Minister for Health and Aged Care - Melbourne press conference - 23 January 2023

Read the transcript of Minister Butler's press conference on Medicare; bulk-billing; Strengthening Medicare Taskforce; Better Access; and mental health.

The Hon Mark Butler MP
Minister for Health and Aged Care

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MINISTER FOR HEALTH AND AGED CARE, MARK BUTLER: Thanks very much for coming. It's never been harder to see a general practitioner or a doctor out in the community than it is right now. We've heard that from Australians now for many months, and it's never been more expensive, particularly after six years of a freeze on the Medicare rebate. Gap fees have skyrocketed over the last decade: for a standard GP consult, for the first time in the history of Medicare, the average gap fee is now more than the Medicare rebate fee itself. And what this means is that too many Australians simply can't get the care that they need, when and where they need it out in the community. And too many are ending up instead in hospital emergency department placing even more pressure on an already very, very stressed hospital system. That is why strengthening Medicare was the centerpiece of Labor's health policy at the last election. We were the only party of government that actually promised more investment in Medicare, with our $750 million Strengthening Medicare Fund, a commitment to 50 Urgent Care Clinics - we've had extraordinary buy in and cooperation from every single state government to ensure that we can start rolling them out this year. And our commitment to extra training, new training and innovative models of care in rural and regional general practice $160 million fund that was delivered in the October Budget.
But I have also been clear that more of the same is simply not going to cut it. Strengthening Medicare means also modernising Medicare. And I want to really thank all of the people who worked so hard with me over the last several months on the Strengthening Medicare Taskforce for their work. We had patient groups, doctors groups, obviously nursing groups, allied health professional representation, and a series of experts all of whom have been working hard over several years, frankly, to come up with the ideas of what a modernised primary care Medicare system looks like.
We worked really hard right up until Christmas. The final written report has been the subject of ongoing work over the summer period. And I look forward to being able to release that final report in the next couple of weeks. It will guide the decisions that our government needs to take in the May Budget to finalise the investment of that Strengthening Medicare Fund that was a clear commitment to the Australian people at the last election. Labor has no higher priority than strengthening Medicare and rebuilding general practice to ensure that Australians get the world class health care they need, when and where they need it, out in the community. Happy to take questions.
JOURNALIST: Minister, to the Taskforce, one of their key recommendations is this blended care model, which I know you've been open to but can you confirm that you've accepted that recommendation and plan to implement it?
BUTLER: The report will be released over the next couple of weeks and there will, as I said, be a process then to make decisions in the May Budget that will be very clearly informed by the work of the Taskforce. But the idea of moving from a purely fee-for-service model that has largely defined Medicare over the last 40 years to something that's more blended, that has more wraparound funding, particularly for older patients and patients with complex chronic disease, is not a new idea. This has been discussed for many years, we had pilots on it when we were last in government, particularly in the area of diabetes.
Over the last few years, pretty much all of the same groups who run the Taskforce worked really hard on a 10 Year Primary Care Plan that was released by the former government at their March Budget last year, but did not have a single dollar of extra investment to actually deliver the recommendations of that plan. And again, that plan saw a whole range of ideas for more blended funding models that will deliver, frankly, better wraparound care for the sort of complex chronic disease that is much more prominent in Australia than it was when Medicare was first designed 40 years ago. So you can expect us to have a particular focus on the needs of people with complex chronic disease because that is such a big part of the primary care system not just here in Australia, but as you see all around particularly the developed world.
JOURNALIST: Do you acknowledge now that most Australians have out of pocket health care costs and that means that we're no longer a universal health care says we don't have a universal health care system.
BUTLER: We do have a universal health care system in a sense that everyone is entitled to go to a public hospital. That's not the case in every developed world country. Everyone is entitled with your Medicare card to medicines on the Pharmaceutical Benefits Scheme. For general patients, we've seen the biggest cut to the price of medicines only a few weeks ago in the 75-year history of the Pharmaceutical Benefits Scheme. And you are entitled to access Medicare rebates through Medicare: a proud Labor legacy that for so long, frankly, was fought tooth and nail by the Liberal Party over decades.
So we do have a great universal health care system. But I've been clear, as much as frankly, the former government tried to disguise this reality, I've been very clear - as doctors have - the bulk billing has been under huge pressure over recent years. Particularly after a six-year freeze on the Medicare rebate. I mean, that's not rocket science. If your income as a general practice is frozen, while your costs are continuing to increase, that does place pressure, upward pressure on gap fees. About two-thirds of Australians are still getting bulk billed service. But about a third of Australians are paying gap fees. And that one third of Australians, a group that frankly appears to be growing and growing relatively quickly, are paying higher and higher gap fees because of that financial pressure on general practice, in particular, on Medicare generally, but particularly on general practice. And that has been a big focus, obviously, of the discussions of the Strengthening Medicare Taskforce. But although I've been clear that Medicare is in I think the worst shape it's been in 40 years, it's also true that we have a healthcare system that is the envy of so many countries around the world. You know, we need to strengthen Medicare, we need to modernise primary care, in particular, to deal with that change disease profile that's developed over the last 40 years. But I as an Australian, certainly as Australia's Health Minister, am very proud of the health care system that we have here.
JOURNALIST: Minister, on out of pocket costs, some cancer patients are forced to pay almost $10,000 a month for treatment not covered by the PBS. This comes after years of treatments that are. So these are families that have been going through the process for years, with potentially devastating effects. The health department said, when I asked about this, patients are encouraged to discuss financial situations with their specialists. Is this good enough for struggling families who can't afford medical costs?
BUTLER: As I've been saying, over the course of this press conference, we're very focused on the fact it's not hard not only harder to see, not just GPs, but specialists as well. We've seen those waiting lists blow out, but we've seen gap fees for specialists climb even faster and higher than gap fees have climbed for GPs. The MBS rebate freeze didn't just impact general practice, it also impacts specialists as well. So there's financial pressure right across the healthcare system, and too many patients are feeling that in their hip pocket.
As for medicines, I think your question is partly about medicines, we live in a turbocharged period of discovery we really do. And new medicines, particularly for diseases like cancer are coming on to the table on a very regular basis. And our Pharmaceutical Benefits Advisory Committee are working very hard to try and get them into our system as quickly as they possibly can.
Now, our system, whether it's medicines, or therapeutic services, or a range of other diagnostic services, is a relatively old system. Our assessment and approval processes for new therapeutics, new medicines for cancer, for example, is relatively old. Which is why we've kicked off the first review in a generation, frankly, about health technology assessment processes, because we want to make sure that these new technologies, these new therapies are delivered from the benchtop, if you like, from the discovery of this new technology into patients as quickly as possible. And that's a very strong focus we have during this term of Parliament.
JOURNALIST: Minister, do you simply have to increase the Medicare rebate. The AMA is talking about rebates potentially have to double to keep with what doctors are experiencing in terms of cost and equipment, prices. I mean, do you simply have to put more money into rebates?
BUTLER: As I said, we're the only party that went to the election, promising more investment in Medicare. But I've also been clear that more of the same is not going to cut it. And I think a range of commentators have also reflected on the fact that simply adding more money to the existing structures is not going to deliver the quality, wraparound care, particularly people with complex chronic disease need and deserve. So we're about delivering a modernised Medicare. A stronger Medicare does mean that we are going to have to look at the structure of the system that was built around much more episodic care, which was more prevalent 10, 20, 30 or 40 years ago than it is right now. So you know, what I want to do is be very clear with people: this is not easy, it's not going to be quick. And our government is not simply going to be adding more money to the existing system. We're about delivering a better, more modern system. And frankly that is the clear consensus of everyone from patients through the doctors, nursing and other experts that I've been engaging with over the last several months.
JOURNALIST: How can primary health, like pharmacy, can there be any of these reforms to take the pressure off the GP systems? And how can we access, like lure more primary health and medical practitioners to regions?

BUTLER: A few questions in that, but to deal with the first one. I've been very clear that at a time of skyrocketing demand for health care, and workforce shortages, that it doesn't make sense not to have every single one of our health care professionals working to the top of their scope of practice, whether that's doctors, nurses, allied health professionals, pharmacists, and others. I've seen some coverage today, for example, about the work that paramedics could contribute to primary care. We just don't have that happening in Australia, there are too many regulations, too many constraints within the MBS system, too many turf wars that constrain the ability of people who want to deliver their full range of skills and training – training delivered by taxpayers to hundreds and hundreds of thousands of health care professionals. So, you know, I want to see out of this Strengthening Medicare process, a much more liberated ability for all health care professionals: doctors, nurses, allied health professionals, to be able to contribute to the need that we have out there to deliver world class health care to Australian patients. That's not going to be easy. But I sense a level of consensus around that, lifting that ability for other healthcare professionals to use their skills and training than I've ever seen before.
JOURNALIST: Just dovetail on that, could you foresee a greater role for nurses in diagnosing and prescribing for patients to alleviate the risk from primary care? And just going back to something you said in response, are you completely rolling out a raised Medicare rebate?
BUTLER: I'm not going to pre-empt what the report of the Strengthening Medicare Taskforce, will say and will contain. And I'm certainly not pre-empting the Budget process to consider all of those things. I'm just making clear my point of principle that doing more of the same is not going to deliver the quality of health care that Australians need and deserve. We do need to look at reform, as well as the additional investment that we promised at the last election. As to your question around nurses, I’m very clear that there is much more that nurses in primary care - practice nurses and nurse practitioners, for that matter - can do. That they want to do, they have the skills and training to do, that our current MBS system is not letting them do that well. And I think that will be something that comes through the Strengthening Medicare Taskforce report very clearly. But it won't be the first time it's been said, it was also a clear recommendation out of the 10 Year Primary Care Plan.
JOURNALIST: Minister, the AMA is renewing its push for the government to introduce a tax on sugary drinks. Is this something on the government's agenda?
BUTLER: No, that's not on the government's agenda.
JOURNALIST: Minister on Urgent Care Clinics, Labor originally committed to have those sites up and running within a year of the election. Will any clinics meet that May deadline? And can you give a timeframe for when all 50 will be operational and their locations decided?
BUTLER: Our commitment was to deliver those this year. And we've be working very closely, as I think I said in my introductory remarks with all state governments. There's been an enormous level of buy-in by every single state government across the country in this model because they know what it was going to do, not only to deliver better care in the community, but to relieve pressure from their emergency departments. And what you also have seen since our announcement is financial commitments also from some state governments, particularly New South Wales and Victoria, to co-invest in this model, as well, we've been talking to state governments, particularly about locations to get them absolutely right.
You'll recall that our commitments were in broad catchment areas to take pressure off particular hospital districts. But we've been working very closely because we know they have on the ground information about where those locations will be most strategically decided, also doing things like developing protocols so that these Urgent Care Centres are working hand in glove with local emergency departments and local ambulance services to make sure that people are going to the right location, depending on what their level of need is. So we'll have more to say about that over the very near future. I'm talking very regularly with my Health Minister colleagues about it. But we're very, very confident that this commitment is on track.
JOURNALIST: Minister, in Queensland changes to how payroll tax is being interpreted means that Medicare payments to doctors are now being captured and taxed under payroll tax. The RACGP has concerns that not only is this impacting on clinics abilities to bulk bill, but it could be spread to other states and become a national issue? Is this something that's been raised with you? And should states be exempting things like Medicare payments from payroll tax to ensure that that full benefit is passed on to the doctors and therefore the patients?
BUTLER: As you know, payroll tax issues are a matter for state governments. There have been developments over the last 12 or 24 months at different state levels about the treatment by state treasuries or state tax offices of general practice. I've been watching those developments. I've had some communication with the College of General Practice, as I think the new President indicated this morning would be the would be the case. We're trying to make time to speak over the next few days.
JOURNALIST: Minister, when you released the Better Access review, why did you fail to mention that the review recommended keeping the extra 10 sessions? And when will you be announcing what you will be doing for people with complex mental health conditions?
BUTLER:  I think, if you have a look at the transcript, I did say that the evaluation, or I have acknowledged that the evaluation said that there was value in additional sessions for people with complex needs. But I also did point out that the evaluation had made clear that this is not a system that is well designed to triage those people with complex needs against people with more mild to moderate needs, which after all, was the population at which this program was initially targeted almost two decades ago. The evaluation made very clear as well, that the additional sessions were not going to people, particularly with more complex needs, it was going to people in particular geographic areas with no triaging about whether the people receiving the additional sessions did or did not have more complex needs than that general population that are usually the target of the Better Access program.
JOURNALIST: So are you saying GPs are referring people for an extra 10 sessions that they shouldn’t?
BUTLER: No, I'm not saying that at all. So, I'd prefer you didn't put words in my mouth. What I'm saying is that the system is not particularly designed for people with more complex needs, which is exactly why the system was performing in the way in which it did. There is no triage system within Better Access for people to be identified with more complex needs, and therefore only been the people entitled to the additional 10 sessions. I think if you read the evaluation, you see that pretty clearly. As to what we'll be doing in the future, on Monday I'll be having a roundtable with several dozen different stakeholders, which I indicated will be the case before Christmas. That's taking place here on Monday, and we'll be having a good discussion about how we improve the equity of this program. This is a good program, where it is received. But as I've said, now for many years, including in response to the last evaluation more than a decade ago, it is not a program that delivers services in an equitable way. That is very clear in the evaluation. People in areas with the most significant need - the highest level of mental distress - receive far fewer services than other areas in the community. And that was even more of a case for the additional 10 sessions. The level of access, particularly the level of equity, was made worse by the additional 10 sessions, as a number of people indicated would be the case at the time the former government announced it.
JOURNALIST: There's a finite amount of resource for these mental health services and your suggestion is that even if they are used and potentially needed in those concentrated areas, that you would rather them be redistributed to areas where there's less access, not just improve access across the board?
BUTLER: This is a demand driven system. The constraint is not within the system itself, the constraint was a workforce constraint. And, frankly, where the psychology businesses, by and large, although there's some entitlement by OTs and social workers to deliver the service as well. But by and large, the constraint is a supply constraint through psychology businesses.
And what is clear through the evaluation is that, first of all, there is a very substantial geographical inequity in that supply. That's been the case, frankly, for well more than a decade in the area of Better Access. But additionally, what it shows is that the number of new people getting into the system declined dramatically after the additional 10 sessions were introduced. Tens and tens of thousands of patients got absolutely no services, got zero services, were unable to get in because as many of your readers, many of your listeners would know, when you try to get into a psychology service, too often, you're told that their books are closed. And that fact was made worse with the additional 10 sessions.
Now, I'm very clear that people who were able to get access to those 10 additional sessions appreciated them and got a benefit from them. The problem though, is it cut out a whole lot of people from getting any support whatsoever. And the evaluation is very clear on that.
JOURNALIST: Minister you spoke about the pressure put on GPs. But the Government has now made it a requirement for people to go to GPs to get permission to have a PCR COVID test. Won’t that just load up GPs even more with people, and also incredibly sick people who possibly have COVID as well?
BUTLER:  Right through the pandemic, there have been a range of ways in which you can get a PCR test. The first is the traditional way you get any sort of diagnostic test or pathology test. That is, you get a referral from a GP and go to your local pathology service. That hasn't changed. The second, for areas like aged care, is that we've been funding PCR testing in aged care facilities, we're continuing to do that. That has continued. We're particularly focused on making sure that where there is a suspected COVID case in an aged care facility, a PCR test is able to confirm that as quickly as possible, so that that patient or that resident can go on to oral antivirals as quickly. That hasn't changed, either. The thing that also hasn't changed is that we have said the third way in which people have been getting PCR tests, by and large, is by going to state-run testing clinics. And we have said that from the 1st of January, we would continue to fund those, co-fund in a 50/50 cost share basis, co-fund those state PCR testing clinics in exactly the same way they were right through the rest of the pandemic. That has not changed since the 1st of January. Now, some states have wound back their PCR testing clinics. In my state they haven't, they're still open. In South Australia I know there’s one around the corner of my office. Some states have wound back those PCR testing clinics, which is meaning that more people are having to rely on the traditional mode of getting a test which is going to a GP and then going to a pathology clinic. We have retained our funding commitments across the full suite, the full panoply of ways in which people can get a PCR.
JOURNALIST: Is there a need to cap the out-of-pocket fees? Is that something that Federal Government can do? And just forgive my ignorance on the block funding - I'm told that that's a lump sum per year payment for patients. If that's the case, won't that be a disincentive for doctors and specialists to see patients?
BUTLER: I mean that that is one way in which you could do this, I don't want to get into pre-empting what recommendations from the Taskforce might be or what our response might be. But you know, obviously, one way in which to do this is to provide a larger lump sum which has flexible arrangements to treat particularly someone with very complex chronic disease, you see that in many countries around the world. Obviously, we're not replacing and there's no one advocating for replacement of fee-for-service. Fee-for-service is still a very effective, efficient way to deal with many, many cases that people will want go and see their GP about - an episodic level of care. So, the question is whether on top of the traditional fee-for-service system, you add some sort of flexible funding that allows doctors to provide wraparound care - not just directly between doctor and patient - but with nurses, with a range of different allied health professionals as well. And that was a topic of substantial discussion, not the only one, but a topic of substantial discussion, at the Taskforce.
JOURNALIST: And capping gap fees?
BUTLER: I'm not going to get into pre-empting what might come out of the Taskforce.
JOURNALIST: Not to pre-empt the processes that are going on for this meeting next week. But would you imagine that the outcome of this process would be that people with chronic conditions, people with more serious complexities would end up getting more than 10 sessions? Would you imagine that they might get back to 20 sessions if you have a complex mental health need?
BUTLER: Let's focus first on the areas of need that were identified by the evaluation. The most significant one, in terms of its size, was the issue of equity. This, as I said, has been a long-standing challenge of the Better Access program, it's not new. And that is: the more affluent your area, the closer you are to the centre of the city, the more likely you are to be able to access one of these psychology services. When you get out into outer suburbs and particularly when you get into regional communities, it is very hard to access one of these services.
And you're not dealing with apples and apples, what the evaluation also showed is that the poorest quintile, the poorest group of Australians, have the highest levels of mental distress, the highest level of need for this sort of support, but they get the fewest services. And so that means, the evaluation shows, that they're much more likely simply to be medicated, rather than have access to good evidence-based psychology services. Equity is the first area of need and I've been very clear with all stakeholders, whether they're delivering services under this program, or work elsewhere in the mental health system, a Labor Government is focused on equitable access to services.
The second area of need is complex care. This is not a new debate: many mental health professionals have been talking about the “missing middle”. Pat McGorry has been talking about it down in Victoria, it was a significant focus of the Royal Commission in Victoria. There have been investments rolled out to try and deal with this “missing middle”. But there will be a question about whether Better Access is well designed to deal with people with more complex needs. That was not the initial purpose of the project.
JOURNALIST: The evaluation said Better Access should be extended for people with complex conditions, which is a recommendation you haven't adopted. And following on from Clare, why is this an either/or debate? Why is it only oh, we're going to give money to people at the acute end and as opposed to continuing Better Access for people who might not be as acute and then finding additional support for people who are acute?
BUTLER: I didn't say that it was an either/or – or that funding would be at the acute end. What I have said is there is a question about the degree to which this program is well designed to triage people with mild moderate needs, against people with complex needs. It's not there, for example, at the moment, so you would have to build in some sort of triage system or review system to delineate those people for whom the program was set up, which was people with relatively short term, high prevalence disorders like anxiety and depression, that can be on average, the evaluation says, supported through maybe four or five sessions, which is has been the average number of sessions for the life of the program for nearly two decades, against those people who I know do need, and aren't getting that need, who have much more complex needs.
JOURNALIST:  So you've spoken about rural access and how it's hard to get but by taking the sessions of someone in the city that doesn't free up GPs rurally for them to all of a sudden get this renewed access. So, have we just robbed Peter to pay Paul and both are missing out in the interim?
BUTLER: I think you'll find that psychology services have closed books right across the community, whether they're in inner city suburbs, or in regional communities. And you know, what is clear is that there are different interventions that needs to take place where there are market failures and regional communities in outer suburbs.  I did that when I was Mental Health Minister more than a decade ago to fund Medicare Locals, so what are now Primary Health Networks to deliver bulk billed psychology services in areas of the community where private businesses simply weren't setting up, so regional communities and outer suburbs. Sometimes addressing these inequalities require different interventions and that's the sort of thing I'm confident we'll be discussing next week. Thank you very much.

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