Why Private Health Insurance won't improve our health

As we play "will-they won't-they" on the GP Copayment – currently rumoured to be dumped, but with the Medicare rebate frozen, that’s just a slow implementation of the co-payment. Health care costs keep rising, and presumably the government know this as they’ve just agreed to allow increases to Private Health Insurance premiums by an average of 6.2%. They rose by an average of 6.2% last year, too. 

Of course, your tax subsidises this to the tune of over $6bn (yes, billion). Governments see Private Health Insurance (PHI) as being an important part of the health system mix in Australia. One of the budget KPIs is to maintain the number of people covered by private health insurance hospital cover. As well as rebates of 30% of the premium, the tax system penalises high income earners who don't take out health insurance. And Peter Dutton, the former health minister, can even be seen spruiking health insurance.

What do the co-payment and Private Health Insurance mean for health policy?

Combining a liking for co-payments and PHI, this is my prediction for the worst case direction of future health policy under the current government:

1. Introduce co-payment somehow for seeing a GP. {Evidence – it’s happening right now}
2. Watch as Private Health Insurers and their members argue that clearly co-payments to see the GP should be covered by Private Health Insurance {Evidence – PHI already lobbying government on this}
3. Bow to this pressure – it’s only what the public want. Allow Private Health Insurance to cover General Practice. {Evidence – Government already allowing trials of this in Brisbane}
4. Private Health Insurers compete for customers by offering favourable access to GPs, and paying GPs more than they get from Medicare. {Evidence – this is the basis of the trial in Brisbane. Admin fee paid to practice, 24 hour access guarantee for members}
5. GPs opt out of Medicare system, as they get better paid and easier access to referral networks {Evidence – compare specialist care in public and private systems}
6. IPA, Private Health Insurance Companies and their customers argue they pay PHI so should be able to opt out of Medicare altogether. {Evidence – this would be the small government libertarian position}
7. Medicare gets progressively underfunded and seen as a second rate safety net rather than a universal health system. {Evidence – it’s already referred to as a safety net}

A look at Private Health Insurance through a lens of who actually needs good health care the most shows why this progression needs to be resisted.

Who has Private Health Insurance?

The Private Health Insurance Administration Council collect excellent statistics about PHI coverage.

Nationally, about 47% of Australians hold hospital insurance coverage. It has gone up slightly each year since 2010, and is fairly constant across the states (with more in the ACT and fewer in the NT).

 

Looking at insurance coverage by age, we see fewer being covered in their late 20s, and a big drop in coverage in the elderly.

 

Who doesn't have Private Health Insurance?

It's a statement of the obvious to say that those who don't have health insurance are those who can't afford the premiums. And that would certainly be true.

 

So, as people are more advantaged, they are more likely to have PHI (orange boxes increasing) and less likely to have a concession card (blue boxes decreasing).

This is all very well, but it is a well know fact that the more disadavntged you are, then the more health problems you have. (I am writing another post all about this, but you can see the stats before I write). 

The area in which this is most well known is in Aboriginal and Torres Strait Islander health, where the statistics are well known. Less well known is that only 15% of Aboriginal and Torres Strait Islander people in non-remote areas have Private Health Insurance. This is Australia's specific example of the Inverse Care Law that applies generally. Those who need health care the most, get it the least. 

Health Costs

Private Health contributes less than 8% of the total health spend (less than half the amount contributed by individuals themselves in out of pocket costs).

 

 What does Health Insurance buy - "For our members"?

Private health insurance have a difficult time selling you something in a universal health system. If the health system is going to give you high quality, timely care when you need it regardless of your ability to pay, what can they offer? This, I suspect, is one reason why the government want to turn Medicare into a safety net, rather than a universal health system - to generate a product to sell for profit. Private health insurance need to be able to convince you you're getting something you wouldn't otherwise get. That's why it's always "For our members." Here are the options:

• Earlier access
  This is the big one. Private Health Insurance companies know that their main selling point is priority access. Waiting times in the public system are subject to a fair amount of political pressure, but everyone knows insurance will get you seen earlier. The boss of Medibank told the AMA that Medibank members should be given priority in the emergency department. There's a trial going on right now in Brisbane between a group of General Practices and Medibank to give priority access. The ability to see a doctor earlier - independently of your need – is the main product sold by Private Health Insurance.
• Access to Allied Health
  This is another major one. Seeing a physiotherapist, or an exercise physiologist, or a dentist or a psychologist can be difficult in the public system, especially if it’s not part of a hospital admission. Medicare will only cover a limited number of these in particular circumstances.
• Higher quality health care
  You will receive high quality health care pretty much anywhere you go in Australia. That is, yes, you will always find people who are unhappy about their care, but health care is complex, and things will go wrong. However, public or private systems have no monopoly on things going wrong. And often, when things go wrong in the private system, people are moved to the public system for it to be corrected.
  It's also worth remembering that in hospitals, it is the public system who is usually involved in education and training of future health professionals, which can make for high quality (and can also look inefficient on a balance sheet!)
• Friendlier staff
  No health professional goes into their job wanting to be rude. It's stress and burnout that make this happen, which comes about from expecting too much of staff while giving them too few resources to do it. That's why staff ratios might be good and cases less complicated. It's easy to be friendly then!
• Nicer rooms
  This is often the case in the private system (though not necessarily if the public system charges your insurer for their services). I don't see any reason for not having nice rooms in public hospitals. It just seems to be that we are happy to see out insurance premiums pay for it, but not our tax. Which seems sort of odd to me.

Remember that having private health insurance doesn’t solve all your health care problems. Most policies are subject to exclusions – are you covered for having a baby? Mental illness? You are with Medicare! There are also significant patient copayments, which are often unclear when the policy is taken out or when you start treatment.

We can see that private health insurance companies, and perhaps politicians who want PHI to take the pressure off the public system, and perhaps health professionals who might be paid more privately than in the public system all have an interest in ensuring that the publically funded system has long waits, limits to the professionals you can see and happens in less pleasant environments. Often this won’t be explicit – it may even be subconscious – but results in thinking of the public system as a safety net, not a universal system.

Summary - why private health doesn't improve population health 

We've seen that Private Health Insurance is mostly bought by those who can afford it, who, by a happy coincidence are also those who are likely to be the healthiest. Clearly, there's not too much profit to be made by paying out on insurance for people with more conditions, or needing more complex case management.

So when we pay over $6bn in tax rebates on private health insurance premiums, that's money going from our tax to those who are already well off enough to afford PHI premiums. But not to those who have most illness or the most need of it. That money can't help Close the Gap, for example, when it has no way of reaching the 85% of Aboriginal and Torres Strait Islander people in non-remote areas without Private Health Insurance.

And when we allow Private Health insurance premiums to rise by 6.2% each year, but freeze Medicare revenues, that's paying more each year for the health care of those who need it least, while ensuring a cut in real terms for those who rely on Medicare, and ensuring they will have to contribute out of their own pockets. General Practices will gradually have to move away from communities that can't pay to those that can.

When we allow Private Health to sell a product that allows us to jump a queue on the basis of our ability to pay, rather than our clinical need, then that moves those better off and less likely to have high health care needs to the front of the queue. This already happens in the hospital system, and will happen in General Practice if we allow it. Freezing Medicare rebates makes this more likely, as the only source of revenue to keep practices viable is patients.

And eventually, if Medicare is a safety net unused by those who are better off (where more political power lies) then it will be allowed to gradually wither as it serves only those without money, power or influence.

A Tricky Question

This article first appeared in the December 2014 issue of the RACGP Publication Good Practice. I have linked to PubMed for the articles, and included links to full text in the references at the end.

One of the most difficult questions in healthcare may be, “Are you a good doctor?”

I am sure, dear reader, that you are a good doctor. You know everything, and you know the things you need to learn. You can see through the twinkle in a drug rep’s eye faster than you can say Vioxx. You are all much better than average, and, even as you know enough statistics to be able to dismiss this as an impossibility, you also know that it is certainly not you who is below average. 

Now that we are patting each other on the back in mutual admiration, here are some people to spoil the party. Let me introduce you to Dr Dunning and Dr Kruger, who won an Ig Nobel prize in 2000 for their work, in experiments showing those who were the least competent in various tasks were also the most likely to rate themselves highly competent.

They also found the same people are the most self-confident. There’s something about not being very good at something that makes you blind to the areas that you don’t know, or even realise that they exist. It’s a good job nothing like that could happen in medicine.

Except, however, research evidence can sometimes be as disquieting as a mirror in a brightly lit room. In JAMA in 2006, Davis and colleagues did a systematic review comparing self-assessment with external observation. The evidence revealed that we are not very good at assessing our own competence. Meanwhile, two years later In Medical Teacher, another systematic review also shows us that we are not that good at assessing our own learning needs.   

In both situations it is the least skilled of us who are the worst at self-assessing, and who are the most confident. 

And then there’s research that consistently shows we think we’re immune to drug repmarketing, no matter how often it’s shown that we’re not. This evidence is entirely consistent with other sociological and psychological research, which confirms that doctors are part of the human race, no matter how much we want to think our training makes us otherwise.

Apply Dunning and Kruger’s research to our profession, and you can see the danger in asking “Are you a good doctor?” It may be the very areas in which we feel highly confident are just those areas we are worst at. It may be that those of us who think they are expert at seeing through drug rep spin are those most susceptible. 

What if those of us who say they are good doctors are the ones we need to be most wary of?

Of course, you could dispute the evidence. All that stuff about education and drug reps doesn’t apply to you, or to Australia. But that is just what you would say, wouldn’t you, if you were subject to the Dunning-Kruger effect! 

In order to show how competent we are, we might have to admit some uncertainty over our competence. In fact, in real life, I have discovered that the doctors I really admire all feel that they will be tapped on the shoulder and outed as a fraud at any moment.

For any eager regulators out there wanting to put conditions on the registration of anyone admitting they think they are a good doctor, the solution is even simpler. As a profession, with specific knowledge and expertise, self-regulation often means peer review. We need - and should welcome - others around us to help us see our blind spots. Perhaps “Are you a good doctor?” is not such a dangerous question if the answer is “You’re asking the wrong person.”

References

Kruger J, Dunning D. Unskilled and unaware of it: how difficulties in recognizing one's own incompetence lead to inflated self-assessments. Journal of personality and social psychology. 1999 Dec;77(6):1121-1134.  

Full text PDF

Davis DA, Mazmanian PE, Fordis M, Van Harrison R, Thorpe KE, Perrier L. Accuracy of physician self-assessment compared with observed measures of competence: a systematic review. JAMA : the journal of the American Medical Association. 2006 Sep;296(9):1094-1102

Full text

Colthart I, Bagnall G, Evans A, Allbutt H, Haig A, Illing J, et al. The effectiveness of self-assessment on the identification of learner needs, learner activity, and impact on clinical practice: BEME Guide no. 10. Medical teacher. 2008 Jan;30(2):124-145.

Full text PDF

Dana J, Loewenstein G. A social science perspective on gifts to physicians from industry. JAMA. 2003 Jul;290(2):252-255

Full text PDF

The Hunger Games

This article first appeared in the July 2014 issue of the RACGP Publication Good Practice. It was written for a GP audience, who I hope would have fond memories of all the food terminology. Perhaps it was just me. The published version was edited slightly, but this is the original.

Being a doctor makes me hungry. Surely, many of us spend a morning clinic thinking about lunch, and an afternoon clinic wondering about dinner. I’m pretty sure it has been the same throughout history. I imagine Hippocrates eating herring, Galen tucking into grapes and Vesalius enjoying veal. However, I think they had stronger stomachs than me. I trained at one of those traditional medical schools that did dissection, and the combination smell of meat and formalin meant I was never hungry. 

This didn’t seem to be true for previous generations of pathologists, though. All those historical types were clearly distracted by their stomachs, as any quick leaf through a medical textbook will tell you. I imagine that as their assiduous students examined yet more examples of pathological body fluids, they’d ask their teachers for adequate descriptions.
 

“What does this stool look like?”

“Redcurrant jelly.”

“And this one?”

“Rice water. Better wash your hands. It’s supper time.”

There would be no fluid too disgusting to describe in tasty terms, every internal organ was ripe for culinary description.

“Your next patient looks a little unwell. Yeuch, he’s just vomited in the waiting room.”

“So he has. And, my goodness, it looks like coffee grounds. Remarkable.”

“Oh. I thought it looked like soil.”

“Watch and learn, dear pupil.”

The analogies continued. As they probed deeper, medicine became like a banquet. The main course was cauliflower ear, with subtle flavouring found in livers that looked like nutmeg. The cheese course was supplied by chest granulomas described as caseating. No-one could resist the chocolate cysts on the ovaries. After the food had settled, the skin was eagerly examined for port wine stains and café-au-lait spots.

It appears we might now be running out of foods to use. Arguments break out, amid confusing errors as to precisely which diseased organ looks like a strawberry. 

“Wasn’t it that strawberry naevus?”

“No, I thought it was a strawberry cervix.”

“Actually, I was talking about the strawberry tongue. I’m not sure how you missed it!”

I’m not sure I believe they really could see these things. Perhaps all they were cooking were the books.

And back to reality. If the thought of all that pathology puts me off my next meal, this is reinforced by my next patients who bring with them the strangest of menus. The first person tells me he has a frog in his throat. The next person has butterflies in her stomach. She’s worried, she tells me. Something is eating away at her. Up next is someone who knows something is wrong from her gut instinct. It’s quite a relief to find my next patient is so hungry she could eat a horse, but she is pleased as the treatment seems to be bearing fruit. My final patient has a few lumps in various places, which I carefully examine and document their sizes – a grain of rice, a pea, and, most surprisingly, a grapefruit. 

I reach the end of my surgery, running particularly late. After this procession of unpalatable symptoms, all I have the appetite for now is my apple, which is successful at keeping the doctor away from his lunch.

As my afternoon patients start arriving and peeling off their coats in the waiting room, I anticipate the feast to come. I reassure myself that, running late, slow food is healthier for all of us. Feeling better, my appetite for the work is not diminished. I look forward to the afternoon with relish.

My Personalised Digital Learning Space Thingummybob

Recently, I made my way down the beautiful escarpment to Wollongong to the Coast City Country (CCCT) GP Supervisors' Professional Development weekend. I was giving my personal experience of creating a "Personalised Digital Learning Space. I didn't realise that this is what I had done - essentially it was about how you use interactive social tools on the internet to enhance your own learning and teaching.

This post will summarise the talk I gave and some of the discussion that took place. Please use the comments to continue the discussion, and feel free to catch up with me on Twitter. You'll notice that the process of putting up this blog, and sharing our Prezis, is a demonstration of the content of the talk - as is commenting!

Sharon Flynn, the CEO of CCCT, opened with an outline of the background and theory, such as it is. You can find her Prezi here, and mine is embedded below.


It's quite possible to feel completely overwhelmed by online tools. There are so many people, and so many websites, apps and tools for so many devices. It can be like getting to grips with the size of the galaxy. In the same way that we don't have detailed knowledge of every drug available on the PBS (but we know where to find it), we can use three or four tools well, and not worry too much about all the others.

Here I'll describe how I use social media, and which tools I use. I don't want you to feel that this is the way of doing it. This is just a way (and probably not even close to the best way.

I was asked to cover the following questions:

• How do I find stuff?
• How do I know it’s accurate?
• How do I share content?
• How do I filter content?
• How do I keep up with all the news?
• How do I organise content?
• How do I categorise content?

My system is very simple. It's based around Twitter and Blogger. Mostly...

How do I find stuff?

You already find stuff! Most people already find stuff through colleagues in rel life, and through Google. Popular medical magazines like Australian Doctor and Medical Observer are widely used. I still look at textbooks, too - I shall never grow tired of Balint, and while Trish Greenhalgh writes books, I shall read them! So online isn't the be all and end all.

I'd add Google Scholar and PubMed (especially Clinical Queries, which adds search filters to help you find systematic reviews and randomised controlled trials). I routinely check out the Tables of Contents (eTOCs) (login required) issued by the RACGP library and the PHCRIS e-bulletin.Some people used the subscription services Up To Date or Dynamed (also available through the RACGP library). These offer evidence reviews supposed to be used at the point of care, though they are not quite succinct enough for this.

The social nature of the web means that you can extend the circle of people you call upon from those you know personally to (potentially) anyone, including leaders in the field. Watching out for accounts on Twitter who regularly point out interesting research and articles is really valuable. For me, Trish Greenhalgh, Ash Paul, Jonathan Tomlinson, Annmarie Cunningham, Melissa Sweet and WePublicHealth would be examples where much of what they tweet I find interesting and relevant. It's much more useful (and fun) to see tweets containing opinions, not just headlines, too.

It's also useful to keep your eye out on some hashtags. Hashtags are search terms attached to tweets which allow you to find information you are interested in from poeple you don't know exist. #FOAMed #FOAM4GP #MedEd and #SoMeGP would be good places to start. As you get more connected, people will learn your interests and direct things to you that they think you will be interested in. For example, some recent tweets I received:

@NACCHO_CEO Aboriginal Health reform Justin Mohamed - @Informa_Oz slideshare.net/informaoz/just… @WePublicHealth @croakeyblog @timsenior @qaihc

— Aboriginal Health (@NACCHOAustralia) March 25, 2014

A #publichealth perspective on the RDA blogs.crikey.com.au/croakey/2014/0… FYI @warrenmundine @GreenJ @NACCHOAustralia @timsenior @LowitjaInstitut

— Melissa Sweet (@croakeyblog) March 24, 2014

How do I know it's accurate?

This is no different to other parts of life! Do I trust the writer? Do I trust the tweeter? Do I trust the publisher/journal/website? There's no reason to suspend you critical judgement. Things on the internet are no more or less reliable than our daily newspapers. Make of that what you will!

How do I share content?

Simple answer: I tweet it. I usually tweet links to things I find interesting, usually with a comment about why it's interesting or useful. Where I want to say more than 140 characters, or want to say something with more thought behind, I'll blog about it (on amsdr.blogspot.com.au for Aboriginal health stuff, and on iofthet.blogspot.com.au for anything else). It's very easy just to use Twitter and a blog as a basis for sharing.

There are other tools that can be helpful. Storify for bringing together a series of tweets and links into a story; Slideshare or Prezi for sharing presentations; Youtube or Vimeo if you fancy making and sharing videos.

So you see I've managed to embed a Prezi to share on the blog. On this post, I've embedded a Storify.

How do I filter content?

I use 2 questions, essentially:


Is it useful – will it change my practice?


Is it interesting?


If the answer to both of these is no, then I won’t bother.


Sometimes when I am really busy, something has to be really really useful or really really interesting for me to worry about it.

How do I keep up with all the news?

I used to try! Now I don’t worry. If it’s important enough, it’s will be tweeted several times through my network. If it’s not, I won’t miss out. You can’t know everything. Remember that it's social media and not social media - your network will find stuff for you! (It’s why you should share interesting or useful stuff you find.)

How do I organise content?

If I see a tweet with interesting info in (for checking out later) I will favourite it. (You can see what I've favourited here).

If I see a journal article worth reading, I will save it to my CiteuLike library. (Incidentally, if you have access to a University Library, see if there is a version of the LibX toolbar you can install...)

If I see a website or some other bit of information, I will save it to my Evernote notebook which is accessible from my computer and phone. This is useful for websites, articles, meeting notes, pictures, tweets, sounds, drawings etc. (I used to use Pocket, too.)

How do I categorise content?

Citeulike and Evernote both use tags. I attach key words of my choosing to interesting articles, and can then find them later. So, for example, these are all my Citeulike articles tagged Education

Some of the discussion

My observation that the development of theory was playing catch-up to the ways people were using social media for education provoked the useful clarification that the educational theory hasn't changed, and that the challenge is to make the most effective use of these tools intelligently. We can't ignore what we already know about educational effectiveness, but neither can we just translate lectures, seminars, workshops, tutorials across to an online environment and expect them to work. (Which incidentally, is why my Prezi here may not be very useful on it own!)

The other interesting discussion was about the use of social media by registrars. Some GP Supervisors were concerned about the use of mobile phones and social media during clinic sessions, especially the distraction of this while seeing a patient. It would be interesting to hear from others about their experience with this. Our discussion thought about using video to see the impact on the consultation, and asking the registrar what they thought the patient might be thinking seeing the registrar checking their phone when it buzzed. (Any doctor not able to put themselves in the patient's shoes at this point probably has bigger problems than just the use of social media!) Where students are engrossed in an electronic device, there is scope to use this as a teaching moment for all concerned, and ask the student to get specific information relating to that consultation.

I'm fully aware that there are many other tools and strategies out there that you will use. Please tell us in the comments below.

When Terry Barnes and I bumped into each other on Twitter