Some common sense thoughts on health reform

When I arrived last night for a meeting with Federal MP Mal Brough, I had to work my way through TV camera crews to get to my chair.

But contrary to what everyone thought, Brough didn’t come to challenge the prime-minister. The meeting with local hospital doctors, GPs and staff was about health reform and the Medicare rebate – and what he had to say was remarkable.

I was expecting the usual: Budget crisis, rising Medicare costs, price signals etc. But this was a different message coming from a liberal MP.

Brough first showed some figures comparing (combined commonwealth and state) hospital expenditure versus GP Medicare rebates: $39.9 billion vs $5.9 billion per year. He demonstrated that hospital costs are rapidly rising but GP Medicare rebates remain more or less static.

His 3 core messages:

1. This must be a debate on improving the health of the nation, not a debate on cost cutting or cost shifting

2. A co-payment or price point should not be the starting point of this discussion

3. There are tremendous efficiencies to be had in hospital, specialist services and aged care if Primary Health provision is enhanced and is the heart of the nation’s health system.

Health organisations are hammering this message: If you want to keep patients out of our expensive hospitals, strengthen general practice – don’t take money out of the industry.

Brough underlined this by showing AIHW data indicating that over one-third of emergency department presentations were for potentially avoidable GP-type presentations (see image). A GP co-payment will almost certainly drive more traffic to the hospital EDs.

Mal Brough’s suggestion: Scrap it.

Minister, please don’t ruin our holiday again

Before Christmas – just as I was about to pack my suitcase – Prime Minister Tony Abbott dropped a bomb.

Together with the Health Minister he announced that the Government had introduced a policy to stop 6-minute medicine – or ‘sausage machine medicine’ as he called it. As a result the Medicare rebate would be reduced in January by $20 for GP consultations of less than 10 minutes.

Battle won, but not the war

This cut to Medicare patient rebates was meant to deliver $1.3 billion in savings over four years. However, as a result of the backlash by GPs and health consumers, the proposal has now been scrapped.

The other 2 components of the Government’s revised co-payment plan are still on the table: $873 million saving from a $5 Medicare rebate cut, and $1.3 billion saving by a four-year freeze of Medicare fees for GPs, medical specialists, optometrists, and others.

Expect more fireworks in the coming months.

6-minute medicine

Was Abbott right about the sausage machine? Are bulk-billing doctors churning through patients in six-minute sessions?

Most GPs felt Abbott’s argument was a sham as the issue was never raised in the budget. The real agenda was obviously to save health dollars. The timing – just before the Christmas break – as well as the one month’s notice before the measure would kick in, added insult to injury.

Some said it was a case of attempted political suicide.

Research shows that the average GP consultation lasts 14 minutes, not six. Some consultations may only take 5 or 6 minutes, but that’s not necessarily a bad thing. Here’s an example:

Someone comes in with a painful wrist after a fall. An efficient, experienced GP can take a history, examine the wrist and, if needed, organise further investigations within 6 minutes. The GP-in-training may take 20 minutes to do the same, should she be paid more? Probably not.

Abbott’s argument is of course not coming out of the blue: ‘6-minute medicine’ has a bad reputation because some business models of larger corporate GP clinics are purely profit-driven, and it is thought that this can lead to a high patient-turnover.

If Abbott has a problem with this practice, his Government should deal with those clinics, and not punish all GPs and their patients. But there’s more to it.

The real problem

The real problem is the increasing gap between the Medicare rebate and the costs of running a practice. While business expenses are going up every year, Medicare has only slightly increased the rebates over the years – barely covering inflation, and for the past 1.5 years the rebate has been frozen.

As a result, doctors need to see more patients per hour or work more hours, if they want to continue bulk billing. Another option is to retire (not recommended). Or they can choose to charge a gap fee or co-payment. This has happened before.

In 2003 bulk billing rates were at an all-time low of 66%. This didn’t make the Howard Government very popular, so the health-minister – Tony Abbott – had to increase the Medicare rebates. As a result, bulk billing went up again.

The solution

At the moment bulk billing rates are at an all-time high, about 85%. If the planned $5 rebate cut and freeze per the 1st of July 2015 go ahead, it is likely that less clinics can afford to bulk bill. History tends to repeat itself: If voters start to complain at a level of about 66% the Government may feel there is room to play – that is if they can get their proposals through the senate.

The new Health Minister Sussan Ley indicated after the backdown last week that she will continue to look for ways to make Medicare ‘sustainable’ and introduce a price signal by way of a co-payment. At the same time she wants to protect bulk billing and maintain and improve high quality healthcare.

I just hope that whatever the solution will be, private insurers are kept at a distance.

It’s good to hear that Minister Ley will talk to doctors – she seems genuine. Many GPs have already started the debate about ways to cut red-tape and increase efficiency in primary care. I’ve heard some excellent suggestions.

A bottom-up approach to health reform takes longer, but is more likely to succeed.

Doctor, do I have to stay on these medications?

This is the first article in the ‘Blogging on Demand’ series. If you have a topic you want me to blog about, feel free to send an email, contact me via social media or leave a comment below. Jen Morris picked the topic of this post. She tweeted me saying: “I’d love a GP view on polypharmacy, deprescribing & importance of reviewing and stopping treatment, not just continuing indefinitely.”

I really like this topic. I’ll explain why. It’s fair to say I have a love-hate relationship with medications. They can do a lot of good, but also cause misery. Prescribing drugs is a bit like cooking, and getting the balance of the different ingredients right an art: Use too little and your dinner guests are unimpressed, use too much and it becomes unpalatable.

There are many guidelines in medicine informing us when to use which ingredients, but unlike cooking books, they never tell when a dish should be taken out of the oven, or, in other words, when to stop treatment. This is odd, especially as patients often rightly ask: “Doctor, do I have to stay on these medications for the rest of my life?”

Here is a summary of the why, when and how to stop long-term medications – based on the limited amount of evidence available. For more information I refer to the sources mentioned below.

#1: Why stop medications?

Research shows that elderly people often feel better after their medication is discontinued. One study found that only 2% of the medications had to be restarted because the original symptoms reoccurred. This suggests that many people take medications unnecessarily.

It is estimated that up to 30% of hospital admissions for elderly patients are related to the medications they take. Reviewing the medication list periodically is therefore important, for example after the annual home medication review by the pharmacist.

#2: When to consider stopping

There may be good reasons why, after review, it is better to continue long-term medications. But there are 5 circumstances when stopping should be considered:

  1. A patient is taking multiple (more than 4) drugs
  2. An adverse drug reaction is suspected
  3. The drug doesn’t work (anymore)
  4. A patient experiences falls or cognitive decline
  5. The condition of the patient improves or worsens dramatically.

 #3: How to stop

Deprescribing can be done safely, but is not without risks. Withdrawal symptoms, rebound syndromes and reappearance of the original symptoms may occur. Medication withdrawal should be undertaken in consultation with a doctor.

The literature suggests different methods, but I particularly like the following simple 5-step approach:

  1. Prepare: Always consider the option of deprescribing at the start of a therapy, in case it is required later on.
  2. Recognise the need to stop: are any of the above mentioned 5 circumstances applicable?
  3. Prioritise one drug at a time to stop.
  4. Wean, especially benzodiazepines, opioids, beta blockers, corticosteroids, and levodopa.
  5. Monitor: Look out for withdrawal symptoms, discontinuation and rebound syndromes, reoccurrence of illness, falls, and changes in cognition and quality of life.

Research into deprescribing has mainly been done in elderly people taking multiple drugs. I believe it is not unreasonable to apply the same principles to younger people, even if they are on a smaller amount of long-term medications.

I always find it extremely satisfying if we manage to cut the number or dose of someone’s medications – and most patients seem to be equally pleased. Less is sometimes more.

Thanks to Jen Morris for the topic suggestion.

How to create a blog that makes a difference

“If you are working on something exciting that you really care about, you don’t have to be pushed. The vision pulls you.” ~ Steve Jobs

It’s great to see the steady increase in interest for social media in healthcare. What’s your passion? If you are keen to start a blog or further improve your blogging skills, there are amazing bloggers you should follow, like Seth Godin, Jeff Goins, Michael Hyatt.

My slideshow How to create a blog that makes a difference (above) contains quotes and tips from some of my idols in the blogosphere. I have also attempted to collect and present the (many) reasons why people start a blog in healthcare, common pitfalls, 3 steps for putting a great blog idea into action, and lots of tips for writing awesome posts.

Enjoy!

How social media is changing the healthcare landscape

How social media is changing the healthcare landscape
Image: Pixabay.com

There seems to be a significant growth of social media usage in the Australian healthcare industry.

In the past years we have seen surprisingly influential social media campaigns, like AHPRAaction, ScrapTheCap, InternCrisis, and very recently NoAdsPlease. These campaigns not only rally for better health care policies; they also signal a shift towards more transparency and accountability.

Characteristics of the social media campaigns are:

  • They spread quickly and generate a lot of media attention
  • The participants are very passionate about their cause
  • They are often supported by different groups including consumers
  • They may or may not be supported by professional organisations
  • They are very effective.

At the same time other social media movements, like FOAM (free open access medical education) are gaining momentum. Again, these grassroots initiatives are driven by passion – a powerful force. It won’t take long before health care professionals can do their continuing professional education via free social media sources.

I don’t think many professional and health care organisations are ready for these changes – yet they are coming whether we like it or not.

Psychiatrist and blogger Dr Helen Schultz is a social media enthusiast. Helen was involved in the successful AHPRAaction campaign. She believes social media skills are important for doctors: “I feel in the next 6-12 months there will be even more awareness of the need for doctors to know how to use social media professionally, but also how to use it to your advantage, building your brand, your platform and your voice.”

“The time has passed where we can be complacent and think patients will listen to us just because we are doctors,” she says. “We are largely absent from health debates currently, and others educate about health which may not always be necessarily evidenced based. In addition, we must claim our social media real estate, ie own our domain names and twitter handles to prevent others pretending to be us.”

Helen has taken it upon herself to organise a social media workshop for doctors and managers, and she has invited me to speak about blogging. Helen: “On the back of the success of the AHPRAaction campaign – and because I was so inspired by my colleagues around Australia, I thought we had to meet and put our heads together about how doctors can use social media in Australia to join health debates and run really successful campaigns.”

Some excellent speakers presenting at the workshop: Ms Dionne Kasian-Lew, Dr Brad McKay, Ms Jen Morris, Dr Jill Tomlinson, Dr Amit Vohra, Ms Mary Freer, and Dr Marie Bismark. Dr Mukesh Haikerwal is guest of honour.

Social Media by the Sea is a full day interactive workshop with practical tips and insights from the experts about their successful use of social media, whether it be as a blogger, advocate or part of campaign building. Time: Saturday, 15 November 2014. Place: Peppers “The Sands Resort”, Torquay, Victoria. Send email.

5 business tips for doctors

When I finished medical school I was clueless about the business of healthcare. Over the years I worked in different settings and businesses and it’s been an interesting journey.

I’ve learned most from my mistakes. Here is my top-5 tips for doctors who are or want to go in business.

#1: Do it for the right reasons

Before you start a business, practice, solo locum company or otherwise, make sure you know why you want to do it. As Simon Sinek asks: do you know the purpose, cause or belief that inspires you to do what you do? We often know exactly the what and how of what we’re doing, but not always the why…

And if you’re joining a partnership: Do you know what drives your business partners? Do their values and believes agree with yours? It has been said before, but money is not a reason, it is a result. It always starts with passion.

#2: Get the right advice

There are many services that may add value to your business: advisors, accountants, financial services, IT consultants, human resources companies, lawyers etc. If you add it all up it can be expensive. Here are some suggestions to keep in mind when dealing with third parties:

  • Avoid becoming dependent on them. Give them a few months to set up systems and train you or your staff. If you have to go back to them for every contract, website update, transaction or other issue, something is wrong (unless they are cheaper than in-house services, but this is rarely the case).
  • Don’t be afraid to make changes. Doctors are loyal – as banks know. But sometimes it is healthy to change providers, especially if you are paying top dollars and feel you’re not getting top service. Another accountant may pick up an overlooked issue, another IT provider may find some holes in your security etc.
  • Work on your terms, not theirs. Some consultants want you to use their products and their systems – and they will often charge for it. This is not always necessary, may create more work and adds to the bottom line. Look for useful advice that empowers you and your staff. Keep things simple.
  • Don’t accept higher fees because you’re a doctor or because a provider specialises in the health industry. As doctors we often think we’re special. This may be the case (although I’m not entirely convinced), but it doesn’t mean that you have to find providers that only service medical clients. When it comes to IT or tax or law, healthcare is not that different from other industries.

#3: Understand your business

If you can’t explain it properly, you don’t understand it well enough – this is true for many things, and certainly for a business. Like doctors, professional consultants should be empowering their clients and encourage them to self-manage.

Aim for a business structure that’s transparent and easy to understand. This also includes the finance structures and legal agreements. Don’t sign off on anything unless you understand it fully. Do your due-diligence and take time to consider decisions. Walk away if you feel uncomfortable or pressured.

#4: Beware of conflicts of interest

A financial advisor receiving bonuses or other incentives to sell products may not be working in your best interest. Always ask for a disclosure of potential conflicts of interest. But there may be other, less obvious conflicts of interest that can become an issue down the track. This can also happen within a group of owners. Examples include:

  • Some owners work on the business where others only work in the business
  • Some owners work full-time and others part-time
  • Some owners own bigger or smaller shares in the business or real-estate
  • Some owners have family members working in the business
  • Some owners have the same lawyers, accountants or bank managers

In an ideal world there are no conflicts of interest but that’s not always possible. Ask yourself: Can I live with these conflicts? It’s important to disclose and discuss all potential issues before signing any agreement.

#5: Commit

Expect ups and downs. It may take a few years before a business takes off. Be prepared for erratic government decisions that will have an impact on your bottom line and the patient services you can provide.

Find a great practice manager – see my post 4 things to look for in a practice manager. A skilful management team is an excellent investment with good returns and will give you peace of mind.

If you’re like me you will make mistakes and hopefully learn from them. You may also need to master new skills – something I enjoyed as it has broadened my horizons. Finally, always look after your team and don’t forget your loved ones at home.

Blocking social media at work is not the answer

Restricting social media usage at work is sometimes done out of fear. “We don’t want our staff to be distracted.” And: “They shouldn’t waste their time on social media.” Other understandable reasons may include perceived cyber risks or the cost of excess data usage.

An organisation that blocks social media sites may send out one or more of the following messages:

  1. We don’t trust our staff
  2. We don’t really understand what social media is all about
  3. Even though consumers are using social media for health purposes, we’re not really interested

In most cases decision makers are probably unfamiliar with social media and may see it as a threat.

Why staff should have access

Here are five reasons why health care staff should have access to sites like LinkedIn, Twitter, YouTube, Blogs etc:

  1. Social networks are powerful learning tools for staff
  2. Social media are increasingly used as health promotion tools (such as embedded YouTube videos)
  3. Shared knowledge accessible via social media will assist staff in finding answers and making decisions
  4. Interactions with peers and thought leaders can increase work satisfaction (and will contribute to staff retention)
  5. Participating in social media and other new technologies will raise the (inter)national profile of an organisation

When it comes to cyber security, I believe there are alternatives that are more effective than blocking social media access including upgrading and updating operating systems, updating antivirus software, improving backup procedures, clever password management and online safety training for staff.

A simple social media staff policy also goes a long way.

Let’s stay out of where they are from and why they’re here

A long time ago I did a locum stint in an asylum seekers centre in The Netherlands.

What struck me was the vast amount of physical and mental illnesses like depression, malnourishment, and neglected chronic and infectious diseases, together with uncertainty, fear, cultural differences and challenging language barriers.

It all came back to me when I saw the people on board of the small, fragile vessel that earlier this year sailed into the Geraldton harbour.

Asylum seeker boat
When the boat sailed into the Geraldton harbour, it didn’t feel like the ‘unprecedented breach of border security’ we heard about in the media. Whatever the reason for their journey, these men, women and children should be looked after properly while they are in Australia.

The sad reality is that many asylum seekers, including children, spend many years in immigration detention facilities. This creates more (mental) health problems. AMA president Steve Hambleton said at the National Press Conference this week:

(…) let’s stay out of where they are from and why they’re here and all the other stuff. Once we are in control or once we take responsibility for people, we should be providing them with first-rate health care.

Whatever the reason for their dangerous journey, let’s hope these men, women and children will eventually find a place where they can live a safe, healthy and peaceful life.

In the meantime, while they are here, we have to take care of them. We are responsible for their health and well-being, including appropriate access to quality healthcare.

Medicare Locals, please make it easier for us, not harder

Health Minister Tanya Plibersek said on ABC’s Q&A that Medicare Locals had developed as a ‘natural successor’ to divisions of general practice to assist primary care at the local level.

Although this sounds great, it seems that Medicare Locals are wasting tax dollars and are creating red tape. Medicare Locals are funded by the federal government and responsible for funding local health projects such as after hours care.

This week, Medicare Locals have been put on notice by the AMA because they are rolling out onerous contracts for GP after hours services. Although the after hours work is still done by doctors and nurses, the funding is now in the hands of Medicare Locals instead of the state health service.

It also appears that Medicare Locals are sending out new contracts to GP practices for PIP incentive payments (‘PIP’ is a bonus paid out to practices if certain targets are met). The contracts require GPs to produce lots of data e.g. quarterly reports, and contain many clauses that give full control to Medicare Locals but put all the risks, costs and responsibilities on health professionals.

It is expected that many GPs will not sign these contracts. This will have serious consequences for patient care.

If we do not stop Medicare Locals, doctors and practice managers will be wasting valuable time behind their computers generating reports, instead of helping patients. Medicare Locals should be supporting health professionals to improve patient-access to health care facilities.

A recent survey also brought to light that about fifty percent of Medicare Local staff is busy writing reports instead of providing or facilitating services to patients or clinicians.

Whichever party wins the next election, this needs to change. Medicare Locals, please make it easier for us to provide patient care – not harder!

Participation – the secret sauce of health care

The previous Christmas parties at work were always nice. We sat down and were served a nice dinner. There was nice live music. We were fed and entertained – what more can you ask for?

Last year our management team took a different approach. We were not fed. We had to prepare our own food: Select the toppings for our pizza and bake it in the wood fired pizza oven. We waited patiently in line. We were the chefs.

There was no band. We had to sing ourselves – on stage. We were the entertainment. There were sumo suits; there was a gladiator ring. It was the best Christmas party ever.

Participation is fun. It creates a sense of ownership, responsibility and improves team spirit. That’s why social media works. Social media empowers. We have become participants instead of spectators.

This is how it should be in health care. I love it how some of my patients take ownership of their health. They are actively engaged, do research, ask questions and understand their treatment. As a doctor I’m not telling them what to do, I’m just part of their team.

Participation is the secret sauce. As health care professionals we must do everything we can to encourage participation.