10:00am 15th May 2016:: Think: Health

The Federal Government has announced the Medicare indexation freeze will continue until 2020, saving over $900 million. How much more will you be paying when you visit the GP? And, why the causes of death among adolescents has remained unchanged since the 1990s. We also look at the prevalence of complementary medicine use among menopausal women.

Presenter/Producer: Ellen Leabeater
Producer: Ninah Kopel


Ellen Leabeater: Hi. Welcome to the show. Ellen Leabeater with you. Today we look at why the cause of death for adolescents has remained unchanged since the 1990s, and…

Wenbo Peng: This is how I use this herb, and I think it’s very useful for me and it can relieve my symptom.

Ellen Leabeater: Why menopausal women use complementary medicine.


Well, depending on where you stand, last week’s Budget was safe, boring and forgettable. But one issue that’s not going away is the Medicare indexation freeze. The Federal Government and Health Minister, Sussan Ley, announced they will save over $900 million by continuing the freeze until 2020.

The Royal Australian College of GPs launched a campaign on Monday, the first day of the election campaign, to warn patients of the impending price increase for health care. But how much more can we expect to pay to see the GP?

[Excerpt from interview]

Bob Hawke: In every Australia, from newborn babe to Prime Minister, can share in the cheapest, simplest and fairest health insurance scheme Australia’s ever had: Medicare.

[End of excerpt]

Ellen Leabeater: That’s Bob Hawke in 1983, encouraging every Australian to fill out their Medicare enrolment form. It’s a stark contrast to the previous Fraser Government, who tried to destabilise Medibank, as it then was.

Margaret Faux: In Malcolm Fraser’s time in Government – so 1975 through to 1981 – he instituted a lot of the same types of changes as Minister Ley is currently introducing into Medicare. It was then Medibank. So with Malcolm Fraser we had Medibank mark one, mark two, mark three and mark four before he finally dismantled the scheme in April 1981.

Ellen Leabeater: Why the history lesson? Well, Malcolm Fraser learned the hard way that health care doesn’t operate in a supply/demand way, like the rest of the economy.

Margaret Faux: And in his later years, when he was interviewed for a book called Making Medicare, he said that he was unable to reconcile macroeconomic reform with health because health doesn’t operate like other markets. So you can’t apply simple principles of supply and demand to health for the simple reason that demand for health is infinite.

Ellen Leabeater: This is Margaret Faux. She’s a lawyer, a registered nurse and CEO of the largest medical billing company in Australia. She’s also currently doing a PhD on Medicare claiming and compliance at the University of Technology Sydney.

So Malcolm Fraser’s lessons might be something current Prime Minister, Malcolm Turnbull, should listen to, but what is indexation? If you visit the GP and you get bulk billed you don’t pay a cent. Instead, the Government pays your GP $37.05 for the consultation. This was rising with CPI, or the Consumer Price Index, up until 2013, when the then Labor Government announced it would freeze the Medicare indexation. This freeze has now been extended by the Coalition until 2020.

Up until now GPs have taken the hit. It means while the costs associated with running a practice – like new technologies, wages and other admin costs – have risen, but the amount GPs receive has remained static. GPs are saying they can no longer afford to just accept the $37.05.

Frank Jones: And if the income that I’m earning as a practitioner is frozen, I’m going to have to start looking at either decreasing my services – which is really not good for the health of the nation – or starting asking my patients for a contributing fee.

Ellen Leabeater: And that contributing fee is what’s being called the co-payment by stealth. Before we get into the so-called co-payment, you might argue that GPs earn enough already and that they can afford to continue on business as usual so long as they take a pay cut. Not so says Dr Frank Jones.

Frank Jones: So most GPs are actually not in this for the money. Yes, of course, we earn a relatively good income compared to the rest of the population. We also put in long, long hours, and we also deal with lots of consequences of decisions that we make. So it really is a relatively high risk profession as well.

Ellen Leabeater: Dr Jones is President of the Royal Australian College of General Practitioners, or RACGP, and he’s also a GP for regional Western Australia. So how much money are we talking here? How much will we have to cough up when we see a GP?

Frank Jones: Yeah, I think you’ll find that the category two patient [depending on] health care cards would be copping, probably, a cost of something along the lines of $15 to $20.

Ellen Leabeater: $15 to $20?

Frank Jones: Yep. I think that reflects the true situation if you want to provide a quality care service. Look, those are the figures that are being talked about in GP circles.

Ellen Leabeater: Keep in mind that that is someone with a health care card, like a pensioner. It’s even worse for the rest of us. The out of pocket costs, according to RACGP, could be around $33. That cost is passed on at the GP’s discretion and it will change depending on the area you live and the type of practice. Dr Jones says GPs may still choose to bulk bill disadvantaged patients, but this will also be at the GPs discretion.

Frank Jones: People who are really disadvantaged in my community here – for example, the homeless youth, for example, people in aged care, people in palliative care, people in Aboriginal/Torres Strait Islander, who have multiple health problems, that probably are not as financially well off as other people – I think general practices will continue to cop it on the chin.

Ellen Leabeater: As mentioned earlier, this is a co-payment by stealth, but it’s not exactly a co-payment. Margaret Faux again.

Margaret Faux: And I actually think there’s a lot of confusion on this concept of a co-payment. It’s illegal to charge a gap.

Ellen Leabeater: When you get bulk billed by your doctor it’s actually illegal for them to charge a little bit extra. So, if doctors do decide to charge their patients more, they will have to charge you the whole amount, and you claim your $37.05 from Medicare later.

Margaret Faux: When doctors say we’re going to charge you a $10 co-payment, what that actually means is that you’re going to have to pay $47.05 up front. You have to have $47.05 cash available on the spot because that’s the law. So what you’ll have to do is pay $47.05, then you will get $37.05 back. So the impact on patients is not $10, $20. You’ve got to have the cash up front to pay the full amount because that’s the law and that’s the way Medicare works.

Ellen Leabeater: So if I’m a student, for example, and I’m living pay-cheque to pay-cheque, I get sick but don’t have enough money for another week, I’m not going to go to the doctor, am I?

Margaret Faux: I wouldn’t have thought so, Ellen. You will actively seek out a bulk billing doctor because you will want to be able to walk in to the clinic, be treated and walk out, swiped your Medicare card and not have had to hand over any money. And as students, vulnerable people, low socioeconomic groups, all of those people will be really, really heavily hit by these cuts, in my view.

Ellen Leabeater: This may make you yearn for the days of the seven dollar GP co-payment, but Margaret Faux says any co-payment is a slippery slope.

Margaret Faux: If you introduce co-payments you’ve basically destroyed the universal health care and bulk billing because what it means is bulk billing just becomes – well, there’s no point in having it. It’s just here’s the Government rebate, and then we’ll just continue to charge whatever we want. And what we know with co-payments in other countries is, once they’ve been introduced, the only direction they go is up.

Ellen Leabeater: Margaret and Dr Jones agree: any cuts to primary health care, like GPs, is bad news for the health system.

Frank Jones: We actually know – and this is very well recognised both within Australia and overseas – that countries with a strong general practice primary health care system have, actually, overall, better health outcomes. So it’s a little bit illogical to be targeting general practice particularly.

Ellen Leabeater: Margaret in particular cites the prices of showing up to hospital versus the price of seeing your GP. $398 for the hospital or $37.05 for the GP.

Margaret Faux: A vibrant, thriving primary health sector is critically important to the overall functioning of our health care system because it’s the front door. If you put barriers up at the front door, or make it unattractive for people to access health, they will go to hospitals, and hospitals are much more expensive. So you compare this: it’s $37.05 to go to the GP.

By comparison, if you go to a public hospital emergency department – the last time I looked at the figures on the Independent Hospital Pricing Authority website – which was last year – the average cost of a non-admitted adult presentation to a public emergency department was $398. So there is no – it’s just a no brainer. You want people going to GPs. You don’t want people going to hospitals.

Ellen Leabeater: Both the Minister for Health and the Shadow Minister for Health were contacted for this story. Both were unavailable for comment. However, the Minister for Health, Sussan Ley, pointed us in the direction of a statement released on Friday, saying bulk billing rates have increased under the Turnbull Government. We will provide a link to the statement on our website.

But back to the other Malcolm, Malcolm Fraser. We know he admitted health doesn’t work like a typical economic model says it should, but were his changes effective?

Margaret Faux: Malcolm Fraser – eventually, everything he did made costs go up, and they were designed to do the opposite. In the end he dismantled the scheme. So I think that is a cautionary tale for the current Government, who’s copying many of his initiatives, and I believe the same will happen. I don’t think it will reduce costs, and it will have a negative impact on health outcomes.


Ellen Leabeater: You’re listening to Think Health on 2SER, 107.3; online at 2ser.com or on your favourite podcast app.


Ellen Leabeater: Adolescents represent over a quarter of the world’s population. Yet when it comes to health they have suffered from decades of neglect. While global efforts have improved the health of children, the leading cause of deaths for adolescents has remained virtually unchanged since 1990.

A new report has revealed that road injuries, self-harm, violence and tuberculosis are still the main cause of death for 10 to 24 year olds. They are deaths that are easily preventable, so why haven’t we intervened?

Ninah Kopel spoke to Peter Azzopardi, researcher with the Centre for Adolescent Health at the University of Melbourne to ask him how the world has let young people fall through the gaps.

Peter Azzopardi: Many of the risk factors for poor health experience during adulthood – particularly the non-communicable diseases – so things like type two diabetes, cardiovascular disease, cancers, stroke et cetera – which are now the leading causes of poor health globally – so many of those risk factors arise during adolescence and are potentially modifiable. So what I’m really getting to are things like tobacco smoking, physical inactivity, obesity.

Ninah Kopel: You’ve mentioned health concerns there already, or specific issues that are causing this problem – things like tobacco, things like mass migration – but these are issues that affect the greater population at large. So why is this group of people, from 10 to 24 years of age, particularly impacted?

Peter Azzopardi: We’re increasingly understanding that adolescence is a really important developmental stage. So for a long time we had framed adolescence as largely a stage of pubertal development, or sexual maturation. But we are increasingly understanding that adolescence is a really important time for social development, so in particularly making that transition from education to employment and starting a family.

I think what were also starting to understand as well are the really important brain maturations, when your cognitive development is occurring during adolescence as well.

Ninah Kopel: In terms of the education you mentioned, did your research look at all at how people were impacted differently in countries like Australia, where there is such a good education offered to people, and other places where adolescents might not be getting the education that they need?

Peter Azzopardi: It certainly seems that in countries were adolescents – and particularly adolescent females – are able to complete secondary education, those adolescents enjoy a lower rate of fertility. So the implications of that are that adolescents who have children earlier have poorer health outcomes themselves. We also know that children born to adolescent mothers also have poorer outcomes as well.

So, certainly, one of the key recommendations to come from the Commission is improving and ensuring access to education is a really great thing. Schools can provide a means for improving the mental health and wellbeing of young people.

Ninah Kopel: How important is that mental health when we’re talking about adolescents around the world?

Peter Azzopardi: So we looked at 188 countries for which data was available, and we essentially grouped these countries into three main types of health profiles that adolescents are experiencing. So the one thing that was common to all of those country groupings was mental health. Certainly, there has been very little shift in mental disorder or poor mental health experienced by adolescents globally.

Ninah Kopel: So to move away from those mental illnesses that we’ve been discussing to some more physical challenges, you’ve mentioned tuberculosis. Why is something like TB – which, essentially, has a cure, I believe – still such an issue internationally?

Peter Azzopardi: That’s a really complicated question, I suppose. I would just say that for a long time now tuberculosis – again, the focus has largely been on tuberculosis amongst adults and tuberculosis amongst children. In terms of the burden of tuberculosis amongst adolescents – well, firstly, that’s been largely uncharacterised and unknown, and so – actually, some colleagues of mine here at the Murdoch Childrens Research Institute are doing some work now to characterise the pattern and determinants of tuberculosis globally.

We haven’t really been able to characterise what even some of the most pressing health issues for young people have been globally. There’s long been the assumption that young people are healthy and don’t have any health issues. So what this Commission report actually has been able to do is to actually paint a picture of what some of the leading health issues are to actually inform policy and program.

I think we still have a long way to go though now in terms of understanding exactly what the determinants of these health issues are. So, for example, take the example of tuberculosis, why are so many young people experiencing tuberculosis? Is it because they’re acquiring the infection primarily? Or is it because there’s been an incomplete treatment as a child – and how we can actually best respond to these health issues as well.

Ninah Kopel: Another issue that’s raised in this research is the frequency that adolescents and young people are victims and perpetrators of crime and criminal offence. So how does that play out when we talk about trying to maintain adolescents’ health?

Peter Azzopardi: Around 10 per cent of the world’s adolescent population live in countries where – in addition to this burden of non-communicable disease – they’re also experiencing higher rates of injury. So these countries largely are in Latin America and eastern Europe. Particularly important causes of injury here relate to firearms, but also as well road traffic and unintentional injuries as well. So in terms of responding to these settings, actually looking at the legislative frameworks is going to be really important.

Ninah Kopel: Is this the beginning of a greater body of research about adolescents’ health around the world?

Peter Azzopardi: Absolutely. If we go back even 10 years, we didn’t know – and we couldn’t describe – what adolescent mortality rate was globally and why adolescents were dying. Now, what happened in 2007 was the first adolescent health series, where we were able to describe what some of the issues were at a global level. So not only the country, but at the global level for adolescents.

Certainly, what this report here is bringing is a shift in thinking, highlighting that the health of adolescents is not just important to their health, but to the health of the next generation and for future adults as well.

Ellen Leabeater: Ninah Kopel speaking there with Peter Azzopardi about the leading cause of death among adolescents.



Ellen Leabeater: Women are the highest users of complementary medicine, so it comes as no surprise that they use them a lot during two key life stages: pregnancy and menopause. Last week on the show we spoke about how pregnant women were using complementary and alternative medicine, also known as CAM.

CAM is things like yoga, herbal medicine, acupuncture and osteopathy. This week we take a look at how menopausal women use complementary medicine. Women can experience two types of menopause: surgical and natural.

Surgical menopause is an induced menopause and occurs when a woman’s ovaries are removed. Natural menopause happens when women stop menstruating. The symptoms associated with both types of menopause differ, but many – such as hot flushes and night sweats – are similar.

Hormone replacement therapy is a common way to reduce some of the symptoms associated with menopause, but many women still choose complementary medicine to ease symptoms.

Wenbo Peng is a Postdoctoral Research Fellow at the University of Technology Sydney. Wenbo has been studying how this group of women use complementary medicine.

Wenbo Peng: It’s really depends on different women. I have to say, for the overall symptoms, includes hot flushes, night sweats, the mood disorders like anxiety, depression, headache, leaking – the urine problems – and the vaginal dryness.

Ellen Leabeater: So how many women – how many menopausal women are using complementary medicine?

Wenbo Peng: In my PhD study – this is part of the Australian longitudinal study on women’s health, which is the largest national representative sample of Australian women – it’s very difficult for them to find the appropriate therapy to treat the symptoms because [for the statement], they have mentioned the hormone replacement therapy may be not useful for them, or maybe they will suffer from more side effects. So complementary medicine may be the option for them.

Ellen Leabeater: So your study has just looked at women aged 60 and over?

Wenbo Peng: Yeah, yeah, from 59 to 64 years. For my study they have more than 10,000 Australian women in this age group. They have been divided into surgical menopause and natural menopause, and also we included, I think, 11 symptoms, menopause related symptoms, in this study. We found almost 40 per cent of these menopausal women who are aged from 59 to 64 years in Australia, and they were used – they have consulted complementary and alternative medicine practitioners.

For the CAM practitioners I mention here we – refers to massage therapist, naturopath or herbalist and chiropractors or osteopaths and the acupuncturist.

Ellen Leabeater: Is there a certain type of complementary medicine that these women are using more than others?

Wenbo Peng: Yes. For the complementary medicine practitioners they were more likely to consult massage therapist and chiropractors or osteopaths. I found why they use massage therapists and the chiropractors or osteopaths more [prevalent] than the other CAM practitioners, just because they were more likely suffer from back pain or other muscular skeletal problems.

Ellen Leabeater: When we’re talking about the evidence base, a lot of complementary medicine there’s no solid evidence backing it up. Is there any evidence to suggest that these practices relieve or alleviate some of these menopausal symptoms?

Wenbo Peng: Yes. For my study we are focussing on using the public health methodology to examine complementary medicine use among menopausal women in Australia. So my research is not focussed on testing the efficacy of each CAM practitioner therapy for certain symptoms. So if you ask me about the clinical evidence, I have to say as far as I know all the evidence is from the public – the published articles.

Ellen Leabeater: So it’s more about understanding how many women and what they’re using it for, I guess?

Wenbo Peng: Yes. We will actually set this as a proof of evidence base for the clinical trial or for the clinical practice. So if we can get any funding or any conclusion about the use of specific CAM practitioners or the specific CAM therapies, the prevalence of each practitioners or the treatments among Australian menopausal women, we can give the clinical trial some hints about maybe they should focus on this therapy because this one is very popular.

Ellen Leabeater: Is there something we found out last week on the program, when we were talking about pregnant women who are using complementary medicine.

Wenbo Peng: Yes.

Ellen Leabeater: Is that sometimes that they are self-prescribing it?

Wenbo Peng: Yes.

Ellen Leabeater: Does that happen with menopausal women as well?

Wenbo Peng: Yes. I think for – I have no idea of the prevalence rate of pregnant women, but in menopausal women the … rate is as high as 75 per cent.

Ellen Leabeater: Seventy five per cent…

Wenbo Peng: Yeah.

Ellen Leabeater: …of women are self-prescribing.

Wenbo Peng: Three quarters. As you see if they – maybe they just read the books or they hear from the other menopausal women or from their friends or from their family members. They said I use this herb and I think it’s very useful for me, and it can relieve my symptom. Maybe she will just go to the CAMs or the supermarket to buy it.

Ellen Leabeater: That’s a bit scary.

Wenbo Peng: Yeah. Also – so that’s why, now, some of the clinical trials, they were more focussed on the vitamin supplements and – or some herbs, yeah, because no-one can guarantee whether they don’t have any interactions between the herbs or the herbs and the drugs, or maybe herbs and herbs.

Ellen Leabeater: So if you’re using some sort of herb that may interact with your heart medication or something like that?

Wenbo Peng: We don’t know, so that’s why. But we would like to let the GPs and specialists have a – let them know, look, the menopausal women – some of them, they use complementary medicine products, but they didn’t tell you, and you should notice. You should always be aware of – maybe your patients – they’re using one type of complementary therapy or the products.

You should always ask them have you used any CAM products or – at least if they know, they may give the patient some idea or some suggestions about how to use it, or maybe you should consult another CAM practitioner.

Ellen Leabeater: Wenbo Peng, postdoctoral research fellow at the University of Technology Sydney.


Don’t forget, if you’d like to find out more about anything you heard today you can visit us at 2ser.com\think health. You can also tweet us at 2ser. Please remember the journalists are not doctors. If we’ve made you ask questions go and see your GP.

This show is produced with the support of the University of Technology Sydney Faculty of Health. I’m Ellen Leabeater. See you next week for more.


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