take only a relatively small drift of patients opting to forego private hospital admission in favour of public hospital admission to make public waiting times go through the roof.

AMA accuses Morrison Government of deliberately constraining supply of public hospital services

ABC News, 24 May 2019:

"Have you got insurance?"

It is one of the first questions any patient is asked when they walk into an emergency room in the United States, no matter how sick they are.

And now Australian doctors are warning our own health system is shifting towards a similar US managed care model — a patchwork of private and public systems, where health insurers hold an increasing amount of power.

The president of the Australian Medical Association (AMA), Dr Tony Bartone, made the comments as he addressed the group's national conference in Brisbane on Friday.

It was the first time Dr Bartone has spoken since the Coalition was returned to power, and he gave an unusually scathing assessment of Australia's health system and the Federal Government.

He called for further private health reforms, telling doctors the increasing corporatisation of the private health system had given insurers unprecedented power within the health sector.

Dr Bartone warned that could lead to a system similar to the model in the US, where patients experience significant variations in care depending on their insurance cover.

"Insurers should not determine the provision of treatment in Australia, they should not interfere with the clinical judgement of qualified and experienced doctors," he said.

"Australians do not support a US-style managed care health system, and neither does the AMA."

The AMA has consistently called for more money for public hospitals, and on Friday Dr Bartone went even further as he accused the government of "making a choice" to constrain the supply of public hospital services.

"Let me be clear. Public hospital capacity is determined by funding," he said.

"The consequences are significant. They can include increased complications, delayed care, delayed pain relief, and longer length of stay for admitted patients."

Dr Bartone said the system was "stretched so tight" elective surgeries were being cancelled.

"Our public health system should be better than this. It is unacceptable our public hospitals have been reduced to this," he said.

"Our public hospitals are struggling and require new funding to be better tomorrow.....

The 2019 federal election is over - so now the Morrison Government cuts are on again

Patient to GP Ratio [RACGP, General Practice: Health of the Nation,  2018]

Having waited until the 18 May 2019 federal election was over, Prime Minister 'Liar from the Shire' Morrison 7 his cronies are rolling out the funding pennypinching once more - and it's no surprise that it's the very young, very old and the poor who are the targets again.

ABC News, 22 May 2019:

Bulk billing of children and pensioners, as well as home visits to elderly and dying patients, could be scrapped in outer metro areas across Australia because of cuts which doctors say they will not be able to afford.

An incoming change to bulk-billing incentives has pushed GPs to breaking point, medical groups have warned, requiring them to provide crucial primary health services for less than the cost of a barber's cut.

The Federal Government has changed a key geographical classification, scrapping some outer suburban zones of incentives intended for rural areas.

From January 2020, the bulk-billing incentive in outer metro areas will be reduced from about $10 to $6 per patient, per visit.

The changes will affect GP practices in as many as 13 outer metro regions, including in Canberra, Adelaide's south, the New South Wales Central Coast, Geelong and the Mornington Peninsula.

The Australian Medical Association SA president, Dr Chris Moy, said many of the affected regions are low socio-economic areas.

He said the changes could put more pressure on already costly hospital systems, because patients could no longer afford to visit their GPs regularly.

"This is an example of a just a small change. It's not a huge change, but it's enough to break the camel's back," he said.

"It's more difficult for individuals to pay a gap in those situations so it's unfortunate this has happened."

Royal Australian College of General Practitioners president Harry Nespolon said general practitioners in the city and in the country were effectively being asked to work for free.

"The Medicare rebates are insufficient to provide the care that patients need," Dr Nespolon said.

"I don't think people want their GPs to do work for nothing but that's effectively what we're being asked to do.

"If the services become marginal in the sense they don't cover their costs, then they've got a choice — they can either go out of business or charge a fee.

"GPs in practices everywhere, rural or otherwise, are considering whether or not the current amount of rebate if they do bulk bill a patient is able to keep them in business."…….

Quick explanation of rebates:

·       The Medicare Benefits Schedule (MBS) is a list of medical services for which the Australian Government provides a Medicare rebate.

·        Each MBS item has its own scheduled fee — this is the amount the Government considers appropriate for a particular service (e.g. getting a blood test or seeing a psychologist).

·        Rebates are typically paid as a percentage of the Medicare scheduled fee. In the case of GP consultations, the rebate is 100 per cent of the schedule fee.

·       This means that bulk-billing GPs agree to charge patients the Medicare schedule fee ($37.60 for a standard appointment) and are directly reimbursed by the Government, and there is no cost to the patient.

·        GPs who don't bulk bill charge a fee higher than the Medicare schedule fee, meaning patients must pay the difference between the schedule fee and the doctor's fee — out of their own pocket.

·       For example, if your doctor charges $75 for a standard consultation, you'll pay $75 and receive a rebate of $37.60 — leaving you $37.40 worse off.

According to the federal Dept. of Health areas which will be losing the higher bulkbilling incentives (for treatment of patients with concession cards and children under 16 years) include:

Mandurah (WA)

Mornington Peninsula (Vic)

Canberra (ACT)

Newcastle (NSW)

Central Coast (NSW)

Queanbeyan (NSW)

Maitland (NSW)

Sunshine Coast (Qld)

Gawler (SA)

Geelong (Vic)

Melton (Vic)

Pakenham (Vic)

Ellenbrook (WA)

Baldivis (WA).

However the existing patient to GP ratio in an area is not necessarily the primary factor in determining who is on or off this list.

It seems you only have to live in an area where the local town/city has grown to over 20,000 residents since 1991 to find GPs being deprived of the full incentive payment per concession card/child patient seen.

Anyone living in the regions mentioned will know that what can appear to be a comfortable patient to GP ratio is not always evenly spread and in some areas certain GPs have already closed their books and are not taking new patients or are having difficulty attracting new GPs to established practices to fill unmet needs.

Just to make matters clear. some of the named places which will see GP incentive payments reduced on 1 July fall into the categories of regional or peri-urban area and, as at 30 June 2018 Australia-wide there were only 6,994 GPs in Inner Regional areas and 3,285 GPs in Outer Regional areas, according the the federal Dept. of Health statistics.

The Abbott-Turnbull-Morrison Federal Government still hasn't made personal health data secure

Since about 2014 it has been known that the personal details of Medicare cardholders has been for sale on the dark web.

Despite an April 2014 report by the Australian National Audit Office that the Consumer Directory - which contains all Medicare customer records - was not secure and that cardholder details were for sale, the federal Liberal-Nationals Coalition Government does not appear to have comprehensively acted act on the issue of database security.

It was not unknown that Medicare cardholder details were being used fraudulently.

In 2016-17 Twenty notifications, involving 123 separate breaches, resulted from findings under the Medicare compliance program. In these instances, certain Medicare claims made in the name of a healthcare recipient but not by that healthcare recipient were uploaded to their My Health Record.

When contacted by the mainstream media in July 2017 the Liberal MP for Aston and then Minister for Human Services Alan Tudge denied any prior knowledge of cardholder details being offered for sale.

It was not reported that at the time if he was asked about instances of Medicare cardholder details being used to commit fraud or identity theft.

In August 2017 eHealth Privacy Australia was telling the Senate Finance and Public Administration Committee that:

• There are fundamental weaknesses in both the HPOS (Medicare card data) and My Health Records systems, which make them vulnerable to illegal access.

• Those weaknesses mean that fraudulent users of the systems can assume the identity of legitimate users to gain illegal access.

• It is not sufficient to mitigate these weaknesses in the My Health Records system.

By 1 January 2019 IT News was reporting that Medicare cardholder details fraudulently obtained had been used to access an individual’s My Health Record:

The number of data breaches involving the My Health Record system rose from 35 to 42 in the past financial year, new figures show.

The Australian Digital Health Agency (ADHA) said in its annual report [pdf] that “42 data breaches (in 28 notifications) were reported to the Office of the Australian Information Commissioner” in 2017-18.

As with previous years, the agency said that “no purposeful or malicious attacks compromising the integrity or security of the My Health Record system” were reported in the period.

Of the 42 breaches, one was the result of “unauthorised access to a My Health Record as a result of an incorrect Parental Authorised Representative being assigned to a child”, the agency reported.

A further two breaches were from “suspected fraud against the Medicare program where the incorrect records appearing in the My Health Record of the affected individual were also viewed without authority by the individual undertaking the suspected fraudulent activity”, ADHA said.

In addition, 17 breaches were the result of “data integrity activity initiated by the Department of Human Services to identify intertwined Medicare records (that is, where a single Medicare record has been used interchangeably between two or more individuals)”, the agency said. [my yellow highlighting]

Despite this knowledge the Abbott-Turnbull-Morrison Government has still not grasped the nettle, because on 16 May 2019 The Guardian reported:

Australians’ Medicare details are still being illegally offered for sale on the darknet, almost two years after Guardian Australia revealed the serious privacy breach.

Screenshots of the Empire Market, provided to Guardian Australia, show the vendor Medicare Machine has rebranded as Medicare Madness, offering Medicare details for $US21.

Other vendors charge up to $US340 by offering fake Medicare cards alongside other fake forms of identification – such as a New South Wales licence.

The Medicare Madness listing suggests the Medicare details “of any living Australian citizen” have been available since September 2018.

Guardian Australia first reported patient details were on sale in July 2017, verifying the listing by requesting the data of a Guardian staff member and warning that Medicare card numbers could be used for identity theft and fraud.

The revelation prompted a review lead by former secretary of the Department of Prime Minister and Cabinet Peter Shergold.

The report did not identify the source of the Medicare data leak but suggested that people could use publicly available information about healthcare providers – including their provider number and practice location – to pass security checks and obtain a Medicare card number through the Department of Human Services provider hotline.

The review panel warned the “current security check for release of Medicare card information provides a much lower level of confidence than the security requirements” for Health Professional Online Services, the portal that allows providers to make rebate claims.

An IT industry source, who refused to be named, said the re-emergence of the data breach brings into question government assurances around the privacy of medical data “when those responsible cannot even manage the security of Medicare cards”.

The source said there is a “concerted effort at the moment by law enforcement to curtail darknet market activity”.

“In reality the darknet markets, while disrupted momentarily when their sites are brought down, easily relocate and continue business.”

Darknet markets can simply private message existing clients with a new link to resume business elsewhere. [my yellow highlighting]

Thus far the federal government has failed to recognise where Medicare cardholder details may be being accessed unlawfully, as this 2 August 2018 ABC online article indicates:

Privacy experts have warned that the system opens up health records to more people than ever before, thereby increasing the threat surface — the number of vulnerabilities in a system — dramatically.

Dr Bernard Robertson Dunn, who chairs the health committee at the foundation, says once the data is downloaded into the health system, the My Health record system cannot guarantee privacy.

"Once the data has been downloaded to, for instance, a hospital system, the protections of the hospital system apply, and then the audit logs apply to the hospital system — not to My Health record.

"So there is no way the Government would know who has accessed that data, and it is untraceable and untrackable that that access has occurred."