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COMMUNITY AFFAIRS LEGISLATION COMMITTEE
DEPARTMENT OF HEALTH AND FAMILY SERVICES
Program 2--Health Care and Access
Subprogram 2.1--Medicare Benefits and General Practice Development
- Committee Name
COMMUNITY AFFAIRS LEGISLATION COMMITTEE
DEPARTMENT OF HEALTH AND FAMILY SERVICES
Program 2--Health Care and Access
- Sub program
Subprogram 2.1--Medicare Benefits and General Practice Development
- System Id
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COMMUNITY AFFAIRS LEGISLATION COMMITTEE
(SENATE-Friday, 14 November 1997)
- Start of Business
DEPARTMENT OF HEALTH AND FAMILY SERVICES
- Program 5--Aged and Community Care
- Subprogram 1.2--Health regulation
- Subprogram 1.3--Health Research and Information
- Subprogram 1.2--Health Regulation
- Subprogram 1.3--Health Research and Information
Program 2--Health Care and Access
- Subprogram 2.1--Medicare Benefits and General Practice Development
- Subprogram 2.2--Pharmaceutical Benefits
- Senator Herron
Content WindowCOMMUNITY AFFAIRS LEGISLATION COMMITTEE - 14/11/1997 - DEPARTMENT OF HEALTH AND FAMILY SERVICES - Program 2--Health Care and Access - Subprogram 2.1--Medicare Benefits and General Practice Development
Senator FORSHAW --I am advised that divisions of general practice have recently been notified of funding changes. Is that correct?
Dr Morauta --Yes.
Senator FORSHAW --Can you explain what those changes are and the reasons for them?
Mr Keith --Basically the changes are a move from providing funding on a project application base to providing block funding on a program base to divisions. The previous arrangement was that divisions were invited to put submissions in for particular projects. At any particular time the department would be handling over 1,700 projects. The projects could start on any one day of the year and conclude on any one day of the year.
A number of divisions and people we consult within general practice found this arrangement unsatisfactory because of the uncertainty it provided. When the program first started there was quite a deal of capacity within the program. Divisions felt that if they put in for an annual project there was a deal of certainty that that project might go on in perpetuity. The difficulty was that, as divisions became more established, they put in more applications for projects. This led to a position where there was no certainty about where funding was coming from for divisions.
It was agreed, therefore, in consultation with general practitioners and divisions to move to program based funding. This would mean there would be certainty in funding, because the entire appropriation for divisions would be distributed across divisions on an agreed formula with general practice. That would provide equity and certainty. Divisions would be given more flexibility in how they applied those funds.
At the moment, funding can be used only on the particular project for which the money is given. A number of divisions from time to time had written in and said, `While we are running this particular project, we would like to use the money for something else.' So the new funding arrangements are to provide more flexibility to divisions to respond better to local needs.
Senator FORSHAW --Are you able to provide a list of the divisions and the funding changes for each one?
Mr Keith --Certainly.
Senator FORSHAW --Would you do that?
Mr Keith --I will happily do that. One of the undertakings we gave to divisions was that we would be quite transparent in ensuring that each division knew what each other division got under the formula.
Senator FORSHAW --So you will take that question on notice. Has a freeze been placed on all future funding?
Mr Keith --No.
Senator FORSHAW --You said a moment ago that the divisions had indicated to you their views about these funding changes and that they had made requests in the past for certain changes. What has been the response from the divisions and interested parties to these changes since they were implemented?
Mr Keith --Divisions were advised of the changes formally on 1 November, and they were asked to respond by 1 December whether they wished to move to these new arrangements. At this stage we have had no adverse criticism of it. One or two of the divisions have indicated they would have difficulty in trading down to the new arrangement and have sought advice on how flexible the arrangements will be.
Senator FORSHAW --So there are still some responses to come in.
Mr Keith --Yes.
Senator FORSHAW --Would you mind providing to the committee indications and, if possible, copies of their responses after the cut-off date of 1 December?
Dr Morauta --We can provide copies of their written responses.
Senator FORSHAW --Thank you. Then we will be able to have an indication of what their attitude has been. I want to now move on to another issue under subprogram 2.1 relating to Medicare benefits. Can you advise where the new Medibank Private offices will be located? Evidence has been given to this committee previously, both in estimates and more recently in an inquiry into the legislation, that Medibank Private offices will be separated from the Medicare offices, and I think approximately 70 specific Medibank Private offices will be opened over the course of the next 12 months. Can you give us an update on where they are going to be and how long it is going to take?
Mr Whelan --The commission of Medibank Private will cease to share branch offices from 30 June 1998, and that has necessitated Medibank Private developing its own distribution strategy, which involves, in part, branch offices. The exact number and final location of those branches has not been decided at this point in time, although the roll-out of those branches has commenced. Two Medibank Private only branches have opened in New South Wales--one at Hurstville and one at Penrith--and I understand a further branch will open in Bankstown in the next week. Plans for further branches are being developed at the moment but have not been finalised.
Senator FORSHAW --A number of Medicare offices have already closed as a result of the other decisions. Have all of those Medicare offices that were due for closure now closed? A lot of them were to go before the end of October, weren't they?
Ms Wood --Seventeen of the 43 offices have closed to date.
Senator FORSHAW --Could you provide me with a list of the 17? I have some of this information from the previous estimates, but they were projected at that time. Could you also give me the proposed dates for the closure of the other 26?
Ms Wood --They have not varied their proposed dates from the earlier information that was given.
Senator FORSHAW --If you could give me a summary, that would be good. With the 17 that have been closed, what has happened with the Medibank Private services that were previously available in those offices?
Ms Wood --When we came up with the criteria for the closure of these offices, the criteria was minimal disruption to the public, within very close distance to another branch office and staff redeployment. So, like all our programs, the Medibank Private program servicing from the branch just moved to the closest branch to the one that closed.
Senator FORSHAW --Can I take it from what you have said that the new Medibank Private offices will be opened progressively? I think that is obvious. Over what period of time are you talking about here? The official date, as you said, was 1 July next year.
Mr Whelan --We expect that the two functions will cease sharing a branch office network from 30 June 1998. We expect that Medibank Private will have rolled out a substantial part of its branch office network by that time. I would add that the branch network is just one mechanism of servicing the customers of Medibank Private, and a range of agency arrangements, telephone support arrangements and direct servicing arrangements have also been put in place for that function.
Senator FORSHAW --If you do not happen to get all of the new offices opened by 1 July next year--which, from what I can see, would be a pretty tall order but maybe you are going to do it--will there be an opportunity for the Medicare offices to continue providing Medibank Private facilities in particular areas where there is no new Medibank Private office open at that stage?
Ms Wood --At this point, no. However, Medibank Private is looking at ensuring that their customers are not disadvantaged by the split.
Senator FORSHAW --That is what is prompting my question. I would have thought that--notwithstanding all the new-beaut ways of lodging claims that Senator Herron and I had a discussion about last time, such as telephones, fax machines and so forth--this is a shopfront service that has been in existence for quite some time and people are quite used to that, particularly certain groups of clients. To just have their Medibank Private service closed in their area without one being opened, albeit in a wider region, would have some impact. Notwithstanding how many letters Medibank Private sends to them, and I get them all the time because I am a member--
Ms Wood --At this point in our planning, everything is running on time and we do not see the problem arising. If we get early notice that there may be some delays, we will obviously deal with the issue as we see a problem arising. At this point, we are quite confident.
Senator FORSHAW --How many of the new Medibank Private offices will be located in rural and regional centres?
Mr Whelan --I cannot give you that detail at the moment. The numbers and final locations of the branch offices of Medibank Private have not been determined at this stage. I would imagine, though, that the branch office and distribution mechanism for Medibank Private would align with the distribution of its membership.
Senator FORSHAW --Why has it not been done? Would it not have been sensible and efficient to have worked out which regions and towns you were going to locate these offices in prior to proceeding to push the legislation through the parliament and also close these other Medicare offices? Why was it not all put together beforehand?
Mr Whelan --There was a lot of planning undertaken in that regard. As you would imagine, Medibank Private operates in competition with a range of other private health insurance funds. My observation, with regard to finalising the actual decision to locate in particular locations, is that the location of its branches is something that goes to its commercial position in the marketplace. So, while a lot of planning has been undertaken and that planning indicates that Medibank Private will be able to support its membership in the future, there is still tuning and finalising of those exact locations. I do not expect that the fund will be in a position to make announcements of those that are at a particular point in time as to what will be the exact number and the exact location of those branches.
Senator FORSHAW --This is a fairly significant change in that you have around 250 or 270 Medicare offices that are being reduced by 43, and Medibank Private and all of those facilities are being closed down in the remaining Medicare offices and 70 new ones are being opened up. That is a pretty big drop. It looks like it is easier to make a decision as to where you close the offices and also a decision to stop the service in all of the Medicare offices but not, at the same time, to have worked out where you are going to put the new ones. That comes afterwards.
Mr Whelan --I guess there are two issues at play here: the issue of the government to close Medicare offices for the purposes of redirecting resources for the distribution of Medicare and the decision of the government to separate Medibank Private from Medicare. They are not necessarily the same decision.
Senator FORSHAW --But for the Medibank Private members, which is the biggest fund--there are a lot of members--it has the same effect. There are 43 Medicare offices to be closed. Originally some of them were going to be closed in regional areas, but the government changed its position on that. In addition, the service is being removed from all the remaining offices, so it has the same effect at the end of the day. Do you agree?
Mr Whelan --At the end of the day the separation of Medibank Private from the Health Insurance Commission is going to have an effect on Medibank Private customers. But Medibank Private is looking to put in place a distribution mechanism to support its membership in both regional and metropolitan Australia.
Senator FORSHAW --I would ask you to take it on notice if you cannot tell me today and tell us where it is intended to locate these new Medibank Private offices; that is, the whole 70 of them. I am particularly interested in the rural and regional areas, where the problems of distance are greater.
Mr Whelan --It may not be possible to provide that information to you. It goes to the commercial nature of Medibank Private. It is an extremely commercially sensitive piece of information.
Ms Wood --We are in negotiations.
Mr Podger --The whole issue about the split will be that Medibank Private will be a full commercial arrangement. We, the government, as shareholder in that, will be very keen to see its financial performance. We would be very keen for it to keep up its membership and so on. But it will not be a matter then for detailed issues of exactly the way they manage their offices and distribution.
Senator FORSHAW --I have asked the question and I am conscious of time, so I want to keep moving on. What is the total cost of the opening up of the new offices? What is the estimated cost of these 70 new offices?
Mr Whelan --I am not making any observation about whether there are 70 offices or whatever number of offices that Medibank Private might open. The cost of the distribution network for Medibank Private is again a matter that is commercially sensitive.
Senator FORSHAW --We were told in the other hearing that it was around $80,000 per office for fit-out and relocation. Take that one on notice too and come back to me. Finally on this one, will people who are members of Medibank Private be able to lodge claims in pharmacies or doctors' premises in the same way it is intended to be able to lodge Medicare claims? Is that facility going to be available?
Mr Whelan --The private health insurance industry in general is looking at the introduction of electronic commerce. I would imagine Medibank Private customers will be able to have access to claims lodgment facilities in pharmacies and other places, but it is unlikely they will be using the same facility Medicare clients use.
Senator FORSHAW --I was not suggesting they were, because there is a separation going on here. But one of the arguments that is put is that there are going to be these alternative ways which are fairly common now anyway. Therefore, I wanted to know whether Medibank Private was getting that set up as well.
Mr Whelan --Yes, it is.
Senator FORSHAW --I had some questions on chronic fatigue syndrome.
CHAIR --Senator Gibbs has put a number of questions on notice on chronic fatigue syndrome. You may care to have a look at them and see if they are similar.
Senator FORSHAW --I think I can put mine on notice. They relate to program 2.1. My recollection is that Senator West also had some questions on that issue but in the context of 2.2, pharmaceuticals.
Senator EGGLESTON --I would like to ask some questions about funding for the WA Centre for Remote and Rural Medicine. I read an article in the West Australian recently where the WACRRM was concerned that its level of funding might be decreased. My questions are in terms of the federal component. What I am particularly interested in is the rural incentive program, RIP. My first question is: are levels of funding for the rural incentive program to be maintained or is there a proposal to change them?
Dr Morauta --The general answer to that question is that there are two reviews going on at the moment about general practice. The minister has said that he is comfortable with these reviews coming forward with changes to existing programs--suggesting ways of improving programs and doing them better. It is not a savings exercise but an exercise in seeing whether there are better ways to do things. It would be fair to say that in any of those general practice programs which are part of the general practice strategy it is possible that changes will occur, but at the moment it is not being seen in the context of a savings exercise. It is more like changing--
Senator EGGLESTON --What you are saying in effect is that you are not proposing to cut the funding to those programs but perhaps to change the allocations within them?
Dr Morauta --Yes, that is the sort of scenario which is on the table with the reviews.
Senator EGGLESTON --I believe one of the factors in the rural incentive program in the allocation of funding is something called the remoteness index. Is that the case?
Mr Keith --Yes, that is right.
Senator EGGLESTON --Are there changes proposed to the remoteness index?
Mr Keith --The index that has been used in the past is quite crude, in a sense. That has resulted in a disproportionate distribution of the money across the states. Western Australia does rather well under the current program. We are looking at that distribution. You mentioned WACRAM. We are having discussions with WACRAM about funding options for the future.
Senator EGGLESTON --WACRAM is quite concerned about the revision of the remoteness index, in that, while Western Australia is in effect a city state and a lot of Western Australia is remote and rural, they feel that WACRAM may be disadvantaged in the rejigging of this index and that Western Australia could lose substantial funding provided under the rural incentive program. Can you give me an assurance that that will not be the case?
Mr Keith --I do not believe that will be the case.
Senator EGGLESTON --How will it not be the case if the index is rejigged but the amount of money is not changed? If the pot does not grow bigger, surely Western Australia will find itself at a disadvantage in comparison with, say, Queensland and New South Wales?
Mr Keith --In saying we would rejig the pot, I used the wrong words. We are looking at the formula at the moment and, in discussions with the people who are doing the rural incentive package, certainly a guarantee has been that there will be no changes this year to the funding in the allocation. That is pending the outcome of the review. I would imagine that we would have difficulty agreeing on a new formula in places like Western Australia and the Northern Territory, given our commitments to this program.
Senator EGGLESTON --WACRAM has an excellent record of having significantly increased the number of doctors in rural Western Australia from something like 250 to over 400. It has provided locum services for doctors in rural and remote WA. It has provided excellent continuing medical education programs and has encouraged high school students in country areas to enter medical school and, on graduation, return to country areas. I would ask that these achievements be borne in mind. In the promotion of the interests of rural medicine WACRAM has become something of a world standard centre. I would like to put on record my concern that WACRAM is concerned that they may, once this remoteness index is rearranged, suffer a considerable funding reduction. If that undermines and lessens the effectiveness of WACRAM's programs, it would be a very great pity.
Mr Keith --We share your confidence in the achievements of WACRAM to date. Part of WACRAM's funding also comes from the state government, and we are having discussions with the state government also, to ensure that there is not substitution of our money for their money. I am quite confident that we will reach an agreement with WACRAM to maintain the high levels of service they currently provide.
Senator EGGLESTON --It seems, though, that most of the funding comes from the federal government, as I understand it, for the WACRAM budget. Is that not the case?
Dr Morauta --Can we take the question on notice? We thought it might have been the other way around. But let us take the question on notice. We will provide you with that information.
Senator EGGLESTON --I think that they get quite a substantial amount of money under the rural incentive program.
Mr Keith --They do. But the state also provides them with money for different other purposes, including infrastructure. There are some discussions with the Health Department of Western Australia about ensuring that they maintain that level of funding.
Senator EGGLESTON --But are there not other factors at work within the Western Australian health budget which might affect WACRAM's funding?
Mr Keith --I would hope not.
Senator EGGLESTON --Could we ask that details of the funding provided to WACRAM and other similar medical organisations around Australia concerned with the promotion of rural health initiatives be provided on notice.
Mr Keith --We are happy to do that.
Senator HARRADINE --Could I go to the question that I was commencing previously. It really is leading up to the Health Insurance Commission and Medicare, as well as requiring some responses from, I suppose, the departmental officials that provide the information. I referred on Tuesday to how Dr David Grundmann, Medical Director of Planned Parenthood Australia, described the methods he used on the ABC 7.30 Report. He referred to the D&X method, dilation and breach of stress method, as follows:
Essentially it is a breach delivery where the foetus is delivered feet first and then, when the head of the foetus is brought down into the top of the cervical canal, it is decompressed with a puncturing instrument so that it fits then through the cervical opening.
That is his own description of what he does. At the last estimates committee I followed up a number of matters that I had asked previously, and one of these was about whether the foetus feels pain. After having written to various people, you gave your response to me on notice No. 127, which must have only recently come in, I suppose in September, because I asked the question on 19 August. Your response is:
The conclusion of the abstracts was that `these data suggest that the foetus may take hormonal stress response to invasive procedures'. They raise the possibility that the human foetus feels pain in utero and may benefit from anaesthesia or analgesia for invasive procedures.
Could I just ask why the department would suggest that. Doesn't the department know that Dr Grundmann does not use a general anaesthetic?
Ms Batman --I did not know that. I do not know whether other people in the department knew that. The article that the Royal Australian College of Obstetricians and Gynaecologists provided us with was not particularly in relation to the procedure that you were asking about. We have asked again. The article in question was really about interuterine needling. But I am just not aware of the procedures that David Grundmann does and whether or not anaesthetic is used.
Senator HARRADINE --I am quoting from a paper that was written by him. It talks about the advantages of the D&X method, that it can be performed under local or twilight anaesthesia and there is no need for narcotic analgesics.
Ms Batman --The issue from the point of view of the Medicare benefit schedule is that we make sure that anaesthetic units are available in connection with procedures which may require anaesthesia. We do not have any capacity to insist on it. The appropriate medical practice in that regard is a question for state authorities most usually, and I understand that the Queensland Medical Board and the Queensland health department are in fact investigating the doctor in question and his practices, and that is generally the appropriate forum for those inquiries.
Senator HARRADINE --I have got another question on the point that you just made, but are you aware that expert testimony provided to the US Senate Judiciary Committee hearings by the American Society of Anaesthesiologists says this:
Very little anaesthesia crosses the placenta when general anaesthesia is administered to the mother, and many pregnant women are safely anaesthetised every day without ill effects to the foetus.
I am asking really why the department should provide information such that, on receiving it, a simple senator might say, `Oh well, general anaesthetic would work,' but in fact it does not on the foetus.
Ms Batman --We did have that advice, that anaesthesia did cross the placenta. I was not aware of the statement that you read out, and perhaps we should take it on notice--
Senator HARRADINE --No, I did not say that the expert evidence was that anaesthesia crosses the placenta. What I said, quoting the expert testimony by the American Society of Anaesthesiology--
Ms Batman --Yes, sorry, I did understand that. I understood that that was what you read out. However, that is not what I had heard in the past. I am not a medical practitioner and I have no basis on which to discuss it, but I can offer to take it on notice and get some research done on it. But it is contrary to what I have been told by medical practitioners, medical advisers and people from the obstetricians and gynaecologists association. I have no expertise in this matter, and I really think I will have to take it on notice.
Senator HARRADINE --I note that you say, `The Medicare benefits schedule makes provision for a Medicare rebate for an anaesthesia associated with termination of pregnancy.' Is it the department's understanding that patients undergoing late mid-trimester terminations of pregnancy would have a general anaesthetic and, accordingly, the foetus would feel no pain?
Ms Batman --The advice that I had been given was that that would be the usual procedure--that, on the basis that these are usually day-only cases, under those circumstances, a general anaesthetic is preferable because people can go home at the end of it whereas with an epidural they may not be able to walk and may need to be admitted overnight.
Senator HARRADINE --I am talking about the question of whether the foetus feels no pain. You have here a statement which says, `It is the department's understanding that patients undergoing late mid-trimester terminations of pregnancy would have a general anaesthetic and, accordingly, the foetus would feel no pain.' What I am putting to you is that I have not seen anything from the expert testimony of anaesthetists to suggest that--in fact, it is quite the contrary.
CHAIR --Senator Harradine, with all due respect--and I am not trying to stymie your questions--Ms Batman has really said that she does not have the expertise to answer the question.
Senator HARRADINE --I understand that, but she has obviously provided information. I wonder whether somebody in the department might take that one up. It is a very important question.
Mr Podger --Senator, we sought some expert medical advice. You have raised a question. We will go and check that medical advice. I think Professor Whitworth, Chief Medical Officer, has advised me that she is not aware of the details you are talking about. Therefore, we cannot give you an answer now, but the department will do so.
Senator HARRADINE --Okay. But this is a very important question: whether you are paying Medicare for procedures done which are causing severe pain to the foetus. Don't you think that the public are entitled to know whether or not they are paying for procedures which are inflicting pain on an innocent being?
Mr Podger --The issue is that we pay medical benefits for medically appropriate procedures. We do not police those procedures. Those procedures are a matter for state governments and for colleges and so on.
Senator HARRADINE --I am not talking about whether you police them or not. I know that you do not. But isn't this a matter for the interests of the public: that you would pay Medicare for a procedure which inflicts pain on an innocent being?
Prof. Whitworth --Perhaps I could assist in relation to the question of pain perception. The reflex withdrawal and increased hormonal secretions that have been referred to may occur as subcortical reflex responses in the absence of pain perception. The critical question here is when the neural connections are formed to make pain perception possible. Although that is not absolutely clear in humans, there is very substantial neural plasticity.
The expert advice is that it is probably around 26 weeks that those neural connections are formed to allow pain to be perceived and that those connections, in line with the extreme plasticity, will further develop up to and possibly after birth. So we would be very safe in saying that it should not be possible for a foetus to feel pain prior to 24 weeks and probably up to 26 weeks. My advice has been that significant amounts of anaesthesia would cross the placenta. But I personally have not taken expert advice from the College of Anaesthetists, and we would be very happy to do so.
Senator Herron --Could you tell me where that report came from?
Prof. Whitworth --Which report is that?
Senator Herron --That, with pain perception, the connections do not occur before 26 weeks.
Prof. Whitworth --That was based on the panel set up by the Royal College of Obstetricians and Gynaecologists in London. I have also personally consulted with foetal physiologists, developmental biologists, neurologists and so on.
Senator Herron --But could you give me the reference of the article?
Prof. Whitworth --Yes, I will provide that to you.
Senator Herron --Could you put it on the record?
Prof. Whitworth --Yes, I will take it on notice.
Senator Herron --You have not got it with you?
Prof. Whitworth --I have not got it with me.
Senator Herron --Because there is considerable evidence--and I have read the reports--that the pain perception occurs at spinal level in any case. The analogy or reference that I can give you is that that is why the current practice is to give analgesics prior to general anaesthesia. The pain relief, after the procedure, is increased because suppression at spinal level occurs by taking analgesics. For example, with a surgical incision, it is now recognised that analgesics should be given prior to a surgical procedure so that the wound pain, after the procedure, is diminished. That is at spinal level. I would be interested to read that report where apparently that understanding is contradicted.
Prof. Whitworth --It is correct, in my understanding, that it is facilitatory at the spinal level. But pain perception requires cortical connections: for example, withdrawal responses and so on that are seen in quadriplegics.
Senator Herron --Yes, but there is current research saying that that is in dispute. I would be interested in receiving that research.
Prof. Whitworth --We will certainly provide it.
CHAIR --This is somewhat different; we have the questions--
Senator Herron --I crave your indulgence. I will not have the opportunity to pursue it in any other forum.
Senator WEST --You should be up here asking questions.
Senator Herron --I miss being up there, but not very much.
Senator WEST --We will get you up here very shortly.
Senator HARRADINE --Professor Whitworth, have you not made yourself aware of the evidence that was given to the Congress committee in respect of this matter?
Prof. Whitworth --No.
Senator HARRADINE --Why not?
Prof. Whitworth --I had not considered it appropriate.
Senator HARRADINE --Just to question what you have said, could you comment on the testimony of the Professor of Neurosurgery at Case Western University in Cleveland? He said:
There are published scientific studies that demonstrate that by the 20th week, many of the neuronal pathways that sense pain have already started to develop. By the 24th week, the connections of the cortex and the thalamus are well under way . . . There is no way to argue with impunity that pain reception is not possible.
Michael J. Murray, who is an anaesthesiologist at the Mayo Clinic in Rochester, agreed. In fact, he said that physicians doing foetal surgery inject narcotic fentanyl and muscle relaxants into the umbilical cord to provide pain relief, even though the mother is already anaesthetised, `because what they get from the mom is not enough'.
Prof. Whitworth --I am very aware that this is a contentious issue and I am also aware that, as with most things in medical science, it really is not absolutely clear. Nonetheless, on the advice I have been given in relation to developments of the connections appropriate for pain perception, certainly the consensus view is that it is around 26 weeks and probably not prior to 24 weeks. I am aware that there are other bodies of opinion.
Senator HARRADINE --What is your position in the department?
Prof. Whitworth --Chief Medical Officer.
Senator HARRADINE --It surprises me that you have not availed yourself of the testimony that was given at the Congress committee. I raise this matter in the context of the D&X method, which is the preferred use. In fact, it is used by Dr Grundmann. In the supply of medical benefits to Dr Grundmann, you should know that it is his statement that he does not use in any event any general anaesthetics.
Ms Batman --We did obtain material on the American bill and the statement by the AMA. But we did not have the transcripts of all the hearings.
Senator HARRADINE --I asked you before about the provision of indicators on the Medicare form as to the purpose for which the procedure was performed, the type of procedure that was performed and why this could not be done. If you were sure that a procedure was performed for the purpose of sex selection, would you pay Medicare?
Ms Batman --It may well be that the Health Insurance Commission needs to answer that. The items that go on the schedule are based on trying to represent appropriate medical practice. There is a question--at the sort of theoretical level, if you like--about what is appropriate medical practice and what items should be on the schedule that reflect that and the fees that go with it. At the detailed level of practice, on the ground, it is not a question that relates directly to Medicare. The Health Insurance Commission assesses claims to make sure that they are in line with the items and looks at, in general, appropriate clinical practice. But the specific matters that you are raising are really a matter for state medical boards. If, for example, a doctor was performing open heart surgery without using anaesthetic, presumably the Medicare benefits may be payable up until a point when that person was found guilty of inappropriate practice.
Senator HARRADINE --I asked about sex selection.
Ms Batman --The questions are, I guess, across a number of jurisdictions. The item exists for when it is used in clinically appropriate circumstances. The question of whether that is a clinically appropriate circumstance has never arisen at the Medicare benefits level.
Senator HARRADINE --Has not arisen?
Ms Batman --No, not in any discussions around that. It has not come up.
Senator HARRADINE --Are you not aware that Dr Grundmann has no problem with the issue of sex selection abortions?
Ms Batman --Again, I think maybe the Health Insurance Commission might answer. If there were a complaint or some evidence that that was the case, then the Health Insurance Commission could refer that matter to the professional services review scheme, where it would be reviewed by a panel of peers as to whether that was appropriate clinical practice. If their decision was that it was inappropriate, then the benefits would have to be repaid.
Senator HARRADINE --Are sex selection abortions illegal?
Senator Herron --It is not really appropriate to ask the officer for an opinion. In this circumstance actions of an illegal nature would be pursued by the responsible state instrumentality and similarly the registration board by the state.
Senator HARRADINE --I understand that, Minister, but what I am getting at is the need for some information for people. The last time I asked for information--and they have given us the information--as to what is legal and what is not legal. In respect of that, I have noted what the situation is with the law in Queensland. I have also noted Dr Grundmann's practices and what is happening there. What I am really getting at is the question of payments by the taxpayer through Medicare for the types of procedures which cause pain to the foetus, the types of procedures which are for the purposes of sex selection and the types of procedures which, on the face of it, are illegal under the Queensland jurisdiction. That is why I am asking the questions.
Senator Herron --Medicare benefits go to the patient. The medical practitioner, on the other hand, could be sanctioned under Medicare only if he or she were convicted of an indictable offence. I think that that process would have to ensue before the Medicare benefits are withheld from the practitioner. I think that is the process now. I will ask the officers whether that is correct.
Mr Watzlaff --Yes. In the event that we were to receive a complaint in relation to a matter like that, we would of course investigate it. But, if the matter concerned issues that went to state law or the fitness of an individual to practise, we would be obliged to refer that matter to the relevant medical board for them to take up the issue. Whilst we look at inappropriate practice and we look at excessive servicing and things of that kind, if there is any suggestion that there is a breach of the criminal law or if there is a question that goes to fitness of practice, those matters are properly matters for the state authority to administer and we would so refer those matters.
Senator HARRADINE --Earlier this week we went through the child-care legislation. There are huge penalties for ordinary parents if they do not, for example, give information. I have asked about a person who is in effect a criminal--and I say that quite deliberately, as the High Court has said it--who is conducting procedures which cause pain to innocent parties and who has no problem with sex selection abortions, and you are asking us to pay--I am here representing the taxpayer--money for those procedures. That is what you are asking. The department is not taking any action. They are not even investigating. They are not even prepared to ask questions on the Medicare form as to the purpose of the abortion or, even if they do not want to ask that, they are not asking as to the procedures to be followed--whether those procedures were undertaken, whether they are the D&X method or not.
Mr Podger --First of all, on the issue of the forms, I recall you raised that issue before and it was raised with the minister and the minister determined he was not going to change the form.
Senator HARRADINE --I was going to ask you questions about that.
Mr Podger --On the issue of the person concerned, you have heard what the procedure undertaken by the Health Insurance Commission is. My understanding is the person is under investigation. That is the process we are following, as per normal process.
Senator HARRADINE --Are you aware that that medical practitioner is seeking to expand his business into the state of Victoria? Are you aware of that?
Mr Watzlaff --No, I was not aware of that.
Senator HARRADINE --Is anybody in the department aware of that?
Mr Podger --I am not aware of that, but I am aware that the gentleman concerned is under investigation.
CHAIR --Mr Podger cannot add anything further to that, Senator Harradine. He has given a comment on the doctor.
Senator Herron --Senator Harradine, before you get onto your next question, could you clarify things for my purposes. You mentioned the High Court in a previous statement. I wonder if you would clarify for me what you were referring to.
Senator HARRADINE --You know I do not make those statements wildly, particularly when it relates to individuals.
Senator Herron --That is why I am asking you to clarify it for me.
Senator HARRADINE --It is Lawrence Edwin Georgeson and David Grundmann on 25 September 1996.
Senator Herron --Yes, I am familiar with that now.
Senator HARRADINE --I refer to the need for the taxpayer to know what they are paying for. Surely the taxpayer is entitled to know whether they are paying for procedures that are likely to be causing pain to innocent parties. I wanted to know the purpose for which the procedure was undertaken and at what stage of pregnancy the procedure was performed. The response to me indicated that there are questions of a patient's right to privacy and the limited Commonwealth role in the health system. It really came down to the question that it could breach a patient's right to privacy. I was not asking for the supply of the forms with the patient's name on them. I was simply asking why there could not be included on the form the stage of pregnancy at which the abortion was undertaken.
Ms Batman --It is a matter of government policy.
Senator HARRADINE --Can I have a copy of the minute that you wrote to the minister about on this matter?
Mr Podger --We will take that on notice. You will understand that it is not usual practice to provide copies of the actual advice.
CHAIR --Officers are asked not to reveal advice given to the minister, Senator.
Senator HARRADINE --I will ask them what their view about the matter is then.
CHAIR --They are also not able to give their personal view on any subject.
Senator HARRADINE --I will ask a factual question. How would the provision for a statement on a form as to the stage of pregnancy reached when the procedures were undertaken breach a patient's right to privacy as a matter of fact? Don't you ask similar questions in certain other procedures?
Ms Batman --No, I cannot recall any. Basically, the payment of a Medicare benefit claim relates to a bill by a medical practitioner and a reference to an item or a description of a procedure. The only questions relate to whether the procedure may have been performed in relation to some sort of compensation arrangement. There are no other facilities where the patient is asked any other details.
Senator HARRADINE --In this particular instance, if the patient were asked or if the doctor were required to include on the certificate the stage of pregnancy at which the abortion took place, how is that going to breach a patient's privacy?
Ms Batman --I feel that we are back in the area of government policy again.
Senator HARRADINE --No, I am asking you a direct practical question.
CHAIR --Ms Batman has already said that there is no provision on the form to provide that information.
Mr Podger --The issue of how much information ought to be collected by the Health Insurance Commission on the details of the procedures rather than which procedure is quite a sensitive issue.
Senator HARRADINE --I will just read what your department said:
As information on the stage of pregnancy in which an abortion occurred is not necessary to establish entitlement to a Medicare benefit, introducing a requirement to include this information could be seen as a breach of a patient's right to privacy.
I concede the first. I am asking a factual question as to how the inclusion of a portion on the Medicare form for the purposes of what I have said is going to breach that person's right to privacy.
Mr Podger --One of the privacy principles is that you do not collect information other than what you need for the purposes of the decision making.
Senator HARRADINE --Oh, is that what it is? It is not going to affect the individual person concerned. It is not going to mean that the person concerned is not going to be paid and the information clearly is not going to be divulged to anybody.
Mr Podger --I cannot see that there would be a basis on which we could automatically decide to pay or not to pay on the basis of that one piece of information.
Senator HARRADINE --I am speaking on behalf of the taxpayers of Australia who I believe are entitled to know more about this subject.
Mr Podger --One of the concerns that a lot of people have on the privacy side is how much information is collected, and an assurance that it is collected only for the purposes for which the administration needs that information. If it is for broader purposes, that raises questions with the Privacy Commissioner that we would have to be able to work through. We would have to explain why there was a general research requirement or general public knowledge requirement that was sufficient to warrant us putting that question as a matter of course, and I think we would have some difficulty in doing so.
Senator HARRADINE --So the department is prepared to continue paying Medicare benefits to a doctor who, as I described him and as the High Court has described him, has no problem with sex selection abortions?
Mr Podger --The doctor is under investigation. Depending on what comes out of that, he may well not be paid in the future.
Senator HARRADINE --You are passing the buck. I am saying to you that the public is entitled to know on the question of pain--at least on the question of pain--at what stage of the pregnancy this pain occurs.
Mr Podger --I am not a medical practitioner either, so I am very reluctant to get into a debate about the details. It seems to me that asking the one question will not give an answer to whether or not the benefits should be paid. There will be a number of other pieces of information required. Once we get those other pieces of information, it would still require us to go back to medical boards and so on to determine whether it really is appropriate and whether the money ought to be paid. It is a very elaborate process, and I am not quite sure whether we would end up with a lot of information that the Privacy Commissioner would say is not actually being used for the purposes of the Health Insurance Commission and the Department of Health and Family Services and therefore should not be asked.
Senator HARRADINE --Is Dr Grundmann the only doctor who is performing abortions post-20 weeks in Australia?
Mr Watzlaff --I really could not answer that.
CHAIR --Is it correct to say that the information is not gathered so you are not in a position to answer?
Mr Watzlaff --The information is not gathered, so we could not ascertain that from our records.
Senator HARRADINE --But, generally speaking, surely somebody within the department is across the speeches and literature that are made on this particular matter? Nobody knows? Nobody cares?
CHAIR --I think that is an unfair inference, Senator Harradine. None of the officers knows. Are there any further questions?