Q&A with… Dr Omar Khorshid, Orthopaedic Surgeon & National President of the Australian Medical Association.

COVID-19 has stripped bare the areas where the health system is fragile. New AMA national president Dr Omar Khorshid is set to take the fight for a healthy future all the way to Canberra.

MF: With COVID-19 dominating the health agenda and government budgets, what will be the national AMA’s focus for the next 12 months?

OK: We’re struggling to talk about anything other than COVID at the moment and it’s clear that it will remain a significant focus of the AMA for some time yet. Australia has done very well by world standards in tackling the spread of the virus, but we are not out of the woods. Governments will continue to need strong medical advice, particularly in the face of unrealistic and potentially dangerous calls to open up the economy before it is safe to do so. We need to get the balance right, recognising that without a strong health response to COVID-19, we will not be able to get our economy back on track at all.

However, although COVID-19 is urgent, the AMA needs to be setting the agenda. The AMA is a trusted voice, and we will be using that trust to call for action on other pressing issues in our health system. We need a stronger, better health system that places disease prevention as its key focus, with the investment needed to make a real change. The AMA is advocating for 5% of the health budget to be allocated to preventive health.

Integrated quality General Practice must be the gateway to the entire health system, further supported by digital health technology such as telehealth. The AMA has just released a detailed policy on this, and we will be prosecuting it.

Our public hospitals need increased and certain funding so they not only cope, but flourish. We need to end the days of public hospital doctors working dangerously long hours due to being short staffed and under-resourced. The AMA believes we need a detailed reform agenda for our private health system – and again, we have developed a series of detailed policy proposals for government that can be actioned now.

Finally, for the most vulnerable people in our society, including those in the aged care sector, we will remain relentless in raising these issues with the Aged Care Royal Commission and beyond, so that we see lasting improvement.

MF: In this context, what can the AMA offer its members by way of support and advocacy?

OK: Members join the AMA for our policy advocacy. They want to work in a health system that supports them to provide quality care for their patients. Our job is to prosecute a policy agenda that supports this – and the above areas of focus are just the beginning. Doctor independence, whether in a government-run system, a privately insured and funded model, or in the context of a nationally regulated scheme, is critical.

MF: The pandemic response has seen agile collaboration between the public and private health sectors. What is needed to continue that co-operation once the public health threat of COVID-19 subsides?

OK: No part of the health sector will remain unscathed by the time the threat of COVID subsides. Waiting lists for surgery will be longer, the viability of many private sector practitioners and organisations will take years to recover, and the community will have suffered greatly.

We also know that the Treasury coffers will have been exhausted and that health will be under the expenditure microscope. If we are to have a healthy economy in the future, we will need a healthy society. This will require investment and reform. We can’t afford to cut our way to a healthy future.

In order for the type of collaboration we have seen during COVID-19, stakeholders will need to understand that life will not return to normal in the foreseeable future and that it is in everyone’s mutual interest to work together if we are to meet the needs of our patients.

MF: What are we getting right and wrong in our national response to the pandemic?

OK: So far, Governments have largely listened to the medical advice that they have been given, and National Cabinet has been an excellent vehicle to support a nationally coordinated response, although cracks are beginning to show.

Australia also got onto the front foot in tackling the virus with a broad lockdown. You must get ahead of COVID, otherwise it will win every time. As we see a second wave, there is a concern that Governments are being too slow to act, focusing too much on daily infection numbers. By the time these rise beyond an acceptable threshold, policy makers are already two weeks behind the eight ball.

We are seeing some divergence in approach among jurisdictions. Some have eliminated the virus and have been forced to close their borders to those jurisdictions that are taking a different approach and continue to report new infections. Depending on what happens in Victoria and, to a lesser extent in NSW, governments need to revisit the elimination debate, otherwise communities may suffer a diabolical cycle of restriction easing followed by lockdowns.

We also know that healthcare workers are at significant risk of COVID-19, making up a significant proportion of infections in the Victorian outbreak. This has exposed problems with access to PPE on many fronts. PPE guidelines have been too weak to properly protect healthcare workers and there have problems with the supply and, probably more critically, the distribution of PPE.

Ultimately, the best protection from COVID-19 for healthcare workers and the community is the achievement of zero community transmission. This will require Government to continue to take tough decisions on restrictions and to be realistic about the extent to which we can open up again while the threat of the virus hangs over us.

The community needs to play its part as well – we all have to change the way we live and how we interact with each other.

We have not done enough to protect our vulnerable populations in aged care facilities, and they have suffered as a result. There has been too much of a blame game and not enough planning and support for this sector.

While this hardly comes as a surprise, given the evidence before the Aged Care Royal Commission, this failure highlights just how far we have yet to go in addressing the systemic problems in our aged care system. We know what needs to be done, we need Governments and operators to heed the advice, and quickly.

MF: The generalised economic pain of the pandemic is impacting on an already fragile private health insurance industry. How important are these funders to the national health system?

OK: Even before the impact of the COVID-19 pandemic, private health insurance was in trouble. Membership has fallen continuously for the past 20 quarters and the government’s recent reforms have not reversed this decline. Younger people continue to drop their private hospital insurance, while people over 65 years are taking it up in increasing numbers, further jeopardising the stability of the system.

Demographic shifts have created a trend which places upward pressure on premiums for those who maintain their insurance, leading the Australian Prudential Regulation Authority to state that private health insurance is in a ‘stable but serious condition, with that stability under threat’. The AMA is concerned that the likely financial impact resulting from the COVID-19 pandemic including unemployment, underemployment and a slowing economy, will result in even more young people giving up their insurance, increasing pressure on an already unstable system.

The unique balance between the public and private sectors makes the Australian health system one of the best in the world. In 2017-18, 66% of elective surgeries (that is almost 1.5 million surgeries) occurred in private hospitals. Without our private system, our public hospitals will not cope with the increased demand. Just last year (September 2018 to September 2019) health funds subsidised more than 100 million services, paying $21.4 billion in benefits.

MF: How can the AMA and the medical profession support that industry? Is that something the profession and the AMA should even have to worry about?

OK: The AMA believes that all contributors want the Australian private health system to be effective, high quality, provide value, and to be inclusive. But we recognise the problem and its severity – the current policy settings for PHI no longer work. However, we also recognise that the government is pivotal in the health insurance equation. It is behind so many of the policy levers that must be adjusted swiftly to reverse these trends and restore value and confidence into our private health insurance system.

The AMA has outlined a few policy prescriptions for private health insurance. We support moves to restore the premium rebate, at least for younger Australians and low-income workers. Premiums need to be within reach of average Australians – otherwise we will have a two-tier system.

The minimum amount returned to members for every dollar going in varies from anywhere between the high 70s to above 90%. This must be standardised, and it must be higher than the industry average right now.

The Lifetime Health Cover loading must be reviewed, particularly the starting age. People are staying in university or TAFE longer, starting families later, and facing mortgage pressures more intensely. The starting age is supposed to be a signal to get into insurance, but it’s now at a point of locking younger people out.

It’s vital that people have transparency around their out-of-pocket costs. Gaps are the biggest bugbear for most people about their private health insurance. In fact, less than 3% of medical services are billed outside a no-gap or known gap arrangement, but that’s no comfort to those patients who find out that they’re not covered when they need it.

That’s why the AMA has developed our Informed Financial Consent guide, to help doctors and patients work through all the issues before treatment starts. We’ve also called on the government private health website to do more. It must help patients understand that each fund pays a different benefit for the same MBS item, and what their health fund will pay.

The AMA has been at the table on all the discussions about private health insurance. We have been at the table to consider alternative clinician-led models of care. We will stay at the table to achieve the best outcomes for the system and our patients.

It’s only by all the players in this equation working together, all of us giving some ground and pursuing reform, that we will succeed.

MF: What are the issues that pose the greatest challenge for the national AMA organisation, which has undergone a volatile period of financial and membership duress?

OK: The AMA is financially strong as its membership base. At a time when membership bodies are finding it difficult to maintain membership, the AMA’s membership penetration would be the envy of many.

Like any other organisation, the AMA works hard to ensure that its budget is balanced each year. This year we have seen the re-organisation of some parts of the Federal office, with a strong emphasis on prioritising expenditure towards our key advocacy areas.

MF: How can the AMA attract more members?

OK: AMA members have told us that they value our advocacy work highest, and at the national level we will focus more than ever on strong advocacy that delivers tangible benefits to our patients and our profession.

Most doctors have little comprehension of the breadth of issues that the AMA deals with and the many threats to the profession that are resolved before most doctors realise they exist.

The AMA needs to refocus its communication strategies with members and other doctors, so that all doctors are aware that they have a strong representative body in their corner that is actively listening to its members and committed to achieving the best possible outcomes in conjunction with other medical groups including Colleges.

The AMA is the peak representative body for our profession – the challenge is to become an organisation that all doctors aspire to join.

MF: Do you think there are too many disparate ‘medical voices’ trying to be heard in the political sphere? With medical advice based on evidence leading governments’ decision-making during the pandemic, will this change the advocacy style of doctor groups in the future?

OK: The pandemic has in many ways strengthened the AMA’s position in the political sphere. The AMA has proven to be a calm and authoritative voice, both with governments and the community. We have been a strong voice for the community and the profession, and governments have listened to our advice.

The reality is we are truly separate from government, and we are the only body that represents all the profession and its specialties. The challenges ahead for the health system are ones that will affect all specialties, and all doctors – no matter what stage of their career. Although there are many other voices, the AMA is the strongest and most respected body representing doctors and will continue to advocate as the peak body in this rapidly changing environment.

MF: What interested you about the AMA national leadership that made you want to stand for election?

OK: I have watched many Federal Presidents of the AMA over the past 20 years and have seen the capacity of the AMA to deliver on a national stage.

At the same time, I have observed the need for the medical profession to lead a reform agenda to deal with the current and future demographic and economic challenges that face our health system.

If we want to enjoy access to a health system that is based around individual doctors and patients making decisions that are best for that patient, then we must be willing to fight for it. That means being willing to challenge some of the sacred cows and defining what we think are the critical aspects of a sustainable, high quality health system.

We cannot rely on the political class to deliver a health reform agenda and if we do nothing, it is inevitable that the solutions others come up with will be unacceptable to the medical profession.

MF: What did you learn from your time as president of the AMA WA that will keep you in good stead as national president?

OK: As AMA WA President, it was very clear to me how important the AMA is to any conversations with the public about health care. There is an enormous amount of respect for doctors and for the AMA in the community and that respect can be used to advocate for changes that can improve the lives of thousands or millions of people, as opposed to the one-on-one interactions that we have as individual doctors.

I also observed how little choice you get in terms of the advocacy issues of the day and how difficult it can be to set the health care agenda. The AMA must be strategic in terms of its advocacy agenda but also nimble in order to ensure that we remain relevant to members and effective in achieving change in a chaotic world.