Chapter 4
Effects of disallowance of item 16525: evidence in support of continued
funding
4.1
This chapter considers the effects of a disallowance of item 16525 in
Part 3 of the Schedule to the Health Insurance (General Medical Services Table)
Regulations 2007 (item 16525) with focus on evidence in support of continued
funding.
4.2
Submitters in favour of continued funding under item 16525 stated that
services performed under the item were clinically relevant and lawful.[1]
Many such witnesses maintained that disallowance of the item would have serious
negative health and financial repercussions whilst limiting the accessibility
and affordability of publicly funded health services for the 'small proportion
of women faced with a difficult and distressing circumstance'.[2]
Services provided under item 16525 in Part 3 of the Schedule
4.3
Services provided under item 16525 relate to both spontaneous abortion
(miscarriage) and medical or induced abortion (termination).[3]
The National Association of Specialist Obstetricians and Gynaecologists noted
that item 16525 would apply to women who 'are spontaneously miscarrying or are
in spontaneous premature labour associated with the relevant clinical
conditions'.[4]
4.4
The Australian Medical Association (AMA) stated that item 16525 provides
a rebate for the 'surgical treatment of non-viable pregnancies' which may be
required in a broad range of circumstances. According to the AMA, in all
situations for which item 16525 procedures apply, 'the women have lost, or are
losing their baby'.[5]
4.5
Dr Sally Cockburn elaborated on the circumstances of the termination
services provided under item 16525:
Labour can be medically induced for various reasons. In the
circumstances under MBS item 16525 this would either be to evacuate the uterus
in the situation where the foetus has died or where the uterus is intentionally
evacuated for reasons of a maternal health crisis or a serious abnormality has
been diagnosed in foetal development and the women has requested termination of
her pregnancy, obviously in situations permitted under the particular State
law.[6]
4.6
The Royal Australasian College of Physicians maintained that second
trimester termination was an essential part of antenatal services:
While in our experience second trimester termination is always a
difficult decision, and never undertaken lightly, it is still a service that is
essential to the range of antenatal services available to women in order to
protect their safety and health.[7]
Intrauterine fetal death
4.7
According to Family Planning NSW in cases where the fetus has died in utero,
the pregnancy does not always spontaneously abort and it may be necessary to
induce the termination of such a pregnancy.[8]
This position is supported by other witnesses before the committee including Dr
Cockburn who stated of item 16525:
This service has been on the MBS for over 30 years. Clinically
speaking, the procedures covered by it are essential to the wellbeing of
Australian women. Following diagnosis of a foetal death in utero it is
necessary to induce labour to end the pregnancy and remove the contents of the
uterus because natural labour may not occur and there is a real risk of a
serious haemorragic disorder occurring if the dead foetus remains in her
uterus. Death of a woman can result. Induction of labour for this purpose is
considered a safe procedure even after 24 weeks.[9]
4.8
Associate Professor Lachlan de Crespigny and Dr Susie Allanson
maintained that untreated intrauterine fetal death risks complications
including infection and clotting disorders which can potentially cause serious
risk to the health and even the life of the pregnant women involved.[10]
Similarly, Dr Cockburn stated that delaying the evaluation of the gravid uterus
following fetal death in utero 'increases the risk of maternal bleeding
disorders' which can be 'fatal'.[11]
Gross fetal abnormality
4.9
Dr Peter Rischbieth from the Rural Doctors Association of Australia
described gross fetal abnormality as a 'situation where there is an abnormality
which will be incompatible with a long life':
They may mean major heart, brain, kidney, stomach and digestive
tract organ dysfunction which may be diagnosable using ultrasound techniques
during pregnancy. Or significant genetic abnormalities that can be discovered
on amniocentesis.[12]
4.10
Professor David Ellwood commented:
Gross refers to the degree. One of my roles at the Canberra Hospital
is chair of the Clinical Ethics Committee. I can say to you with all honesty
that virtually all cases of late termination of pregnancy are either for
conditions which are incompatible with extra-uterine life or where the foetal
condition would be associated with very severe disability after birth.[13]
4.11
A number of submissions highlighted that the nature of fetal
abnormalities, screening and diagnostic testing meant that cases of gross fetal
abnormality were often not able to be diagnosed until the second trimester.[14]
This was explained by Associate Professor de Crespigny and Dr Allanson:
Reliable screening does not occur in early pregnancy but occurs
at late gestation, may require repeat tests and may involve the woman and her
family taking time to make a decision.[15]
4.12
SHine SA elaborated further:
Amniocentesis, which is an invasive diagnostic test, is
generally carried out at 15 – 18 weeks gestation and sometimes later. Receiving
accurate results from this test generally requires two weeks. Sometimes
amniocentesis needs to be repeated if the original sample was inadequate. This
leaves women well into the second trimester of pregnancy contemplating a
termination of the pregnancy for foetal abnormality, which is a difficult and
sad decision to have to make. Women require access to safe services in this
situation, whether they are public or private obstetric patients.[16]
4.13
Any delay in diagnosis of fetal abnormality will result in a delay in
accessing termination services. Of diagnostic testing, Family Planning NSW
stated:
Women with a family history of genetic abnormality and older
women are usually offered the opportunity for testing for chromosomal
abnormalities during pregnancy, so that a decision can be made by the couple
whether to continue the pregnancy in order to have a healthy baby. In some
cases, unexpected sporadic abnormalities come to light on routine antenatal
testing during the pregnancy. Of necessity, many of these diagnoses can only be
made after the first trimester. While some may argue that there is never a
reason to terminate a pregnancy, no matter how severe the abnormality, the
Australian health care model aims to place the pregnant couple in the best
possible position to have a positive outcome for their pregnancy. Careful and
considered counselling, correct diagnosis and decision-making takes time. Many
diagnoses will not be possible until well into or at the end of the second trimester,
making a termination later than 14 weeks the only option for these couples.[17]
4.14
Dr Christine Tippett from RANZCOG also commented that currently in Australia
80 to 90 per cent of women have a mid-trimester ultrasound scan which is funded
by Medicare. If an abnormality is detected there is an expectation that 'they
will have a choice to terminate the pregnancy or not to continue the pregnancy'.
Dr Tippett went on to state:
Over 85 per cent of women have Down syndrome screening. This is
provided and supported by federal and state government funding on the understanding
those women may choose to terminate a pregnancy afterwards. On the one hand we
are providing women with access to diagnostic imaging and to different
diagnostic tests on the expectation that they will have a choice whether or not
to continue a pregnancy.
It seems to me to be somewhat contrary to then say, 'We have
picked up an abnormality. You have decided that for you and for your family
this is a major abnormality that will adversely impact on your child and your
child’s life and you have decided to terminate the pregnancy. Sorry but we do
not think that is right. We have decided that these abnormalities are okay and
these are not—so we will fund some and not the others.' I do not think that is
very logical.[18]
4.15
Dr Cockburn noted that in some instances of gross fetal abnormality or
where a woman's life is threatened by a medical condition if the pregnancy at a
gestation below 22 weeks continues, women may request to have their pregnancy
terminated but not for an abortion per se. Dr Cockburn explained that this is a
'plea from distressed parents that they may hold their hopelessly premature or
abnormal baby before it dies'.[19]
4.16
The Atheist Foundation of Australia took the view that:
Political assessment of what constitutes severe foetal
abnormality is inappropriate. The pregnant female is in the best position to
decide, on advice from the medical profession, whether or not to continue with
the pregnancy.[20]
Life threatening maternal disease
4.17
The Department of Health and Ageing noted in its submission that examples
of life threatening maternal conditions that pregnant women may experience
include premature rupture of the membranes with infection, severe antepartum
haemorrhage, severe pre-eclampsia, pulmonary hypertension and cyanotic heart
disease.[21]
4.18
In relation to item 16525 services provided under this category, Dr Cockburn
stated:
It is even more difficult to dispute the clinical relevance of
the need to have an MBS item number covering the situation where a woman
requires termination of her pregnancy to save her in a serious medical crisis.[22]
Psychosocial indications
4.19
Contrary to the view that 'psychosocial indications' (PS) are
commonly utilised as the basis on which medical terminations of pregnancy are
carried out under item 16525, a number of submitters held that termination
services provided under the item number are carried out primarily for reasons
other than psychosocial. President of the Women's Hospitals Australasia, Professor
David Ellwood, stated before the committee:
Many women find themselves making a very
difficult choice about termination of pregnancy in the second trimester, for
reasons that are beyond their control—primarily to do with the inability to
diagnose many serious foetal conditions or, indeed, many serious maternal
illnesses until well into the second trimester.[23]
4.20
Professor Ellwood went on to state that 'it is extremely uncommon for
there to be a request for termination of pregnancy beyond 20 weeks outside of
this qualifier—foetal death, gross foetal abnormality or life-threatening
maternal disease'. Furthermore 'about the only circumstance in which second
trimester induction of labour is carried out because of life-threatening
maternal disease is where it is truly life-threatening'. Professor Ellwood
concluded:
I do not think changing the wording would change practice at all
because clinical practice around that qualifier really is limited to
life-threatening maternal disease.[24]
4.21
Dr Andrew Pesce from the National Association of Specialist
Obstetricians and Gynaecologists, stated in evidence:
The vast majority of requests for termination of pregnancy at
this later stage of pregnancy occur for two reasons. Firstly, there might be an
antenatal diagnosis of a significant foetal abnormality. There is increasing
use of nuchal translucency and serum screening for Down syndrome, which when
offered to women is very, very highly taken up. Probably about 95 per cent of
women who are offered it will take the opportunity. Secondly, at the 18- to
20-week ultrasound scan when a woman goes to see how the baby is developing,
there may be diagnosis of a major congenital heart problem or a major renal
problem—something which sometimes is incompatible with life and sometimes could
be compatible with life but with major disability and multiple surgeries. Women
agonise about these decisions. They have to think about the children they have
and what they are going to be going through and about the multiple surgeries
which are required to correct congenital heart problems. I just cannot fathom
how people can say that this is just some disorganised bimbo who has decided
she is going to have a termination at 20 weeks. I am sure it happens, but the
vast majority of the time that is not the case.[25]
4.22
Similarly, Dr Peter Rischbieth of the Rural Doctors Association of
Australia held that:
My understanding is that the decision to go ahead to have a
termination is made if the continuation of the pregnancy may
cause significant harm to either the foetus or the
maternal health. There would be very few areas where the psychosocial aspects
would be a key reason for a termination to be sought.[26]
4.23
Furthermore, the National Association of Specialist Obstetricians
and Gynaecologists noted in its submission that there are 'no reliable data to
determine the extent to which termination of pregnancy for PS indications
contributes to the utilisation of 16525'.[27]
The Family Planning Association of Western Australia stated in relation to such
claims:
Contrary to the view Senator Barnett made in his speech to the
Senate on 24 June 2008, where he stated, "Late abortions are being done
for 'maternal psychosocial reasons', which in reality means abortion on request", our experience is that women have to traverse,
at times several legal and medical hurdles before they can have an abortion.
The phrase 'abortion on request' negates the process a woman goes through when
deciding her options and is an emotive phrase used by the anti-choice movement.
There is a plethora of evidence that reports women take seriously their
decision whether to continue with or terminate their pregnancy. Likewise there
is strong evidence that where a woman has access to legal and safe abortion and
makes her decision voluntarily, there is less immediate or long lasting
psychological impact.[28]
4.24
Quoting 2006 data, Ms Letitia Nixon, Manager of SHine SA noted that of
post 20 week gestation terminations in South Australia for example:
There is a very small number—0.7 per cent—that might have been
done for psychosocial reasons; primarily it is for maternal health conditions,
foetal abnormalities or foetal conditions that are incompatible with life.[29]
4.25
It was also noted that in relation to Victoria, where the number of
terminations for psychosocial indications are highest, there were 150
terminations of pregnancy of 20 to 27 weeks gestation for 'maternal
psychosocial indications' undertaken in 2006. Of the 150, 90 such procedures
(or 60 per cent) were carried out for interstate and overseas residents.[30]
Associate Professor Lachlan de Crespigny informed the committee of the
Victorian context:
Data is available from 20 weeks, and that shows that almost
three-quarters of the post-20 week terminations on Victorian women are for the
diagnosis of foetal abnormality and something a little above a quarter for
psychosocial reasons. They are classified as either one or the other. It is a
simple classification. The situation is that terminations later in pregnancy,
variously defined, are available in a very limited way across the country. So,
even when termination is lawful, access can be extremely poor in many parts of
the country and many parts of the state as well such that there is a group of
women from around the country and even overseas who seek services in Victoria.
So I think the Victorian and the non-Victorian figures need to be pulled apart
to get any reasonable assessment of that. So, yes, there are psychosocial
terminations done post 20 weeks, but it is the minority when one considers
Victorian women.[31]
4.26
In relation to the seriousness of conditions under which the
classification 'psychosocial' applies under item 16525 of the MBS, Dr Sally Cockburn
stated:
The word 'psychosocial' can be many things but in order to make
a claim under this item number the psychosocial condition would have to be
life-threatening for the mother.
If you ask, 'What psychosocial conditions could be
life-threatening?' some examples could be suicide, homicide—although you would
hope you would be able to take her out of that sort of situation—or maybe a
severe psychiatric condition that required medication that could be harmful to
the foetus. But I think the term 'psychosocial' has been, if I may say so,
bandied about as if it might be that I would like to buy a new pair of shoes to
wear to the Cup. I have to say that in my experience in medicine I have never
met a woman or seen a woman who would ever decide to terminate her pregnancy
for a reason of a trivial nature. I would really like to put that on the
record, because these are real people we are talking about, people who are
probably watching us right now, and I think that they would be insulted to
think that we are saying that maybe they will do it because they do not fit
into their dress for the Cup.[32]
Clinically relevant
4.27
A number of witnesses before the committee maintained that services
carried out under the item number were 'clinically relevant'. When questioned
about the rigour applied to ensure that such services are 'clinically
relevant', Mr Colin Bridge of Medicare Australia informed the committee:
There is a process involving a separate agency, which is the
Professional Services Review. Should, in the course of our examination of any
medical Medicare item, we develop concerns about that particular issue, our
role is to refer it to the Professional Services Review. The Professional
Services Review is an agency within the department of health which has a range
of powers to undertake investigation of that particular point, including,
potentially, peer review.[33]
4.28
Mr Bridge further clarified, that from Medicare Australia's records, 'we
have not been able to find any cases of that sort being referred from us or
issues we have raised over the last 10 years'.[34]
Termination methods
4.29
Professor David Ellwood commented on termination methods and stated that
from his knowledge of practices in the tertiary women's hospitals country, the
only method used is one that induces labour. Professor Ellwood went on to note
that 'I think the reference to partial birth abortions would be restricted to
the private sector and, as far as I am aware, it is restricted to one clinic'.[35]
4.30
Dr Christine Tippett also commented on termination methods:
I think there is a great deal of misunderstanding, too, about
how pregnancy terminations and late pregnancy terminations are undertaken.
There has been comment made and pictures shown—once again referring to Victoria—of
procedures that I, in 30 years of practice, have never heard of being
done. I had to inquire as to what they were because I was unfamiliar with them.
I have worked for a long time in the public system.[36]
4.31
In relation to practices in private clinics, Dr Tippett commented on one
clinic in Victoria where a significant number of late terminations are
undertaken and stated:
That is the most regulated medical clinic
in Victoria. There
have been case reviews, and it has been looked at very carefully. I have
a very good working knowledge of how that clinic works and I think it does
provide a service for women. It does mean those women are not in the public
system, and I think it provides a very valuable service.[37]
4.32
Dr Tippett also commented on the term 'left to die' and stated:
I think it is a very unfortunate term, and I feel some disquiet
that it has been used so generally here. If a pregnancy is terminated and the
baby has the capacity to be born alive, and that can happen any time after 14
or 15 weeks, those babies will die if they are not given supportive care. As
you get closer to 24 weeks they will take longer to die than if the pregnancy
is terminated sooner.
Those babies will die from hypoxia because they cannot breathe,
they cannot get oxygen to their brain and although we think there is no
difference in the way foetuses or babies of this gestation experience pain, in
fact those babies are hypoxic just like an adult who becomes hypoxic and
effectively unconscious and unaware of what is going on around them. I think one
can be confident that these babies do not suffer.
Secondly, where those babies are cared for will depend on the
parents. Usually we tell parents that the baby may be born alive and if the
parents say they do not want that to happen, the baby will be given an
injection prior to or during the termination so that the baby is not born
alive.[38]
4.33
Professor Ellwood made some comments concerning fetal pain:
I am familiar with a lot of the scientific literature on foetal
pain and I am aware that there is a lot of controversy around the gestational
age at which the foetus is able to experience pain. I am not sure that the
science has yet progressed to the point where you can answer the question
honestly and say at a certain gestational age the foetus is able to feel pain
and below it the foetus cannot.[39]
The effects of disallowing item 16525
Discriminatory to women
4.34
A number of submissions including the Rural Doctors Association of
Australia considered the potential disallowance of item 16525 as discriminatory
to women particularly of low socio-economic backgrounds, Indigenous women and
women living in rural and remote areas.[40]
The Australian Reproductive Health Alliance (ARHA) and Royal Women's
Hospital argued that disallowance would amount to an erosion of access to adequate
health care for women.[41]
Others including the Health Services Commissioner, Victoria and Dr Cockburn
held that withdrawing the item could in fact increase maternal morbidity and
mortality for those reasons.[42]
4.35
The ARHA highlighted that procedures undertaken under item 16525 include
not only termination of pregnancy, but also procedures undertaken in the event
of spontaneous miscarriage or premature labour. According to the ARHA, removing
funding from this item would therefore remove funding from 'a series of legal
and required medical procedures, denying women in this situation the access to
funded healthcare afforded to other members of Australian society'.[43]
This view was supported by Associate Professor de Crespigny and Dr Allanson who
maintained that a disallowance will result in 'financial hardship, delay in
service, or denial of appropriate medical care for some women suffering
miscarriages or requiring other procedures for which this item is currently
used'.[44]
4.36
The ARHA stated that removing the item has the potential to violate the
human rights of women of reproductive age given that it would be 'tantamount to
the government deciding who may give birth and who may not'.[45]
This view was supported by the Parliamentary Group on Population and
Development.[46]
According to the ARHA, such a course of action would effectively result in one
category of pregnant women denied government health and payment programs that
are offered to other pregnant women.[47]
The Family Planning Association of Western Australia held that:
The United Nations Committee on the Elimination of all forms of
Discrimination Against Women (CEDAW), recognizes women's rights and equal
citizenship. Underlying this is the right of the woman to choose what is best
for her, situating her as a mature and responsible person with the capabilities
of self determination. The withdrawal of the Medicare rebate will undoubtedly
create financial hardship for many women, and a decision by the committee that
would make access to a safe and legal abortion more expensive would
discriminate against women already economically disadvantaged.[48]
4.37
Associate Professor Lachlan de Crespigny and Dr Susie Allanson argued
that rights upheld by human rights conventions to which Australia is a
signatory include that of reproductive health:
Australia is signatory to various United Nations human rights
conventions respecting the right of men and women to self-determination, to
plan their families and control their fertility including the right to bodily
integrity (UN 1966), health, reproductive health, family planning and deciding
the number and planning of children (UN 1979; UN Population Fund, 1994).[49]
4.38
Dr Christine Tippett commented on the rights of an unborn child:
...I think the proposal to put in place legislation for the rights
of the unborn child is extremely difficult. The main reason for that is that in
many ways then puts the woman in a very difficult situation. There are some
countries that are looking at this—and I know that Canada has some proposal on
the table. The college in Canada are strongly opposing it, and we would
strongly oppose it also. Basically it means that the mother loses her autonomy.
So people outside the mother are telling that mother what she should do with
her pregnancy.
...The foetus is not autonomous until it is born. The thought of
bringing that in without a huge amount of consideration from the point of view
of a women's rights issue is extremely problematic. Does that mean that the
foetus that comes out whose growth is restricted because of hypertension can
sue the mother when it is 30 because she smoked? The implications of such a
thing are enormous. There is much written about this but I would not like to
see the discussion go down that pathway.[50]
4.39
Dr Tippett concluded:
It is extremely concerning when the mother's wishes are
overridden by a court of law. How do you then quantify when the baby's rights
are greater than the mother's? Who decides that?[51]
Women's physical and mental health
4.40
A number of submissions including that of YMCA Australia maintained that
disallowance of item 16525 would have serious implications for women's mental
and physical health.[52]
The Royal Australian and New Zealand College of Obstetricians and
Gynaecologists (RANZCOG) argued that disallowance of the item would result in
poor psychological and physical health outcomes resulting from the increased
stress on women, which in turn will 'add to the burden on other health
services'.[53]
Family Planning NSW (FPNSW) noted that such a disallowance would increase
maternal and infant morbidity and mortality rates:
FPNSW holds the strong position that disallowance of Item 16525
would cause unnecessary and severe hardship for people at an extremely
vulnerable and stressful time in their lives and would increase levels of
poverty in Australia through increases in maternal and infant morbidity and
mortality. This is contrary [to] the achievement of the Millennium Development
Goals (MDGs), to which Australia is a signatory.[54]
4.41
Dr Cockburn elaborated on the potential impact of a disallowance on
maternal mortality rates:
Removing the Medicare rebate could, in the short term at least,
lead to overburdening of the public system, and delays in treatment. Delaying
the evacuation of the gravid uterus following foetal death in utero increases
the risk of maternal bleeding disorders. These can be fatal.[55]
4.42
Similarly, the Royal Australasian College of Physicians argued that
disallowance of the item may result in both physical and mental risk to the
women in question including 'risk to the woman's life and health because of a
medical complication, or to her long term mental and physical health as a
result of the pregnancy complication for which she has decided to have the
termination'.[56]
4.43
Dr Cockburn maintained that whilst disallowance of the item would ensure
that these procedures are transferred to the public sector:
...the message to the Australian people is that Federal
Parliamentarians believe that a woman should be forced, against her will, to
carry a grossly abnormal foetus to term knowing for months on end that she is
carrying a foetus that has little chance of the life they had hoped for it. It
could be that foetus has abnormalities that are incompatible with life outside
the uterus or may die shortly after birth.[57]
4.44
The ARHA also argued that the removal of the item may increase the
number of foetuses with severe and/or life threatening abnormalities being
carried to term. According to the ARHA, an American Psychological Association
review of 20 years of evidence found that women who experience miscarriage,
stillbirth, death of a new born or termination of a wanted pregnancy due to
fetal abnormality have equivalent negative psychological reactions but that
these 'are less than [for] women who deliver a child with a life-threatening
abnormality'.[58]
Thus, according to the ARHA, removal of item 16525 'looks set to increase
the likelihood of mental health issues in women who are pregnant.'[59]
Accessibility and affordability of
appropriate medical services
4.45
A number of submissions held the view that disallowance of item 16525
would disadvantage women who attend as a private patient in a public or private
hospital, or private practice.[60]
As one case in point, the Women's Hospitals Australasia maintained that
abortion after the first trimester is 'an essential component of women's health
care' and removal of item 16525 would discriminate against women 'because it
undermines access to affordable, accessible health care'.[61]
4.46
The Royal Women's Hospital held that:
Should item 16525 be disallowed, it would reduce the options for
care for those women needing this service. A woman who has booked for private
antenatal care may need to transfer away from a known and preferred provider,
in this already distressing situation, if the care she needs is not covered by
Medicare benefits.[62]
4.47
Similarly, the Health Services Commissioner, Victoria argued that
removal of the item would place restrictions on the ability of women to have
the procedure carried out in a hospital of their choice by a doctor of their
choice:
We need to make sure women who require these
services have the option of having the procedure done with the doctor of their
own choice locally where family and support systems are available. The removal
of this service from Medicare benefits could cause many to have to travel long
distances on a very lonely and stressful journey. There is an emotional aspect
to these services which must be taken into account.[63]
4.48
Moreover, Dr Cockburn stated:
Aside from the obvious clinical benefits like saving women's
lives, this item number provides services that improve health outcomes for
women by allowing them the option of timely access to safe induction of second
trimester labour in private hospitals with doctors of their own choice. In
doing so it would reduce the stress in an otherwise difficult time for families.[64]
4.49
The Rural Doctors Association of Australia maintained that withdrawal of
item 16525 would impact upon 'those private hospitals that use the number to
cover induction for fetal death in utero even though they do not support
genetic pregnancy terminations'.[65]
4.50
According to the ARHA, anecdotal evidence suggests that there has been a
decline in the availability of termination services of public hospitals and
that removing the financial support currently made available to private medical
providers will 'place further pressure on the dwindling public services
available'.[66]
Citing evidence from the Victorian Law Commission which established that
approximately two-thirds of abortions in Victoria are provided in private
clinics, the Women's Hospitals Australasia argued that disallowance of the item
would shift demand from the private sector to state funded services requiring
increased resources for the state and territory systems.[67]
4.51
The view that removal of the item from the Schedule would place an
additional strain on state public hospitals which would then require more
resources was held by the Rural Doctors Association of Australia, Health
Services Commissioner, Victoria, and Royal Women's Hospital.[68]
As one case in point, Dr Cockburn maintained that removal of item 16525
would not significantly reduce Medicare's financial burden given that it
amounts to a relatively small portion of its business, but would instead
constitute a cost-shifting exercise to the states.[69]
4.52
Greater demand on termination services in public hospitals and increased
waiting time for women seeking to access such services has the potential to
increase the number of second trimester terminations according to the AHRA, 'as
women are forced to wait longer because of their economic inability to access
private termination services'.[70]
Similarly, Catholic Health Australia held that disallowance of the item would
reduce the scope of private providers (usually clinics) to provide such
services and likely lead to greater demand for such services in public
hospitals, 'resulting in an adverse impact on acute care facilities, without
reducing the demand on the incidence of abortion in Australia'.[71]
4.53
SHine SA argued that disallowance of the item will 'punish pregnant
women accessing care outside of the public hospital system and delay their
access to services' whilst placing 'unnecessary pressure on public hospitals at
a time when there services are under heavy demand'.[72]
This view was supported by RANZOG which maintained that:
Women are likely to experience delays in negotiating the system
while seeking public hospital services they require at a time when they are
distressed and vulnerable.[73]
4.54
Dr Cockburn held that:
If this item number ceased to exist the procedures would move
across to the already overstretched public hospitals and most likely extra
funding would be sought by State and Territory Health Ministers through the
public arm of Medicare and the State Health Service Agreements. Indeed the
Commonwealth may end up paying even more when the States put in the bill for
the true cost of these complex procedures in their public hospitals.[74]
4.55
This view was also supported by Family Planning Queensland who
questioned the equity of such changes for women experiencing financial
difficulty and those in regional and remote settings.[75]
Continuity of care
4.56
The issue of continuity of care for women undergoing second trimester
services under item 16525 was raised in evidence. Professor Ellwood of the Women's
Hospitals Australasia stated before the committee:
The use of this item number allows continuity of care by private
providers working within the public system. Many women access tertiary services
in prenatal diagnosis and in late termination of pregnancy through the public
sector. Enabling continuity of care for private providers is an important part
of services to women. For that reason, we believe that the removal of this item
number would be discriminatory.[76]
Women in rural and regional areas
4.57
The disallowance of item 16525 was recognised as an added disadvantage
to women in rural and regional areas who are already faced with existing
inequalities in access to health services. The Rural Doctors Association of
Australia explained:
Rural women's ability to access this procedure is already
constrained by distance, continuing rural hospital downgrades and closures that
limit reproductive health interventions and shortages of appropriately
credentialed medical practitioners. Nor do they have the same access to
services like preconception counselling and sophisticated diagnostic testing as
women who live in or close to a major city. Yet the acknowledged lower health
and socio-economic status of rural populations suggests that they are
particularly vulnerable to financial pressures which limit their access to
essential health services even further.[77]
4.58
Of the situation for women in rural and remote areas, Dr Cockburn
stated:
What about a scenario where the only close hospital is a private
facility and the nearest public hospital is a long distance away? By
disallowing or restricting this item number it could mean that a woman who
would have otherwise had the procedure with a doctor of her choice in a local
facility close to her family and support systems, may now need to travel great
distances to have the procedure in a public facility far from her loved ones by
a doctor she doesn't know. The cost in financial terms of travel and time off
work is one thing, but the human cost associated with the emotional fall out of
such a situation could be enormous.[78]
4.59
Similarly, Associate Professor de Crespigny and Dr Allanson maintained
that removal of item 16525 would be discriminatory to poor and rural women:
Access to prenatal testing and termination of pregnancy should
not depend on her personal resources or where a woman happens to live. Rural
women already face much higher costs because of needing to fund travel and
accommodation. A woman might feel forced to take on the emotional, physical and
financial costs of continuing with an unwanted pregnancy and rearing a disabled
child because she wants, but could not fund, pregnancy termination.[79]
4.60
The Rural Doctors Association of Australia further noted that whilst
women would still be able to access item 16525 procedures without charge in
their local public hospital if the item were disallowed, in jurisdictions such
as Western Australia, where regional funding is managed differently, women
would have no other option but to travel to Perth:
This means many rural women will face economic hardship on top
of the costs of their travelling to another centre for the procedure and their
separation from their families and local health care providers at a very
difficult time. Some many have to delay their journey, prolonging the distress
of their situation.[80]
Resort to methods outside the
medically regulated system
4.61
The question of whether the inability to access safe, timely and
affordable second trimester termination services would result in a greater
number of women resorting to dangerous methods outside of the medically
regulated system was raised before the committee. Citing evidence from the
United States where funding cessation and other limits on abortion led to the
utilisation of unsafe abortion practices, Associate Professor de Crespigny and
Dr Allanson held that the removal of item 16525 may lead to 'a small number of
women desperately turning to dangerous self-or other-administered methods, with
a resulting need for additional health treatment'.[81]
4.62
This view was supported by RANZCOG which stated:
Women may resort to home / backyard attempts at self abortion
resulting in the need for additional health services. It is known that the drug
misoprostol, which is used, safely and legally in Australian hospitals for the
medical termination of pregnancy, is easily accessible on the Internet.[82]
Potential financial effect of a
disallowance
4.63
The Australian Medical Association noted that disallowance of the item
would have the effect of 'removing any financial assistance for appropriate
medical care for women for all of the clinical circumstances covered by the
item...'[83]
YMCA Australia argued that removal of funding for services under the item 'will
have the greatest impact on poorer women, who may be forced to continue
carrying a dead or dying baby against medical advice'.[84]
4.64
Of the potential financial impact of the disallowance of the item on
women's health, the Department of Health and Ageing stated:
If a woman was faced with higher charges, it would have some
disincentive effective on the woman's decision as to whether or not to proceed
with the service. To the extent it might thus cause women to defer or avoid a
service considered medically necessary, it would be likely to result in
negative health consequences for those women.[85]
4.65
Ms Amy Naivasha held the view that removing funding for item 16525
services would 'foster an environment of decision-making based on financial
capacity and not on the physical and/or mental health of the pregnant woman and
her foetus'.[86]
4.66
RANZCOG and the Rural Doctors Association of Australia argued that
removing the rebate to women facing severe emotional and financial stress would
be inequitable and would only add to such stress.[87]
RANZCOG maintained that involved families will suffer due to loss of income,
travel and child care expenses and that:
Women would experience added stress knowing that they have paid
the Medicare levy from their own and their partners' wages only to be denied
benefits for a legal and medically indicated procedure.[88]
Adequacy of the rebate
4.67
A number of submitters took the view that the procedures under item
16525 are under-funded.[89]
Dr Cockburn continues:
These are expensive procedures for patients to have in the
private sector. According to one website a termination at 16 weeks' gestation
may cost as much as $1100. At 19 weeks the cost can arrange from $1100 to
$3000.
The rebate from Medicare for item 16525, however is $200.25. And
even after a Medicare rebate and possibly even with Private Health Insurance,
patients undergoing these procedures in the private sector, may still be
thousands of dollars out of pocket.[90]
4.68
Associate Professor de Crespigny and Dr Allanson argued that the rebate
should be increased to 'ensure a more equitable access to this vital medical
service for women from differing socioeconomic backgrounds'.[91]
Similarly, RANZCOG expressed the view that the rebate be increased.[92]
Potential effect on second
trimester abortion numbers
4.69
A number of submitters argued that removal of item 16526 from the
Schedule would not reduce the number of second trimester abortions in Australia.[93]
Amongst them, Dr Cockburn held that:
No matter what proportion of the services are abortions, the
procedures described in this item number are lawful and clinically relevant, so
they will continue to be performed. Only the venue and/or funding mode will
change...
For those who believe that there are illegal abortions happening
in Australia, removing this item number won't affect that either. It would be
hard to imagine an illegal "abortionist" being bold enough to try to
allow someone to claim their work under Medicare.[94]
4.70
Children by Choice suggested that if the objective of removing item
16525 is to restrict termination of second trimester pregnancies, it is
unwarranted:
If the aim of removal of Item no. 16525 is to restrict
termination of pregnancy over 20 weeks it is unnecessary and unwarranted.
Second trimester medical termination for foetal abnormality over 20 weeks
gestation is generally heavily regulated via legal restrictions, hospital
review panels and committees, along with doctors working in team consultation
with their colleagues.[95]
4.71
Dr Cockburn argued that removal of the item will not eradicate the
procedures carried out under the item as the need for them will continue:
Removing or restricting it might take the issues off the Federal
Parliamentary agenda in the short term, but it will not improve maternal health
outcomes, make gross foetal abnormalities go away, and importantly, nor will it
reduce abortion numbers. It will only add to the financial and emotional burden
already facing people requiring the procedures currently covered by this item
number. Disallowance of this MBS item number would be nothing more than a cost
shifting exercise that makes little sense other than to allow some people to
turn a blind eye to a set of lawful and clinically relevant services that they
find morally repugnant.[96]
4.72
Similarly, the Rural Doctors Association of Australia stated that it is
unaware of any evidence that disallowance of the item will lead to a decrease
in second trimester termination of pregnancy and noted that:
...second trimester terminations are usually undertaken in
circumstances and for imperatives that are not susceptible to policy change. In
other words, they will be undertaken in any case.[97]
4.73
Associate Professor Lachlan de Crespigny and Dr Susie Allanson suggested
that removal of item 16525 from the Schedule may in fact result in a greater
number of women terminating earlier in their pregnancy:
Reliable screening does not occur in early pregnancy but occurs
at later gestation, may require repeat tests and may involve the woman and her
family taking time to make a decision. If women face additional hardship
impacting on their pregnancy choices in second trimester, more women may decide
precipitously to terminate a pregnancy in early stages (where a rebate is
available) when they have a concern about the health or viability of the
pregnancy.[98]
Medicare responsible for providing
equal access to health care
4.74
A number of submitters in support of continued funding for item 16525
such as the ARHC noted that Medicare describes itself as Australia's universal
health care system responsible to 'give all Australians, regardless of their
personal circumstances, access to health care at an affordable cost or at no
cost'.[99]
The ARHC took the view that removal of item 16525 is not consistent with the
Medicare's stated role:
The removal of item 16525 from the Health Insurance Regulations
ignores the stated intentions of Medicare, denying universal access to
affordable and safe termination of a pregnancy, and removing women’s right to
choose a practitioner based on personal preference, rather than financial
circumstance.[100]
4.75
This view was shared by Associate Professor de Crespigny and Dr Allanson
and the Rural Doctors Association of Australia who noted of efforts to disallow
item 16525:
Manipulating a system designed to ensure that all Australians
have access to free or low-cost medical and hospital care in this way would be
repugnant and improper.[101]
4.76
The National Foundation for Australian Women argued that the
disallowance of item 16525 would effectively remove a rebate for a lawful
medical procedure which would be inconsistent with the availability of rebates
for other lawful medical procedures.[102]
Similarly, RANZCOG stated that:
Manipulations of the Medicare schedule to limit access to a
lawful procedure is unacceptable.[103]
Lack of clinical evidence to support disallowance of item 16525
4.77
A number of submitters such the ARHA maintained that the services
provided under item 16525 are clinically accepted procedures.[104]
Family Planning NSW stated that there is no financial imperative to disallow
item 16525 and that the current effort to do so was not evidence based.[105]
RANZCOG argued that:
It would be extraordinary if benefits for the legal and
medically indicated management of labour in the second trimester were not
payable.[106]
4.78
The Health Services Commissioner, Victoria maintained that disallowance
of the item would contradict the 'work of all of the expert committees which
included it in the first place...' and that:
The Parliament, with all due respect, is not as qualified in clinical
obstetric practice as the expert committees which set up service 16525 as a
Medicare item in the first place.[107]
4.79
This position was also held by the Rural Doctors Association of
Australia:
As the Association is unaware of any clinical reason for removing
this item from the Schedule, it presumes that any proposal to do so relates to
non-clinical policy or opinion. The Association points out that changes to the
Schedule should be based on evidence relating to the need for the service and
the health impact of these changes.[108]
4.80
The YMCA Australia highlighted that the process by which Medicare item
numbers are listed are based on best practice:
Medicare item numbers are determined by expert panels of
Medicare Australia, in line with current best practice in clinical care. We
believe moves to disallow or remove Medicare item number 16525 interfere with
the integrity of the Medicare Australia processes and will compromise the
healthcare of pregnant women.[109]
4.81
Whilst respecting the Senate's right to disallow regulations, the
Australian Medical Association held that it was 'more appropriate for the
Minister of Health and Ageing to consider the clinical and policy aspects of
Medicare funding with the advice of the medical profession'.[110]
Senator Polley
Chair
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