Health care fraud and abuse.

In recent years, health care fraud and abuse have become major issues, in part because of the rising cost of health care, industry consolidation, the emergence of private "whistle-blowers," and a change in the concept of fraud to include an emerging concern about quality of care. The 3 types of conduct that are generally prohibited by health care fraud laws are false claims, kickbacks, and self-referrals. False claims are subject to several criminal, civil, and administrative prohibitions, notably the federal civil False Claims Act. Kickbacks, or inducements with the intent to influence the purchase or sale of health care-related goods or services, are prohibited under the federal Anti-Kickback statute as well as by state laws. Finally, self-referrals-the referral of patients to an entity with which the referring physician has a financial relationship-are outlawed by the Ethics in Patient Referral Act as well as numerous state statutes. Consequences of violations of these laws can include, in addition to imprisonment and fines, civil monetary penalties, loss of licensure, loss of staff privileges, and exclusion from participation in federal health care programs. Federal criminal and civil statutes are enforced by the US Department of Justice; administrative actions are pursued by the Department of Health and Human Services' Office of Inspector General; and all state actions are pursued by the individual states. In addition, private whistle-blowers may, acting in the name of the United States, file suit against an entity under the False Claims Act. Enforcement of health care fraud and abuse laws has become increasingly commonplace and now affects many mainstream providers. This trend is likely to continue.     

Health care safety: what needs to be done?

Recent MJA editorials assert that Australian hospitals are no safer than they were when the first hospital safety report was published in 1995. Despite many recommendations by several committees and much activity to improve safety over the past decade, we lack concrete evidence that safety and quality of health care have improved. Efforts to promote hospital safety in the United States and the United Kingdom also remain unevaluated. Incentives for safer care have been implemented locally, but not applied to entire health systems. A recent review in Australia has recommended replacing the current Australian Council for Safety and Quality in Health Care with a smaller Commission on Safety and Quality in Health Care. The Commission will link all national safety activity and report annually to Australian health ministers on hospital safety. We need a system that measures quality and safety, and provides financial incentives for safer care. Implementing the national framework for education about patient safety would develop teamwork skills and skills in techniques of continuous improvement. Linked to this, adequate financial support should be available to make safety changes in the health care environment.     

Welfare reforms in Australia: how will they affect women's health?

Like most Western countries, Australia is in the process of introducing welfare reforms to curb costs. Australian reforms follow and are informed by similar reforms in the United States and United Kingdom and will be incrementally implemented until 2003. Australian reforms emphasize mutual obligation, preventing people from "taking advantage" of the welfare system, and avoiding long-term reliance on welfare. In contrast to the United States, where the mothers of young children have specifically been targeted, reforms in Australia do not privilege women's roles as workers over their roles as caregivers. Work obligations will be introduced only for mothers whose youngest child is older than 16 years. In fact, financial incentives for providing care for young children and people with disabilities have actually increased. Existing health research suggests that the impact of welfare reform on both health and society will depend on how the balance between women's roles as caregivers and workers is struck.     

Research output of Australian general practice: a comparison with medicine, surgery and public health

OBJECTIVES: To compare the productivity of Australian general practice in terms of research publications with the productivity of other medical disciplines. DESIGN: A survey of Australian general practice, medicine, surgery and public health publications carried out by manual searching of specific journals and an electronic search of the US National Library of Medicine's "PubMed" database. MAIN OUTCOME MEASURES: The number of original research publications by Australian general practitioners, physicians, surgeons and public health physicians during 1999; the relative publication rate of Australian general practice, medicine, surgery and public health over the period 1990-1999. RESULTS: Of original research articles published in 1999, GPs authored 65% (17/26) in Australian Family Physician and 3% (3/90) in the Medical Journal of Australia; physicians published 4% and 37%, respectively. The electronic search identified 54 research articles relating to Australian general practice published in 1999 in 21 different journals, only two of which were primary care journals. Over the period 1990-1999, there was a publication rate of one general practice [discipline] article per 1000 GPs in practice per year. Corresponding rates for medicine, surgery and public health were 105/1000, 61/1000 and 148/1000, respectively. CONCLUSIONS: There is considerable disparity between the level of research output of general practice and that of the disciplines of medicine, surgery and public health. If we are to have effective general practice research, we urgently need to develop research skills, a supportive infrastructure and a culture that nurtures research.     

Legislation for smoking control in Western Australia

This historical analysis of public issues relating to smoking control in Western Australia examines relevant Western Australian state and Australian federal laws, their introduction, and their consequences. Public and political support and opinion led by the health professions resulted in two attempts to legislate against all forms of cigarette advertising in 1982 and 1983. Both attempts failed, and public support for such measures has been seen to be affected by the campaigns mounted in opposition by the tobacco and advertising industries. Other smoking control measures which have been successfully introduced in 1983 and 1984 are higher tobacco taxes and a comprehensive coordinated public education and information programme. The activities associated with the legislative initiatives resulted in a greatly increased level of community awareness of the dangers of smoking and acceptance of the need for some action on this major health problem.     

Communication and health--health as an ecosystem

The importance of communication in public health is described with reference to recent experiences in Australia where good progress has been made with certain major public health problems. There has been a 30% fall in road accident deaths and a 40% fall in deaths from coronary heart disease, and a smoke free environment has been established in public places and in the work place. These successes depended on effective communication based on appropriate data. Evaluation data have also been used to keep the public informed and to reinforce the message. The cooperation of the media has been most important in stimulating a new awareness of health and the opportunities for self help and community initiatives. In central Australia, new initiatives involving the Central Australian Aboriginal Congress have led to an improvement in the health of Aborigines, the training of Aborigines as health workers and the development of a Centre for Appropriate Technology at the Alice Springs College of Technical and Further Education. At the international level, Australia sponsored a World Health Assembly resolution in 1986 calling for the elimination of iodine deficiency disorders. With the support of the Australian International Development Assistance Bureau and the United Nations Children's Fund (UNICEF), an international expert group of scientists and public health professionals, the International Council for Control of Iodine Deficiency Disorders (ICCIDD), based in Adelaide, has been able to work with the World Health Organization (WHO) and UNICEF in the development of an international public health programme aimed at eliminating iodine deficiency disorders by the year 2000. The ICCIDD is a new model for communication and action in international health which is now being advocated for other areas.     

Assisted reproductive technology treatment costs of a live birth: an age-stratified cost-outcome study of treatment in Australia

OBJECTIVES: To calculate the cost of assisted reproductive technology (ART) treatment cycles and resultant live-birth events. DESIGN: Cost-outcome study based on a decision analysis model of significant clinical and economic outcomes of ART. SETTING AND PARTICIPANTS: All non-donor ART treatments initiated in Australia in 2002. Treatment cycles, maternal age and birth outcome data were obtained from the Australian and New Zealand Assisted Reproduction Database. Direct health care costs were obtained from fertility centres, and included government, private insurer and patient costs. MAIN OUTCOME MEASURES: Average health care cost of non-donor, fresh and frozen embryo ART treatment cycles. Average and age-specific costs per live-birth event following ART treatment. RESULTS: Average health care cost per non-donor ART live-birth event was 32,903 US dollars (range, 24,809 US dollars for women < 30 years to 97,884 US dollars for women > or = 40 years). The cost per live birth for women aged > or = 42 years was 182,794 US dollars. The average treatment cost of a fresh cycle was 6,940 US dollars, compared with 1,937 US dollars for a frozen embryo transfer cycle. CONCLUSIONS: Debate regarding funding for ART services has been hindered by a lack of economic studies of ART treatments and outcomes in Australia. This is the most comprehensive costing study of ART services to date in terms of resources consumed during ART treatment. It confirms that ART treatment is less cost-effective in older women. Alongside economic considerations of ART, community values, ethical judgements and clinical factors should influence policy decision-making.     

Eliminating waste in US health care

The need is urgent to bring US health care costs into a sustainable range for both public and private payers. Commonly, programs to contain costs use cuts, such as reductions in payment levels, benefit structures, and eligibility. A less harmful strategy would reduce waste, not value-added care. The opportunity is immense. In just 6 categories of waste--overtreatment, failures of care coordination, failures in execution of care processes, administrative complexity, pricing failures, and fraud and abuse--the sum of the lowest available estimates exceeds 20% of total health care expenditures. The actual total may be far greater. The savings potentially achievable from systematic, comprehensive, and cooperative pursuit of even a fractional reduction in waste are far higher than from more direct and blunter cuts in care and coverage. The potential economic dislocations, however, are severe and require mitigation through careful transition strategies.     

National health information privacy: regulations under the Health Insurance Portability and Accountability Act.

Health information privacy is important in US society, but existing federal and state law does not offer adequate protection. The Department of Health and Human Services, under powers granted by the Health Insurance Portability and Accountability Act of 1996, recently issued a final rule providing systematic, nationwide health information privacy protection. The rule is extensive in its scope, applying to health plans, health care clearinghouses, and health care providers (hospitals, clinics, and health departments) who conduct financial transactions electronically ("covered entities"). The rule applies to personally identifiable information in any form, whether communicated electronically, on paper, or orally. The rule does not preempt state law that affords more stringent privacy protection; thus, the health care industry will have to comply with multiple layers of federal and state law. The rule affords patients rights to education about privacy safeguards, access to their medical records, and a process for correction of records. It also requires the patient's permission for disclosures of personal information. While privacy is an important value, it may conflict with public responsibilities to use data for social goods. The rule has special provisions for disclosure of health information for research, public health, law enforcement, and commercial marketing. The privacy debate will continue in Congress and within the president's administration. The primary focus will be on the costs and burdens on health care providers, the ability of health care professionals to use and share full medical information when treating patients, the provision of patient care in a timely and efficient manner, and parents' access to information about the health of their children.     

Selection into specialist training programs: an approach from general practice

Procedures to select medical specialist trainees aim to predict which junior doctors will become the best specialists. A 1998 review of Australian postgraduate selection processes recommended use of the principles of good assessment. Australia has expertise in national procedures used by medical schools to select students for undergraduate and graduate courses, but little experience in national specialist training program selection. A system for selection into postgraduate general practitioner training, based on a national "selection-centre" approach used in the United Kingdom, is being piloted in Australia. Initial evaluation shows the piloted system to be feasible but further evaluation is needed. Any selection-centre approach must be adapted to the Australian health care context and have the confidence of the trainees, the professional colleges, the training providers and the public.     

Diabetes-related lower-limb amputations in Australia

OBJECTIVE: To identify the prevalence of diabetes-related lower-limb amputations and its regional variations in Australia. DESIGN AND SETTING: Cross-sectional analysis of a hospital morbidity dataset in Australia. METHODS: Analysis of the National Hospital Morbidity Database of all hospital separations for the ICD codes 84.10-84.19 (lower-limb amputations) and 250.0-250.9 (diabetes and its complications) for the financial years 1995-96 to 1997-98. MAIN OUTCOME MEASURE: Number of lower-limb amputations in people with diabetes mellitus in Australia, and in each State and Territory. RESULTS: 7887 diabetes-related lower-limb amputations were reported during the study period, with a mean +/- SD of 2629 +/- 47 per year. The prevalence in Australia was 13.97 per 100,000 total population, and varied from 11.34 per 100,000 in the Australian Capital Territory to 20.68 per 100,000 in South Australia. CONCLUSION: Diabetes-related lower-limb amputation poses a substantial personal and public health cost in Australia.     

Primary care research--what in the world is going on?

Primary care research has been described as a "lost cause", and, although this claim has been strongly refuted, general practitioners publish less research than their colleagues in surgery, medicine and public health. Despite a fivefold increase in Australian general practice research papers from the 1980s to the 1990s, fewer than half of these focused on clinical topics. Trying to establish a global figure for expenditure on general practice and primary care research is difficult, but data show that public expenditure for primary care research is minimal in Australia, New Zealand, the Netherlands and the United Kingdom--fewer than 1.50 dollars per capita in 2002-2003. Compared with hospital- and laboratory-based research, primary care receives significantly fewer resources, ranging from 3.2% of total public expenditure on health and medical research in the Netherlands to 6.8% in New Zealand. Government-led investment in interventions such as strengthening primary care departments and colleges and supporting primary care academics, establishing practice-based networks, fostering international initiatives for cross-national efforts, and engaging individual primary care practitioners in research projects, are all required to build research capacity in primary care.     

Chlamydia screening--Australia should strive to achieve what others have not

Chlamydia screening programs overseas have failed to reduce chlamydia prevalence despite screening 20%-30% of young sexually active women. The Australian federal government announced in 2005 that it would provide $12.5 million for chlamydia control. Policymakers must look to chlamydia screening programs in other countries to learn from their experience. Australia has an excellent primary health care system and a strong track record in establishing highly successful public health programs. This experience places it in a strong position to design and implement an innovative chlamydia screening program to reduce chlamydia prevalence.     

Estimating Australia's abortion rates 1985-2003

AIM: To estimate national rates of induced abortion in Australia from 1985 to 2003, using Medicare claim statistics for private patients and hospital morbidity statistics for public patients. DESIGN AND SETTING: Estimates were based on Australian and South Australian data collections relating to abortions. SA hospital morbidity statistics were compared with SA statutory notifications of abortions to estimate the accuracy of these collections. Medicare statistics on abortion procedures performed on private patients in South Australia were then compared with hospital morbidity statistics for private patients. National statistics on abortion derived from Medicare and hospital morbidity statistics were adjusted for inaccuracies found in these sources. MAIN OUTCOME MEASURES: Numbers of induced abortions in Australia for each year from 1985 to 2003; abortion rates per 1000 women aged 15-44 years. RESULTS: Abortion numbers based on Medicare claims by private patients overestimated by 18.7% the number of abortions derived from statutory notifications in South Australia during the period 1988-89 to 1999-00. Hospital morbidity data using principal diagnosis codes relating to medical abortion overestimated statutory notifications by 2.3% (mainly because of readmissions). National statistics were adjusted for these overestimations and for the estimated 14.1% of private patients who would not have submitted Medicare claims (based on surveys of private-clinic patients in New South Wales and Victoria). The estimated Australian abortion rate increased from 17.9 per 1000 women aged 15-44 in 1985 to a peak of 21.9/1000 in 1995, then declined to 19.7/1000 in 2003 (estimated number of abortions, 84,460). CONCLUSION: There are no data currently available for deriving accurate numbers of induced abortions in Australia. Suggestions are made for collection of national statistics.     

健康、积极和富有成效的老龄化:澳大利亚政策、研究和社区服务的战略性主题

在澳大利亚,65岁及以上者已占总人口的13·1%,政府于2001年推出国家战略,并在2003年提出针对老龄化的研究框架,旨在推动全社会“健康和富有成效的老龄化”。在老龄化及相关研究中,纵向研究具有特别的意义,通过收集和分析老龄化的生命过程、多维度影响因素、多个干预因素评价、因果关系推断,为政策决策和服务管理提供高质量的信息支持。社区卫生服务是健康老龄化的中坚力量,通过社区卫生工作者的努力以及社区资源之间的合作,使政策和服务措施得以落实,贡献于健康、积极和富有成效的老龄化社会。本文系统地综述澳大利亚健康老龄化的政策、研究和实践,并提出深化和完善我国老龄化政策、研究的建议。     

Transition care: will it deliver?

Transition care is a new program to Australia that is designed to facilitate transitions of frail older people between the hospital and aged care systems. This program is designed to deliver potentially important improvements to the Australian health care system--but will it deliver? The current evidence base regarding the efficacy of this type of program is mixed, and there is little evidence to indicate improved patient outcomes. An average transition care episode is expensive (about $11 000). Therefore, careful consideration of the relative cost-effectiveness compared with other interface programs such as inpatient subacute services is essential. Transition care services should be established within the context of overall regional plans for aged care, incorporating hospital acute and subacute inpatient services, and long-term community and residential care programs.