The 'Dispatched' Week in Review' - 17 April

An unhinged reaction to the new pharmacy prescribing initiative in New South Wales, why Australia needs to be humble in any health system comparison with the US, and given that the Government sets and umpires the rules for reimbursing innovative technologies, it can hardly complain when companies say no.

Transcript

Paul 0:09

Hello and welcome to the Dispatched Podcast Week in Review. It's Friday, 17th April. My name's Paul Cross. I'm delighted to be joined by my co-host Felicity McNeil, PSM, Chair of Access Australia. Hi Felicity.

Felicity 0:20

Hi, Paul. Can both of us just say we're not talking about any football this week, okay?

Paul 0:28

Why did you bring it up then?

Felicity 0:31

Because I just wanted to say I don't want to talk about it.

unknown 0:35

God damn.

Paul 0:36

Okay. Let's talk about something equally unhinged, which was the response of the RSCGP to the New South Wales prescribing, pharmacy prescribing initiative.

Felicity 0:49

For the initiation of um access to a contraceptive as opposed to a repeat prescription.

Paul 0:54

Yes. It's quite unhinged stuff.

Felicity 0:58

Yeah, and I guess we saw that a couple of weeks ago when uh further discussions in RACGP and AMA and a few others, I think also uh an MP who uh misunderstood some of the materials and what the TGA has done in recent years, also all got unhinged about it. I kind of got the giggles because it took a while for that unhinged response to come through, but I realised it's because they were all at the National Press Club listening to the president of the AMA talk about Australia's health system and not realising New South Wales had made a public announcement on that. Sorry, it it kind of made me giggle.

Paul 1:38

Yeah, I mean the whole Oh, they gave ninety-nine thousand dollars to the Israeli Labor Party in the last two years, three years or something. I mean, if that's what it costs to get a policy outcome, it's pretty cheap.

Felicity 1:52

Very cheap. I'd like to if if I did that, could I get new one screening fixed, please?

Paul 1:58

It's just total it was totally just zany. And they're conflating two separate issues. The downscheduling is very different to what they've done because downscheduling is very different to requiring certified training before you can participate in this program.

Felicity 2:15

Yeah, and a prescription. So it's still downscheduling just means that it can be behind the counter and can be handed over without a script. And we have many medicines that are dual listed. So for example, my my adrenaline or epinephrine is schedule three. Why? Because it normally requires a script, but in an emergency I don't have time to run to a doctor and get that script and get it filled. Same with insulin. But there are a lot of things that over recent years, uh, for example, uh proton pump inhibitors, wanting to talk to one of our favourite topics, used to be a schedule four, and part of that was down schedule to schedule three. That's that's a very different example as opposed to someone sitting with a patient and determining whether or not the prescribing of a medicine, a scheduled for medicine, is appropriate. And I think some of the unhinged language was also that inferring that a pharmacist who is prescribing has not done adequate training. My observation is they they seem to have done a a lot more. And I trust a pharmacist actually a lot more to understand the medication than most um doctors, to be honest. But second of all, this insinuation that they are not taking the appropriate time and care to check blood pressure, to check history. I mean, pharmacy does that all the time. If any GP or member of the AMA ever went to a pharmacist and handed over a script, you'd know that they'd ask, Are you on other things? Do you have a history of these things? And that's just a handover script, let alone to write it. Um and I think also we're starting to see the argument, and about, you know, you can't be a prescriber and a dispenser, and you know, this is, you know, Australia has a long, proud history of separating them. Yes, we have a long history of trying to separate that, and we used to have a lot of doctors that used to prescribe and dispense, which and we still have an emergency power to do that in circumstances where you have an adequate access to the health system. But I appreciate that that is an issue for long-term financing, and we need to look at that. But what the general practitioners are missing right now is that access to health has to be timely. And if people are choosing to go to their GP uh to their pharmacist b instead of their GP, it's usually about the timeliness of that access, the affordability of that access beyond whether or not having to go to an urgent care clinic for a bulk build initiative. We really need to open up the conversation and why on earth isn't AMA and RACGP f focusing more on what the impact of urgent care clinics are to the accessibility of proper health care.

Paul 5:02

Well, I think urgent care clinics are somewhere between five and ten percent of all general practice clinics now. Uh so their profession is being nationalised more than more than it already has been through Medicare. I would have thought they should be more concerned about that. I am trying to understand the strategy because it's not obviously it's having no impact. They must have some kind of view about what they want. I wonder if they understand that the government are doing this, federal and state, because they see pharmacy as a viable partner on prescribing these sorts of treatments and the solution to a problem that maybe the GPs can't readily solve. And what does that say? I mean, if you go back to the 60-day battle three years ago now we always said that pharmacy was going to lose that battle, but they were going to win the war ultimately, and this is the war that they're winning, which is they're in a str strategic alignment with government about addressing addressing primary care challenges. Uh and general practice don't appear to have got their head around that.

Felicity 6:34

But I think it's even more than that. So if we go back to 60-day dispensing, and we at Better Access were calling from this from the start, which is first of all, you should have consulted with pharmacy. If you really wanted to do this, the people that can implement this are pharmacy. And uh the the government thought it was too clever by half. But we always said that if you actually want 60-day dispensing it is a two-part solution, which is you have to make general practitioners write a 60-day script. So those the the issuing of those longer-term scripts is significantly below what the government's expectations and modelling were.

Paul 7:13

It's less than half.

Felicity 7:14

We always said, well, if you want pharmacies to if you want GPs to do this, you need to make that their KPI. You need to automate that into their software, like you did for uh non-brand specific uh prescribing rights. And yet they didn't. Because we're also missing why why are they focusing so much on prescribing rights? Because repeat prescriptions are a cash cow for primary care. So this is an easy, quick throughput. Um, you know, if whether you come in to see your GP or whether you ring up the receptionist and, you know, get the frosty reception and say, well, if you need that, then that'll cost you this amount of money for them, right? And you know, to issue the repeat prescription. Because it is seen, uh it's a bit like the discussions we used to have on immunisation. There are certain services in the cost mixed model of providing health care. Some are quick and high value, some are long and lower value, but that's the trade-off. We not every service is priced equally, and not every service requires the same time and attention, and some can be very quick throughputs, which generate your revenue to allow you to spend more time with more complex care patients. The fight here is not about the patient, as in their best health care. The fight here is about the money, and let's own, let's be honest that that's what AMA and RICGP are talking about. These are the high throughput services that are quick that fit into six-minute medicine. These are also young women, and young women are captured by the health system very early on. Um, you know, I I don't mean to get too gender specific between you and I, but our experiences going through primary care between the ages of 18 and 40, I expect are markedly different. Because as a woman, I must go in there for contraceptive care, I must go in there for cervical cancer checks, I must go in for all these things. I am medicalized from a very young age because that's what it takes to actually be a woman of reproductive age in Australia who may or may not choose to have a child. And so therefore, capturing that person and having them as part of your health care clinic is incredibly important in the health system because once I go in, then I take my partner in and then I take my children in. And so can we just kind of own for a minute about what is the concern here? Because they haven't really been complaining about the expansion for skin care and skin diseases. So these pharmacies can also prescribe medicines in these particular areas or for baseline other conditions. The real focus of RACGP and AMA has been women's health, UTIs and contraceptives. And the cynic in me says it's because you think that once we're in, you we're like a captured client for life.

Paul 10:04

Yeah, yeah. I have no doubt that's generally what most debates in the health system are about. As a former bureaucrat many years ago said to me, it's just about sticking a big barrel of money in the middle of the room and getting the relevant stakeholders in to fight over it. Because it's a system of health financing, certainly at the Commonwealth level, less so at the state level where it's service delivery, but that's pretty much what it's all about. I just think I struggle to understand the strategy of the doctor groups here. I understand the tactical response. I mean, they let it let it all hang out, basically. I I and I and I don't really understand that, but uh where do they go from here? Because what are they gonna say now? I mean it's you know, it's it's they've they've gone straight to the mattress, it's making these wild accusations about donations. Uh which it's it's quite unhinged.

Felicity 11:01

It is, and and I'm with you. If if I was AMA and RAC GP, it's urgent care clinics that I would be concerned about, incredibly concerned about, because that is actually the battleground. So that urgent care clinics are doing the same thing that pharmacy is meeting with their responses to a systemic problem in primary care, which was people having trouble getting access to their GP either because of cost or because of time. And we know, particularly in Canberra, how hard it can be to get into a GP on a regular basis and the out-of-pocket costs. But they're taking on the pharmacy who've met an unmet need in at a state level over and over, because in the end, state-based systems know that if you can't get into your GP because you can't get your script, and if you can't get into your GP because your kid fell off their skateboard, yes, quoting the government's ads, then you show you show up at the hospital. And that is a huge cost. That is a massive cost, both in the disproportionate amount it costs to treat a patient and the disproportionate amount of time it takes away from someone else who genuinely needs acute care. But they haven't been engaged in that conversation.

Paul 12:13

And I don't understand that.

Felicity 12:15

They just continually think that their battle is with the pharmacy and actually their battle is with the government.

Paul 12:23

Well, and the urgent care clinics are evidence, the government doesn't trust general practice to be a solution. That's that's effectively what they're doing. So we're gonna set up our own it's a bit it's a bit like remember when uh Kevin Rudd, the Rudd government 20 years ago decided to put fifty billion dollars or whatever it was into the NBN because Telstra wanted to do it on its terms. Yes. And it was a spike policy, you know, because they didn't trust Telstra to do it, so they're gonna set up an entirely new government-owned business to create NBN.

Felicity 12:56

Hasn't that been a roaring success?

Paul 12:58

Yeah, and Starlink's gonna make it basically irrelevant. Irrelevant and worthless, probably, but but but to me that's that's the much greater issue. And you and I both know that if a government-owned pharmacy popped up and I think the one in Collingwood is still going.

SPEAKER_02 13:13

Yes.

Paul 13:14

You know, I'm surprised that the guild haven't fly bombed it, to be honest, because pharmacy would go straight to the mattress on that because they'd see, as we've seen with urgent care clinics, where there's going to be hundreds and hundreds of them. I mean, I haven't seen a media release from the minister for two weeks now about opening an urgent care clinic, which must be the longest time. It was all he was doing. I I I think we've got two or three in one week. Yeah. So they see it as a massive winner, the nationalising general practice. And the the GP groups are issuing this unhinged statement about uh pharmacy prescribing, which as you say, it's now an institutional part of the system. Yeah, we don't want to end up like Japan where it was a massive issue, but we it's never going to be that in Australia because we're not starting from that point.

Felicity 14:04

Exactly.

Paul 14:05

We're not going to they can prescribe, you know, in Japan where 50% well I don't think it's the case anymore, but certainly when I worked there, it was the case that 50% of GPs also dispensed.

Felicity 14:17

Yes. So you get a lot of drugs.

Paul 14:20

You get a lot of drugs. So but but that it had been that way for a long time. That was an institutional part of the system. That is not the case in Australia. You can see all the guardrails that have been put around this, the way they're doing it off the PBS, uh only for concession card holders. Um the f the funding, certainly, but but also that the training they have to go through. And you and I both know a pharmacist who didn't get through it the first time. And was proud that the system was high standard. So and we've both dealt with pharmacy, and I've certainly dealt with Dr. Grooves, and I always say it, people think government hates the pharmacy guild, they don't. They get frustrated with them because they're very effective, and not just the lobbying bit, but in policy delivery. When we introduced improved monitoring entitlements, believe it or not, you didn't 25 years ago you didn't have to provide your pharmacy with a Medicare number to demonstrate evidence that you qualified for the PBS. We implemented that, paid them hardly anything to do it per script to collect the Medicare number, and it's like 98% compliance in two months.

Felicity 15:29

Yeah.

Paul 15:30

That's that's a good deal for government.

Felicity 15:32

It is, and there's a you know, I said on the podcast last week, the reason it works so well is because the and why the uptake of prescribing is going so well is because the outcome that the patient wants is a is aligned to what the outcome of a pharmacist wants, which is if a customer is happy, then they come back. That is their business. But in GP sector, that's not the case. Like I am bereft for uh general practice in this country because the fact that they have allowed the urgent care clinics, the fact that they accept it costs four times to the value that's the wrong way to put it. The fact that the government is paying four times the value of a bulk billing arrangement in their urgent care clinics versus the bulk billing that they would give to someone in private practice. I want to go and see my own GP. I want my GP's practice to be open for longer hours and to have the flexibility based on the funding that you're putting into an urgent care clinic. So whilst you know, these doctor groups are there going, oh, we're a bit worried about, you know, pharmacy, I'm worried about continuity of care. I'm worried about um forcing me to go and see an urgent care clinic as opposed to supporting my general practice clinic to stay open for longer, because that's that's the basic thing here. And you know, in the ACT, we've had that model for 25 years. So the CARMS, which is the after hours locums network, which is if your local GP signs up to it, we can all go once your GP is closed, you can ring up and you can go and see one of the three clinics rout located near the hospital, so you don't go into the hospital itself. And then it all goes back to your GP. So it's based on that whole you can only see it, you can only see that service if your GP is closed.

Paul 17:17

I I actually wonder whether the GP response to this is a bit of a confession. Because obviously, you can make an appointment to go and see your GP days to get in, you then you know, you have to sit outside some of the time, inside, you've got to go through the process of actually getting into your GP. They're very busy people, so they always run late. They always run late because that's that's the nature of that job. Sometimes they have to devote more time to a patient, which is completely fair enough. You then go in, you then pay if you're not bulk billed, you've got to it's quite a process. Or I can just wander into my local pharmacy and have a consultation on the spot because you can speak to your pharmacist effectively straight away. There's very little waiting time to see a pharmacist in my experience. I'm yeah, probably in some bigger pharmacies, it might it might be a little different, but the the customer experience, and let's call it what it is, that customer experience is far superior financially, but also just more timely. And so, in a way, pharmacists certainly in that space, that primary care delivery space, just have a huge customer service advantage because of their the n the the way they engage with their patients and their customers. So it's it was interesting, but I I saw it and I actually just started laughing because we were because remember we talked early in the morning about it, about it, and I said, Oh, well, I haven't seen the GPs for this. They must be typing away because you know they're gonna write something you can cook your breakfast on. And it came late in the day. And I I was only after that, uh which is probably very unprofessional a bit, but you know my view of the National Press Club, that that that that the uh they're all too busy having lunch and listening to each other. Yes, yeah. So that was that was interesting. Uh I I'm in the middle of a series at the moment, publishing a series about comparing the US and Australian health system.

Felicity 19:07

Yeah, I love them.

Paul 19:08

And part of that is having lived in the US and experienced the health system, albeit some time ago, I I I thought it was very good. I thought it was very good.

Felicity 19:18

Yes, I've been to a few functions with you and other people who've lived there, and all you do is sit there and go, yeah, this was great, and this was awesome, and this was so much easier.

Paul 19:25

I think Obamacare mucked it up a little, um, changed a lot of the the actual actuarial settings, I suppose. Uh the system went to a lot of deductibles, uh, which wasn't ideal, but but uh, you know, I had employer-based insurance. And people say, oh yeah, but you know, well, no, no. The vast majority of people have employer-based insurance. It's generally very comprehensive. Uh it involves relatively low premiums because employers, the insurance pool for employers is generally quite healthy. So it has a low claims ratio. This is this is where it contrasts with private health insurance in Australia, which is an unhealthy group because you have private health insurance because you need it a lot of the time. Yes. So it tends to be a more unhealthy, high claiming group. I think I paid relatively small premiums, but the premium that my employer paid was um is effectively tax-free income. So it's not it's not taxed. So that's that's a big that's a big advantage uh from an employee perspective. 92% of Americans have a form of insurance. They spend lower out of pocket as a share of total health spending than than Australia does. Yes, their overall health spending as a share of GDP is significantly higher than Australia, but Medicaid, uh, which are the state programs, covers a lot of stuff that we wouldn't recognise as healthcare, including disability services, meal plans, for example, for uh people with diabetes. It covers a lot that we would recognise as disability. If you put NDIS and health spending together in Australia, it our our our share of that as that as a share of GDP jumps quite significantly. Uh you know, I wrote a piece today saying, well, which system is better? I think it very much depends on your circumstances. People say Australia's system is fair. I don't think it is particularly fair. I think it's a system of rationing. There are things I'm not permitted in law to insure against. So my private health insurer, and no product can be offered that enables me to insure against high out-of-pocket pocket costs to see a specialist in an outpatient setting.

SPEAKER_02 21:40

Yeah.

Paul 21:41

That's not the case in the US where you're probably paying$10 to$20 out of pocket. Uh, prescription medicine costs are generally much lower in the US. No one, these the myth of the published price is ridiculous. Prescription medicine costs a share of total health spending. In the US is around 10%, Australia is around 15%, because the big spending gap, the big driver of the spending gap between the US and the rest of the world is actually hospitals. They have a thriving and very competitive private hospital and charitable not-for-profit hospital system. And I suppose my conclusion was that if you need access to innovative treatment or ready access to diagnosis and treatment, you want to be in the US. You want to be in the US. It is w when it is unfair, if you're uninsured, if you're a low-income worker or who doesn't have employ employer-based insurance. Yeah, when it's unfair, it is deeply unfair. But I don't think Australia's got much to brag about.

Felicity 22:45

No, and I think it's you you've often talked about people see the US health system through the television programs they watch, and that's not real television. It's, you know, dramatization. So everything's always about, you know, someone being, you know, coming in without insurance and how does everyone deal with it. Or the other things that they tend to talk about is, you know, they're arguing against the insurer about when it can and can't be covered for a patient. And people get up in arms in that, and I'm like, ha have you met the PBAC or the MSA?

Paul 23:17

Well, at least they let you have the argument in the US. Yes. Your doctor can argue on your behalf, whereas here you can't even have the argument.

Felicity 23:21

You can't have the argument. I can't appeal it. Like, you know, it comes down from from up above and they say this, and then the law says that I'm not allowed to challenge it as a patient. Even my drug, the drug companies or the device companies aren't allowed to. I I can't take it to an administrative appeal tribunal. I, you know, I will get a lovely letter from someone in the department saying, Oh, you could try compassionate access.

SPEAKER_02 23:41

You can beg. You can beg.

Felicity 23:43

You can beg for the thing, or you can do a GoFundMe page. Um, you know, we've had a lot of success with that. So I think those those issues are sometimes overlooked. And and like I said, I've enjoyed, you know, you've be you've touched upon it a bit this year, but this the series this week's really important. And I think the other thing is that when I read it all, I reflect that in the end Australia is a sees health as welfare. It doesn't see it as a service, whereas the US sees it as a service and health as a kid's an economy. And I think Australia tries to do, we'll give, you know, we want everybody, all 27 million Australians, to have a minimum level of access. And the price we pay for that is the majority of what you're going to need throughout your life, you're going to have to pay for a lot of yourself in either time for access, delayed access, or the cost that you're going to have to put into your your own pocket yourself to make that meet. And I think it's time we kind of owned that a little bit because we, you know, like you said, every time you go somewhere, Australia has the belt health system in the world. No, we don't. No, we don't. We really, really don't. And we don't have the fastest access, you know. You know, a 17-week PBAC cycle is not the fastest system in the world when we're talking about the duration of time it actually takes to get access to something, let alone a diagnostic, let alone a device in the in the primary care sector. So I find it informative for people. And I think also, you know, I've liked again that you've reinforced discussions we've had earlier on, which is the the life expectancy, because uh that it is distorted by the high murder rate. You know, and Australia can be proud. We don't have that many guns, so therefore we we don't have that distortion. That's a great thing. But like you said, over the age of 65, it's kind of pretty much the same.

Paul 25:42

They've got better outcomes in some cancers. Their screening program's better. Yeah, and then then there there are um they get access to things pretty much immediately because it's mandated in law.

Felicity 25:53

Yeah, I think but the other thing that I thought was important in your your writing this week was to remind everybody that disability is included in their spends. So we we separate that, we disaggregate it, um, we disaggregate age care, and yet the the US is puts all of that together. All of it together. And so we don't compare, you know, as we all like to say, with the politicians, you know, we can't compare apples with apples. Well, we should be. So we actually need to count that all together and stop being so, you know, virtue signalling about how much we require people to wait. Now, look, to be fair, you know, the the minister can be pretty proud right now. Like people are waiting on, you know, over 700 days for access to a medicine if it's if if it's ever actually recommended. Um, people who are waiting for support at home packages are waiting often until they end up in the residential aged care facility themselves.

Paul 26:52

Just to get assessed.

Felicity 26:53

Yeah, just to to die before they actually get assessed. So, you know, that that's consistent, that's good. Um, then we can move to the disability services and the amount of time it takes to actually get an assessment and a a uh a response and then a a budget and then the annual reviews on the the disability system, that's not going particularly great either, although it is better than aged care, so you know, swings and roundabouts. So, yep, the the minister can be very proud. It is a system of equality in that the entire system is designed on how long you have to wait.

Paul 27:24

Yeah. We we use language to describe our system, it's just not accurate. You know, we describe it as universal. Well, yeah, I suppose it is. You get a universal everyone has a universal minimum standard, but then you can buy your way to the front of the queue. Obviously, you're hugely advantaged if you have private health insurance or you can afford high out-of-pocket costs. So there's a universal minimum standard. And that that minimum standard is much lower than the average standard in the US. Much lower. And we also pay more for it. The Prime Minister and other ministers have this habit of using that Medicare card as if, you know, oh well, you don't need a credit card. Well, I'm sorry, you do. Like if you just need to see a GP and they happen to bulk bill, that's great. But if they prescribe you something, if they send you, refer you to a diagnostic or a specialist, not only are all of those things potentially going to take some time, but they're also going to involve potentially very high out-of-pocket costs. So our system words like universal, universal and equitable, equitable are highly subjective and they can mean lots of different things. And and and I'm I'm convinced that most people, most people who talk about the US health system, I'm bringing a sort of a political perspective to it. We have a we with Europe decided on a socialist path post-war for our health system. America almost went down that path with Truman, but they said no, no, no, we'll we'll never get that supported. So we're going to go through an employer-focused uh insurance system, which has been incredibly successful in creating a very dynamic, dynamic healthcare economy that is responsible for every single healthcare innovation that we enjoy in Australia. That's that's a fact. That's a fact. You know, I do a lot of work in biotech. Every single Australian biotech company is focused on getting their product approved in the US and basically treat Australia mostly as an afterthought. It's very, it's incredibly dynamic. And and and that's what it's chosen to prioritize. Now, part of that being, part of that dynamic and part of creating a very dynamic healthcare economy in the US is giving the individual agency and power. I, as a patient or a consumer of healthcare in America, have an extraordinary power. Extraordinary power. I can I get to choose my insurance, the nature and extent of that insurance, even with employee programs, what you get every year is you get a big booklet and you basically decide what's right for you and your family around insurance product. And that that is also determines how much you pay a month as a premium, which as I say is effectively tax-free income. So that that dynamic healthcare economy gives a lot of agency to individuals. And you rightly point out that a lot of people, when a product is approved by the FDA, is it is essentially funded by private and government insurers immediately. That's a mandate in law. Some take a little bit longer, but it's essentially immediate. And because companies have great confidence in that timeline, they tend to provide it free because they know it's going between that uninsured and insured time timeline. But what it means is that you might be prescribed a product, your doctor might prescribe your product, contact the insurer, and the insurer will reject it. But in that system, the doctor and you can pick up the phone and argue with your insurer and make the case. And most of the time it gets reversed because the individual has agency. In Australia, this is just restrictions we're talking about.

SPEAKER_02 30:59

Yeah.

Paul 31:00

If you if you are denied access to a drug in Australia because of the restriction, you can't argue with anyone.

Felicity 31:05

Just asked the BCNA this week.

Paul 31:06

Okay, so yes, well, we need to talk about that. But but but the point is that we have a institutional framework for healthcare that is effectively it's an ideological framework of the left that mandates that the people who run the institution know best. And not only are you not going to get a say or have any agency in this system, we're not even going to let you make the case.

Felicity 31:32

No.

Paul 31:32

And that's I find that I find that really problematic.

Felicity 31:35

It is problematic. And I I guess I also want to go back to your you started talking about you do thanks to private health insurance, you can buy your way to the front of the queue. And I to a point, I think one of the greatest frustrations we at Better Access have had for many years is what a deplorable product private health insurance is in Australia, purely because of the way the government sees it. So if you think about it, most people who have private health insurance, not only is it a grudge product insurance, yeah. But it's usually because they don't want to pay the Medicare levy surcharge.

Paul 32:11

A lot of people, yeah.

Felicity 32:12

Yeah. For a lot of people, that's what actually kicks it over for you. You hit over 30, and here it comes. But let's think about what those, you know, for a government that this this week says they won't look at income testing for the NDIS, which I think is quite a curiosity. You as an individual have to earn as little as$101,01 this financial year to be subject to the Medicare levy surcharge. So when we think about the average incomes in Australia being around$89,000, when we think about the fact that you can't get access to a concessional status for either the PBS or the MBS if you earn over$66,000, we're literally saying after tax before tax,$101,000, we're going to tax you even further. So people purchase private health insurance to meet that requirement. Majority of those people, of course, will not be using it because we can only insure for the acute care setting with the nominal, you know, little bit of extras for you know something that never covers the cost of my my prescription sunglasses, glasses or you get a virtually nothing but if you retire two sets of glasses like I do. Yeah. And so the the issue here is so we make people do that. So for families, you know, to be fair, at least it's a little bit better. It's$202,000. So that's that's a little bit of a buffer. But you think about that for individuals, we are making you purchase insurance for something that you cannot use. In and you know, and and then you go, but I I really need access to that medicine. Well, you we're not listing that, so you can pay for that one privately yourself as well.

Paul 33:51

Yeah, there's no the law doesn't permit a a company to provide an insurance product.

Felicity 33:55

No, and you can only do it and it's it's it's a maximum of$50 a month for anything that's not on the PBS. We don't allow you to insure against the uh diagnostics. You know, I've just got an email from someone today saying I got this blood test done and now I've they they did B12 and now I have to pay for it, and I didn't know. I just the doctors ordered the comprehensive test and suddenly someone's got a bill again, can't insure for it. There are all these things in our system that are constantly about cost and add-on. And the the genuine opportunity to buy you out of the front of the queue with insurance is only when I need an a form of elective surgery or I'm in a public hospital and I want to choose my own doctor. And we need to stop pretending that there is a great haves and have nots because people have private health insurance. I think for a lot of people it is purely because, well, financially it makes more sense for me to to make that contribution. And I appreciate that when younger, healthy people healthier people contribute to PHI, it helps offset the cost of the old folk. But really, is is that what we're trying to do here? Or should young families be able to insure for medicines for um the gap gap costs in primary care? Why are we so derog derogatizing the US where I can insure for those things? And yes, you're right, my insurer may say maybe yes, maybe no, but like you said, I can individually have the argument. Whereas I, you know, here's a family putting out two and a half thousand dollars a year on an insurance product they'll never use, and that's two and a half thousand dollars they could spend on the diagnostics and care for their families.

Paul 35:34

And it's not a very good insurance product, two and a half thousand dollars for a family, but but the thing is that the even even the debate about private health insurance in Australia is generally focused around more government intervention and regulation, which I I find just bizarro that we are so our our you know, I talk about HTA a maze with no exit, and everyone sort of just walks around in it like a zombie, but that's not just true of that part of the health policy debate. Our health policy debate is so muted by institutional framing, which is that government good, private bad. And I and I just don't I don't understand it. So private health insurance has increasingly been regulated simply as an adjunct to the to the to the government paid system, in that I think I believe policymakers see the twenty-three, twenty-four billion in PHI premium paid each year as theirs to administer.

Felicity 36:43

Yeah.

Paul 36:44

And like they're giving us a gift. Yes, yeah, and I and I and I I find it deeply pro deeply problematic. I would like a lot less regulation around that product. I should be able to ensure NIB in New Zealand and I think other private health insurers offer a prescription drug benefit.

Felicity 37:01

Exactly. I was talking to someone about that today, which is but the New Zealand's got better as well.

Paul 37:06

They're not allowed to do it here because people don't realise that PHI is a regulated product in every single way. If you want to change your product, you've got to get it approved by by the government. And and the pricing is regulated as well. It's absolutely madness. And so what we have is a system that's undynamic, uh policy discussions that generally mimic someone trying to walk through wet concrete or on wet sand, and new ideas, particularly around more private sector involvement and leadership, is just considered a no non-starter. And we so so so my view, my view is that a lot of the criticism of the US is is political because there are so many people who dominate health decision making in Australia who are basically Marxists who who don't like the commercial underpinnings of the US health system. And so they pick and choose what they like, having never lived there, never experienced it, it is highly complex, undoubtedly. It's a country of 350 million people. Europe is much bigger than US in population terms, but is responsible for virtually no healthcare innovation. All all the healthcare innovators go to the US, they do all their RD in the US, mostly. And develop products based on what they can get in the US, and then countries like Australia are seen as a global charity case. And I think we should stop being so arrogant and self-important about it. Yes, Americans criticize the health system. Absolutely they do, like everyone does. Like everyone does. And and their gripes don't differ greatly from ours, but just some key facts. Out-of-pocket spending, direct consumer out-of-pocket spending in the US as a share of total health spending is less than it is here, substantially less than it is here. 92% of Americans have a form of health insurance. Every single one of those products is more comprehensive than what we get via Medicare. People are empowered to make decisions. The health system, the health economy in the US is financially far healthier than it is in Australia. Look at the private hospital system in Australia, which everyone is saying is on the verge of collapse. And in fact, one company has collapsed. And now other companies are picking through the bones of it. Because this is what happens with government intervention. It's like the mayor of New York, who's basically a lunatic. His great idea is to have government run grocery stores. You just know that's gonna end well. And he's announced one thirty million dollars, and it's gonna take three years to build.

SPEAKER_02 39:53

What?

Paul 39:53

That's what happens when government do things that are perfect done perfectly well by the private sector. And and the the private health sector in Australia is a classic example of why are you constantly arguing for more regulation? You need less. You need to free up this market, make it an attractive product for people to buy. Yes, insurance is always a grudge purchase, but if you were allowed to cover more, I would pay more. You would get more healthy people in there. But that discussion just isn't possible. It is such an ideological framing of the health policy discussion in Australia that it's sort of doomed to this sort of oh, we're gonna nationalise general practice, take over nationalised hospital, which they did in Canberra, perfectly well-run hospital has now been nationalised, you know that's gonna end well. Yeah, and it's impossible to have a rational discussion about actually the US health system is responsible for every single innovation. I used the HPV vaccine, yeah, Australia claims that Australia did not develop that vaccine, it was a bench top proof of concept at the University of Queensland. Great idea, great idea. It was CSL acquired rights to it, but at that point in time, CSL had just been privatized. Like it wasn't the company that we know today, it wasn't capable of delivering a global innovation. So it essentially onsold it to MSD to MSD, which took it from phase one all the all the way through, manufactured it in the US and licensed it back to CSL. Yeah, and it CSL had rights to it in Australia. But that's not an Australian vaccine, it was an Australian benchtop discovery. And which is great. Which is great. But in the end, it was the economics of the US health system that delivered it as a vaccine and now is on the verge of basically eliminating most cervical cancers. Absolutely extraordinary. But let's understand that all of those innovations come here because of the incredibly dynamic US health system. And yes, they do spend a lot. They do spend a lot. I don't know. It's it's but they they they they cover, as I wrote this week, they cover stuff that we would never classify as health. Yes. We separate all those things out. They don't do that in Medicaid, in those state-based programs, which is two-thirds funded by the feds in the US, and that causes a lot of tension like it does here, because the states just expand these programs into all sorts of stuff, uh, and that triggers federal funding. So a lot of it's got completely out of control, particularly in states like California.

SPEAKER_02 42:25

Yes.

Paul 42:26

Where they're just covering all sorts of crazy stuff that we would never count as health, but in all those OECD numbers that compare different systems is counted as Canada's health. So it it frustrates me because a lot of it's just a brief, oh, we don't want a US health system. Well, what don't we? If I'm diagnosed with a disease, I know where I want to be. And look, when they do MTOP, the medical treatment overseas program, where do you think they're all going? Yeah. They're all going to the US, into the university hospital system.

Felicity 42:58

Yeah, I think it's you know, and we do we we saw that I think when we talked last week about the uh presentations by some government officials at the diabetes summit and you know, government good, industry bad, can't trust clinical trials, can't trust real world, just can't trust. You know, it's a it's a miracle we can get anything done. And I think getting into the ironically, the the MFN and President Trump issue should have been an opportunity to have a sophisticated discussion. And once again, without sufficient consistent information coming in from the sector explaining that, it's being weaponized by the government to say, you know, they're attacking our PBS and we're not going to pay outrageous prices and we're not going to cost the money like the US. Instead of actually coming three steps back and saying, all right, let's just ignore the US for a minute, okay? What are the design principles and the health Outcomes we want from our health system. There is no point everybody saying the Productivity Commission says this, you know, whether all sides of government and all sides of industry quote it. And it is great. The Productivity Commission acknowledges that actually, if you invest in health and disability, you get a better outcome. Can we just stop and say, what is our expectation of our health system? What do we expect to get as the people who are paying for it? We never get to have that conversation. We never get to say, I'm sorry, these waiting times are not acceptable for me for access to basic medicines in the primary care space that stop me needing to go to hospital. I'm sorry, it's not good enough that because you're not pet caring properly for chronic disease, the waiting cues in the emergency department are XYZ. We're not having that sophisticated conversation. We're going, oh, we just don't want the the US to tell us how much to spend on medicines and oh we don't want to spend as much as them on anything. As opposed to saying, well, I I actually I care about the US in that I know that I would have got better outcomes. And as someone who's worked with people in the newborn blood spot screening and had to sit with mums who flew home from the US to ensure their children would have better health care and their children died because the quality of diagnostics and screening in this country was so inadequate, they lost their child by coming home to Australia. I do see why there's a lot of good value over there, but we need to stop. What why is pharmacy working really well? Because pharmacy is private. Can we just own a skin? It's a full private service with aspects of that subsidized partially or fully by various governments.

Paul 45:44

Competition?

Felicity 45:44

Yep. And do you know what? It works.

Paul 45:48

Well it's the one part of the health system that works incredibly well. So And the government doesn't actually spend much on it.

Felicity 45:53

So why is it that it's able to keep, you know, innovating? Why is it able to keep delivering, like you said, look how easy it was when I was sitting there looking at planning our flu shots. Everyone get your flu shots. Um how easy it was to go online, find different places that would do it, tell me what type of the vaccine I was going to get. It's a service that's aligned to me as a customer, so it makes it really easy to get my health care.

Paul 46:17

That's that's the critical thing, is it to give we have agency. I can choose the pharmacy I go into, it's an incredibly good experience, or I go somewhere else. I go to another pharmacy. I've got one 200 metres from the front door, I've got one three or four or five minutes away. Okay, so if I don't get a good experience with Rob, I'll go somewhere else. But I always do it. We love you. I do always get a good experience with Rob. But but yeah, this is this is the thing is that in Australia we prioritise population level aggregate outcomes. And so we perform well on those. In the US, they have a lot more respect for the individual and have choice. They build choice into their system. So it goes really performs very well on those on those measures. So you perform well on what you prioritize.

SPEAKER_02 47:07

Yes.

Paul 47:07

And I think that's that to me is really really critical. I do want to talk about that that Pfizer thing this way. Yeah, I said someone lines well. Oh well, of course I agree with the minister that uh, you know, the PBS is not for sale. Well, who would want to buy it? That was kind of that's kind of was my response. You know, and and I wrote a response and I said, look, government sets the sets the system, appoints the umpire, and can overturn their decision. Yes, the government, oh my goodness. The government runs this system, it does everything, it regulates it, funds it, umpires it, it it does everything. It it sets the rules and it protects that, as we've discussed on this podcast. It defends that role for itself very aggressively. So if a company decides that, well, what you're offering us is not viable for us, particularly in the context of what's happening now the Americans are taking understandably a far more assertive posture on those things. Well, it's up to the government to change what it does. It's not for the company to bend. It's like um it's your job, and you and I both know the minister can just flip this tomorrow if he if he wants it and wanted to. He's got total discretion on pricing.

Felicity 48:21

But I also find that I I find it ridiculous because the PBS is not for sale. Well, no, the medicines are for sale and the PBS isn't buying them. Like, can we just actually have an honest conversation? And it really concerns you when you hear consumer and patient advocates starting to replicate, oh, we've got to do the right thing by the system. No, we have to do the right thing by patients. And fuck the system. If the system is saying they won't pay that amount, then okay, if you if you really want to support the system, then you just have to accept that, actually. You have to say that this is actually what a medicine costs. Vars has given it's you know, this is the best price we can give you. And the PBS wardlords have said, well, this is all we're willing to pay, and they've gone, all okay, well then there is no sale. Which is for anyone trying to buy or sell a house or buy or sell a car. That's actually what you're doing. The medicines are for sale and the PBS ain't buying people. The PBS is not buying, it is using its monopoly power to say, well, we reckon we can screw a better deal out of you. And the citizens finally saying, Well, actually, no, that that's just a bit too cheap. You know, if you could go here, if you could push up a little bit, or you could include more patients and you know, actually pay for all the patients that will have access, not just you know, 45% of them. You know, we we need to have an honest conversation about that.

Paul 49:38

And let's be clear about what's happening here is and it's tragic for the patients. Absolute tragedy. Yeah. But this is the government's decision. If the minister chooses to intervene on oral contraceptives or menopausal hormone treatments, as he did, uh well, that's his choice. If he chooses not to intervene here, well, that's his choice and something that he has to explain why he doesn't think it's worth intervening to ensure women with breast cancer uh can can access this treatment. And the idea that I mean essentially it what amounts to is that well Pfizer should just accept the price that w that the system wants to offer. It's the gl it's the chariot Australia is a charity case. It's like the Prime Minister going around Southeast Asia begging for fuel. It's it's it's which Chris Bowen didn't notice. Yes, oh my goodness. It's embarrassing. I find it incredibly embarrassing. Is that we're an incredibly wealthy country. We're an incredibly wealthy country, and uh we're just choosing not to help these women. That's the choice that's been made here. It's not for Pfizer to bend, and particularly in the context of a US like a far more US, assertive US on pharmaceutical pricing. And it's that's the deal. And if that's going to be the consequence, as I say, it's absolutely tragic for those patients. But the problem here is the system.

Felicity 51:10

Yeah, well, you know, and if if Mark doesn't want to intervene, any minister doesn't, and he tends not to intervene on most things, actually. So there's a lot of things that get rejected or not progressed. Uh the two-year expiry on the the recommendations is just standard practice these days. But you know, a bit like he didn't intervene on, you know, the the what is now to year three of the pediatric access to Crohn's um medications. He doesn't. He doesn't intervene all the time. No, either. So that's fine. But perhaps then he could actually reform PHI and allow these women to insure against it. And then they could have access to themselves.

Paul 51:46

And and the I think for me is you and I both know that the idea logs in this system and it is flooded with ideology, will use most favoured nation and a more assertive US as an excuse. They they will double down and say, well, you know, it's not our fault. We blame Trump and it's this terrible American pharmaceutical company that's prioritizing the US, which by the way, is a completely rational thing to do given the Australian population is roughly the size of Florida.

Felicity 52:21

Well, the from reading your article, the Australian population is the total of the non-insured population in the US of 340 million people, you've only got 26 million uninsured.

Paul 52:31

Uninsured.

Felicity 52:31

So Australia? You're just uninsured in the US.

Paul 52:34

Yeah. So let's not let's not it's the it's this idea that we should sort of somehow are a sort of charity case. And you know, when I spoke at that thing in Wellington last year, didn't really get much of an ovation, I have to say. But but I just said, I'm sorry, these are two wealthy countries. Yes, Australia is much wealthier than New Zealand, but we can afford to pay, we're just choosing not to. And I don't know why. What's the big issue? If we have to pay more for medicines in order to ensure people are okay, what's what's where's the big scandal in that? I mean, that's just okay, that's a perfectly rational response. But as we've seen in many countries around the world, and as appears here sometimes, people's loathing of the industry exceeds their want to help patients.

Felicity 53:20

Yeah, if you're if And they're Marxists. If you're a healthcare provider, you are, you know, a first responder. We'd like to thank you, and you know, we thank all the the people that were there. Yeah, I know, that's why I said it. Um But we we value those who provide care, but we do not value the tools they use to actually keep us healthy and keep us safe. So we don't value the devices, we don't value the diagnostics, and we we don't value the medicines equally and at all times. I'm not saying it's a free-for-all. And I agreed with you, I think, earlier when I was saying that MFN is being weaponized now against patients and against the industry. But we do need to have a grown-up conversation about this, which is where has the balance come? And I'm fine with it. I I just if if you want to keep going this way, then the law has to change, and I as an individual patient need the right to be able to challenge these recommendations by a committee that literally determines life or death in this country. That is something that should be allowed to be appellable through the administrative processes that anything in social services, you know, for the NGIS, for age care, for um various pensions, etc., I have a right of redress for when you as a collective make a decision that puts my human rights and my health rights at risk. But no, I can't because this is exempt because it's just such a special thing. And once again, it's purchase a provider. And again, I say to the industry, if you supported things like patients being able to go through the appeals tribunals, think how much that would empower you.

Paul 55:03

Well, if I'm applying for the NDIS and I'm rejected, I can go straight to the administrative review tribunal.

Felicity 55:10

Yep.

Paul 55:10

And in fact, NDIS has its own has its own process. Yeah. So why can't I do it? If I can do it in disability, why can't I can't I do it in healthcare? Yes. Particularly if I've got a chronic condition and I've been denied a treatment for migraine or dermatitis or whatever because of the restriction, why shouldn't I have a right to appeal it? In fact, I've got no right to appeal. And they say, Oh, well, the company can do a resubmission. Well, that it doesn't that doesn't help me.

Felicity 55:35

Oh no, but remember, you can write some compass compassionate access, Paul.

Paul 55:38

I can beg for it.

Felicity 55:39

You can beg. But it is, it's an important issue, and I I I would strongly encourage the industry to rethink where you genuinely think patient access is and patient empowerment is as an individual and a collective for us.

Paul 55:54

Well, this whole comparative thing and the discount rate, we already know the PBSC's view on this. If you lower the discount rate or change anything on comparatives, we're just going to use one of the other 60 levers at our disposal to keep it down to get the same outcome. You can't win that discussion. You can win a discussion about rights. What are my rights as a person, as an individual? I should have the right of review. And particularly if it's affecting my healthcare, but all right. Yes, a$30 million for a year to build that guy in New York, he is mad. I thought I mean he's never basically had a job. He was a like a far rapper.

Felicity 56:37

Does he not know the history of bread lines in communist countries?

Paul 56:42

Socialism, but but I did I think it was George Will, the presidential historian, who said it's just important every 20 or 30 years to have a discrete case study, lived experience of socialism, so everyone can remember just how bad it is. What a dumb idea it is, and and just how dangerous, how dangerous it is. So he said we should see this as an opportunity just to wake everyone up. But the way people vote now, it's so tribal. This is one of the consequences of social media. Uh it's crazy. But anyway, thank you, Felicity. Have a lovely weekend. You too, and uh we'll chat next week.

Felicity 57:20

See ya.