The Wall Street Journal reports that Merck has just released its list of payments to doctors for giving talks at promotional events. The list also includes some nurses, pharmacists and scientists.

The payments range from $150 to more than $20,000.

The paper reports that many drug companies are moving to do likewise, and that Eli Lilly published its own list earlier this year.  There is also a political push to require drug companies to report the payments.

It seems that Australia really is dragging the chain in this area.

His piece prompted some queries along the lines, what is the difference between a physician assistant (PA) and nurse practitioner (NP)?

As this question is often raised when the subject of PAs arises, I’ve asked Dr Rod Hooker, a PA for 30 years in the US and also a health economist, to explain how he sees the differences. Hooker is Director of Rheumatology Research, Medical Services, Department of Veterans Affairs, Dallas, Texas.

He writes:

“Important issues arise when discussing similarities and differences between PAs and NPs.  Viewing this from the prism of a health economist at first glance they look alike.

However, in the aggregate there are some differences that are notable.  The generalist training of PAs permits role flexibility and mobility that neither NPs (nor doctors) have.

A urologist may employ a PA to do office based procedures, and undertake pre-surgical admission examinations – not to assist in theatre.

An emergency medicine PA may experience role fatigue after a few years and take up primary care or work in cardiology as an alternative.

The other differences may lie in the aggregate. NPs are highly skilled in the cognitive disciplines and tend to be providers of health promotion and disease prevention than doctors or PAs.

PAs in turn tend to be more technical oriented in nature.  PAs in uniform are trained for combat roles as well as occupational health, battlefield medicine, family medicine, and refugee management.  NPs are not deployable for combat roles and are not trained for those roles.

Finally, what Americans have found in PA/NP development is that diverse populations seem to like the idea of choice in providers; the younger generations have never known what it was like to not have a doctor, PA, midwife or NP in their midst.”

“It is very fashionable to encourage care of sick patients in the community right now. Health reform efforts are pushing to keep people out of hospitals as much as possible – whether by not admitting them in the first place, or by discharging them as quickly as possible.

As an Aboriginal nurse practitioner who specialises in the care of patients with chronic conditions, I’ve been contributing to such practices myself.

I know, from both my own experience and the research literature, that many patients will do better if cared for at home.

But through my own work, I’ve become increasingly aware that these policies promoting home-care are often taking an unrecognised toll upon another group – the carers at home.

As carers, by and large, tend to be female, this is also an under-recognised gender issue.  It seems as if some of our health policies may have the
unintended effect of contributing to economic and social disadvantage for women.

Ever time we send someone home early from hospital, there is a good chance we are taking another woman out of the workforce. We socially isolate her, relegate her to the lowest economic bracket, and limit her educational opportunities.

The rising tide of chronic diseases means that many patients are going to be unwell for long periods. Carers are often confined to that role, not for
weeks as might once have been the case when acute illness was more common, but for months and years.

Through my work I am very aware that this is a particular issue for Aboriginal women, who are already disadvantaged on so many levels.

If health reform is going to result in even more people being cared for at home, we have to make sure that their carers receive much better support
than is currently available. Their needs also have to be factored into health planning.”

He concluded that the industry might be flexing its might – warning the Government off making any real changes to current arrangements – as well as trying to attract customers through the time-honoured technique of a fear campaign.

In interesting timing, the SMH reported recently that the Rudd Government may be preparing for the sale of Medibank Private, with a draft platform to be put to Labor’s national conference next month calling on governments to “support and strengthen private health care”.

In NSW, the acting general secretary of the NSW Nurses’ Association, Judith Kiejda, is not impressed. She has written the following article for Croakey:

“This comes as no surprise given the prominence of private health insurance interests in the National Health and Hospitals Reform Commission and the failure thus far of that process to confront the truth about the impacts of the massive public subsidies currently enjoyed by the private health insurance industry.

Let’s be clear about the effects of privatising health care.  Essentially this is about increasing the burden of costs onto individuals and lessening the extent to which society takes collective responsibility for providing health care.  This cannot be the solution if our goal is to avoid the spiralling cost of care and lack of equity and access we see in the United States.

Australia’s expenditure on health as a proportion of GDP will not lessen because more of the burden is shifted to private interests.  More likely it will inflate costs because private sector providers and insurers demand profits.

Or, worse, it will lead to declining standards of care and we need look no further than the litany of issues emerging in the aged care sector to see what the profit imperative does to staffing levels and quality care.

If the private health insurance industry is so inefficient that it cannot survive without billions in public subsidies then surely good sense would demand that we direct our attention to how those billions could be invested in ways that ensure that every Australian has access to excellent care in the public system.

Universal insurance in this country has delivered very high standards of care at low costs compared to other systems.  Clearly there are a range of reforms necessary to ensure that this level of performance keeps pace with changing demographics and patterns of demand.

But to attempt to resolve the problems in the system with greater privatisation of the health care market is resigning ourselves to a system with higher overall costs and where there will necessarily be winners and losers.”

It’s a landmark night for maternity services for Australian women. Finally, after more than 20 years of discussion and debate this Federal government has been brave enough to acknowledge that maternity services are provided by a number of health professional including midwives, GP obstetricians and obstetricians.

Tonight’s announcement goes towards redressing the balance in access and equity in maternity care in this country, enabling midwives to, for the first time, to work as private practitioners, provide services subsidised by the Medical Benefits Schedule and prescribe medications subsidised under the Pharmaceutical Benefits Schedule.

The Improving Maternity Services Package is an initiative for all Australian women. It is an important move forwards and is strong evidence that the recent Review of Maternity Services has been addressed, especially for women in rural and remote areas.

Of course the devil is in the detail. What exactly does “subsidised medical indemnity for eligible midwives working in collaborative arrangements in hospitals and healthcare settings” mean for midwives who provide homebirth services? How will an “advanced midwifery credentialing framework” fit with the existing national peer review process for midwives?

This is not the moment to retreat to professional corners.

This is the moment to take a deep breath and develop new and more constructive ways of working together recognising and respecting our different skills and capacities. We must keep women and babies at the centre of the discussion, not our various professional perspectives.

This is the time to move forwards using the available workforce in the best way, ensuring that midwives, GPs and obstetricians can each work to their full scope and capacity to ensure the best possible maternity service for all Australian women.

***

Justine Caines, Maternity Consumer Advocate – Mother of seven, living in rural NSW, is also calling it a “Landmark Day for Women and Babies”. She writes:

The budget has announced new funding of $120 M over 4 years to introduce Medicare funding for midwives.

This heralds a new age for maternity care.  To date maternity care has catered to the needs of health professionals rather than women and their families.  The all powerful medical lobby has dictated the terms. It would seem that their greed has been a major part of the reform agenda.

In the 4 years since the Medicare safety-net was introduced, Obstetricians have increased their charges by approx 300%. This budget has reeled these obscene costs in with a cap to the safety-net.  By enabling private practice midwifery through Medicare, private health funds will be able to finally offer choice to women. Importantly midwifery care will also have the capacity to reduce unnecessary costs (by reducing interventions, especially caesarean section and associated costs esp when babies are harmed through surgery and spend time in special care nurseries).

With the introduction of Medicare for midwives rural women can breathe a sigh of relief, soon many more women will have the option of primary midwifery care in their local communities.  The social dimension of midwifery is well placed to make in-roads to close the gap for Indigenous Australians, considering the shocking media recently reporting the tragic consequences of foetal alcohol syndrome this is welcome news.

The only down-side is that homebirth is not yet to be funded. It would seem medical groups will ‘die in a ditch’ over funding homebirth services. Perhaps I’m crazy but at the moment it is easier to terminate a pregnancy than to give birth at home.  Men in white coats wrangle to keep control of women’s bodies. Overall thumbs up to Nicola Roxon, I look forward to working through the implementation.

Nobody expected a generous budget, and at first blush the health budget is definitely not generous.

However, the good news is that the vital area of Indigenous health has received a strong influx of funding (apparently not to be distributed via the jurisdictions), and the programs to incentivise a rural and remote workforce will give an additional boost, as will the establishment of a medical school in the NT. It is unclear why the incentive scheme is lmited to GPs – the bush needs nurses, specialists and allied health care professionals as well. And the opposite applies to dentists – there is funding for Indigenous dental services in rural and remote Australia, but nothing for urban settings.

My dream that the budget would fund the much needed Prevention/Public Health Agency has not come to fruition, in fact the budget is a bit light on the ground on direct prevention initiatives. The funding around cancer is definitely welcome, and of course there is also the potential for hypothecation of a comprehensive alcohol tax package when that makes it through parliament (I am an optimist).

There is a significant amount of money for upgrading hospital infrastructure, much of it directed at regional locations.

Providing MBS and PBS access to nurse practitioners is clearly a sensible move, as is the introduction of access to midwives – although this will be restricted to ‘advanced’ eligibile midwives, which has yet to be clearly defined.

****

The Consumers Health Forum press release says:

The 2009-10 Health Budget will provide better access to health care, particularly for rural and remote communities, Indigenous Australians and those seeking maternity services, the Executive Director of the Consumers Health Forum of Australia, Carol Bennett, said tonight.

‘This budget is a step towards real health care reform in these areas, but does not provide for implementation of the significant reform agenda commissioned by Government,’ she said.

‘We are very pleased that midwives and nurse practitioners will have access to Medicare and PBS, which is an important reform consumers have been advocating for. We are also pleased with the significant expansion of rural health and Indigenous measures which will improve access for consumers,’ she said.

‘We welcome changes to the extended safety net which will reduce perverse incentives for some practitioners rather than penalising consumers. These measures should tighten the system to create better efficiencies.

‘CHF is looking forward to working with Government to deliver on these new measures.

Disappointments

‘We are disappointed there is no new money to implement the recommendations of the reform committees that will be reporting soon, including the NHHRC and Preventative Health Taskforce. We can’t afford to lose sight of the reform agenda even during this economic crisis as it will deliver better health outcomes and cut health spending into the future.

‘We are also disappointed that there is no new funding for important e-health activities. Consumers see e-health, particularly e-health records, as crucial for better safety and quality of health care.  It’s also cost effective – a classic example of how spending now will reap cost benefits.

Private health

‘The health insurance rebate cuts were expected, but consumers want those savings to be fed back into health care to improve the public hospital system, particularly if it needs to cater for those who drop their insurance.’

***

Michele Kosky, Health Consumers Council WA, writes:

Health consumers Council welcomes the initiatives in the 2009-2010 Budget particularly the initiatves for Nurse Practitioners and Midwives. Great benefit to consumers and the begining of real reform in the health workforce and hopefully the end of the tribal warfare that plagues the health professions in Australia.Means testing the Private Health Insurance Rebate seems reasonable in the face of the the GFC as long as benefits evident in public hospital system.
We are particularly pleased that there is continual investment in Aboriginal health in the Close the Gap campaign.
Overall pretty good we think!!
***

A joint statement from nursing groups says:

Royal College of Nursing, Australia (RCNA) and the College of Nursing (CoN) applauds the Rudd Government on its pragmatic decision to provide nurse practitioners access to the Medicare Benefits Schedule (MBS) and Pharmaceutical Benefits Scheme (PBS).

The Federal Government tonight allocated $59.7 million over four years to provide access to MBS and PBS for nurse practitioners. RCNA has lobbied for over a decade for this breakthrough.

“This is a practical decision acknowledging the untapped potential of the nursing workforce,” said Debra Cerasa FRCNA, Chief Executive Officer, RCNA.

Nurse practitioners are already legislated and regulated to safely prescribe medications, but until now, clients have had to pay the full cost of prescriptions.

“Nurse practitioners have the flexibility to reach a range of communities, including those often marginalised and under serviced. Tonight’s announcement will provide greater equity in access to the health system reducing bottlenecks in GP clinics and hospital emergency
departments,” Ms Cerasa said.

“The role of the nurse practitioner complements and sits alongside other health professionals, this step will simply enhance the capacity of the health system to meet community health demands,” said Tracey Osmond, Chief Executive, CoN.

“People currently do not have timely access to appropriate health services. Nurse practitioners will now be better able to meet the community needs within their defined scope of practice.”

“The Budget demonstrates good policy. It will result in making better use of our available health workforce,” said Ms Osmond.

The Budget decision challenges conventional health care funding arrangements. It is a positive sign that the Government is committed to a sustainable, equitable and efficient health system. RCNA and CoN are encouraged by the investment in the role of the nurse
practitioner, and look forward to future decisions that support fundamental structural reform of Australia’s health care system.

****

It’s not all smiles from the Australian Healthcare & Hospitals Association (AHHA). Its statement says:

The AHHA has welcomed the Federal Government’s announcement of much-needed health infrastructure projects.  However the Association’s members are disappointed that the funding for hospitals and health service facilities appears to fall short of the promised $5 billion from the 2008-09 Budget.

The AHHA is the peak national body representing public hospitals, area health services, community health centres and public aged care providers.

“The AHHA is also disappointed that the Federal Government has made the decision to remove the commitment of the additional $5 billion in expected funding to the Health and Hospitals Infrastructure Fund.  This is undermining the future of the health system and threatens the Government’s goals for health reform,” Ms Prue Power, Executive Director, said.

“The community will share our concern that Australia’s strained hospital and health service infrastructure has not been given the much-needed attention that was promised in the last Budget. The health needs of the population do not slow down even when the economy does.

“The funding saved through the means testing of the inefficient Private Health Insurance (PHI) Rebate Scheme should be used to make up the funding shortfall for the Health and Hospitals Infrastructure Fund.  As the Department of the Treasury stated previously in advice to the Government, direct funding to hospitals is much more effective, rather than via the PHI rebate.  The AHHA does not accept that the funds should be lost from the health system as a savings measure.

“The AHHA welcomes some Budget measures, such as the reform of the Medicare safety-net to target benefits more directly to those in need and to reduce the opportunities for private providers to manipulate the system. The AHHA also strongly supports funding to hospitals for elective surgery and subacute care, two key issues identified in the AHHA’s Service Integration policy released in 2008.

“We also support health workforce initiatives announced, specifically incentives to increase the number of doctors in rural and remote areas, and the expansion of MBS and PBS for some nurse practitioners and midwives.  The announcement of infrastructure funding for research and clinical training is also a welcome investment in the future.

“However, the effectiveness of these initiatives will be undermined if our hospitals and health services do not have the infrastructure required to support high quality care.   Unless we want the next generation of Australians to inherit a health system that is not physically equipped to meet the needs of the community and lags behind that of other countries, the Government must increase funding for health infrastructure,” Ms Power said.