TOP STORIES

Big boost for obstetrics

A new $950 item for complicated births - estimated to represent about 25% of obstetric cases - has been approved by Federal Health Minister, Dr Michael Wooldridge. National Association of Specialist Obstetricians and Gynaecologists (NASOG) chairman Dr David Molloy said the item - proposed following talks between the AMA, NASOG and the Federal Health Department - was a good start to address problems with obstetrics funding.

AMA win on registrar salaries

Junior doctors and GP leaders have applauded the Government's decision to scrap its proposal for salaried GP registrars and replace it with a package developed in consultation with the profession. Under the new package, GP registrars will retain their provider numbers and will continue to bill Medicare for consultations.

New look provider numbers

The AMA and the Federal Health Minister have agreed to establish a process to look at allowing trainee specialists and doctors outside of training programs to be given limited Medicare provider numbers. AMA Federal President, Dr David Brand, said the Minister may allow these doctors to do some work in the private sector, provided it was supervised and not a back-door way to a full time provider number. AMA Doctors-in-Training Chris Merry, said junior doctors would hold off on a planned national campaign on the provider number issue, pending written confirmation from the Minister regarding the proposal.

AMA 'needs restructuring'

AMA Victoria President, Dr Gerald Segal, has called for a meeting - run by a professional facilitator - to look at restructuring the AMA in order to clarify representatives' fiduciary duties. Dr Segal's proposal follows a meeting last month of presidents and CEOs of state branches, and the Federal AMA, which highlighted problems faced by some branch representatives. AMA President Dr David Brand has welcomed the suggestion.

Gaps cover announcement delayed

The Federal Government has delayed announcing a new initiative on medical gaps cover for private health insurance members until later in the election campaign. But a spokesman for Health Minister, Dr Michael Wooldridge, confirmed to AM that many of the details of the gaps proposal have already been revealed in the media. (AM, 3 August) These include the Government paying 100% of the MBS fee for in-hospital care, with health funds paying an average of 25% above the schedule and patients meeting any additional costs.

INSIDE

Debate: Is the new PHI rebate scheme money well spent?

While former AMA President, Dr Brendan Nelson claims the new rebate scheme is a step forward in terms of commitment to both private and public health care, the Opposition Health Minister, Michael Lee, says it's unfair and simply won't work.

Feature: A tragedy waiting to happen

As rural towns all over Australia struggle to maintain obstetric services, Wagga Wagga obstetrician Dr Ian Stuart, warns that the crisis in south western NSW will inevitably lead to tragedy.

Feature: Position statement on genetic issues

The complex ethical issues, possible benefits and risks of clinical genetics have been formally considered by the AMA

From the Vice-President: Who gets what?

At last the Medicare agreements are signed. The states have extracted $900m extra from the Federal Government. Will those extra dollars do anything visible to the public hospital system? How will we know?

The most visible signal that the public hospital system is in difficulty is the length of waiting lists. For most major hospitals these lists are probably masterpieces of spin doctoring. Many hospitals are financially penalised for having more than a specified number of patients on an acute waiting list. It is hardly surprising that all engaged in the management of that waiting list may seek to minimise the numbers in order not to reduce even further the dollars available to treat patients. An ethical argument might even be mounted that could justify 'gaming' the list, so that the hospital did not incur financial penalties. Despite the possible perverse incentives of such arrangements, and whatever the problems associated with casemix funding, these mechanisms for funding public hospitals are far preferable to historical block funding, as they at least provide some incentive to manage efficiently the enormous amount of money required to run hospitals.

What then do waiting lists really represent? They are a disguised form of rationing health care delivery in a system which is insufficiently provided with adequate funds to treat all patients seeking interventions. Improving quality and reducing costly adverse events in a non-punitive environment has the potential to make significant, rational savings. Removing as many patients as possible from the pool would be a significant start, but the foolishness of a free system offered to all, existing beside an optional expensive system, makes that an unlikely event. It is unlikely also that even if this occurred, there would be enough health dollars to treat all patients who sought interventions, in a timely manner. If health spending is to be maintained at current levels of GDP (a form of rationing in itself) then rationing will continue.

The complexities of investigating rationing health care are daunting but need to be faced openly rather than surreptitiously. They come in a range of disguises. Should I continue to work in the heart-lung transplant unit at my hospital or would the dollars be more 'useful' in the community mental health service? Can the knowledge gained in expensive high tech endeavours eventually flow through to less exotic areas? Is this any justification for trading expensive interventions and medications for less costly ones in other situations? Expensive interventions may grab headlines while less dramatic and much cheaper endeavours cannot be funded if dollars are directed to quell an emotive and emotional plea from the parent of a dying child seeking additional funds for a novel and probably futile treatment.

The concepts of rationing are quite confronting. Who should get what health care? Those who can pay or those who need few resources? Those who have not contributed to their ill health? Those who intervene most effectively in the system and make it work for them, or those who are most disabled and voiceless?

Should all health care be available to everyone in a giant smorgasbord? When only those interventions that are evidence based and delivered according to quality-defined criteria are available, should only a defined group of core treatments be provided? Does this approach stifle innovation and research?

Our waiting lists are arranged using an amalgam of judgements regarding medical neediness and perceived quality of life. These decisions presume a covert moral framework driven primarily by the medical profession. In some other places these decisions have been determined by public debate. Publicity about waiting lists is often reduced to simplistic arguments about insufficient money and a presumption that additional resources from some other source, usually government, would fix everything. This level of debate does nothing to advance the much more difficult dilemma of the 'bottomless pit' for health care demand. If the AMA is to participate usefully in discussions regarding public hospital funding then it must acknowledge that this contentious aspect of the problem must form part of the agenda.

Dr Sandra Hacker is Vice-President of the Federal AMA.