A victory for common sense (and patient care)

Yesterday Sonic Healthcare pulled out of their deal with Sigma’s AMCAL pharmacy chain to sell blood tests to pharmacy customers. I believe it was a wise decision to withdraw from this so-called ‘screening program’.

Just think about it. If it is up to AMCAL pharmacies their customers will be able to purchase for example a vitamin D blood test for $89.50 to ‘screen’ for vitamin D deficiency.

Initially the president of the Royal College of Pathologists of Australasia (RCPA) said: “They are all valid tests and they can all be done on patients without symptoms or abnormalities in those areas.”

But look at the recent Choosing Wisely recommendation by the RCPA:

Vitamin D screening

The RCPA’s position statement on the use and interpretation of vitamin D testing also clearly states: “The testing of healthy individuals will reveal a significant subgroup with low 25OH‐D (vitamin D) levels. This leads to treatment and perpetuates repeat testing without information as to whether such patients will benefit from vitamin D supplementation.”

Although I am sure that AMCAL’s ethical standards would not have allowed staff to push vitamin D pills for customers with low levels, I understand why Sonic has withdrawn from the initiative as it wasn’t exactly the best example of ‘screening’.

It looks like it was just about commercial stand-alone pathology testing without pre-agreed collaboration with doctors. There was no medical involvement or integration with other healthcare providers and the out-of-pocket costs for patients would have been high – with no Medicare rebate.

I imagine there were also some ethical dilemmas. Take the RCPA’s Code of Ethics, which contains the following principle:

To protect patients from harm. This includes commitment by each individual to the achievement and maintenance of clinical competence and professional standards; to referring issues beyond their clinical competence, scope of practice or accreditation; and, taking appropriate action when the conduct or lack of competence of others places patients at risk of harm.”

I really like the online RCPA library. For example, I found an excellent document titled ‘Making sense of testing; a guide to why scans and health tests for well people aren’t always a good idea.’ It explains why and how testing can cause harm (see image).

Why and how medical tests can cause harm
Source RCPA Library: ‘Making sense of testing; a guide to why scans and health tests for well people aren’t always a good idea.’

The RCPA Code of Ethics further urges fellows and members of the pathology college to “maintain professional integrity” and to “recognise and eliminate conflicts of interest that interfere with free and independent medical or scientific judgment.” As it happens, the President of the RCPA is also CEO of one of Sonic’s pathology companies.

I congratulate Sonic Healthcare on its decision and I’m pleased to see that a corporate giant in Australia seems to have made the decision to follow ethical principles instead of prioritising commercial interests over professional standards. Let’s see what the pharmacy sector will do next.

Doctors vs corporates: who’s winning?

When trying to inform government policy, the medical profession is often up against lobbyists representing large corporate commercial interests. This usually does not improve patient care. It is also difficult for patients to distinguish between groups that advocate for the public good versus those that are after increased profits, power or influence. Below are some examples.

There are strong indications that funding for after-hours medical services in the community is used inappropriately. For example, I have received reports from some of these services (who mostly employ non-GPs) delivering repeat prescriptions after-hours to patients’ homes. After-hours visits classified as “urgent” attract a Medicare rebate of $130–$150 compared to non-urgent visits of $55 and $36 for standard GP surgery consultations.

The after-hours industry is booming.

Let’s look at the ACT: since the arrival of the bulk-billing National Home Doctor Service in the capital, home visits rose from 1588 in 2013–14 to 20,556 in the last financial year. This trend is seen at a national scale and there is no reasonable explanation for the steep rise in home visits.

What we need is ethical and efficient after-hours deputising services that work seamlessly with day-time medical services.

After a pushback by the profession and the launch of a Medicare Benefits Schedule (MBS) Review Taskforce, the National Association for Medical Deputising Services started an aggressive lobbying campaign to “protect home visits”.

Although several after-hours services recently quit the lobbying group – including the Canberra After-Hours Locum Medical Service, the Melbourne-based DoctorDoctor service and the Western Australian Deputising Medical Service – the campaign is still ongoing.

Big pathology

Another example of an influential lobbying group is Pathology Australia, representing several big corporations, which converted their public “Don’t Kill Bulk Bill” campaign to a backdoor deal with the government to reduce the rent they pay to GP practices for co-locating their pathology collection rooms.

The response from the Royal Australian College of General Practitioners (RACGP) was that the proposed changes will create an anticompetitive environment, propping up multinational corporations that make hundreds of millions of profit each year, while GPs running small businesses lose funding on top of the ongoing MBS freeze.

The Australian Medical Association also made it clear that this proposal went too far, interfered with legitimate commercial arrangements that have been entered into by willing parties, and that it would damage medical practices.

Pathology Australia made five donations to political parties in the last financial year alone, totaling $69,600.

Big vitamins and pharmacies

A recent episode of Four Corners once again revealed the influence of the Big Vitamins industry, selling their unproven complementary products via community pharmacies.

Complementary Medicines Australia, a lobbying group representing the complementary medicines industry, argued on the program that, despite lack of evidence, there was a role for homeopathy and that “some consumers do find that it works”.

The Pharmacy Guild of Australia does not oppose the sale of unproven products, such as homeopathic ones, via community pharmacies.

The medical profession has been calling for more transparency about efficacy for years. RACGP president Dr Bastian Seidel said that the current retail business model of pharmacies, which allows products like vitamins and supplements to be sold to Australians, is inappropriate within the health care environment, and that these products must not be sold as complementary or alternatives to evidence-based medicines prescribed by a doctor.

Health consumers also have concerns: the Consumers Health Forum of Australia reiterated in a media release, following the broadcasting of the Four Corners episode, that the Therapeutic Goods Administration (TGA) does not include a check of the efficacy of most complementary products, and that a clear signal from the TGA about the therapeutic worth of these products is required.

The Pharmacy Guild made 37 donations to political parties in the last financial year alone, totaling $236,530.

There are other examples, such as the private health industry lobby and of course Medicines Australia, the pharmaceutical manufacturer lobby group. The Grattan Institute estimated that if the Department of Health kept vested interests out of the Pharmaceutical Benefits Scheme policymaking, taxpayers would save $320 million a year. As the Grattan Institute put it: “Seeking the advice of drug company lobbyists gave the foxes a big say in the design of the hen house”.

Medicines Australia made 17 donations to political parties in the last financial year, totaling $82,212.

Pressure

It appears that there is increasing pressure from a broad range of big corporations and lobby groups on the health care sector. I believe this usually does not improve patient care and, in some cases, will adversely influence health outcomes.

It is clear that politicians and decision makers are being heavily lobbied by these organisations, and the questions arise: will they be able to withstand these forces, and are they able to make decisions in the best interest of Australians – even though this may not always be popular?

This article was originally posted in MJA Insight

Follow me on Twitter: @EdwinKruysDisclaimer and disclosure notice.

Big health corporates win, but who keeps your family out of hospital?

Big health corporates seem to be doing well at the expense of grassroots general practice. This raises concerns about the delivery of patient care in our communities – including keeping people out of hospital.

Last month shares in Primary and Sonic jumped around five per cent after the government promised a number of carrots, including a potential rent reduction for their pathology collection centres within GP surgeries.

Last week the government struck a deal with the Australian Diagnostic Imaging Association. The Sydney Morning Herald: “The Turnbull government forged a deal with the sector late on Friday, promising to delay the cuts for non-concession holders till next January if elected, and to evaluate commercial pressures on the sector.”

Today The Australian reported: “There are groups that are doing well from the status quo, notably the health insurers and pharmaceutical companies. Last year, Medibank Private increased its operating profit by 32.5 per cent. Not bad during a period it lost policyholders.”

“There has been a percentage decrease in spending on hospitals and general practice medical attendances in recent years. At the same time, private health care premiums continue to beat inflation.”

The Australian Newspaper: “The big winners, however, are the pharmaceutical companies. The government funds $10 billion a year (up from $7bn in today’s money a decade ago) and on top of that, consumers stump up a whopping $10bn in over-the-counter preparations. Saving even a fraction of this increment would make an enormous difference to hospitals, general practice and outpatient care.”

Meanwhile, GPs and patients are still faced with the freeze on Medicare rebates. As RACGP president Dr Frank Jones has pointed out on many occasions, this situation has placed GPs and their practices in an invidious situation whereby all patients will have to financially contribute to their consultation and practices will have to curtail some quality patient services to survive financially.

It seems to me there is something seriously wrong with the priorities in our healthcare system.