tag:theconversation.com,2011:/global/topics/medical-specialists-14925/articlesMedical specialists – The Conversation2023-12-04T19:17:08Ztag:theconversation.com,2011:article/2178812023-12-04T19:17:08Z2023-12-04T19:17:08ZEndometriosis: It’s time to change the pattern of pain, stigma and barriers to diagnosis and treatment<figure><img src="https://images.theconversation.com/files/563001/original/file-20231201-29-ehllq0.jpg?ixlib=rb-1.1.0&rect=135%2C45%2C6527%2C4366&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The Government of Canada recently announced more than $1.6 million for endometriosis patients and research, the largest single investment in endometriosis care in Canada for the last 20 years.</span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><iframe style="width: 100%; height: 100px; border: none; position: relative; z-index: 1;" allowtransparency="" allow="clipboard-read; clipboard-write" src="https://narrations.ad-auris.com/widget/the-conversation-canada/endometriosis-its-time-to-change-the-pattern-of-pain-stigma-and-barriers-to-diagnosis-and-treatment" width="100%" height="400"></iframe>
<p><a href="https://www.who.int/news-room/fact-sheets/detail/endometriosis">Endometriosis</a> is a debilitating disease that <a href="https://doi.org/10.1016/j.jogc.2020.05.009">affects an estimated one million Canadians</a>. It involves the overgrowth of tissue similar to endometrium tissue (the tissue that lines the uterus). </p>
<p>For people with endometriosis, this tissue grows excessively, both inside and outside of the uterus, which can cause pelvic pain, extreme menstrual cramping and non-menstrual cramping, as well as chronic fatigue and reduced fertility. </p>
<p>The Government of Canada <a href="https://www.canada.ca/en/health-canada/news/2023/09/government-of-canada-strengthens-access-to-sexual-and-reproductive-services-for-people-living-with-endometriosis.html">recently announced more than $1.6 million</a> for endometriosis patients and research, the largest single investment in endometriosis care in Canada for the last 20 years. This much-needed, long-awaited funding will go far to address the many challenges that endometriosis patients face, including struggling to get a diagnosis in the first place, dismissal of their symptoms, related stigma, and ineffective treatments.</p>
<p>Left untreated, endometriosis can affect the central nervous system, leaving patients at heightened risk of abnormal pain and chronic pain presentation, which too often negatively impacts their overall quality of life.</p>
<p>In fact, endometriosis patients often experience a reduced ability to participate in the activities of everyday life. Yolanda Kirkham, an obstetrician-gynecologist (OBGYN) from the University of Toronto, <a href="https://obgyn.utoronto.ca/news/invisible-disease-endometriosis">has reported that</a> girls and young women are unable to attend school for a few days each month due to their symptoms, while others with the disease frequently miss work due to nausea and vomiting. </p>
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<img alt="A doctor and a young woman patient in a clinic" src="https://images.theconversation.com/files/563224/original/file-20231204-18-l6ikwn.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/563224/original/file-20231204-18-l6ikwn.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/563224/original/file-20231204-18-l6ikwn.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/563224/original/file-20231204-18-l6ikwn.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/563224/original/file-20231204-18-l6ikwn.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/563224/original/file-20231204-18-l6ikwn.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/563224/original/file-20231204-18-l6ikwn.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Most cases of endometriosis are not diagnosed by primary care providers, but by specialists — namely OBGYNs to whom they are referred. Long waiting lists to see specialists can contribute to delayed diagnosis.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
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<p>The unfortunate outcome for these patients is not just their reduced ability to participate in activities. It also means they experience significant losses in their economic productivity. Researchers have found that the average endometriosis patient in Canada <a href="https://doi.org/10.1016/s1701-2163(16)34986-6">loses around $3,400 in economic productivity per year.</a> </p>
<h2>Delayed diagnosis</h2>
<p>One of the significant challenges faced by people with endometriosis is receiving a diagnosis. Patients experience an average delay of <a href="https://doi.org/10.1016/j.jogc.2019.10.038">5.4 years</a> from the onset of symptoms to diagnosis. The symptoms are similar to other reproductive health issues (such as <a href="https://www.nhs.uk/conditions/polycystic-ovary-syndrome-pcos/">polycystic ovary syndrome</a>) or severe period pain, which can be confusing for non-specialist health-care professionals. </p>
<p>Research with endometriosis patients has shown that most cases of endometriosis are not diagnosed by primary care providers, <a href="https://doi.org/10.1016/j.srhc.2015.11.003">but by specialists</a> — namely OBGYNs to whom they are referred. Taken together with long waiting lists for specialists, the barriers to diagnosis are significant. </p>
<p>Another barrier is that women often have difficulty convincing care providers their pain is real and a cause of concern. In a recent research project, one of us (Sarah Seabrook) examined 70 publicly available accounts of people experiencing endometriosis, including quotes printed in newspapers, as well as from the narratives published by endometriosis not-for-profit <a href="https://endoact.ca/">EndoAct</a>. </p>
<p>Patients described being dismissed, that their pain was “<a href="https://endoact.ca/maureen-2/">just muscle pain</a>,” “<a href="https://endoact.ca/kat/">all women go through this</a>,” and “<a href="https://www.cbc.ca/news/canada/saskatoon/endometriosis-chelsea-fataki-1.4605830">this is the way cycles are for women</a>,” and to live with it.</p>
<p>This dismissal of pain is particularly troublesome because people don’t often share their menstrual experiences and may be unable to differentiate between normal and abnormal menstrual experiences. In an article published by CBC News in 2021, a woman with endometriosis reported that the first few times she had her period, she was hospitalized for severe pain, but because this was her initial experience of menstruation, “<a href="https://www.cbc.ca/news/canada/british-columbia/endometriosis-lacking-research-1.5910342">she thought the pain related to her period was normal</a>.”</p>
<h2>Lack of effective treatments</h2>
<p>Once endometriosis is diagnosed, there are significant barriers to receiving effective treatment. <a href="https://doi.org/10.1016/j.fertnstert.2017.01.003">The first line of treatment is typically hormonal birth control</a>, which does nothing to address the growth of endometrium-like tissue, although for some people it can help with controlling menstrual pain. The same is true of anti-inflammatories and painkillers, which can reduce pain, but do little for the growth of endometrium-like tissue. </p>
<p>When things are more severe, patients might be given surgical options such as tissue excision (removing the entire endometriosis lesion) or ablation (burning off the surface of the endometriosis lesion). However, these procedures are rarely curative — the excess endometrium-like tissue grows back in a lot of cases. As a final resort, <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4286861/">some patients undergo a hysterectomy</a>. For the most part, endometriosis care is focused on either temporarily reducing pain, or temporarily controlling the growth of tissue. </p>
<p>The lack of effective treatment options is tied to an ongoing failure to understand endometriosis, its underlying causes and effects. Leading <a href="https://doi.org/10.1503/cmaj.220637">Canadian experts</a> have been calling for the improved understanding of endometriosis care and its treatment options, and <a href="https://endoact.ca/wp-content/uploads/2023/04/DiscussionENF2023.pdf">advocates</a> have been mobilizing for increased funding to understand, diagnose and treat endometriosis in Canada. </p>
<p>To improve outcomes, endometriosis patients need more research, more options and more attention to be paid to the disease. The newly announced federal investment in endometriosis research and care by the federal government is a good first step — although continued funding and support will be needed to address the continued, far-reaching effects of endometriosis in Canada.</p>
<p><em>This is a corrected version of a story originally published on Dec. 4, 2023. The earlier story used the term “endometrial tissue” instead of “endometrium-like tissue” or “tissue similar to endometrium tissue.”</em></p><img src="https://counter.theconversation.com/content/217881/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Alana Cattapan receives funding from the Social Sciences and Humanities Research Council of Canada and the Canadian Institutes of Health Research. </span></em></p><p class="fine-print"><em><span>Sarah Seabrook does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Endometriosis often means years of severe pain, lost productivity and dismissed symptoms before getting a diagnosis — followed by ineffective treatment. New funding aims to change this pattern.Sarah Seabrook, Research Assistant in the Department of Political Science, University of WaterlooAlana Cattapan, Assistant Professor and Canada Research Chair in the Politics of Reproduction, University of WaterlooLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1921632022-10-11T19:03:56Z2022-10-11T19:03:56ZSome GPs just keep their heads above water. Other doctors’ businesses are more profitable than law firms<figure><img src="https://images.theconversation.com/files/488898/original/file-20221010-57880-2zni7j.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C1920%2C1077&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.pexels.com/photo/black-and-white-photo-of-window-with-message-9295975/">Sonny Sixteen/Pexels</a>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span></figcaption></figure><p>Almost all GPs and most non-GP specialist doctors (such as cardiologists, gynaecologists and dermatologists) run private businesses to provide medical care in Australia. Business decisions can influence the costs of medical care, the care patients receive, and access to medical care in different geographic areas. </p>
<p>But until now, we’ve had no national data on the costs or profitability of running a private medical practice.</p>
<p>Our ANZ-Melbourne Institute Health Sector <a href="https://www.anz.com.au/content/dam/anzcomau/documents/pdf/ANZ-Melbourne-Institute-Health-Sector-Report.pdf?adobe_mc=MCMID%3D44747976514731566262638549714644871422%7CMCORGID%3D67A216D751E567B20A490D4C%2540AdobeOrg%7CTS%3D1665566472">Report</a>, out today, uses data from the Australian Bureau of Statistics on all medical businesses in Australia.</p>
<p>We examined trends in growth, costs and profitability, and how the financial health of doctors’ businesses has been affected during the COVID pandemic.</p>
<p>Among our findings, we show how medical businesses, in particular for non-GP specialists, remain very profitable compared to other businesses, including law, accountancy and finance.</p>
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<h2>Why should we care about medical businesses?</h2>
<p>Many people seeking health care do not think about the costs involved, or the profitability of, running a private medical practice.</p>
<p>But the sudden <a href="https://www.abc.net.au/news/2022-08-11/tristar-medical-clinic-closures-to-leave-some-towns-without-a-gp/101322264">closure</a> of GP practices for financial reasons reduces access to health care for communities. For others, a focus on seeking profits means out-of-pocket costs can rise. </p>
<p>There are also more widespread <a href="https://www1.racgp.org.au/newsgp/professional/drop-in-national-bulk-billing-rate-signals-increas">reports</a> of reduced access to bulk billing (where there are no out-of-pocket costs).</p>
<p>So how doctors run their private businesses is very much in the public interest.</p>
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<a href="https://theconversation.com/health-worker-burnout-and-compassion-fatigue-put-patients-at-risk-how-can-we-help-them-help-us-191429">Health worker burnout and 'compassion fatigue' put patients at risk. How can we help them help us?</a>
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<h2>The growth of private practice</h2>
<p>It was not too long ago that GPs and non-GP specialists worked largely on their own. But the benefits of working with others has led to a growth in private group medical practice. </p>
<p>GPs were the first doctors to do this. Now almost 90% of GPs report working in a group practice. But other specialists are rapidly catching up, where almost 70% now work in a private group practice. </p>
<p>The total number of doctors in a solo private practice has fallen by 0.5% between 2013 and 2020, while the number in group private practices has increased by 28.9%.</p>
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<a href="https://images.theconversation.com/files/488942/original/file-20221010-26-39u7f5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Patient talking to doctor receptionist or health staff behind desk" src="https://images.theconversation.com/files/488942/original/file-20221010-26-39u7f5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/488942/original/file-20221010-26-39u7f5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/488942/original/file-20221010-26-39u7f5.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/488942/original/file-20221010-26-39u7f5.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/488942/original/file-20221010-26-39u7f5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/488942/original/file-20221010-26-39u7f5.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/488942/original/file-20221010-26-39u7f5.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">Groups practices can keep costs down by sharing the costs of premises, administration and support staff.</span>
<span class="attribution"><a class="source" href="https://www.pexels.com/photo/a-receptionist-smiling-at-a-person-4269203/">Cedric Fauntleroy/Pexels</a>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span>
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<p>Group practices can be good in keeping costs down by sharing the costs of premises, administration, nurses, and medical equipment. Working together can improve the quality of care and access to health care, as patients can easily see another GP in the practice if their preferred one is too busy. In a group practice, doctors can also more easily share knowledge. </p>
<p>But if businesses get too big, this could mean less choice for patients looking for a local doctor, and less competition. This could further increase out-of-pocket costs as there is less competitive pressure to keep fees low.</p>
<p>While more non-GP specialists are working in group private practice, they are also on average spending less time there. In 2020 they spent about three hours per week less in private practice compared to 2013.</p>
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<h2>Rising profits and costs</h2>
<p>We show profits rose by an average of 2.4% a year for GP businesses and 5.3% a year for non-GP specialists businesses between 2005-6 and 2020-21. </p>
<p>Costs for GPs rose by an average 2.7% a year over the same time period. Turnover from total fees charged grew by 2.9%.</p>
<p>For non-GP specialists costs rose by an average 2% a year over the same time period, while turnover grew by 3.5%.</p>
<p>Overall the growth in costs for GP businesses was higher than for other specialists, and the growth in turnover was lower. This gap between costs and turnover has grown over time. </p>
<p>Non-GP specialists’ businesses made 50% more profit than GP businesses in 2020-21 ($216,468 and $144,485), compared to 14% more in 2005-6 ($120,452 and $105,924).</p>
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Read more:
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<h2>Impact of COVID</h2>
<p>Medicare coverage of telehealth meant GPs avoided losing income from the fall in face-to-face visits because of COVID. So revenue from fees continued to increase, though at a lower rate than before 2020. </p>
<p>Medical practices could also claim JobKeeper payments to maintain employment of practice staff. This financial support meant the number of GP and non-GP specialist businesses winding up or going bust actually fell during 2019-20. In fact, the total number of medical businesses continued to grow throughout the pandemic. </p>
<p>Profits initially fell during COVID by 1.9% for GPs and by 4.5% for non-GP specialists between 2018-19 and 2019-20. </p>
<p>But profits bounced back the following year because of the pent-up demand during the pandemic. People who were avoiding health care because of COVID or who had their elective surgeries cancelled, came back and still needed care.</p>
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<a href="https://images.theconversation.com/files/488943/original/file-20221010-11-5addt1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Two surgeons operating" src="https://images.theconversation.com/files/488943/original/file-20221010-11-5addt1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/488943/original/file-20221010-11-5addt1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/488943/original/file-20221010-11-5addt1.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/488943/original/file-20221010-11-5addt1.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/488943/original/file-20221010-11-5addt1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=502&fit=crop&dpr=1 754w, https://images.theconversation.com/files/488943/original/file-20221010-11-5addt1.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=502&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/488943/original/file-20221010-11-5addt1.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=502&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">People who once had their elective surgeries cancelled can now go ahead.</span>
<span class="attribution"><a class="source" href="https://www.pexels.com/photo/surgeons-performing-surgery-2324837/">Павел Сорокин/Pexels</a>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span>
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<p>This was especially the case for non-GP specialists, where profits grew by 10.8% between 2019-20 and 2020-21 compared to 2.2% for GPs. </p>
<p>However, medical businesses, especially GPs, experienced sudden increases in costs as they adapted to COVID settings. For GP businesses, costs increased by over 8% during the pandemic (4.1% between 2018-19 and 2019-20, and by 4% between 2019-20 and 2020-21.</p>
<p>It is expected demand will remain high for private medical care provided by GPs and non-GP specialists as people who delayed care and treatment during the pandemic return to seek care. </p>
<p>In fact, medical businesses, especially non-GP specialists, remain very profitable compared to other businesses such as law, accountancy, finance, construction and agriculture. In 2021, the median gross profit per business (turnover minus costs before tax) was $216,468 for non-GP specialists, $120,452 for GPs, and $124,431 for legal businesses.</p>
<h2>Implications for patients</h2>
<p>Achieving good access to high-quality medical care requires medical businesses to be located in areas of need and where out-of-pocket costs are kept to a minimum for low-income populations.</p>
<p>The growth in private group medical practice can mean medical businesses are run more efficiently, with continuing cost pressures leading to the formation of larger medical groups, especially for non-GP specialists. </p>
<p>In most cases maintaining profitability of private medical businesses is necessary to ensure their survival and maintain access to medical care, as long as out-of-pocket costs don’t increase at the same time.</p><img src="https://counter.theconversation.com/content/192163/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Anthony Scott receives funding from the Australia and New Zealand Banking Group for the annual report series 'ANZ-Melbourne Institute Health Sector Reports'. Professor Scott conducts the data analysis and writes the report. </span></em></p>The cost and profits involved in running a medical practice is everyone’s business. It can influence the type of health care you receive.Anthony Scott, Professor of Health Economics, The University of MelbourneLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1759142022-02-03T19:08:08Z2022-02-03T19:08:08ZCritically understaffed and with Omicron looming, why isn’t NZ employing more of its foreign-trained doctors?<figure><img src="https://images.theconversation.com/files/444181/original/file-20220203-27-p7fsi5.jpg?ixlib=rb-1.1.0&rect=38%2C0%2C6451%2C4330&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">GettyImages</span></span></figcaption></figure><p>New Zealand’s critical <a href="https://www.rnz.co.nz/news/political/460780/new-zealand-competing-with-other-countries-to-recruit-icu-nurses-national">shortage of specialist nurses</a> made headlines again this week, but it’s not the country’s only pressing medical need.</p>
<p>The Association of Salaried Medical Specialists (<a href="https://www.asms.org.nz/">ASMS</a>) has estimated <a href="https://www.asms.org.nz/news/2022/01/25/we-need-to-declare-a-health-workforce-emergency/">almost 3,000 more</a> GPs and specialist doctors, and 12,000 more nurses, are needed to match Australia’s per-capita staffing levels.</p>
<p>The predicted impact of Omicron adds to the urgency, but since the beginning of the COVID-19 pandemic there have been regular <a href="https://www.nzdoctor.co.nz/article/we-are-drowning-gp-workforce-survey">reports</a> of a medical workforce <a href="https://www.rnzcgp.org.nz/GPPulse/RNZCGP/News/College_news/2020/New-Zealands-GPs-are%20a-workforce-in-crisis.aspx">in crisis</a>, with <a href="https://www.nzherald.co.nz/nz/auckland-hospitals-overloaded-patients-waiting-in-corridors-as-demand-skyrockets/NIU26VB3XCSZFHHGASKSXOXP2A/">longer waiting times</a> and patients being <a href="https://www.stuff.co.nz/national/health/124477572/doctor-shortage-forcing-gp-clinics-to-turn-away-new-patients">turned away</a>. </p>
<p>Border closures and immigration restrictions have only made the doctor shortage worse. We need to ask, therefore, why many foreign-trained doctors currently living in New Zealand are still not allowed to work.</p>
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<h2>Brain drain and brain gain</h2>
<p>Doctors have <a href="http://neuron.mefst.hr/docs/CMJ/issues/2001/42/5/11593497.pdf">always moved around</a>. It’s been an important aspect of the medical profession for centuries, as a way of learning new skills and knowledge. According to a 2019 Medical Council <a href="https://www.mcnz.org.nz/assets/Publications/Workforce-Survey/6be731ea72/Workforce-Survey-Report-2019.pdf">workforce survey</a>, around 40% of New Zealand-trained physicians from the 2005 cohort were living overseas after ten years.</p>
<p>To compensate for this “<a href="https://www.bmj.com/content/324/7336/499">brain drain</a>”, which leads to roughly <a href="https://www.asms.org.nz/wp-content/uploads/2017/02/IMG-Research-Brief_167359.5.pdf">one in six</a> New Zealand-trained doctors working overseas, doctors from other countries are encouraged to immigrate. New Zealand’s health system depends on this migrant “brain gain”.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/omicron-is-overwhelming-australias-hospital-system-3-emergency-measures-aim-to-ease-the-burden-175233">Omicron is overwhelming Australia's hospital system. 3 emergency measures aim to ease the burden</a>
</strong>
</em>
</p>
<hr>
<p>Before the pandemic, almost <a href="https://www.mcnz.org.nz/assets/Publications/Workforce-Survey/6be731ea72/Workforce-Survey-Report-2019.pdf">43% of New Zealand doctors</a> were from overseas. But many have joined a general <a href="https://www.stuff.co.nz/business/125796584/skilled-migrants-are-leaving-in-droves-frustrated-by-lengthy-residency-delays">exodus of skilled workers</a>, with some blaming <a href="https://www.rnz.co.nz/news/national/441433/departing-gp-warns-govt-failing-to-retain-overseas-medical-staff">delays over residency</a>.</p>
<p>To make matters worse, not all of those who stay are able to <a href="https://www.nzherald.co.nz/nz/covid-19-delta-outbreak-immigrant-doctors-denied-work-at-understaffed-hospitals/OKRC764YCBPNOUSOPRUIJ7FOVM/">work as doctors</a> in their adopted country.</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1488907606995259392"}"></div></p>
<h2>Long pathways to practising</h2>
<p>The reason lies in the way New Zealand licenses foreign doctors depending on where they trained. Those with training and experience in “comparable health systems” <a href="https://www.mcnz.org.nz/registration/getting-registered/">can generally practise</a> as soon as they receive a job offer. </p>
<p>That comparability is <a href="https://www.mcnz.org.nz/registration/getting-registered/registration-policy/comparable-health-system-criteria/">measured by indicators</a> such as life expectancy and doctors-per-capita in other countries. It’s hardly surprising that only wealthier countries are on the list.</p>
<p>Doctors who can’t claim comparability must first complete a medical knowledge exam from either Australia, the UK, US or Canada, pass an English test and then pass the New Zealand Registration Examination (<a href="https://www.mcnz.org.nz/registration/getting-registered/registration-exam-nzrex/">NZREX</a>). </p>
<p>This process can cost more than NZ$10,000 and takes years – especially since COVID-19 has meant half of the exam offerings were cancelled in 2020 and 2021, adding to wait times.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/new-zealands-border-quarantine-has-intercepted-thousands-of-covid-cases-but-is-it-time-to-retire-the-flawed-system-176144">New Zealand's border quarantine has intercepted thousands of COVID cases, but is it time to retire the flawed system?</a>
</strong>
</em>
</p>
<hr>
<h2>A hurdle too far</h2>
<p>Once a doctor has passed the exams and met the required standard, they must still complete two years of supervised work before being licensed. </p>
<p>This is where the catch comes: <a href="https://www.mcnz.org.nz/registration/maintain-or-renew-registration/pgy1pgy2-and-nzrex-training-requirements/">first-year supervised positions</a> are limited, prioritised for New Zealand medical graduates and rarely offered to foreign-trained doctors. </p>
<p>Most doctors from comparable health systems, on the other hand, don’t need to take the NZREX or complete two years of supervised work. By not competing with New Zealand medical graduates to be licensed, they don’t experience the same bottlenecks.</p>
<p>Of the foreign doctors who passed the NZREX <a href="https://www.mcnz.org.nz/assets/NZREX/b6d370fe8b/NZREX-Clinical-Pass-Rates-and-Subsequent-Registration.pdf">between 2016 and 2021</a>, just over half now have provisional registration and can work. This leaves 94 who have passed the exam in the past five years but are still not licensed to practise medicine. </p>
<p>For those who passed the exam earlier, the results are valid for only five years. If they haven’t been able to secure a supervised position in that time, they are back to square one. </p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1485358014135939072"}"></div></p>
<h2>A wasted workforce</h2>
<p>The government has an ongoing <a href="https://www.careers.govt.nz/jobs-database/health-and-community/health/physician/">recruitment campaign</a> to lure overseas doctors. The Medical Council is also looking for ways to <a href="https://www.mcnz.org.nz/about-us/news-and-updates/consultation-on-the-comparable-health-system-registration-pathway/">simplify the pathway</a> for doctors from comparable health systems. </p>
<p>Despite the obvious need, qualified immigrant doctors have reportedly been <a href="https://www.nzherald.co.nz/nz/covid-19-delta-outbreak-immigrant-doctors-denied-work-at-understaffed-hospitals/OKRC764YCBPNOUSOPRUIJ7FOVM/">denied work opportunities</a> at understaffed hospitals during the pandemic.</p>
<p>It is difficult not to see an apparent assumption that a doctor’s competency as a physician is associated with the country they are from. This is not an unusual phenomenon – migrant physicians from non-Western backgrounds often <a href="https://link.springer.com/article/10.1007/s11127-014-0152-8">experience barriers</a> to registration and licensing in their destination countries.</p>
<p>But in New Zealand the disadvantage some foreign doctors face also extends to the licensing pathways. To be registered, those from non-Western countries must demonstrate clinical skills, including showing Māori cultural competency, while those from “comparable health systems” don’t. </p>
<p>One might ask, if cultural competency is important in the context of New Zealand’s <a href="https://waitangitribunal.govt.nz/news/report-on-stage-one-of-health-services-and-outcomes-released/">inequitable health outcomes</a>, why shouldn’t all foreign doctors be required to demonstrate this before being licensed? </p>
<p>With so many foreign-trained doctors in New Zealand unable to work, even after passing their licensing exams, we argue the problem is less about brain drains or brain gains. Rather, it reflects a “brain waste” for both the doctors themselves and for Aotearoa New Zealand, as Omicron threatens to stretch a system already in crisis.</p><img src="https://counter.theconversation.com/content/175914/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Sharon McLennan received funding from the Royal Society of New Zealand's Marsden Fund.</span></em></p><p class="fine-print"><em><span>Johanna Thomas-Maude does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The pathway for foreign doctors to practise in New Zealand is neither easy nor very fair, meaning an over-stretched health system is missing out on valuable expertise.Johanna Thomas-Maude, PhD Candidate, Massey UniversitySharon McLennan, Senior Lecturer in Development Studies, Massey UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1246382019-11-11T19:01:05Z2019-11-11T19:01:05ZDodgy treatment: it’s not us, it’s the other lot, say the experts. So who do we believe?<figure><img src="https://images.theconversation.com/files/296329/original/file-20191010-188797-1wp5mk4.jpg?ixlib=rb-1.1.0&rect=1%2C4%2C997%2C661&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Will my surgery work? Well, it depends on who you ask.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/concentrated-surgical-team-operating-patient-operation-1265400856?src=m2MZzzAzKRA2Zx3XNqfTmw-1-3">from www.shutterstock.com</a></span></figcaption></figure><p>Patients might not be getting the best advice about which treatments do or don’t work, according to our study published today. We found professional societies are more likely to call out other health professionals for providing low-value treatments rather than look in their own backyard.</p>
<p>Our study in <a href="https://doi.org/10.1186/s12913-019-4576-1">BMC Health Services Research</a> looked into recommendations under the global <a href="https://www.choosingwisely.org/">Choosing Wisely</a> public health campaign. We found professional societies are reluctant to publish recommendations against treatments and procedures that generate income for their members. </p>
<p>But they are much more comfortable at recommending against treatments that generate income for members of other professional societies.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/less-is-the-new-more-choosing-medical-tests-and-treatments-wisely-40756">Less is the new more: choosing medical tests and treatments wisely</a>
</strong>
</em>
</p>
<hr>
<h2>How does the Choosing Wisely campaign work?</h2>
<p>Choosing Wisely aims to reduce the use of medical tests, treatments and procedures that provide little-to-no benefit, or in some cases can harm.</p>
<p>It then recommends patients question their doctors about whether these so-called low-value tests, treatments or procedures are necessary.</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1171566184073854976"}"></div></p>
<p>To take part in the Choosing Wisely campaign, professional societies publish recommendations relevant to their members.</p>
<p>For example, a surgical society could list a surgical procedure of questionable effectiveness. A physiotherapy society could also list a poorly justified physiotherapy treatment. This ensures recommendations raise awareness of low-value care among the practitioners most likely to provide this care.</p>
<p>However, an <a href="https://www.nejm.org/doi/full/10.1056/NEJMp1314965">ongoing</a> <a href="https://www.bmj.com/content/351/bmj.h6760">concern</a> is whether professional societies focus on low-value care provided by their members or whether they tend to make recommendations for care provided by others, outside their own society.</p>
<p>Many low-value tests, treatments and procedures also generate substantial income for the practitioner who provides them. So societies might be reluctant to recommend against or “call out” these examples of low-value care because of fear of affecting their members’ bottom line.</p>
<h2>What did we do?</h2>
<p>To investigate these concerns, we evaluated all Choosing Wisely recommendations worldwide since the campaign began in 2012.</p>
<p>We reviewed 1,293 recommendations from eight countries, including Australia, to investigate the proportion of recommendations that target income-generating treatments. We also investigated whether recommendations on income-generating treatments were more likely to come from societies involved, or not involved, in providing this care.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/needless-treatments-spinal-fusion-surgery-for-lower-back-pain-is-costly-and-theres-little-evidence-itll-work-91829">Needless treatments: spinal fusion surgery for lower back pain is costly and there's little evidence it'll work</a>
</strong>
</em>
</p>
<hr>
<p>Treatments or procedures that attract a fee-for-service and are performed outside a routine encounter with a practitioner were considered income-generating for the practitioner performing the treatment. Examples included arthroscopic surgery of the knee and shoulder, cesarean section, removing a breast lump and radiotherapy.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/296334/original/file-20191010-188797-7ohdv6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/296334/original/file-20191010-188797-7ohdv6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/296334/original/file-20191010-188797-7ohdv6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/296334/original/file-20191010-188797-7ohdv6.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/296334/original/file-20191010-188797-7ohdv6.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/296334/original/file-20191010-188797-7ohdv6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/296334/original/file-20191010-188797-7ohdv6.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/296334/original/file-20191010-188797-7ohdv6.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Radiotherapy was one of the treatments counted as income-generating, as part of our study.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/woman-receiving-radiation-therapy-treatments-breast-1097370944?src=J77SkxBy3P-8gXMxgs35Hg-1-0">from www.shutterstock.com</a></span>
</figcaption>
</figure>
<p>We then examined each recommendation and determined whether the society making the recommendation was targeting a treatment routinely provided by members of their society or members of another society. </p>
<p>There were over 230 professional societies with Choosing Wisely recommendations across medicine, surgery, diagnostic testing and allied health. Examples of professional societies from Australia included the: <a href="https://www.racgp.org.au/">Royal Australian College of General Practitioners</a>; <a href="https://www.surgeons.org/">Royal Australasian College of Surgeons</a>; <a href="https://australian.physio/">Australian Physiotherapy Association</a>; and <a href="https://www.rcpa.edu.au/">Royal College of Pathologists of Australasia</a>.</p>
<h2>Here’s what we found</h2>
<p>Overall, we found only 20% of Choosing Wisely recommendations target income-generating treatments. But more importantly, of these recommendations, most target treatments provided by practitioners that are not members of the society making the recommendation.</p>
<p>For example, the <a href="https://rheumatology.org.au/">Australian Rheumatology Association</a> <a href="http://www.choosingwisely.org.au/recommendations/ara">recommends against</a> arthroscopy for knee osteoarthritis, a surgical intervention that rheumatologists don’t perform (this is generally carried out by orthopaedic surgeons):</p>
<blockquote>
<p>Do not perform arthroscopy with lavage and/or debridement or partial meniscectomy for patients with symptomatic osteoarthritis of the knee and/or degenerate meniscal tear.</p>
</blockquote>
<p>Meanwhile, the <a href="https://www.aaos.org/Default.aspx?ssopc=1">American Academy of Orthopaedic Surgeons</a>, whose members perform arthroscopy, doesn’t recommend against the procedure. Instead, it <a href="https://www.choosingwisely.org/societies/american-academy-of-orthopaedic-surgeons/">points the finger</a> at clinicians who routinely provide insoles:</p>
<blockquote>
<p>Don’t use lateral wedge insoles to treat patients with symptomatic medial compartment osteoarthritis of the knee.</p>
</blockquote>
<h2>Why does it matter?</h2>
<p>Choosing Wisely aims to reduce waste in health care. But when societies mainly look for waste in fields other than their own, their recommendations are likely to have less impact. </p>
<p>To illustrate this, eight societies of orthopaedic surgeons have collectively published 48 Choosing Wisely recommendations. But only nine of these recommendations target low-value surgery routinely performed by orthopaedic surgeons. Most of these are from the <a href="https://www.orthopeden.org/">Netherlands Orthopaedic Association</a> (five out of nine recommendations).</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/antibiotics-for-colds-x-rays-for-bronchitis-internal-exams-with-pap-tests-the-latest-list-of-tests-to-question-56007">Antibiotics for colds, x-rays for bronchitis, internal exams with pap tests – the latest list of tests to question</a>
</strong>
</em>
</p>
<hr>
<p>By shying away from publishing recommendations that target ineffective and expensive interventions performed by their own members, professional societies are not acting in line with the spirit of the campaign. </p>
<p>Choosing Wisely could have a large impact on redirecting health-care spending from low-value care to recommended care, thereby improving the lives of millions. But for the campaign to realise its potential, ensuring future recommendations focus on the care provided by members of the society making the recommendation is a good place to start.</p>
<hr>
<p><em>Dr John Farey, a surgical registrar affiliated with the Institute for Musculoskeletal Health and the Sydney Local Health District, co-authored this article.</em></p><img src="https://counter.theconversation.com/content/124638/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Professional societies of doctors, surgeons or physiotherapists are more likely to recommend against treatments provided by others, our new research shows.Joshua Zadro, Postdoctoral Research Fellow, University of SydneyChristopher Maher, Professor, Sydney School of Public Health, University of SydneyIan Harris, Professor of Orthopaedic Surgery, UNSW SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1009482018-08-02T04:16:32Z2018-08-02T04:16:32ZDoctors’ fees shouldn’t just be transparent, they should be fair and reasonable<figure><img src="https://images.theconversation.com/files/230349/original/file-20180802-136655-yr7zxw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">High fees are prohibitive for many people who need to see a specialist.</span> <span class="attribution"><span class="source">From shutterstock.com</span></span></figcaption></figure><p>Out-of-pocket costs is a hot-button issue. It is on the agenda for a health ministers’ meeting this week, where the Victorian health minister will <a href="http://www.abc.net.au/news/2018-08-02/vic-medical-bill-shock-first-appointment-transparent-coag/10062418">push the Commonwealth</a> for more transparency about doctors’ fees. </p>
<p>The Medical Board of Australia is also finalising consultations on its <a href="http://www.medicalboard.gov.au/News/Current-Consultations.aspx">draft Code of Conduct</a> for doctors this week, which also emphasises that fees should be transparent. </p>
<p>Of course fees should be transparent, but that’s not good enough. Doctors, and especially specialists, should also be required to set fees that are “fair and reasonable”.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/specialists-are-free-to-set-their-fees-but-there-are-ways-to-ensure-patients-dont-get-ripped-off-97372">Specialists are free to set their fees, but there are ways to ensure patients don't get ripped off</a>
</strong>
</em>
</p>
<hr>
<p>From <a href="http://health.gov.au/internet/main/publishing.nsf/Content/Quarterly-Medicare-Statistics">January to March</a>, only 30.8% of visits to specialists were bulk-billed, and the average out-of-pocket costs for those not bulk-billed was A$87.62 for each visit. </p>
<p>The visit to the specialist may lead to further costs such as diagnostic imaging (such as X-rays, ultrasounds and <a href="https://theconversation.com/the-science-of-medical-imaging-magnetic-resonance-imaging-mri-15030">MRI scans</a>), where 78.2% of services are bulk-billed and the average out-of-pocket is A$104.56. The alternative to these high charges is referral to a public hospital outpatient clinic, but the <a href="https://theconversation.com/getting-an-initial-specialists-appointment-is-the-hidden-waitlist-99507">wait between a referral and an appointment</a> can be very long indeed. </p>
<p>The <a href="http://www.abs.gov.au/ausstats/abs@.nsf/mf/4839.0">Australian Bureau of Statistics</a> estimated that in 2016-17 about 815,000 people missed out on seeing a specialist because of cost. That amounts to one out of every 14 people who needed to see a specialist. </p>
<p>Unlike other aspects of health disadvantage, people in metropolitan areas report higher rates of skipping specialist consultation:</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/230348/original/file-20180802-136655-l3laog.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/230348/original/file-20180802-136655-l3laog.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/230348/original/file-20180802-136655-l3laog.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/230348/original/file-20180802-136655-l3laog.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/230348/original/file-20180802-136655-l3laog.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/230348/original/file-20180802-136655-l3laog.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/230348/original/file-20180802-136655-l3laog.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/230348/original/file-20180802-136655-l3laog.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption"></span>
</figcaption>
</figure>
<p>What are doctors’ ethical obligations when it comes to fee-charging? The draft Code says doctors should:</p>
<ul>
<li><p>ensure that your patients are informed about your fees and charges </p></li>
<li><p>be transparent in financial and commercial matters.</p></li>
</ul>
<p>But, as I argue in a <a href="https://grattan.edu.au/news/good-medical-practice-needs-to-be-founded-on-patients-rights/">Grattan Institute submission to the Medical Board</a>, this is too weak. The medical profession in Australia is out of step with consumer expectations, and with practices in other professions. </p>
<p>The legal profession, for example, has a statutory obligation to charge “<a href="http://www5.austlii.edu.au/au/legis/nsw/consol_act/lpul333/s172.html">costs that are no more than fair and reasonable in all the circumstances</a>”. The Legal Profession Uniform Law in NSW also sets out factors which may affect fees, such as “the quality of the work done” and the “level of skill, experience, specialisation and seniority” of the lawyers involved.</p>
<p>Fees charged by medical practitioners, especially specialists, have recently been the subject of media criticism, notably by medical journalist <a href="http://www.abc.net.au/news/health/2018-05-28/how-out-of-pocket-medical-costs-can-get-out-of-control/9592792">Dr Norman Swan on ABC TV’s Four Corners</a>. So they should be. </p>
<p><a href="https://onlinelibrary.wiley.com/doi/full/10.1002/hec.3317">Academic studies</a> have also shown that specialist fees – especially surgeons’ fees – vary wildly.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/why-it-costs-you-so-much-to-see-a-specialist-and-what-the-government-should-do-about-it-81998">Why it costs you so much to see a specialist – and what the government should do about it</a>
</strong>
</em>
</p>
<hr>
<p><a href="https://www.theguardian.com/australia-news/2018/jan/03/greg-hunt-to-investigate-exorbitant-out-of-pocket-medical-expenses">Policy responses</a> have been based on the assumption that the problem is confined to a small number of specialists charging egregious fees. </p>
<p>If this were the case, it could be argued that these doctors were operating outside professional norms. But the evidence shows it’s not unusual for fees to be <a href="https://www.mja.com.au/journal/2017/206/4/variation-outpatient-consultant-physician-fees-australia-specialty-and-state-and">significantly in excess</a> of even the Australian Medical Association (AMA) rate. The AMA rate is significantly above the Medicare rebate but is often regarded by medical practitioners as the appropriate fee to charge.</p>
<p>This can be an acute problem for some of the most vulnerable Australians: patients with several chronic diseases – such as diabetes, heart disease and depression – who are excessively billed by each of their medical practitioners several times a year.</p>
<p>Under the draft Code of Conduct, these doctors could not be seen as acting unprofessionally if they had simply informed their patients of the proposed fees. </p>
<p>Doctors, especially specialists, have a lot of power in these circumstances. Patients are often reluctant to shop around for a different specialist, if they have been referred to a specific specialist and have initiated contact with that specialist.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/230350/original/file-20180802-136661-1jm9tip.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/230350/original/file-20180802-136661-1jm9tip.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/230350/original/file-20180802-136661-1jm9tip.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/230350/original/file-20180802-136661-1jm9tip.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/230350/original/file-20180802-136661-1jm9tip.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/230350/original/file-20180802-136661-1jm9tip.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/230350/original/file-20180802-136661-1jm9tip.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Diagnostic imaging, such as a CT scan, is a further cost that often follows specialist fees.</span>
<span class="attribution"><span class="source">From shutterstock.com</span></span>
</figcaption>
</figure>
<p>An obligation to be transparent is a necessary but not sufficient ethical obligation for contemporary medical practice. The draft Code says doctors should</p>
<blockquote>
<p>not exploit patients’ vulnerability or lack of medical knowledge when providing or recommending treatment or services</p>
</blockquote>
<p>But an obligation to not exploit patients’ vulnerability is not enough. The Code should be expanded to include a specific obligation on doctors to set fair fees.</p>
<p>This is not to dismiss the transparency obligation as irrelevant. Rather, the Code needs to supplement an obligation to disclose fees (transparency) with an obligation not to exploit patients financially.</p>
<h2>Better transparency provisions</h2>
<p>The existing transparency obligation should also be tightened. Too often, patients do not learn of the proposed fees until their initial visit to a specialist. </p>
<p>Patients may be able to discover the out-of-pocket costs associated with the initial consultation when making the booking, but probably not the out-of-pockets for any procedures which might be recommended. By then, the patient may not be able to assess properly whether they want to continue with this specialist.</p>
<p>And in some situations – particularly with anaesthetists – the fee discussion can take place at the time of an operation or procedure, leaving the patient with no effective choice at all.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/how-much-seeing-private-specialists-often-costs-more-than-you-bargained-for-53445">How much?! Seeing private specialists often costs more than you bargained for</a>
</strong>
</em>
</p>
<hr>
<p>It is therefore important that the transparency of fees is timely. Indicative fees for procedures could be revealed on specialists’ websites, for example, so that patients (and their general practitioners) could make informed decisions before committing to their first consultation.</p>
<p>The Medical Board should tighten its Code of Conduct for doctors. If it doesn’t, too many Australian patients will continue to pay unfair, even exorbitant, fees.</p><img src="https://counter.theconversation.com/content/100948/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Grattan Institute began with contributions to its endowment of $15 million from each of the Federal and Victorian Governments, $4 million from BHP Billiton, and $1 million from NAB. In order to safeguard its independence, Grattan Institute’s board controls this endowment. The funds are invested and contribute to funding Grattan Institute's activities. Grattan Institute also receives funding from corporates, foundations, and individuals to support its general activities as disclosed on its website.</span></em></p>Yes, doctors’ fees should be transparent, but that requirement alone doesn’t go far enough to combat “bill shock”. Specialists should also be required to set fees that are “fair and reasonable”.Stephen Duckett, Director, Health Program, Grattan InstituteLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/866302017-11-01T23:34:21Z2017-11-01T23:34:21ZFinancial motives drive some doctors’ decisions to offer IVF<figure><img src="https://images.theconversation.com/files/192796/original/file-20171101-19900-1gbptma.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Patients must be able to make informed decisions about whether to pursue IVF – and when to stop.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/download/success?src=gW-4sbvJQ3VY77Y8lOtoOQ-1-15">posteriori/Shutterstock</a></span></figcaption></figure><p>Around <a href="https://npesu.unsw.edu.au/surveillance/assisted-reproductive-technology-australia-and-new-zealand-2015">one in 25 Australian babies</a> are conceived using assisted reproductive technologies (ART), including in-vitro fertilisation (IVF). These interventions are almost all offered in private fertility clinics, backed by a <a href="http://www.afr.com/business/all-eyes-on-500m-monash-ivf-float-expansion-plans-20140523-iupi2">thriving fertility industry</a>. </p>
<p>Women who are deemed eligible for IVF can have an unlimited number of cycles subsidised by Medicare, but out-of–pocket <a href="https://www.mamamia.com.au/how-much-does-fertility-treatment-cost-in-australia/">costs can range</a> from several hundred to <a href="https://www.ivf.com.au/ivf-fees/ivf-costs">several thousand dollars</a> per cycle. </p>
<p>Our research, published today in the journal <a href="http://www.tandfonline.com/doi/full/10.1080/14647273.2017.1390266">Human Fertility</a>, suggests the money being made from IVF could be subtly changing the advice doctors give.</p>
<h2>Informed consent</h2>
<p>Although IVF is a well-established procedure, it is not without its <a href="https://www.mayoclinic.org/tests-procedures/in-vitro-fertilization/details/risks/cmc-20207080">risks</a>. These include <a href="https://www.betterhealth.vic.gov.au/health/conditionsandtreatments/in-vitro-fertilisation-ivf">ovarian hyperstimulation syndrome</a>, where hormone levels rise too much (causing abdominal swelling, nausea, vomiting and diarrhoea); obstetric complications such as premature delivery; and psychological distress, especially if the process fails. </p>
<p>Although long-term outcomes for children conceived using IVF appear to be similar to non-IVF children, <a href="http://pediatrics.aappublications.org/content/early/2016/02/02/peds.2015-4509..info">questions remain</a> about possible harmful impacts, including developmental abnormalities and cancer. </p>
<p>Given the financial, physical and psychological burdens of IVF, patients must be able to make informed decisions about whether to pursue these treatments in the first place, and when to stop. So it’s concerning that couples are often <a href="http://www.abc.net.au/radionational/programs/healthreport/fertility-clinic-data-kept-from-public,-costing-government/6459674">oversold the likelihood of success</a>. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/five-traps-to-be-aware-of-when-reading-success-rates-on-ivf-clinic-websites-68806">Five traps to be aware of when reading success rates on IVF clinic websites</a>
</strong>
</em>
</p>
<hr>
<p>This “overselling” may be a result of <a href="https://www.mja.com.au/journal/2017/207/3/assisted-reproductive-technology-australia-and-new-zealand-cumulative-live-birth">the way information about “success rates” is conveyed</a>. A 30 year-old woman has a 40% chance of a live birth after a single complete IVF cycle (so, after all viable embryos have been transferred). A 40 year-old woman, in contrast, may have a 10% chance of a live birth following a complete IVF cycle.</p>
<p>The same 30 year-old might have a 70% chance after six complete cycles, while the 40 year-old might only have a 25% chance. </p>
<p>Success rates of IVF may appear deceptively higher if success is defined as clinical pregnancy (of just six to eight weeks), or live birth at a stage that is generally incompatible with sustained life (as early as 20 weeks or 400 grams). </p>
<p>Alternatively, rates may appear lower if they are reported per embryo transfer rather than per complete cycle.</p>
<h2>Commercialising IVF</h2>
<p>In 2014, two <a href="http://www.smh.com.au/business/markets/monash-ivf-makes-solid-asx-debut-20140626-zsmjz.html">major players</a> in the ART industry were <a href="http://www.smh.com.au/business/investors-jump-into-virtus-float-20130611-2o1a8.html">floated on the stock exchange</a> for more than A$300 million each. This reportedly <a href="http://www.smh.com.au/business/investors-jump-into-virtus-float-20130611-2o1a8.html">boosted some fertility specialsits’ annual salaries</a> to more than A$1 million. But what about the effect of commercialisation on patients and taxpayers?</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/audio-qanda-the-business-of-ivf-28272">AUDIO Q&A: The business of IVF</a>
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</em>
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<hr>
<p>To investigate this question, we conducted in-depth interviews with a range of professionals involved with ART in Australia, including obstetricians, policy advisors, researchers and counsellors. </p>
<p>Interviewees said financial motives were influencing ART practices in Australia, with some women offered IVF who don’t actually need it. Others are offered repeated cycles of treatment, even when they aren’t likely to succeed.</p>
<p>This dynamic was seen to be facilitated by the current Medicare system. The safety net protects patients by limiting the amount they have to pay out-of-pocket once they reach a certain threshold. </p>
<p>But it can also potentially encourage over-servicing and over-charging. There is no cap on the number of procedures that can be offered or the fees that can be charged. Doctors can therefore offer additional services for higher fees without patients incurring significant additional costs. This has serious implications for the health system. </p>
<p>As one of the people interviewed in the study observed:</p>
<blockquote>
<p>I just think the business model and the fact that it takes advantage of Medicare, and the fact that the Medicare safety net helps spread the risk of out-of-pockets from the patient to the taxpayer is just basically being used to make some people a lot of money.</p>
</blockquote>
<p>Importantly, nobody who was interviewed suggested that ART clinicians were deliberately misleading patients for their own financial benefit. The problem identified was subtler and reflects a deep ambivalence at the heart of medicine. </p>
<p>On the one hand, doctors are expected to be committed to their patients, research participants or the general public, and not concerned primarily with their own enrichment. On the other hand, doctors need to earn a living and, in Australia at least, do so in a health system that supports – and even depends upon – publicly subsidised private practice. </p>
<p>There is no reason these interests are incompatible but their co-existence raises questions about how commercial interests may influence practice. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/dont-dismiss-conflict-of-interest-concerns-in-ivf-they-have-a-basis-60246">Don't dismiss conflict-of-interest concerns in IVF, they have a basis</a>
</strong>
</em>
</p>
<hr>
<p>The commercialisation of ART raises questions not only about the motives and behaviour of clinicians, but also about how those seeking ART services should be viewed. They could be seen as patients who are potentially highly vulnerable and to whom clinicians have a duty of care requiring them to play an active role in guiding patients in their health care choices even if this means that some interventions are strongly discouraged.</p>
<p>Or they could be viewed as consumers free to choose whatever interventions they want in a health care marketplace, no matter how much they cost or how unlikely they are to succeed. This idea is, of course, predicated on the assumption that consumers will be provided with accurate information about risks, costs and benefits which, as many others have noted, cannot be assumed.</p>
<p>Although the <a href="http://www.tandfonline.com/doi/full/10.1080/14647273.2017.1390266">Human Fertility</a> study was small and does not represent the views of all professionals involved with ART in Australia, it reveals that concerns about the impact of commercial interests in ART have not simply been drummed up by the media for dramatic effect. It is time for an honest discussion about the Australian fertility industry, and about the role of money in medicine more generally.</p><img src="https://counter.theconversation.com/content/86630/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Wendy Lipworth receives funding from the National Health & Medical Research Council (NHMRC) and Australian Research Council (ARC)</span></em></p><p class="fine-print"><em><span>For this project, Brette Blakely received funding from the NHMRC. </span></em></p><p class="fine-print"><em><span>Ian Kerridge has received ARC research grant funding for research into oocyte donation. He was also a member of the NHMRC Working Party that developed the NHMRC Ethics Guidelines on the Use of Assisted Reproductive Technology in clinical practice and research (2017). </span></em></p>Some patients might be offered IVF who don’t actually need it, and some might be offered repeated cycles of treatment, even when they aren’t likely to succeed.Wendy Lipworth, Senior Research Fellow, Bioethics, University of SydneyBrette Blakely, Post-Doctoral Research Fellow, Macquarie UniversityIan Kerridge, Professor of Bioethics & Medicine, Sydney Health Ethics, University of SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/408272015-05-06T04:14:38Z2015-05-06T04:14:38ZWant to reform Medicare? Target specialist services, not primary care<figure><img src="https://images.theconversation.com/files/80403/original/image-20150505-8376-y86el5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">GP attendances make up just one-third of Medicare expenditure.</span> <span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-94624057/stock-photo-doctor-inspecting-muslim-baby-boy-tongue-for-viral-infection.html?src=v5Gl3ZyZq180_rvdktLPWA-7-37">Ezz Mika Elya/Shutterstock</a></span></figcaption></figure><p>The government’s latest attempt at Medicare reform is a review of Medicare-funded items. The aim is to improve and modernise clinical practice by de-funding <a href="https://www.mja.com.au/journal/2012/197/10/over-150-potentially-low-value-health-care-practices-australian-study?0=ip_login_no_cache%3D9f5d5d19ea3ec3101135c1eb8c310c2f">low-value and ineffective health services</a>. Savings will go to fund the promised <a href="http://www.news.com.au/national/medical-research-future-fund-cure-for-cancer-delayed/story-fncynjr2-1227329143739">medical research future fund</a>. </p>
<p>But it <a href="http://www.abc.net.au/am/content/2015/s4221124.htm">seems likely</a> the Coalition is also motivated by a long-term imperative to <a href="http://www.smh.com.au/federal-politics/political-news/australia-running-out-of-money-for-medicare-hockey-20140221-335j0.html">constrain Medicare spending growth</a>.</p>
<p>A policy that has already been enacted is the <a href="http://amavic.com.au/icms_docs/187873_Freeze_on_Medicare_rebates.pdf">Medicare rebate freeze</a>, which was introduced in 2013 and extended by the government last year for a further two years. The freeze is a real-terms cut that grows over time as costs rise and rebates don’t keep up. It is a very crude policy measure, treating all Medicare items as equally deserving of cuts. </p>
<p>However, some rebate cuts and freezes will have more of an impact on patients than others. We therefore need to look closely at the components of Medicare spending to inform more targeted savings measures. </p>
<p>Medicare Benefits Schedule (MBS) spending has a range of small categories but is broadly divided into four main parts: </p>
<ul>
<li>GP attendances (A$6.4bn, 33%)</li>
<li>pathology and diagnostic imaging (A$5.5bn, 28%)</li>
<li>in-hospital specialist procedures (A$3.7bn, 19%)</li>
<li>out-of-hospital specialists services (A$2.4bn, 12%). </li>
</ul>
<p>Cutting rebates for GP services (including the current rebate freeze) will hit all Australian patients, including those on low incomes and in the worst health. Bulk-billing rates will surely fall (although there is <a href="https://theconversation.com/how-likely-are-doctors-to-charge-more-due-to-the-rebate-freeze-38375">no evidence of this as yet</a>) and out-of-pocket payments will increase.</p>
<p>In contrast, other areas of the MBS do not benefit everybody equally and in fact tend to favour the better off. </p>
<p>Take the A$3.7bn spent on in-hospital specialist services as an example. This area of Medicare spending goes towards subsidising treatment of private patients, mainly in private hospitals. As such, this spending does not benefit us all but overwhelmingly the <a href="http://phiac.gov.au/wp-content/uploads/2013/05/Qtr-Stats-Mar13.pdf">47%</a> of Australians with private health insurance. Public patients are funded through a different funding channel via the state government budgets.</p>
<p>To explore this point further we can use Medicare data to explore the contrasts in private health insurance coverage and Medicare spending in different small areas of the country using data from the <a href="http://www.adelaide.edu.au/phidu/data-archive/sha-aust/2008-2014/phidu_data_2014_ml_aust.xls">Public Health Information Development Unit</a>.</p>
<p>The affluent Inner-East Melbourne Medicare Local, for instance, has one of the highest rates of private health insurance coverage at 63% and attracts A$135 million in Medicare spending on in-hospital specialist procedures, 26% of its total Medicare spending. </p>
<p>In contrast, just a few kilometres away in the less affluent South-East Melbourne Medicare Local, there is below-average private health insurance coverage of 38%. This lower-coverage area attracts only 9% of its Medicare spending, A$32 million, on in-hospital specialist procedures. </p>
<p>For anybody who knows Melbourne suburbs, this is a part of the Medicare budget that benefits well-off Camberwell and Kew more than lower-socioeconomic Cranbourne and Dandenong. This pattern is repeated across the data; wealthy areas with high levels of health insurance coverage have larger amounts of Medicare spending on in-hospital specialist procedures.</p>
<p>So cutting MBS rebates for in-hospital specialist procedures could be preferred to cutting GP rebates on equity grounds, but there could be efficiency reasons too. We know that <a href="http://health.gov.au/internet/main/publishing.nsf/Content/1A9DB6D72BD5879ACA257BF0001AFE28/$File/Copy%20of%20MBS%20Statistics%2020144%20DecQtr%2020150120.pdf">more than 80% of GP services are bulk-billed</a>, as opposed to around 40% for in-hospital specialist services. </p>
<p>One reason is that GPs operate in relatively competitive markets, in metropolitan areas at least, and can only make small profit margins. Rebate cuts are therefore very likely to lead to GPs being forced to charge higher co-payments to more of their patients, leading to higher out-of-pocket fees for everybody.</p>
<p>In contrast, the market for in-hospital private specialist care seems much less competitive. Patients are often uninformed about the final price of their treatment in hospitals and are usually allocated to doctors on the recommendation of a GP, or through default if an emergency admission. This removes the market incentive for specialists to keep their prices low to attract patients.</p>
<p>Another complication is health insurance. Private health insurance usually covers some or all of the gap between the Medicare rebate and the price specialist charge. This also removes the incentive to keep prices low.</p>
<p>Overall, it’s reasonable to assert that the market for in-hospital specialist procedures is less “competitive” than for GP services. Economic theory tells us that in this situation, when their subsidy is reduced through a cut in the rebate, specialists will increase their prices by less than GPs.</p>
<p>While the Medicare review should consider many strategies for an efficient reform of the system including the <a href="https://theconversation.com/medicare-review-must-deal-with-elephant-in-the-room-incentives-40819">role of incentives</a> and a <a href="https://www.mja.com.au/journal/2012/197/10/over-150-potentially-low-value-health-care-practices-australian-study?0=ip_login_no_cache%3D9f5d5d19ea3ec3101135c1eb8c310c2f">culling of ineffective treatments</a>, the big differences in equity and efficiency across the categories of Medicare spending should be of paramount importance. </p>
<p>Medicare’s dual roles in funding universal primary care and in subsidising private patients in secondary care are not of equal benefit. The latter should shoulder the burden of cuts more than the former.</p>
<p><em>* Medicare spending figures quoted in this article come from the Department of Human Services Medicare Australia Statistics <a href="http://medicarestatistics.humanservices.gov.au/statistics/mbs_group.jsp">website’s</a> 2013/14 financial year data.</em></p><img src="https://counter.theconversation.com/content/40827/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Peter Sivey currently receives funding from the Australian Research Council and has previously been funded by the National Health and Medical Research Council and Health Workforce Australia.</span></em></p>Cutting Medicare rebates for GPs affects us all, whereas in-hospital private patient rebates, which only benefit the better-off, are ripe for the razor gang.Peter Sivey, Senior Lecturer, Department of Economics and Finance, La Trobe UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/371112015-02-15T19:34:51Z2015-02-15T19:34:51ZFor real health reform, turn the spotlight on specialists’ fees<figure><img src="https://images.theconversation.com/files/71939/original/image-20150213-13215-1mnh5o4.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">We need more transparency around specialist charges so referring GPs and patients can make informed decisions.</span> <span class="attribution"><a class="source" href="https://www.flickr.com/photos/theenmoy/9209914881">Theen Moy/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by-nc-nd/4.0/">CC BY-NC-ND</a></span></figcaption></figure><p>The impact of specialist fees on government and patient budgets has received little reform attention. This is despite the government’s push for controls in health-care spending and <a href="http://www.aph.gov.au/Parliamentary_Business/Committees/Senate/Community_Affairs/Australian_healthcare/Report">growing evidence</a> of the affordability problems faced by sick Australians. </p>
<p>A high-quality specialist sector is an essential component of an effective health-care system; patients rely on specialist doctors when they are sickest and most vulnerable. And when their treatment inevitably involves expensive treatment options. But specialist care in the community is increasingly hard for many Australians to access, due to geography and cost.</p>
<p>In 2011-12, the number of people who <a href="http://www.nhpa.gov.au/internet/nhpa/publishing.nsf/Content/Report-Download-Healthy-Communities-Australians-experiences-with-access-to-health-care-in-2011%E2%80%9312/$FILE/NHPA_HC_Report_Patient_Exp_June_2013.pdf">reported</a> seeing a medical specialist in the preceding year varied nearly two-fold across Medicare Local populations nationally, from 22% to 42%. But there was no strong association between health status and seeing a specialist. And up to 14% of people <a href="http://www.nhpa.gov.au/internet/nhpa/publishing.nsf/Content/Report-Download-Healthy-Communities-Australians-experiences-with-access-to-health-care-in-2011%E2%80%9312/$FILE/NHPA_HC_Report_Patient_Exp_June_2013.pdf">reported</a> they had delayed seeing a specialist because of cost.</p>
<h2>Keeping track</h2>
<p>Many specialists work in both community and hospital settings, sometimes in both public and private hospitals. In private practice, they bill Medicare on a fee-for-service basis. They also negotiate with private health insurance funds to deliver no-gap or known-gap services to privately insured patients. </p>
<p>All this means that tracking specialists’ fees, practice costs, their time and how it’s integrated with that of the doctors-in-training they oversee, their reimbursements from Medicare and private health insurance, and the quality and outcomes from their services is just about impossible. </p>
<p><a href="http://www.medicareaustralia.gov.au/provider/medicare/mbs.jsp">Medicare Australia</a> provides some data on specialist services, with specific data for obstetrics, anaesthesiology, operations and assistance at operations. But this is data developed solely for administrative and reimbursement mechanisms. Out-of-pocket costs, once provided, are no longer included. </p>
<p>Theoretically, it’s possible to request linked Medicare data for analysis; in practice it’s expensive and time-consuming. There appears to be little interest from the federal bureaucracy in understanding what’s happening in this section and why.</p>
<h2>A suitable guide</h2>
<p>In 1969, the Gorton government introduced the notion of “<a href="http://www.aams.org.au/contents.php?subdir=library/history/funding_prof_med_au/&filename=index">the most common fee</a>” – a list based on the fees most commonly charged for over 1,000 medical services. This forerunner of the scheduled fee list was to serve as a guide for health insurance. And each benefit was set so the amount charged to patients should not exceed A$5 (A$1.20 for GP visits).</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/71943/original/image-20150213-13186-lrls0j.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/71943/original/image-20150213-13186-lrls0j.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/71943/original/image-20150213-13186-lrls0j.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/71943/original/image-20150213-13186-lrls0j.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/71943/original/image-20150213-13186-lrls0j.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/71943/original/image-20150213-13186-lrls0j.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/71943/original/image-20150213-13186-lrls0j.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Many specialists work in both community and hospital settings.</span>
<span class="attribution"><a class="source" href="https://www.flickr.com/photos/proimos/6870109454">Alex Proimos/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by-nc/4.0/">CC BY-NC</a></span>
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<p>It’s here the origins of higher pay for specialists over general practitioners, and for procedures over consultations, are found.</p>
<p>Under Medicare, the schedule fees for new and updated items are set by a tripartite tribunal comprising representatives from government, the profession and the community. But there’s never been a legal obligation on doctors to charge the set fee. And the <a href="https://ama.com.au/media/ama-speech-ama-president-aprof-brian-owler-private-healthcare-australia%20">Australian Medical Association</a> has maintained the right of doctors to set their own fees, taking account of their practice costs and earning a living that’s commensurate with their years of training. </p>
<p>The consequences have been predictable and inevitable. And they’ve been made worse by the failure of successive governments to update and modernise the fee schedule, and to index fees appropriately. </p>
<h2>Free for all</h2>
<p>As far back as 1971 the <a href="http://www.aams.org.au/contents.php?subdir=library/history/funding_prof_med_au/&filename=indexhttp://example.com/">media were reporting</a>:</p>
<blockquote>
<p>particularly in wealthier areas, fewer than a third of doctors are still charging the most common fee… Patients are again being forced to pay what the traffic will bear. </p>
</blockquote>
<p>The constraint the Medicare Benefit Schedule (admittedly not always successfully) once imposed on specialists’ fees has long disappeared; even the more generous AMA fee schedule, which is indexed annually, is ignored by many. The Royal Australasian College of Surgeons <a href="http://newsstore.smh.com.au/apps/viewDocument.ac;jsessionid=4A86E295F9327675DFC1F79EB2C1C59C?sy=afr&pb=all_ffx&dt=selectRange&dr=1month&so=relevance&sf=text&sf=headline&rc=10&rm=200&sp=brs&cls=631&clsPage=1&docID=AGE1501242DL9N6KI89Q">acknowledges</a> some specialists charge as much as ten times the recommended fee. </p>
<p>Unlike general practice, specialists receive no incentives to bulk bill even the most needy of their patients. The result is that bulk billing rates are extremely low (around 27% of specialist services are bulk billed) and patients are paying increasingly large out-of-pocket sums. </p>
<p>In <a href="http://www.smh.com.au/national/health/bulkbill-increase-has-come-at-a-cost-20120523-1z5m0.html">2012</a>, the average out-of-pocket cost to see a specialist was A$58.20, but this hides a huge variation in cost by both speciality and geography. About <a href="http://www.smh.com.au/national/health/bulkbill-increase-has-come-at-a-cost-20120523-1z5m0.html">41% of obstetrics services</a> are bulked bill, for instance, but the average out-of-pocket cost is A$218. </p>
<h2>Not getting better</h2>
<p>The <a href="http://www.heraldsun.com.au/news/national/medicare-rebate-only-16-per-cent-of-amas-recommended-hospital-fee/story-fndo48ca-1226537468794?nk=62c97bde142c6ced2139dacfb1913545">Medicare rebate now covers</a> as little as 16% of the AMA-recommended fee for some common private hospital procedures. Patients with gap cover for specialist Medicare services delivered in private hospitals are largely protected thanks to the generosity of private health insurance fee schedules and the industry’s negotiating power. </p>
<p>But the amount the doctor receives varies tremendously depending on the private health insurance fund, and hospitals and the public are unaware of these differences. There are also <a href="http://www.news.com.au/lifestyle/health/specialists-accused-of-charging-different-rates-based-on-what-a-patient-looks-like/story-fneuz9ev-1226609529552">accusations</a> that some specialists charge people who have private health insurance more, based on their apparent ability to bear the additional cost. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/71944/original/image-20150213-13219-1dwdt88.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/71944/original/image-20150213-13219-1dwdt88.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=450&fit=crop&dpr=1 600w, https://images.theconversation.com/files/71944/original/image-20150213-13219-1dwdt88.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=450&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/71944/original/image-20150213-13219-1dwdt88.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=450&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/71944/original/image-20150213-13219-1dwdt88.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=566&fit=crop&dpr=1 754w, https://images.theconversation.com/files/71944/original/image-20150213-13219-1dwdt88.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=566&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/71944/original/image-20150213-13219-1dwdt88.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=566&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">The Royal Australasian College of Surgeons acknowledges some specialists charge as much as ten times the recommended fee.</span>
<span class="attribution"><a class="source" href="https://www.flickr.com/photos/68751915@N05/6793817419">401(K) 2012/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span>
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<p>There’s a lot of anecdotal evidence about what this means for sick Australians and for GPs who struggle to find specialists to accept their patients. It has been <a href="http://www.abc.net.au/news/2014-05-13/annual-specialist-referrals-wasting-millions-say-gps/5447822">reported</a> that some specialists require regular patients to go back to their GPs for new referrals annually. This rejection of “indefinite referral” is not just an impost on busy GPs, it also facilitates the increased charge for a “new” visit. </p>
<p>The <a href="https://ama.com.au/ausmed/patients-face-hip-pocket-pain-specialist-care">AMA says</a> the situation will only get worse due to the freeze on fee indexation and the new safety net arrangements in the 2014-15 Budget. </p>
<p>The last time an Australian government moved to tackle out-of-pocket costs for specialist fees was when Tony Abbott was health minister and introduced the <a href="http://www.health.gov.au/internet/main/publishing.nsf/Content/Review_%20Extended_Medicare_Safety_Net/$File/ExtendedMedicareSafetyNetReview.pdf">Extended Medicare Safety Net</a>. This provides an additional rebate for people who have out-of-pocket costs for Medicare-eligible out-of-hospital services once an annual threshold in out-of-pocket costs has been reached. </p>
<p>Abbott’s approach was recognisably flawed from the beginning. And it quickly led to inappropriate fee increases by some specialists, forcing successive governments to tinker with the policy to limit cost blow-outs. The majority of safety net benefits now flow to well-off Australians; the policy serves as a salutary lesson on the pitfalls of ad-hoc policy-making. </p>
<h2>A sensible approach</h2>
<p>So what should be done? The list of issues to be tackled includes:</p>
<p>• More publicly available data and analyses to inform an expert, well-resourced and on-going <a href="http://www.msac.gov.au/internet/msac/publishing.nsf/content/reviews-lp">review</a> of the items and fees on the Medicare Benefits Schedule. To date only about 3% of these items has been reviewed since 2010. </p>
<p>• Investment in a <a href="http://www.nps.org.au/media-centre/media-releases/repository/choosing-wisely-australia-launching-in-2015">Choosing Wisely</a> focus to assess low- and high-value services and an education and awareness program to ensure that the findings are acted upon. The medical colleges can play a key role here.</p>
<p>• Incentives to address geographic need and affordability. The current situation has led to <a href="http://www.aihw.gov.au/WorkArea/DownloadAsset.aspx?id=10737422169">major inequities</a> in access to health-care services. </p>
<p>• A program to tackle <a href="http://www.safetyandquality.gov.au/our-work/variation-in-health-care/">inappropriate variations</a> in services. This will deliver not just cost savings but improved quality.</p>
<p>• More transparency around specialist charges so referring GPs and patients can make informed decisions. This might go so far as to <a href="http://newsstore.smh.com.au/apps/viewDocument.ac;jsessionid=4A86E295F9327675DFC1F79EB2C1C59C?sy=afr&pb=all_ffx&dt=selectRange&dr=1month&so=relevance&sf=text&sf=headline&rc=10&rm=200&sp=brs&cls=631&clsPage=1&docID=AGE1501242DL9N6KI89Q">name and shame</a> the extreme outliers. </p>
<p>As Jennifer Doggett and I have <a href="http://apo.org.au/research/tackling-out-pocket-health-care-costs-discussion-paper-0">previously proposed</a>, tackling these issues will require strong leadership, considerable discussion with all stakeholders and a multifaceted approach. Failure to boldly address these admittedly difficult issues will disadvantage patients, discourage doctors and leave Australia stuck with an inefficient specialist health-care system.</p><img src="https://counter.theconversation.com/content/37111/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Lesley Russell does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The impact of specialist fees on government and patient budgets has received little reform attention. This is despite the government’s push for controls in health-care spending and growing evidence of…Lesley Russell, Adjunct Associate Professor, Menzies Centre for Health Policy, University of SydneyLicensed as Creative Commons – attribution, no derivatives.