WA News Feature Articles Cost Challenge for Specialties
Cost Challenge for Specialties
Written by MF
Wednesday, 25 January 2017


Dr Sue Ulreich, Radiologist

201702-Ulreich-Sue-Dr-SKG-Feb17SKG's Dr Sue UlreichDr Sue Ulreich, CEO of SKG Radiology, sees funding for private radiology as one of the challenges ahead. She said affordable access to radiology services resulted in early diagnosis which improved outcomes but some patients were missing out due to cost barriers.

“It’s time to end the freeze on patient rebates,” she said, pointing out that the radiology indexation freeze had been in place for 19 years. Her point was that health professionals made up 60% of SKG’s costs and their services were not a commodity to be treated that way.

All practices look for efficiencies while facing the freeze but inevitably some costs filter down to patients. She said one-third of radiology services in WA were not bulk billed, with out-of-pocket contributions by patients averaging $114 in 2015-16 (a 70% increase since 2007).

“Many services have rebates so far removed from the cost of providing the service – diagnostic mammography is a good example – that practices either charge significant gaps or don’t offer the service at all because they can’t even afford to bulk bill concession patients.”

“Before the election last year, the Government announced that it would index radiology rebates when it ended the GP freeze but this isn’t scheduled to happen until mid-2020.” She felt the funding shortfall was more urgent than that, for the patients’ sake.

She wants a HICAPS-style billing system for radiology.

“Bulk billing has become increasingly difficult for radiology practices, yet the Medicare rules and systems impose a double whammy on patients. Not only do they pay gaps, but they need to pay the full cost of the service upfront then claim the rebate from Medicare.”

“We regularly hear about West Australians who don’t present for radiology services requested for them by their GP or specialist because upfront costs averaging $235 – and $500 or more for CT and MRI – are out of reach.” She considers this potentially damaging to a patient’s health.

“It is a very strange anomaly that I’m able to pay just the gap when I go to the dentist, while they claim the rebate directly from my private health insurer using the HICAPS system.”

Dr Gordon Harloe, Pathologist

201702-Harloe-Gordon-Dr-mate-Oct14Clinipath's Dr Gordon Harloe and Mr Chris AtkinDr Gordon Harloe, is a practising pathologist and CEO of Clinipath Pathology. He has seen many changes, the latest of which is the recent sale of Perth Pathology and SJOG Pathology to private equity company Australian Clinical Laboratories. What pressures are labs under?

 “With the chronic Federal Government underfunding of pathology and increasing cost pressures, laboratories have had to sell in the eastern states. These ‘forced aggregations’ enable laboratories to survive with economies of scale,” he said.

“Path labs are only paid by Medicare for the three most expensive groups of tests ordered by GPs [the cone] while specialist work is currently not coned and all tests requested by them are paid for. Successive governments have cut pathology rebates and it concerns the pathology sector that the MBS Review, under the guise of best practice and quality, may introduce further fee cuts.”

“About 70% of clinical diagnoses are supported by a pathology test and 100% of cancer diagnoses. So we will always need that scientific confirmation of the clinical diagnosis. Tests also monitor chronic disease, such as diabetes using glycosylated Hb, and molecular pathology is already being used to monitor cancer and cancer therapy”

Test costs are coming down

“As computing costs drop molecular tests will become more affordable. For example, the non-invasive prenatal test [NIPT] was well over $1000 and it has now dropped to $425 in 2017. If the government drags its heels on paying for new tests, such as the NIPT, the patient pays and there are big savings for government.”

In the example of the NIPT, Medical Forum guesses that pregnant mums may be more willing to pay, particularly if they (and government) benefit from reducing the number of amniocenteses.

We have also noted the proliferation of pathology collecting centres since the government stopped regulating them in 2010. Increased numbers must be adding to each provider’s bottom line although the final number of collection centres is sure to reflect market forces, with factors such as co-location within medical practices, rental paid, and staffing costs coming into play. In a twist, in response to threat from the government to again regulate, the AAPM has come out against this idea partly because many medical practices now rely on the income from collecting centres.

Consumerism is having an influence.

“Patients expect everything to be just around the corner. Having pathology collection centres located in every suburb comes at a significant cost as does being open after hours. Where does it end? The Medicare rebate doesn’t properly support this extended level of service and convenience,” Gordon said.

In the pathology world, one big change this year is to cervical cancer screening with added benefits for women poorly screened under the previous regime.

“Those women who were averse to Pap smears can now be screened using self-collection of a sample under supervision in medical practices.”

“There is also provision for HPV screening of women after their second episode of post-coital bleeding and for those who are immunocompromised. So it’s a very comprehensive, safe system that is going to prevent cervical cancer in up to 30% more patients and we hope make inroads into reducing adenocarcinoma of the cervix.”

On the downside, with the reduction in Pap smears, fewer cytologists will be required to review the cytology specimens and there will be redundancies. Furthermore, the draft guidelines suggest 2000 screening tests per month are needed to maintain competency, and some labs will fall below this minimum threshold and Pap smear cytology departments will have to close.

Liquid biopsies break new ground

Another big change coming is ‘liquid biopsies’ for cancer by sampling peripheral blood. Testing is currently for research and is expensive but has the potential to replace either direct tumour biopsies or imaging as it can detect very early recurrences and small metastases. By detecting either circulating tumour cells or circulating free tumour DNA, future testing may help identify mutations that lead to tumour resistance, changes that might be missed on biopsies.

“Immuno-oncology is a rapidly growing area. Testing can be used to identify tumours with a particular gene expression that would benefit from particular immunotherapy, such as PD-L1 expression in non-small cell lung cancer. Genomic tests are used to analyse tumours, identifying the active genes, and provide guidance as to the likely behaviour of the tumour. For example, the Prosigna test is used to predict the risk of recurrence of hormonally sensitive breast carcinoma in post-menopausal women.”

“Where will it end?” he said, referring to future screening for cancer.

Gordon wants Clinipath to remain the laboratory of choice in 10 years’ time, providing a high quality diagnostic service that WA doctors and patients trust and rely on. This means stronger linkages with the parent company to ensure access to the latest advances.

Dr Mark Hands, Cardiologist

201702-Dr-Mark-Hands-June 13-Western Cardiology's Dr Mark HandsDr Mark Hands has been chair of Western Cardiology for 25 years so it’s fair to say he’s seen some changes in his time. He believes the great agents of change and innovation have been IT, equipment technology and pharmaceutical advances.

Information Technology

“IT has certainly changed the way we do things,” Mark said.

“Telehealth has given us better access to regional and rural patients; electronic referrals and reports provide rapid turn-around times; we can report and review wherever there is internet access, electronic scripts have reduced prescribing errors; we have better recording keeping and generally there is improved communication with everyone on the patient journey.”

Equipment technology

Open heart surgery with its attendant risks and morbidity is now often avoidable with the development of percutaneous procedures such as aortic valve replacement for significant stenosis, reduction of significant mitral regurgitation (with Mitraclip), and closure of the left atrial appendage for stroke prevention.

“An enormous advance is that we can now accurately and percutaneously measure blood flow across coronary artery blockages to determine if an intervention such as coronary stenting should be undertaken or not. This approach now has proven prognostic benefit,” he said.

Pharmaceutical advances

These include the new novel oral anticoagulants which Mark says provide safer stroke prevention in the very common non-valvular atrial fibrillation without the need for INR blood-test monitoring. Advances also include the development of the potent lipid-lowering PCSK 9 inhibitor (Repatha) for resistant significant secondary dyslipidaemia.

“But in the end it is the high quality health professionals we have today that make all these innovations work to produce good patient outcomes. We have to be a highly qualified and trained team to achieve those outcomes,” he said.

However he saw troubled times ahead with little innovation in the timely treatment of uninsured patients requiring inpatient services, and the lack of complete cardiology services in rural and regional areas.

For those privately insured, Mark believes that health funds are not providing adequate cover and while the Federal Government’s review into private health insurance is exploring some of these thorny issues, he’s not hopeful of its success.

He believes that over the next five to 10 years, methods of reimbursement will change and will be related to outcome data.

“I suspect governments of all persuasions and private health funds will demand this given the present exponential growth of health care costs. The biggest issue here will be the accuracy of the collected data,” he said.

He also sees a significant growth in procedures done as day cases, with increased patient convenience and reduced overall costs.

“Also expect to see an explosion in genetic testing and diagnosis. That is sure to come.”

And putting it out there, Mark reckons that in 10 years, drones will be the medical couriers of choice.