Dermatologists were not represented on the Strengthening Medicare Taskforce committee and that absence is reflected in the report.
The Strengthening Medicare Taskforce handed down its report this month promising $750 million of funding to drive reform in health care. Non-primary care specialists are barely mentioned in the report despite historical disparities of rebates which especially disadvantage dermatology patients.
Dr Clare Tait, president of the Australian College of Dermatologists, said there were “definitely a number of positives in the report”, however, it failed to address three critical Medicare schedule issues that create a “significant financial impost” on dermatology patients.
The first issue relates to all specialties; the inadequate indexation of Medicare rebates since the mid-1980s. Because of inadequate public health funding for dermatology in hospitals, most dermatology care is through private practice, exacerbating the funding issue for dermatology patients, Dr Tait said.
“Out-of-hospital medical services, which are largely what we do, can’t be covered by private health insurance. Specialist fees are a major cause of high, out-of-pocket payments for patients,” she told Dermatology Republic.
Secondly, Dr Tait said there were historical disparities for rebates across the specialties that were “unacceptable” and did not reflect the increasing complexity of care required for dermatology patients.
“If a patient sees a dermatologist for a follow-up appointment with a complex condition, they’ll receive a $39.25 rebate from the government,” she said.
“However, if you have asthma and you go see a consultant physician for a follow-up appointment, you will receive a $68.90 rebate. Our patients are being significantly disadvantaged. It’s totally inequitable.”
Dr Tait said patients were presenting more frequently with complex multisystem conditions alongside their dermatological disease. Fortunately, some patients were eligible for biologic therapy, which brings an additional time burden to complete administrative and compliance tasks.
“There’s a real lack of understanding about how complex these consultations are and how the patients are losing out in terms of Medicare rebates,” Dr Tait said.
The third issue missed in the Strengthening Medicare Taskforce report applies to all non-GP specialities – the absence of government funding to offset the costs of servicing complex care.
“The only government funding we have is rebate for the individual patient. We have no care plan item numbers, no incentive item numbers, no offset for nurse practitioners,” Dr Tait said.
This issue especially impacts dermatologists because it is both a surgical and physician speciality.
“We have significant costs running surgical services that physicians don’t have. All our costs for surgery and for nursing time for wound care, suture removal, management of skin cancer, all have to be entirely funded through our patient fees,” she said.
According to Dr Tait, the Strengthening Medicare Taskforce (the Taskforce) might have addressed these issues if non-GP specialists were represented in the taskforce committee.
The Department of Health and Aged Care told Dermatology Republic that they “invited interested organisations to submit their top priorities for reform”. Still, the report almost solely focuses on primary care.
This is despite one of the four key pillars of the report encouraging multidisciplinary team-based care that reinforced the need for integration between specialists, hospital services and primary care providers.
Beyond the low representation of non-primary care voices on the Taskforce, a critical barrier to multidisciplinary team care has been raised by digital health experts; almost all health software used in Australia cannot share data with other healthcare providers.
Dr Tait said she supported the concept of “a truly shared digital record that’s secure” but given the current models of care, there were lots of stages to work through to ensure effective data sharing.
Speaking as a private clinician, Dr Tait said that in the group practice where she works, dermatologists used two different patient management systems which did not share data and have varying levels of functionality.
Unlike the US and Scandinavia, the Australian government does not mandate that health software should link and share data. It puts the onus back on clinicians to share patient history using outdated technology and Australia Post.
The Taskforce report’s solution to Australia’s digital health woes was to “modernise My Health Record”. This was despite My Health Record being largely underused, especially by non-primary care specialists.
Dr Tait said she did not use My Health Record in her clinical practice for a number of reasons.
“There are patients who are still not happy to have their information on My Health Record and at the moment there’s limited information on it,” she said.
“It’s not thought to particularly help with patient care. It also doesn’t integrate very well with our software so it’s an extra step in a pressured consultation.”
Whether or not these issues can be overcome has digital health experts divided.
My Health Record was intended to be an immense electronic health record where, in theory, health data for every Australian was uploaded to a huge, centralised database and accessed as required.
This database currently holds most data in a format similar to PDF documents. However, since its inception, cloud-based solutions and consumer demand for real-time data has opened possibilities for distributed technology models such as those in Denmark and the United States.
Distributed models don’t require one central database. Instead, technology securely connects patients and healthcare providers to a variety of clinician databases containing current health records across all levels of care. Patients use a secure phone app to draw their complete health data from the various databases as needed.
Dr John Halamka is President of Mayo Clinic Platform and has helped various governments plan their healthcare information strategies. He said that customers in the US expect to easily access their real-time health records on their smartphone.
In considering the taskforce report, Dr Halamka posed a few thought-provoking questions about the intention to “modernise My Health records”.
“Has Australia put the data before the patient? Is this data-centric or patient-centric? Would making the strategy patient-centred, rather than data-centric, change the ambition to retain a centralised library of historical health data?” he asked.
Tim Blake, managing director of Semantic Consulting, also questioned the Taskforce’s technology recommendations. He said the report was “largely just hand waving” by a group of people who knew change was needed but were unable to implement what was technically required.
“Digital health experts have been advising the Government on this issue for nearly a decade. I can show you a report I wrote for the Commonwealth Department of Health from 2015 where I recommended similar changes,” he said.
Mr Blake said that significant cultural change would be required to move on the Taskforce report.
“Many clinicians today see documentation, and the sharing of that documentation, as far more of an administrative issue than a clinical one. Until we can change that mindset, it doesn’t matter how many (data-sharing) interfaces we build,” he said.
In the meantime, dermatology patients remain “significantly disadvantaged”, according to Dr Tait.
She said that although aspects of the Taskforce report were highly constructive, any meaningful change to Medicare required “a whole system approach”, which meant having non-primary care specialists at the table.
“Without that, it’s quite possible there will be significant, unintended consequences with flow on effects from the strategies that [the Taskforce] develops. This has been a real missed opportunity,” she said.
