Still raving about Better Access

From: //blog.artdoxa.com

This blog post is actually a very long comment on the blog by Jacinta Patterson titled "Argument by anecdote in mental health". The anecdote that Better Access money was being wasted on the over-concerned rich and not on the disadvantaged and genuinely mentally ill, seemed to be the main reason put forward in the press, explaining the cuts to Australia's mental health budget for 2011- 2013.

Aha- this post (referred to above) is still getting responses! I dropped in when it was first posted, but my comment doesn't seem to have got through! As a Better Access client and a former mental health researcher trained in public health, I can find many ways of examining the whole scheme!

It's difficult, firstly, to examine Better Access without the stats from the rest of the outpatient mental health sector. As someone said above, many people, mainly with schizophrenia or manic depressive disorder [these names make it clearer as far as I'm concerned; I know the controversy], are covered by Headspace and  community mental health clinics [which are hospital outreach disguised]. The NEW cases of psychoses, or those at high risk [pro-dromal; the people who were to receive medications if they seemed on the edge of real psychosis], hopefully benefited from Better Access, but I can't see how I can tease them out of the figures from the govt. I would assume that plenty of these people would not recognise they needed help, just as always happened in the past- the only way I imagine they got into Better Access would be if their GP was alert enough when seeing them for another complaint. How alert are GPs usually? Don't know- no figures. There's no epidemiological data from the past on this and I don't know anyone collecting it, so we can't judge.

Anguish at work- needs help

The figures suggest many new clients for mental health care under Better Access and the sudden proliferation of various therapist groups in the community suggests the same- there are community nurse mental health counsellors, psychology-trained, social-work-trained, [I don't know any] occupational therapy-trained plus more, putting up shingles. Most have few empty slots in their calendars, so someone is filling them. My guess is that new clients who couldn't afford private care before are cashing in on the Medicare scheme to get help they've needed for a long time. I know hardly anyone besides myself who has seen a psychiatrist for more than one session under Better Access and I think that is because psychiatrists won't take merely the Medicare rebate as full payment. Mine agreed to it beforehand, because I asked specifically and because I knew her before she qualified. However, her receptionist didn't know this and when I had received 2 sessions and handed her the rebate cheque for the first one she asked: "How would you like to pay the rest; cheque or credit card?". I told her I had no income, no insurance and no benefits, so she was going to have to accept Medicare or take me to court! My shrink cleared it up with her!

USA, ER visits for mental illness increased

I would suggest that psychiatrists have kept on seeing the same sort of clients they always saw- those referred through hospitals and other professionals, mainly privately insured [the uninsured wait to see their psychiatrist in hospital outpatient clinics every week and get the same doctors as they had privately], a slight leaning towards upper income, definitely more city/suburban people and hardly a trace of indigenous Aussies. However, at outpatient clinics there have continued to be stacks of lower-income clients, young people avoiding parental scrutiny and indigenous and other-cultural-group clients. Because there are virtually no psychiatric emergency "drop-in" centres, the poor old Emergency departments of public hospitals have copped the majority of psychotic, alcoholic and suicidal people, usually in terrible emotional states and which the emergency doctors, nurses, police and ambulance personnel are least trained to handle. Better Access could do with setting up a few Psych Emergency Facilities at least on the outskirts of  major towns. I don't think the community is going to suddenly get better at detecting mentally ill relatives and friends before they reach crisis point- they've never seen psychosis etc before, it's scary and they hope it will go away if they ignore it. Maybe the NEW Headspace places can change the culture of stigma and disdain of help-seeking by young men, but I'd like to see it happen before I'd have much hope.

In bed crying? Get help via Better Access

I'm a bit confused about why the change from 10 to 18 sessions in Better Access had to be made and announced because the clients from last year are going to have to see SOMEONE sooner or later. If clients who are still in need of care go back to their previous therapist, which most of us would prefer to do [and that would be therapeutically beneficial], are they suddenly going to say "Bugger off or pay me twice as much?" I can't see it happening except where psychiatrists have hard-hearted receptionists! I'd like to hear from some people about their experiences, since there's NEVER going to be a statistic on this!

As for GPs getting less money for the first consultation under Better Access- I can't work out how the huge amount extra was justified in the first place. The GP gives you a batch of questionnaires to fill in while he/she sees another person, then asks a few brief questions face-to-face, adds up the simplest depression/anxiety scores, gives feedback and may write a standard referral on the computer if you seem to need care elsewhere. Otherwise, if the GP is doing the counseling themselves, people just make regular appointments as they would for anything. I can't imagine that many GPs deduce much themselves from this 1st appointment, even those with special mental health training- mine didn't, that's for sure. Apart from questionnaires, the GP does have some documents to complete proposing a treatment plan, etc, but it's not clear how an ordinary GP could predict what is going to happen with a mental health case anyway- psychiatrists find it hard enough. In my book, the cut in Medicare rebate is justified- doctors just got used to it. Couldn't they feel good about contributing to Public Health with these sessions, rather than through some dubious primary care "health promotion" program? The cuts for ongoing counseling I'm not sure about- halving the rebate seems harsh.

ER will always get self-harm clients

As for the $1.4 billion: Why won't this much be NEEDED for mental health in the future and blow out lesser budgets? You can't hope to "cure" many people, and for the ones fixed up enough to go it alone, another new one will walk in the door & use the Medicare dollars.

Have a look at what happened in California after their mental health budget was slashed. DO we want that in Australia? :
http://disabilityrightsgalaxy.com/2011/10/01/the-system-is-broken/

The USA has even more problems with mentally ill people reporting to ER than we do in Australia:
http://www.msnbc.msn.com/id/25520178/ns/health-mental_health/t/some-psych-patients-wait-days-hospital-ers/
http://vtdigger.org/2011/11/09/frustration-over-upheaval-in-states-mental-health-system-mounts/

Wrong place for mental health care- too tense & anxious

Why self-harm now?: http://thelinc.co.uk/2010/03/self-harm-the-cause-the-facts-the-support/

Moving ahead: http://www.bipolarlifestyles.com/tag/hospitalization/

MS is now a Public Health Concern

'via Blog this'

Last night on ABC TV [national, free to air, Australia], I saw an interview with a woman who claimed she had been cured of MS by a controversial surgical procedure to the blood vessels draining the spine and brain. I pricked up my ears as I had never heard anything on the topic of CCSVI [Chronic Cerebrospinal Venous Insufficiency]. A neurologist explained that an Italian, Doctor Paolo Zamboni, had discovered that the veins in the neck of MS sufferers were not big enough for the volume of blood coming from the brain, so that back pressure built up, injuring nerves. I assume this guy has done blood flow studies to support this idea of insufficiency in MS vs all clear in non-sufferers- I don't know. The transcript of the interview with various doctors and sufferers is available at: http://www.abc.net.au/7.30/content/2011/s3399100.htm

This sounds reasonable because MS is a progressive condition where muscles throughout the body become weaker due to deterioration in the nerves which carry messages from the brain and spine. There are many theories on why the nerves become damaged, but no one has proven any one cause for all MS people. Some alternatives have included stray measles virus (just as poliomyelitis virus left over from childhood infection can produce post-polio syndrome in adults); toxic chemicals in the environment breaking down nerve coverings; vitamin and nutritional imbalances or insufficiency or above-normal need; damage from leached metals from amalgam dental fillings and good old genetic inheritance.

Apparently a Newcastle [NSW, Australia] general medical practitioner [not a neurology specialist], has been assessing blood flow in MS patients' necks and referring them for stenting or balloon angioplasty procedures to widen the channels inside veins carrying blood back to the heart. Dr Paul Thibault claims that two thirds of people referred have had significant improvement in their muscle function, including the woman on the program [ who has been able to go on a vigorous overseas holiday.

Quote:

KERRI CASSIDY: I actually went on an overseas holiday and I walked halfway around Europe for three weeks. I couldn't believe it that I really didn't think I'd ever be able to do that.

She looked and sounded really good compared with footage of her before the procedure, so I did a little exploration on the Internet.

First, I was quite surprised to see that someone had won a medical award for clinical and research contributions to Multiple Sclerosis because I had thought MS was only a problem suffered by very few people and that the cause was unknown or highly disputed. More surprisingly, it wasn't Dr Thibault from Newcastle, but a Professor Bill Carroll from Perth!

The award announcement says:

"Professor William (Bill) Carroll wins the 2011 John Studdy Award
John Studdy, Multiple Sclerosis Australia (MSA) and Multiple Sclerosis Research Australia (MSRA) would like to congratulate Prof William Carroll on being awarded the prestigious John Studdy Award.
The John Studdy Award is given annually to an individual in recognition of their outstanding,
consistent and selfless provision of meritorious service to people with MS.
... In addition to being one of the country’s most eminent neurologists, Bill performs a
leadership role throughout the world...
...Prof Carroll made a significant contribution in promoting ... and helping to subsequently
establish Multiple Sclerosis Research Australia (MSRA)..."

At various times I heard that there were some promising trials of drugs for MS in Australia, but assumed these measures were supportive but not curative. The national prescribing service [PBS] had approved some new drugs which I understood were very expensive, under their provisions to fund a certain number of treatments for "rare" conditions where the economics of private use were impossibly restrictive. Two people I know personally are taking some of these new drugs and they've told me they are feeling better and can do things they couldn't previously, eg. stand up in the kitchen and prepare food, rather than half-heartedly chopping up the lettuce on a wheelchair tray. However, neither has taken a walking tour around Europe!

The PBS started subsidising oral Gilenya (fingolimod) on 1st September, 2011, bringing the cost of using it down from X to $34 per script. Because this can be taken via the mouth, it is far more convenient than other drugs preceding it, such as injections of Interferon Beta. The latter often caused reactions at the needle site and flu-like symptoms. One friend of mine complained of feeling as though she was getting the flu and having to use her asthma inhaler more, but thought she had improved her muscle strength in her arms for using her wheelchair.

When Interferon was first tried in Australia I can remember it cost a lot- something like $1200 to $2 000 per month, which was not affordable for most people. When the PBS adopted Interferon under their subsidised program, it reduced to between $30 and $80 per month, depending on changing doses in line with improvement/deterioration. The new Gilenya should now be $34 per prescription filled, like any other medication, eg. Ventolin asthma spray [2-pack].

As the ABC program revealed, the surgical procedure to widen the blood vessels in the neck needs to be subjected to the same vigorous trials as the new drugs have been through, to make sure it works for the majority of people with MS. The procedure is moderately dangerous and there have been a few deaths, so it is more than a simple experience with guaranteed good results. Even when performed well, only 2/3 of patients report improvement, so the costs must be considered in proportion to the number of people likely to benefit [this is where Public Health gets into the act].

The MS Society lobbyists and individuals in the community do not fully understand what a dilemma their requests to surgeons create. Many with MS want the procedure right now, before their function deteriorates or before the disease progresses too far, but this is fraught with medical and economic dangers. Economically, since so many requested the procedure when it was subsidised under Medicare, people with other more common conditions (such as blocked veins in the legs or arms) were being pushed further down waiting lists by the perceived urgency of the CCSVI for the MS patients. Surgeons became concerned [and tired from long operating hours] that the Medicare system was becoming "unfair" because more people with rare conditions were receiving procedures than those with common conditions with PROVEN treatments.

Thus, the relevant government authorities have withdrawn support for CCSVI as an MS treatment until good trials have shown that it benefits a significant majority, just as the procedures for blocked veins in the legs do for their sufferers. With leg vein clearing or bypass people gain a lot of function [eg. they can walk again, maybe work], deaths associated with it are very rare, the danger is not high compared with operations on neck veins and the costs per patient are reasonable given the good results achieved.

At this stage I don't feel confident to summarise all the factors we should consider when assessing the "fairness" of public health spending on Multiple Sclerosis, but there are some good articles on which you can base your own assessment:

Benchmarks of fairness:

http://www.who.int/bulletin/archives/78(6)740.pdf

Justice & fairness in Public Health:

http://plato.stanford.edu/entries/publichealth-ethics/#JusFaiPubHea

In the UK a subsidised drug for MS seems to make people worse than no treatment at all. Where's the fairness?:

http://pharmexec.findpharma.com/pharmexec/Europe+Features/Fairness-Risk-Sharing-and-the-European-Price-Cuts/ArticleStandard/Article/detail/676558

A discussion of fairness and provision of subsidies for hyper-expensive treatments:

http://www.nuffieldbioethics.org/sites/default/files/files/Hyper_expensive_treatments_background_paper.pdf

"...Why... does our nation’s health stay bad, even in some areas get worse, and the poor still die younger than the rich?":

http://www.sochealth.co.uk/news/Withoutwalls.html

For summaries of information about MS, read:

Australia; The MS Society: http://www.msaustralia.org.au/aboutms-moreinformation.asp

USA; NINDS: http://www.ninds.nih.gov/disorders/multiple_sclerosis/multiple_sclerosis.htm

Daron Acemoglu on Inequality | FiveBooks | The Browser

Daron Acemoglu on Inequality | FiveBooks | The Browser:

'via Blog this'

Public health views economic disadvantage and inequality as the main factors behind poor population health. If the lot of the most deprived in every country cannot be improved, the whole community cannot become healthier.

Ray Moynihan has written this one so I don't need to

We should stop pharmaceutical companies from dealing directly with practising physicians/doctors. An accountable government-approved/appointed group should be the party to recommend drugs for use by a country's doctors. I'll keep saying it and I guess, so will Roy Moynihan. His article:

It’s not you, it’s the patients: why doctors should tell drug firms it’s over

Doctors' wining and dining by drug companies distort prescribing patterns and may influence them to recommend less-than-ideal drugs. PhillipC/Flickr

This week Radio National’s Background Briefing looks at how pharmaceutical companies market their products to doctors.

The program is presented by Ray Moynihan, an award-winning journalist, columnist at the British Medical Journal and conjoint lecturer at the University of Newcastle.

---

You’ve written and researched extensively about the business of medicine – what is it that attracts you to this area?

It’s a good story. I’m essentially a journalist and the corruption within the medical world is an incredible story to follow and investigate.

The extent of the financial entanglement between doctors and drug companies seems to know no bounds and I think it’s vitally important that there’s more scrutiny of these relationships.

The reason people are interested in doctor-drug company relations is not because of the desire to expose doctors wining and dining habits, the reason to expose this is because it distorts prescribing patterns and it means doctors are more likely to prescribe the latest and most expensive medicines. Sometimes a good thing but other times, wasteful and dangerous.

The example we use in the program is the antidepressant Cymbalta. Here’s a drug that is getting the thumbs down from a number of independent educational groups but is being ferociously promoted by drug company reps who stand to get a sizeable bonus if they can get a certain number of patients taking this drug.

And it’s being promoted by specialists, who are being paid generous fees secretly to present company slides about it at “educational events” to their peers.

Rennett Stowe

This is an extremely unhealthy aspect of the Australian health-care system, and I think one of the most frightening aspects of what Petra Helesic [a former drug company insider] says is how she became aware in recent years of how aggressively anti-psychotic drugs were being marketed for depression.

That, in itself, is worthy of a great deal of public scrutiny.

What can be done to ensure the independence of the medical profession?

There are many ways in which doctors, professional groups, universities, hospitals and other players in the health-care system can roll back their interaction with some of the unhealthy marketing practices.

A classic example comes from Christchurch, New Zealand, where many doctors have stopped seeing pharmaceutical company sales representatives and have replaced that kind of interaction with independent education.

In the same town, the college of general practitioners has stopped taking drug company sponsorship for their annual conference.

This is one of many examples around the world where there are small-scale attempts to engender a more independent relationship between health professionals and the pharmaceutical industry.

One of the simple things that every single university could do tomorrow is to mandate all of their staff to declare their financial relationships with drug and device makers and make that available on a publicly-searchable website.

That’s the sort of thing University of Sydney’s Professor Martin Tattersall and others have been suggesting. It’s going to become standard practice around the world and I would love to hear an argument about why it’s not possible for Australian universities to do that.

There’s also a great opportunity here for the tertiary education sector to offer genuinely independent education to our health professionals.

The industry appears to fund the lion’s share of ongoing professional education either directly at these dinners or indirectly through their sponsorship of conferences, seminars and meetings.

But there’s an abundant amount of evidence that industry-funded approaches are not in the best interest of patients or the public.

There’s a real, genuine, timely opportunity for the tertiary education sector to play a bigger role in this kind of education.

The AMA strongly opposes having a public register that names doctors who receive benefits or attend events sponsored by pharmaceutical companies, instead favouring disclosure of the cost of meals and names of restaurants.

AMA president Steve Hambleton says, “bringing it down to an individual level is going too far”. Why do you think the AMA is resisting transparency?

One of the things that Steve Hambleton says very clearly in the program is that one of his concerns is that being on a public register could besmirch a doctor’s reputation.

ArtBrom/Flickr

But if there’s something wrong with being associated with these marketing events, then why are doctors going to them?

If doctors believe that attending drug company lunches and dinners or accepting those generous speaking fees ($750 to $1500) are in the interests of their patients and in the public interest, then they should have no problem at all with that information being transparent and publicly available.

But there’s huge resistance from the AMA in Australia and its very much behind thinking around the world on this.

In fact, one of the senior executives of one of the companies in Australia has already publicly flagged the potential desirability of much greater transparency, in terms of disclosing the names of doctors who attend dinners and the amount of money that drug companies pay to individual specialists.

And Medicines Australia, the industry body for pharmaceutical companies, has said greater transparency is one of the things they will be looking at in their review of their voluntary code.

But more importantly, the United States has a law called the Sunshine Act, which is sitting there as a policy option for the Australian government.

It would be great to hear the argument for why such transparency isn’t appropriate in Australia but is in the United States.

What ways could doctors be learning about medicines that are independent or not emanating from drug companies?

There are three that were mentioned in the program – the National Prescribing Service, which is Australian; the Drugs and Therapeutic Bulletin out of the United Kingdom and; Prescrire which is a very reputable French journal.

There are many other sources, such as the Cochrane Collaboration, and there are many ways in which doctors can educate themselves.

But the truth is that going along to a dinner in a fancy restaurant in your local area is easy, and it’s fun. And you’re treated like a bit of a VIP.

A small but growing number of other doctors are absolutely horrified by the fact that their colleagues are still going in their thousands to these promotional events – which are described as “educational” in an extremely disingenuous way.

This article was originally published at The Conversation. Read the original article.

If you would like to hear from the other side, there is an account here: http://circ.ahajournals.org/content/121/20/2221.long