August 26th 2000


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Articles from this issue:

COVER STORY: “Stolen Generation”: where to now?

EDITORIAL: Indonesia falls apart?

CANBERRA OBSERVED: Why Howard’s IVF hand-grenade rattled ALP

NATIONAL AFFAIRS: Protests to confront World Economic Forum

DRUGS: Victorian Liberals reject injecting rooms

Straws in the Wind

HEALTH: Ways to shorten hospital waiting lists

HEALTH: US-style Managed Care comes to Australia

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HEALTH:
Ways to shorten hospital waiting lists


by Bob Browning

News Weekly, August 26, 2000
Bob Browning concludes his appraisal of Australia’s health care system.
Under-funding is the immediate cause of the deterioration of Australia’s public hospitals, including the rationing of medical treatment through waiting lists.

Some blame the funding squeeze on Medicare, arguing that increasing demand and rising costs are making a universal, tax-funded, free-at-the-point-of-service health system unaffordable.

Others blame neo-liberal policy. They claim its focus is ideological and its priorities are less about better, more equitable and affordable health care than about smaller government, privatisation-corporatisation, reduction of company tax, and promoting individual responsibility.

Anomaly

The anomaly is that while government is effectively restricting the amount of money Australians spend on conventional, scientifically-based medicine, people are spending more on alternative health services and products.

This comparatively unregulated market already consumes $2 billion a year, according to research by Adelaide University’s Associate Professor Alastair MacLennan.

This is twice as much as Australians spend out-of-pocket on all orthodox medical treatments.

The Government’s Medicare monopoly and its regulation of private health insurance keep a cap on spending on conventional public and private health care. Government policy aims to keep national health care spending below an arbitrary figure of about 8.5 per cent of GDP, even though people are ready to spend more on health when they consider it beneficial.

Under-funding is the overriding but not the only problem of Australia’s health system.

An elderly NSW couple took their own lives last month after an internet health site convinced them that the wife had terminal cancer. An autopsy revealed the woman did not have cancer at all. This prompted the AMA to issue another warning against internet sites that may encourage people to self-diagnose.

There are an estimated 15,000 health-related sites on the web. Many enable individuals to self-diagnose, self-prescribe, and dabble in a wide range of pharmaceutical and alternative medicines.

The recent National Health Benchmark report conducted for the Royal Australian College of Physicians confirmed fears that doctors are under growing pressure from patients to prescribe antibiotics and other medications for a range of illnesses.

The associated growth of medication-resistant disease is only one of the undesirable results. The Australian editorialised (July 15-16, 2000) that growing “patient activism” could lead to the “degradation of the general practitioner”. Patients and drug companies were putting increasing pressure on doctors to solve illnesses with pills.

American experience

America was already well down the track in this respect, the newspaper noted, but there was no clear evidence that Americans were living longer or better than other people in developed nations:

“Instead, there is an argument to suggest they are over-serviced and periodically racked by scandals about the over-prescription of certain widely publicised drugs. The latest scandal is the heavy prescription of the amphetamine Ritalin to school children, a scandal which has resulted in a congressional inquiry”.

Australia has been protected by regulation including a legislative ban on the public advertising of pharmaceuticals.

But the big multinational drug companies are already lobbying to overthrow this protection. The Australian reported that drug companies were already “mounting advertising campaigns that target people suffering from illnesses for which they have just launched remedies.”

Another new phenomenon is the spread of call centres to the health system. Despite widespread reports that they infuriate many of the populace, call centres have become highly fashionable in management thinking.

Call centres are allegedly highly efficient cost-saving and profit-maximising techniques of management.

High Performance Healthcare has already set up health call centres in Perth and New Zealand, and is tipped to win government backing for another in the ACT.

ACT Health Minister, Michael Moore, recently announced a $9 million tender for a call centre.

In many doctors’ eyes, the move to call centres is more about government seeking ways to cut costs than it is about improving the quality and availability of healthcare. Moore denies that these government-encouraged call-centres have any relevance to the self-diagnosis web sites that the AMA warns against. But controversy continues.

Many believe that call-centre systems merely provide medical diagnosis on the cheap, delivered dangerously at a distance and impersonally by inadequately qualified phone answerers.

Numerous other serious problems are emerging amidst the rash of neo-liberal change.

Many are ethical dilemmas, for example, decisions about turning off life-support systems, euthanasia, rationing scarce resources such as kidney transplants, dealing with gene and IVF technology, choosing the sex of children, and with difficult moral issues like abortion and medical privacy.

Melbourne anaesthetist Elliot Rubinstein recently raised a number of such issues in The Age (July 15, 2000) including:

“There is no longer any tolerance, or acceptable rate for complications. If anything does wrong, you’re likely to be sued. Medical defence premiums are rising because more people are suing their doctors for ever larger amounts. Support a lawyer — send your child to medical school.”

Many bright young people are being put off studying medicine at all, let alone being willing to set up practice in doctor-deprived country areas.

Many prospective medical students fear that after completing a demanding six year medical course and undertaking another six years of high pressure post-graduate hospital work, government may not give them the provider number they need to enter private practice.

Many of the most talented think that it is becoming increasingly unlikely that they will gain the sort of income, social status and fulfilling work that doctors had in the past. As with education, the quality of healthcare will decline if the quality of people attracted to it drops.

Deprofessionalisation — working at the beck and call of bureaucrats and money-managers — puts off many of the brightest and most idealistic potential students.

Solutions

What solutions are being offered? Both the Coalition and Labor think the answer lies in the new (non-doctor) managerialism the US-style system of managed care.

For the Coalition, health care is one of the nation’s biggest industries and requires private sector, preferably corporate management to handle such extensive, complex resources efficiently. In its view, radical change is required to restructure the doctor-centered “cottage industry” of the past.

The construction and management of new style, so-called co-located public and private hospitals are being contracted out to corporations like Mayne Nickless, formerly a security and transport operation.

Federal Health Minister Dr Wooldridge makes little secret of the fact that he wants to restructure general practice as well as the public hospital system.

“I wanted to see the reinvention of general practice”, he declared, after commissioning the Reports of the General Practice Review.

Wooldridge may become remembered for doing to the hospital system and the medical profession what Labor’s John Dawkins did to Australian universities and the academic profession. Like universities, hospitals may soon become dot coms rather than dot orgs.

Labor’s view also is that management can and should be improved, but within the government-run public system. More money should go into the public system, including the large amounts currently being spent trying to get people to take out private health insurance.

For many doctors, managed care, irrespective of whether it be conducted by government bureaucrats or corporate executives, throws the professional baby out with the bathwater.

For them, health care is not an industry in the usual sense. And they believe health care runs better on co-operative principles than competition policy.

Consequently, many doctors are becoming attracted to an alternative solution — a system of health savings accounts, roughly along the lines of the Singapore system.



Savings scheme

A health savings account is a savings account dedicated to paying the saver’s health costs when required, in conjunction with a high deductible trauma insurance policy.

A tax-deductible, individual or family health savings account would be used to pay the excess for hospital and other medical treatment after the trauma insurance pay-out. It could also be used to pay the insurance premium.

When no health treatment is required, the savings build up and remain the property of the saver.

A health savings account system needs to incorporate a quality care safety net to catch not only the needy but the chronically ill.

It should also retain, as in Singapore, a subsidised public system and community services, which make high quality health care more affordable to medium and low income groups.

The advantages of health savings account systems are that patients choose their doctor and hospital.

Doctors make clinical decisions in the interests of patients, without interference by cost-cutting government bureaucrats or profit-maximising corporate managers. Individual responsibility is enhanced and dependency reduced.




























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