The 'Dispatched' Podcast
BioPharmaDispatch - discussing the issues impacting the Australian biopharmaceutical and life sciences sectors with Paul Cross and Felicity McNeill.
The 'Dispatched' Podcast
The 'Dispatched' Podcast - Episode 2, Series 5
The Government has announced an additional $25 billion for public hospitals over five years, representing close to two PBSs, while NDIS spending is still rising by $1 billion every few months. Can anyone seriously still argue that there is no new money available to invest in medicines?
Hello and welcome to the Dispatched Podcast. My name is Paul Cross. I'm delighted to be joined by my co-host Felicity McNeil, PSM, Chair of Better Access Australia.
Felicity:Hi, Felicity. Hi, Paul. Had a good week enjoying the luscious heat here in Canumbra.
Paul:It's starting to get the better of me now. You should see my dogs.
Felicity:I can see your dogs and um yeah, already.
Paul:Heat's not their thing.
Felicity:Yeah.
Paul:Well never get weather is not their thing. Walking's not their thing. No. I should send a photo of them at some point so people can see them. They are they're very regal-looking dogs, but they're hounds.
Felicity:So they've got big ears and droopy faces and they look like big balls of fur right now. Right, massive rolls of fur as they just get I ain't moving. At least you won't make a lot of noise during the podcast today.
Paul:So uh I I feel like this is the first week where there's been sort of a lot happening. Uh so we're gonna go through them, devote a few minutes to each. Uh let I want to start by talking about the government's the federal government's decision or announcement earlier this week that it was going to amend the laws to require privately funded medicine services. And we all know who they are instant scripts, uh Juniper Pilot. There's a lot of them now. I saw a new one being advertised this week. They are going to be required to provide information to my health record. This was in response to I mean it's a very sad sad case, but a mother's advocacy, I think it was last year or the year before, recently, her daughter accessed medicines from different providers and they weren't recorded in her My Health Record, and she overdosed. I completely understand the mother's sentiment and upset. I don't have a My Health record, knowingly. As you pointed out to me, I do have one.
Felicity:You do. You have a unique health identifier and it's there.
Paul:I don't want a central repository of my healthcare information outside of my own brain. So according to the minister's announcement, the default will be switched. So that information will be provided. I certainly, if I if I ever knowingly go into my health record, we'll switch that default because I don't think it's the it's the government's business or any other health care provider's business to know the conversations and health care I'm being provided by someone else. That's the choice I make. I'm angry enough about the fluvax that I pay for that. I go to my local pharmacist and and get the fluvax every year, and I'm required to hand over my Medicare card so that information can be provided to the government. I'm just not ha I'm just not happy with that. And I I this constant assault on on privacy and our ability to manage our own information, I've got a real problem with it.
Felicity:And I do too, and we've included it. Thanks for the timing. At least we can include it in our budget submission. But if you recall, I used to at one point in time be president of Hepatitis Australia, and that's when the government was looking at opt-in versus opt-out, and Consumer Health Forum was given a huge amount of money to promote just let it go. And we at Hepatitis Australia came out against that, saying you shouldn't just be telling everyone it's fine. There are seven questions that really an individual should be asking themselves about whether they're comfortable about having a health record and what's included on it. Because we worked with some of the most marginalized, discriminated against, stigmatized people in the community who didn't want having rebuilt their lives, their newfound relationship with a new provider being stigmatized. And let's be really honest, a lot of GPs propagate a lot of stigma. And we couldn't get people to understand that you actually encourage people to run outside the system. I have done a lot of work, of course, still in opiate dependence treatment programme, where again there is regular case studies of particularly young mums who've had a a past that was difficult for them and they've recovered from that and have their own, you know, and have children and a family who will go to their regular GP for everything that relates to their everyday health, their chronic disease, their papsmia checkups, their their children stuff, but they will not tell them that they are still going to a clinic once a week for access to a long-acting injectable because they are terrified about what that GP may do with that information and what it might do to jeopardize their family relationships. We now have a community that regularly is, you know, one in three scripts on the PBS is already being fully funded for, and the government's recording it. But this is different. This is, we are seeing, and you've been writing a lot about it, and I know we'll come to this issue, people taking control of their own health care with respect to obesity. So not only is it not funded on the PBS, but a lot of people are choosing not to go to their GPs who are saying, try more of this first, or you don't quite actually, you know, meet the criteria yet. So you know, you either get fatter or you, you know, you go to somewhere else. And people are doing that, that's secretly. The fact that most people who are taking those drugs do not want anybody to know that they are taking those drugs is a classic reason about why this is incredibly dangerous and may have deleterious impact on people and the way they're actually engaging with the system. I am really sorry for this mum and her daughter. Medication misadventure is unsadly in many different circumstances, not just because of this, but I'm equally frustrated because we we took paracetamol away from people with chronic pain because of a small number of young women who were using it for suicidal ideation problems. And we disenfranchised 26 million people because of 13 incidences over a period of years. Those lives mattered, those children mattered, their parents matter, but this knee-jeck reaction we have, and particularly under this government that loves to control everything, it's a real problem for me. And we did that in COVID. COVID allowed government, which had been hoping for years, to include in the Australian Immunisation Register not only subsidised vaccinations, but every vaccination that someone paid for privately themselves. So we will know everything, Paul. If you get a vaccination for yellow fever, you know, we'll all know you're going somewhere. If you get a vaccination for this, they know.
Paul:Yeah, and I I I I resented. I it was the same when I got a hooping cough vaccine, which everyone you need to get every ten years. As as an adult who had hooping cough ten years ago, I recently paid for it myself and expressed deep frustration to the pharmacist that I was obligated to hand over my Medicare number.
Felicity:And and they are legally obliged to do that. That's not their fault. It is not their fault. And the the problem with this is that the default medical um software that they used, and so thank you to some pharmacists who educated me on the current AIR, I do appreciate it and how it's operating. Basically, a majority are using a particular brand of software to actually record and administer that, it automatically sends it through to the AIR. If it's subsidised by the NIP, that the charge that they are given there is actually included in the cost that the government pays for you to administer that national immunisation programme vaccine. And if it's privately done, then they factor that into the price. So ironically, you're paying in many instances for your information to be put on the AIR, which is the Australian Immunisation Register, without your consent. And this is the kicker. You cannot actually say no. And this is where it becomes a huge disenfranchisement. And a bit of advice to all the FIFO workers who are coming to Canberra next week for um Parliament. If you for any reason need to enter the ACT hospital system, so you know, let's say you have an anaphylactic attack up at Parliament House or coronary or a stroke, you by default, even if you're not conscious, actually agree that every piece of information about you will be stored on an electronic record and sent to someone. You have no control over your information once it's in the hospital, and they can do they will they deny service without you actually agreeing to it. So it's literally a gun to your head. If you want to be cared for, you have to agree to this all being handled.
Paul:Yeah, no, I I don't want to labour the point, but I've had people say to me, We've got nothing to hide. I've got absolutely nothing to hide. I take some medicines, uh, I take paracetamol. I've got bad legs, as you know, uh, that relate to something that happened when I was younger.
Felicity:I've got some bone I've had uh A woolly's gonna have to start you know logging when you purchase paracetamol at the time.
Paul:I've skied a lot over the years and and had a lot of injuries as a result. So uh I've got some creaky old bones and a couple of other things that I take I take medicines for. I'm not I don't have any I've got absolutely nothing to hide on on that. And even if I had it's my right. That's I I I if I want to access a particular form of healthcare outside of the funding framework and not reveal that to other healthcare providers and the government, by the way, that should be my right. And that's that that is the default position on that is being taken away.
Felicity:And the great irony of this is why are we all doing two-factor authentication these days? Oh my god, because of breaches of privacy, Medibank, and the the leak of the information. And so, in a time when we're saying to people, don't share your information, don't do this, think about what you collect, do you really need to collect it? And as someone who sits on a board where we look at you know patient information and go, what do we what do we need? Absolutely, what is necessary for us to do our jobs and to retain for how long? But yet, no, this I I am actually really sick and tired of it because also there are times, and you know, I've had this conversation with many, many parents over the years, is that your children go through a lot in their younger years and what in their formative years, and when we talk about mental health and stigmatization and how things are done and when things are done and points in time. I do not want my children to not have the enfranchisement that they deserve to decide what isn't is is and isn't recorded that will follow them for the next 50 years. And so I've always been quite adamant, don't you dare, and and saying no, but you do need to be careful, you do have a health identifier.
Paul:Well, well said, and that I will I will action that. Uh Centre for Disease Control, which has a logo now and a whole organization chart. How excited must they be with this weird thing that's happened in West Bengal or something? Press conferences, you know, the national incident room, all the TVs will be on, they'll be bringing the TV crews in there soon enough. They're gonna be so excited. We've got relevance so early.
Felicity:Not only have we got relevance, it's budget time. We can get at least a couple of hundred extra million for this. Oh my gosh.
Paul:They're gonna need an app for sure.
Felicity:We're gonna need an app, and we're gonna need to start, you know, scrutinizing AFL footballs as they fly through there. Oh my goodness. And what about pizza books?
Paul:I thought that the and and if this actually does become serious and it that it looks like it's quite hard to transmit, and they're still working all of those things out. So I don't I don't want to downplay it. People have have died from it. But this is where COVID, the chickens are gonna come home to roost.
Felicity:Oh, and if only we'd done the actual Royal Commission that the Prime Minister promised us in his election commitments in 2022, we would not only understand the impact on the community, the impact on the economy, and how to and how some of the decision making was completely flawed or misinformed. And yeah, brillio, guys, brilliant.
Paul:Uh so that's uh we were both laughing about that. They'll be they won't be high fiving, but they'll certainly be mentally high fiving.
Felicity:They are so high fiving, and it's a zoonotic. And so anyone who works in that sector they or has worked in that sector, the zoo dudes, they love it when you talk about that and they try and encourage you basically to as someone who has a restricted diet anyway because of my allergies, and they say, Well, don't eat this, this, and this. And I'm like, I'm gonna starve. Like, let's take a chill, Bill.
Paul:Yeah. Uh a couple of things that uh we wrote about this week. One was the communication framework for health technologies in Australia and how I doubted it is. It's not that it's not in the 21st century, it's barely what did I write this way? The internet was technically the World Wide Web was established in 1989, the public had access to it from 1991. Our current law legal framework for the promotion of therapeutic goods was established in law in 1989, the same year that the World Wide Web. Now, there is no way that that law, in all fairness, could have foreseen what we've now got. Uh and the legal framework actually just gives the TJ or the government the power to s establish regulation. And the regulation has always been that it's not just that pharmaceutical companies cannot communicate to patients or cannot cannot have promotional information on medicines. They can't facilitate access to it. So, unless you have a VPN, some of these websites in the US are very hard to get onto, so they geolocate locate you out because of course as we know the US is a country run by lawyers.
Felicity:Yes.
Paul:And they have a very strict interpretation. Some, particularly the American companies, have a very strict interpretation of those things, and it's very unhelpful. But the reality is that and I use the context of obesity medicines because I want to talk some more about those, but the fact is that I can find any range of information on these therapies online. Some of it is very specific. If you search some of these brands, particularly if you use an AI platform, they will very helpfully tell you brand names, TGA approval, the fact they're not funded, and where you can get them. Now none of that information can be provided by the actual companies. The the the manufacturers are limited to these 1980s, 1990s disease awareness campaigns, where they say, hey, if you have this condition, you might want to think about doing this. And I just think it's to me, it's what what's happening is that the loudest voices, and some researchers uncovered this last year, I think it was the Edelman trust barometer, is that people, particularly younger people, are accessing healthcare information from a lot of different sources. Particularly TikTok. Yeah. Now unfortunately, when it comes to medicines, and as I say, I use the example of the obesity medicines, uh, that information is not the the regulated source, i.e. the manufacturer, is not allowed to communicate. And that to me is look, you mightn't like it. Yes, they are for profit, but if I am a gym, I can promote the weight loss benefits of my service. If I am one of these food providers, you know, the pre a lot of my neighbours get it, um I can advertise the benefits of those with case studies. If I make an OSATS dairy product like margarine, I can claim a uh cholesterol-lowering benefit. But I can't do anything like that as the maker of a regulated approved product, which as an as an ev as an evidence base has more than visually any other product in the economy. Now we all know why those laws were framed in the 1980s and the 1990s, because the government was concerned about the cost implications for them.
SPEAKER_02:Yeah.
Paul:But it's also driven by this public health orthodoxy, which thinks we're all stupid and we can't handle the information. And we might actually go into our doctors and ask them about the product. Now, if that's the objection, I'm sorry, people are doing that now because who doesn't go on ChatGBT or Perplexity or whatever, uh, or or on Google now, which has a pretty good AI capability, who's not doing that before they go to the doctor?
Felicity:Yeah, and they don't even need to, because you know, as long as you're over 16, um, Minister Wells, you can watch your Instagram feed, which will bring you anything and everything. Like I'm I'm always amazed why you don't what you click onto one thing that leads to another, and I get I get plenty of that information. And it tells you what it is and it tells you how to do and it links to more information. And I always find it um farcical because I can sit and watch an ad that tells me that if I take a supplement like magnesium or apple cider vinegar gummies, that it may help with this, this, and that, or Ray Meyer from Home and Away can tell me that, you know, if I just use that machine to move my feet while I'm sitting watching him on Home and Away.
Paul:The circulatory one. Oh, that's right.
Felicity:But when we actually have clinical evidence and uh authorised use in in Australia, why we are not respecting the community and allowing for health literacy is understanding what is there and what is not. And it's important, you know. I've seen a lot of that experience where you talk to your doctors, particularly a GP, who cannot be across everything and say, Well, what is this, where's this, what's this is happening, these are the new medications, etc. And discussing informed about my own health, having self-determination and asking for that information is really important. And I'm with you because I just think that the ability to have clear, accurate information, you're not trying to sort of, you know, sell it on. And as you've written about with all the risk share arrangements in this country, no pharmaceutical company really wants anything that's on the PBS to be there.
Paul:No, but New Zealand being the classic example where direct consumer advertising of prescription medicines is allowed in law and no one does it.
Felicity:Yeah, so I just I I feel that we are sometimes sometimes we we we live too far much in the past. So I always talk about you need to learn from history and need to understand it. And that's why your articles this week are important. This is where it came from. It could not foresee this. We always have to change the law because we didn't foresee something coming in and the interruption, the disruption. Just ask taxis and Uber. So we we need to go with it and grow with it. And I I am more concerned as a as a mother of you know 2.5 daughters, the types of information that they get on on health is through social media channels. And at least I've got a relationship with I'll come to me and say, Mum, you know, all about this stuff. What about this? What about this? What about this? A lot of families don't have that opportunity. I would like them to be able to find accurate sources of information, and yeah, and I'd also like to be able to say to a company, you've got permission to do this, and if you cross the line, then we come after you.
Paul:I mean, with the regulatory framework that exists.
Felicity:Exactly.
Paul:It's the one source that can be properly regulated. Now, are all companies going to do it? No, they're not, because of the risk share arrangements. We're in this ridiculous situation now where in many cases, well well, in quite a few cases, companies stop promoting their medicines to doctors because of the risk the risk share arrangement. So it's not going to be an issue.
Felicity:Well, let's take it one step further. So if we're all so worried about pharmaceutical companies putting any information out there that explains their products and you know how it may be appropriate in a particular disease condition, we should probably tell the health minister that he needs to stop announcing new listings every month because he sits there and he'll sit there with all the patients and he'll tell the stories and the companies coming and say, that's great, because the minister says it. So why is it okay for a minister to say, hey, I've listed this drug. It would otherwise cost you this. It's for this indication. You should go to your pharmacist or your doctor and see if this is happening. So why is he allowed to do it? But the pharmaceutical government.
Paul:Well the law explicitly permits him to do it because he's not covered by it.
Felicity:But I appreciate it. I'm asking why do we why do we accept it from him, but not from someone else.
Paul:Yeah. They think we're all stupid. And it it's it's deeply offensive. And so even some s so-called patient groups, I don't know, the Consumers Health Forum, presupposes that we're all idiots and can't cope with the information that we're getting anyway from other sources. I think it would be sensible to revisit this law, but also to take on this orthodoxy, which is academically proven to be false. People are not stupid. People know advertising is advertising. And I, as you know, I did a ninety thousand word thesis on this very issue, which basically said, concluded that you know, when the roadrunner drops the anvil on the coyote's head. Kids know it's not real. Kids know it's not real. People engage with information based on their societal context. Okay, so if you're getting all of your information on medicines from someone overseas on TikTok, he's neither the company, a regulator, a policymaker, a doctor, that's risky. But a lot of people are getting their information from that from that source. And so that doesn't leave a lot outside of the regulated framework. And I just think we would be sensible and growing up and mature to say, well, you know what? I think we need to accept that the internet exists. And we need to accept that all these platforms have basically brought down borders. And it's not very hard to access information on these things. And that and that but you know, I was having arguments with people on LinkedIn about this. It's just and it's just you you genuinely think we're we're all stupid, don't you? And that people can't handle this information.
Felicity:It's amazing how much information we are. We'll happy for us to be exposed to. We can watch, you know, over and over again, and and sorry to bring it to this moment, but the exposure to what happened in Bondi and the repeating and the reshowing of those two terrorists, I won't say alleged, because they were terrorists, um, and we watched it over and over again. That was the thing, we were all had to do that. We can write about infinitum and we're fine with that. But then when people say, Well, I'm worried about people being influencers, I'm worried about people with um eating disorders, or I'm worried if people I understand that we're all worried about that, but it's like we've talked about this morning, uh, that with this particular issue on the privacy and how we're changing something because one person did something, and we've changed paraced more because one person did something, and we've changed access to codeine because we were worried about something that hadn't actually eventuated yet in Australia. We we kind of to solve, to plug one little hole, we literally bury 26 million people under something else. And like you've said, we are far more educated, there is far more exposure to information, and we should actually embrace that. And you know, this is a government that loves controlling, so control what they're allowed to put out, but but let it start being you need those counterfactuals out there because otherwise, like I said, you you're sitting down and having these very interesting conversations.
Paul:Yeah. It's it's very frustrating to me, and then then I linked it to the weight loss therapies. And you get you get this blowback from people. And I described it today as stigmatizing people, but it's almost it's quite Protestant. You know, Max Weber wrote about the Protestant work ethic, and that that's kind of what it's like, in that it's well don't make it too easy for those people, you know, you don't reward their poor lifestyles. And my argument to people was well okay, we don't do that in the health system, we try to avoid it. There's always been a hard minimization uh approach, and at its most uh focused, it's pill testing in concerts, and it's free needle exchange. Because it's better that we avoid those people sharing diseases. Okay.
Felicity:So Australia was a leader in that approach. Yes, yeah.
Paul:Yeah, but there is this area and it's and it's I likened it today to some of the blowback I got when writing about opiate dependence. And I thought, well, so where where do you draw the line? Okay, so if you don't think we should help give people direct support to reduce their weight, to get it manageable, but also to avoid some of the comorbidities, does that mean we shouldn't treat the comorbidities?
Felicity:Yeah, I mean it's interesting. You know, we've got a national obesity strategy which doesn't really contemplate any medication to help. And we have a national preventive health strategy, and that is one of the things we've written about in better access in our budget submission. If you want to talk about preventive health, tackling obesity and making available the treatments that would actually prevent all of the multiple complications, because all everyone ever tells us, you know, about you know what helps me not eat that second bowl of ice cream is if you do this, you could get diabetes, or you could get this, or you could get that, and you've got to look after your health. So if we really believe that, and some people can't actually address that themselves, and the medications may help, then like you said, we provide we only provide lung cancer screening for people who've been smoking all their lives. We don't care about women who've never smoked in their life. Well, you just you just risk it, girlfriend. But if you've been smoking two packs a day, we go, you know what, this is a risk.
Paul:City years, by the way.
Felicity:Yeah. So we will do this. So we will look after you. But apparently when it comes super easy, and I look, I get it, everyone's just saying, Well, why am I not eating and why am I not doing this? And why am I being healthy? Well, you know what? That's the way it is. And I think part of the challenge of that, and you and I have had this discussion, is the extreme limits about what qualifies you to be able to take the medicines versus not and what the subsidies may mean. I mean, the subsidy that they're proposing is just so preposterous.
Paul:Well it's not the patient group who would benefit the most.
Felicity:No, and you know, and uh the BMI of 25 and how much people have to get there, and so people are saying, well, you know, can I can I get access to the 20? Oh no, I know, but the the the registrations and things and under um Australian Health, you're considered overweight if your BMI is greater than 25. So what I'm trying to say is that this is when we say to people, well, that's enough. And then so some people go, okay, well I'm getting close, I want to deal with this, I've got menopause, I've got whatever. Yeah, but you're only 23. So let's just keep trying that stuff that's not working. And I think that's where I think a lot of the stigma comes from, is that who's getting it, who's not, and you know, who can, you know, where's the flexibility and where's not, as opposed to going, okay, well, let's just have an open conversation. Is this actually, I think as you nicely wrote about, and I am old enough to remember the norm campaigns.
Paul:Have you seen I would recommend if you want to look at a stigmatization of someone, go back and have a look at the norm ads, the life be in it. So most of the audience won't know what the hell I'm talking about. But it was the first weight-focused public health program launched in Australia in the 1970s. I think it was Victorian, and then it went national, and it was norm, life be in it. And it's worth a search on YouTube because let's say the whole ad is premised on stigmatising people overweight.
Felicity:Yeah.
Paul:Even with the language.
Felicity:And I think it's interesting because whilst you're writing about this, there has been the defunding of Vic Health in Os in Victoria, which is like$461 million worth of, you know, pre preventive health effectively, like, but mostly campaigning. So, you know, skin cancer and um, you know, get getting fit and all those kind of things. And the the question here is we assume that if you're not w willing to be educated and told what to do, that therefore you're lazy and therefore you don't shouldn't have access to these things. But the reality is we do it in every other disease. So we tell you the dangers of smoking. But if you do smoke for the the 30 years, the the two packs a day, then we want to screen you before anybody else, rather than, like I said, the mum of three kids who's got the same cough, but she doesn't qualify. So we just really need to take a different approach to this and we need to stop being so um I was gonna use the term paternalistic, but it's not male-female. It's just we need to stop being so righteous. Um, when in public health, we go, we just told you what was best for you. And the reality is the whole premise of public health. People live. People live, and they some things go really well and some things really don't. And some people actually have a genetic predisposition to putting on weight, just like some people have a genetic predisposition to type 2 diabetes. And we just need to take a grown-up look and say what's best for these individuals and what's best actually for our healthcare system.
Paul:The decades of public health government-funded public health campaigns about lifestyle choices and weight are a case study in failure. Absolutely in wasted money. In wasted money. Now I'm sure that there is some academic out there who'll say, yes, but this is what it would have been without those can those campaigns.
SPEAKER_02:Yes.
Paul:And of course, you know, as Orwell said, some ideas are so dumb, only an intellectual would agree to it. But but it's and then along comes these therapies and Wushka. We've seen the massive impact in the US. We are, I suspect, 12 months behind that. The problem we've got at the moment is that the people who would most benefit, not just individually, but from a population level and also from an economic perspective, because the people who might be able to return to the workforce, the people who will be have have a reduced impact on the health system, they'll be engaging less, they're not able to afford these therapies. And so, unfortunately, as is always happens, and we're going to discuss this in a minute, uh it comes down to how these issues are always framed in Australia, is one of health financing.
Felicity:Yeah, and look, I also do understand as someone who was in the system during the biological demands and the lesson that was learned about that, and we've talked about it before, which was these originally, you'll be on it for two years, and then it'll all be good. You won't need these drugs, everything will be fine. And the system learnt that actually, if you're taking them after certain years of um suffering from a disease and actually waiting too long too long to get on the biologics, you you're taking them the rest of your life. There is no remission. Ironically, if you start to treat children, we look like we actually can put a disease into remission. But the system just says, this isn't two years, this is lifelong. I'm going to be paying for this for lifelong. And then you look at the information that's coming out of like the the UK and and some of the US, the early information that says, we're concerned because it works really well for two years, but then when people come off, you know, they put on 65% of the weight within you know a certain period of time, or the actual appetite suppressant functionality starts to diminish over time as well, too. And what does that mean? And I get that and I understand that. So that's where putting on my finance hat. I understand the system going, am I just giving it to you for 12 months, two years? What am I doing? Are you expecting to do it for lifelong? How am I going to actually say to, you know, if if the information changes, you know, what's the payback when I have to keep doing this? But also, is this a solution? Is it better to um, and I remember the PPS's advice, should it actually be with something about maybe this is the education opportunity time to talk about better food and the exercise because you're you're more energized and you're more um able to move about because you've lost so much weight and you can change some behaviours that might make you less reliant on the drugs when they they may or may not work as well. So, or do you cycle through them? So I understand that part of a financing point of view. What I don't like about it is that they are pretending it's about people being lazy and not being, you know, worthy of the investment, as opposed to saying we should be just honest and saying we're worried about how long we have to keep doing this. We'll start here and then we'll work with the companies and say, if these things actually constantly rebound, then this is we we don't need to have that conversation.
Paul:Okay, the fact is that people are gonna have to be on these products for a long time. Like people with high cholesterol have to be on satins for a long time, like older people with high blood pressure have to be on them for a long time. The fact is these these therapies, which are all protected by patents, the price of those things in a compet highly competitive environment that's emerging is gonna drop precipitously. And finance, the health financing people just need to get their head around the fact that these they're gonna have to spend on those things. Otherwise, the existing disparity in our health outcomes, driven significantly by socioeconomic factors, is going to worsen. And we need to be somewhat imaginative about it. The government has announced today an extra 25 billion over five years for public hospitals.
SPEAKER_02:Absolutely.
Paul:The cost of the NDIS is growing up by one one to two billion dollars every four or five months, and for several years went up at a cost of total PBS in 12 months. What two years in a row it did that. So there's money. There's money. And no one is saying, oh, we're gonna have to spend$10 billion on those things. No, we're not. We need some, as we wrote this week, some innovative thinking about policy, potentially outside the PBS, and there are risks associated with that. But then this and that brings us into the health t HTA conversation, where whilst we're everyone else is talking about greater investment in health,$25 billion extra for public hospitals from the federal government. From the federal government, over$200 billion over five years in public hospitals. Whilst that's going in there, while the NDIS is growing with some half-hearted efforts at controlling or minimizing the growth in that spend, the HTA people are talking about disinvestment in global forums. I mean, it drives me absolutely bananas.
Felicity:Yeah, of course they are, because that's something that we've you know been fighting since they put it into the the National Medicines Policy Review. We'll we'll have a discussion about where these your ideas on a separate program, which I'm not supportive of, purely because once again it's a bit like I didn't like the COVID vaccines not going through PBSC and being in a separate place because it didn't actually take head-on the issues within the HTA environment, which is the reason that there aren't enough migraine treatments, it's a reason there isn't enough stuff for eczema and dermatitis, there's a why a whole heap of common chronic diseases are not getting the contemporary access to medicines. And my greatest concern is that when you set up a special program for obesity and you put it outside the system, you solve one problem, but everybody else who doesn't have that problem is still stuck with a PBS that has its tight, obsessive, unyielding approach to evaluation reinforced and perpetuated because they got out of having to deal with that one.
Paul:Well, conversations about the PBS. I agree, I agree with you in many ways, and I and I think a framework outside the PBS is not the desired outcome. Okay, because it'll turn into a tender, and everyone out there, you know, if you you get a a sniff of a tender in this area, they'll become commonplace. So you've got to be be careful what you wish for. The problem is, I look at conversations about PBS and this cult-like commitment to health technology assessment where change and the reform discussion, as I describe it, is it's like putting old wine in a new bottle, nothing ever changes. Everything is framed in terms of technical inputs, and now the conversation has arrived at disinvestment, and you've got these industry people on these social media platforms at these and these events I tell these events about HTML. Do you notice they're never in Lagos or Abuja or you know, some developing country? They're always in really nice parts of the world, and that annoys me. I wish these people thought through and considered the consequences of of these discussions and their acquiescence to these really bad ideas, and disinvestment is a very bad idea. You know, and you've seen me on some of these on stage with some of these people, where they just can't cope with the counterfactual. If you're trying to have a conversation with with the HTA cult about Well uh that's not right. I don't agree with you. I think we need to challenge the system head on. The institution is is fundamentally disrespectful and patient-hating. And unless we're willing to have that conversation, then yes, inevitably you're gonna have a conversation about discount rates and comparators. And that frustrates me, but is the system so broken that we're gonna squeeze the life out of this obesity issue and it's gonna be ten years before we get to a meaningful solution. And I guarantee you they'll they will have already engaged an IP firm to look at what are the patent expiring some of those medicines. I don't think semaglutide is that new. So they'll be looking at all of those issues about affordability. Meanwhile, public hospitals talk about a broken, outdated frame framework, these cathedrals to 1950s public health, they get an extra$25 billion, and it's a nice round twenty-five. And what do the states have to do in return for that?
Felicity:Nothing.
Paul:Nothing.
Felicity:Just keep whinging.
Paul:Just keep whinging, and we're gonna have this same conversation in five years. And it's just to me, it's really frustrating when the people who who I got some bad news for everyone, and particularly the industry listeners. This system exists, the one that you seem to hate so much, or or seem very happy to talk about in in favorable terms, and the classic favorable term is Australia's got a world-class system, but it's like okay, you everything after the comma no one's listening to. Of course. Because you've completely invalidated it. My my frustration with this is that everything happens in this system because you agree to it. Farmac in New Zealand exists because the industry acquiesced to it. And the PBS is now one-third private.
Felicity:The ultimate disinvestment.
Paul:Yeah. One in six groups to non-concessional patients are uninsured in Australia, which is much higher than it is in the US. All of that has happened because you've allowed it to happen. The one group of people who are actually capable of delivering change in this system seem very reluctant to have a meaningful conversation about it and to actually attack the institutional framework. And I got some other bad news is that if you want change, you you have to argue for it. This is the crazy thing about it. If there's an outcome that you want, you have to make the case for it. And I just don't see the case being made if it's a if it's a conference somewhere on the other side of the world talking about disinvestment and then people making some posts on LinkedIn. Like that to me, I have to say work in government, know a bit about it. That's unlikely to deliver change. Except to your flying status, your airline status. Sorry, and and it really it irritates me because you just it's like the traps, but this is not you know you're in your own bubble.
Felicity:And I think, you know, we we ha we have a history of where disinvestment goes wrong in Australia. So we've we've had obviously in the the mid-2000s where um the central agencies thought removing paracetamol from the PBS would be a brilliant idea. And of course, all everyone did was transfer the scripts to the more expensive medicines, so quickly re-added it. And look, don't get me wrong, I removed um paracetamol in 2015 because we you we removed anything that was under the copay and just said if you're paying your copay when these things are costing less than that, you might as well just pay for them yourselves. Uh to deliver some changes there. But when we consistently talk about disinvestment, what exactly do we mean? Because if it's about like the National Commission of Audit, which thought it should be one medicine on, one medicine off, and looking at those older medicines, and you know, I do remember saying to some of my finance colleagues, you do realize they're the cheap ones, right? Like, you know, you're trying to avoid people using a BD mud by using methotrexate and selezapyrin, which is like a tenth of the price. In fact, even less, it's probably a a fiftieth of the price. So be careful what you disinvest in. And then is it about, you know, to me, it's usually about wanting to bring something back, the the equivalent of the post-market reviews, and just saying, oh, we've been paying for this and we want to pay less for it. Oh, we didn't quite achieve the outcomes, you know, so we'll we'll we'll we'll threaten, you know, if you if you don't drop the price, we'll remove it. But what do we mean by disinvestment? I I'm quite curious because my experience of the health system, in particular in medicines, is no one seems pretty keen to keep anything on the subsidy system, either the individual companies or the PBOC or the government funders, if it's not working. So what what are we trying to achieve here? Or is it you know, you just want to get rid of the the really expensive things, you know, it's it's a threat. Well we we just can't have that anymore. So I um it's a word that's really bandied about, and I you you only have to look at how nervous Mark Butler got when a particular insulin was removed during the um those catch-up price reductions. You know, ministers are fine with nothing coming to Australia, but deal is something that people are already using and they don't like it.
Paul:Remember when he issued that press release saying, I've instructed the company. He's so great. It's like that's a supply-only arrangement, dude. There's nothing exciting about that. Yeah, it's it's to me the system is already characterised by far too much disinvestment. And this was the point I was recently making in those articles to say that we we have a system that's now premised on recycling within the program. Recycling is disinvestment, and it's moving it from one part of the program to another. It's nothing wrong in principle. The problem is if it goes for too long without actual new investment in a system where tens of millions of scripts have come off a subsidy, you're going to have less to recycle in that disinvestment process. And you know, it always worries me when a group of HTA people get together. Because you just know it means more HTA. It's like when you get a group of lawyers together, they're going to propose new laws. You get a group of regulators in every any area together. They're going to propose more regulation. You get a group of HTA people together, they're going to be saying, more HTA, more HTA, more HTA. Because that's what happens. And it's not a criticism of them personally. It's just when they come together, I don't know, something happens. And and they start talking about all this technical process. That is not the problem. That is not the problem. And you see that in the ACOU document. It's almost impenetrably appalling as a document. Poorly written, nice graphical design, which seems to be the big focus of the health department.
Felicity:I mean their IGB was awesome.
Paul:It was lots of action photos, lots of colours. So obviously the graphic design department in the CDC logos, they got all those things going on.
Felicity:They won't be taking 23,000 public servants from there.
Paul:That's right. So I'm just waiting for the CDC app. If there is already a CDC app.
Felicity:I've kept all my apps from during COVID.
Paul:Oh I haven't. I've just expunged them from my phone. But yeah, but that's something where we just need to get the conversation away from that and onto the problems facing this institution. And stop accepting this framing that somehow, if you challenge the underpinnings of this institution, that oh you're threatening its independence and you're threatening this and you're threatening that. Well, yeah. Well, it's not independent, but I want to challenge the quality of its decision making. That's what matters to me. I really want to challenge that. And the way these debate is often framed is that if you do that, it's like it's not this blob. It's like you're attacking the big blob of the faceless people that determine our health outcomes a lot of the time. And I and I really resent that.
Felicity:Well, I think the the PBAC recommendation on um the weight loss treatments was probably the I mean I'm I'm hoping the company although technically it's recommended, so you can't, which is part of the problems with the system, is the the cohort in which these drugs were recommended, I can't understand how they actually are cost effective once you're that sick, that unwell, have power all these other bits and pieces. As as the AHW reported in you know November last year, the the top cause of possible preventable hospitalizations now is diabetes at$962 million last year. The second one is cardiovascular disease at I think it was$913 million. I mean diabetes has finally overtaken C V D. I mean, yay, diabetes.
Paul:But the Olympics are coming up.
Felicity:Yeah, exactly. We but we we need to think about these things. So it's like, you know, when you're you're pouring the$25 billion into the hospital system, a hospital system that has so many avoidable hospitalizations. When we talk about primary care, it's not about getting into an urgent care clinic. It's about there's no good going to a bulk-billing doctor if I can't actually afford the medicines or even access to medicines on the PBS that actually would assist me in preventing that hospitalization and the development of those comorbidities in the first place. And that goes for devices as well, too. So we have this real anachronistic approach to it. And I just find that that was probably the most appalling recommendation.
Paul:Well, you have to have BMI over 35.
Felicity:Or 32 if you're Asian.
Paul:Yeah, I wonder what classifies an Asian these days. I I you know I got very worked up about that.
Felicity:But let's just all put that thinking hat on and like how is that the cost-effective thing? Usually it's like, you know, if I treat you before you get all sick, well, you know.
Paul:Well, it's the c the clinical trials have divided people in that way. My question is, you know, they just throw this term out Asian.
SPEAKER_02:Yeah.
Paul:Like, okay, okay. So is it the continent of Asia? Like, what are you talking? What are you talking about? So it's I would love to hear an explanation as to exactly what they mean. Because I think there are a couple of trials in places like Thailand or Korea or something, something like that. So yeah, I I'd love to see the uncomfortable conversation about how they're going to define Asian.
Felicity:Yeah, and and how that aligns with um our discrimination acts in Australia. You're allowed to positively discriminate against First Nations people, as in in their favour. The rest of the system doesn't actually allow you to be able to do that.
Paul:I think it's it's a path before we embark on that path, because clinical trials are becoming far more diversified in that way, then we need to have a conversation about the sort of system we want.
SPEAKER_02:Yeah.
Paul:Uh yeah, it's it's an interesting one because what is it's BMI, 35 or over, so these are very overweight people. And you have to have had a heart attack or a stroke. Yeah, PAD, yeah. People have a vast array of health issues. Are these the people who are going to benefit the most?
Felicity:That's my point.
Paul:And there is the the reason I was looking online yesterday is what's the data, early data on productivity gain? And it's pretty early from the GLP ones, but it is starting to emerge that people who are have GLP one derived weight loss have fewer sick dose at work. So that that would suggest a productivity benefit, but but most of the discussion was the data is in the process of being collected, but it's still very early.
Felicity:But so you mean compared to what they're used to versus the general population?
Paul:Yes, yeah, yeah. So but that's still it's still pretty early, but it sort of stands to reason that if you Yeah, just to me it does. But I know that in the world of HTA, we're gonna have to have a clinical trial on that. Um hey, today's the cutoff for budget submissions, I think, pre-budget submissions.
SPEAKER_02:Yeah.
Paul:And BAA, I've I've had a a a look at yours, and it's really good because you actually say something really clear. And it's not the same thing people have been saying for the past 30 years. So as a final item, why don't you take can you take take the audience through what you're proposing? Sure. Um You don't have to like read it, but just give us a few.
Felicity:Yeah, no, I was gonna say well, the key point. So we're we're basically focusing on the fact that um, you know, the government's application of means testing is mean and needs reform. So we're pointing out the fact that um, you know, you have introduced greater means testing and contributions to aged care. Sort of our elderly are being forced to pay more at the later stage of life, but we expanded child care subsidies for family earning as much as$573,000 per annum. We've got the government demanding families earning over$89,000 to$103,000 a year, pay$25 a script, and have a$1,700 a year medicine subsidy safety net. And yet we've allowed a blanket subsidy for electricity for new solar batteries, irrespective of your income.
Paul:No, but they say$5 billion on that subsidy.
Felicity:I know, but but not by changing the subsidy to people, but just changing which batteries you could use. Um we're we're insisting that families spend$2,699 out of pocket for an MBS schedule before they get any relief. Um they have to there is no safety net on the National Diabetes Services Scheme and copays of up to$35.50.
Paul:And there's discriminant, there's some have copies and some don't on CGM, don't they?
Felicity:Yeah, there's different. If you if you were if you're in if you were an early type one person with eligibility, you get it for free. If you were part of 2022, you pay everything. And so, you know, when you think about the average annual full-time income in Australia is 105 to 108, and the household income is 121, we're just saying we have got this kind of all the wrong way around.
Paul:So we're like it. We're talking about the different and don't forget newborn screening.
Felicity:And yeah, so you know, we'll have it online and we look forward to sitting with Treasury.
Paul:Yeah, we'll put it out on we'll put it out on Friday, sorry, on Monday, because today is Friday. Uh because I think it's it's good because you actually said something, which is which is nice.
unknown:Yeah.
Paul:Um I'd just like to finish on a Bassett update. So we've been talking for 50 minutes and they have not moved.
Felicity:And to regular listeners, that's really unusual.
Paul:They have not moved. They've definitely it's well it's wiped them out this week, and they uh you know they are carrying around big bodies though, in fairness to them.
Felicity:Well, we all are.
Paul:And I'm not fat shaming them like they were fat-shaming norm in the 1970s. You've got to you've got to have a look at that ad.
Felicity:You should send a link.
Paul:Yeah, it is so like it is just quintessential fat shaming.
Felicity:I know. It it's yeah. It's like get off the couch and do something.
Paul:Yeah, basically, it's basically you're eating too much.
Felicity:Well, it's the greatest funny thing for for me, which is you know, when they talk about the advertising, and a lot of that was based on the time when if you do go to the US like you are inundated with ads on television for that. I just laugh because I don't know anyone under the age of 35 who watches free-to-air television or even the the apps related to free-to-air television to even be, you know, attacked by those ads. It's all these social media stuff.
Paul:I mean, there are a lot of pharma ads in the US, no doubt. There are a lot. Um that's but you can get the So first it's a constitutional right to advertise in the US too. All the only restriction is, you know, they've got to put all of the side effects at at the end. But I don't understand. I have no philosophical objection to it when I can claim that the my circulation is going to improve by sitting on my backside using that that paddle thing on my feet or eating margarine, which is not even real.
Felicity:And I'm sorry, I didn't mean to wind you up again.
Paul:To know about, so that makes it makes absolutely no sense to me. But Felicity, thank you. I know you've had been a little bit distracted this week because you also had the first F1 stuff.
Felicity:Oh yeah, Shakedown Baby, and no media.
Paul:It's been like I know I did see the Cadillac livery as you know I'm not gonna be a Cadillac fan. And the most disappointing thing, Cadillac brand is in Australia now, and they're only bringing their EVs to Australia. And I'm so angry about it because the car I want is a 6.2 litre supercharged V8.
Felicity:You know where you live, right?
Paul:Why I because even in my car now, which is you know large. I get so many dirty looks when I park between a couple of Teslas. I absolutely love it. I absolutely love it. But I would love a Cadillac, but I'm not getting an AV. I'm like I get a I think about a hybrid, not an AV.
Felicity:Anyway, Parliament next week. Lots of people back in town, so look forward to catching up with me.
Paul:Yes, there's a couple of events in Parliament House. There's the GBMA one on Wednesday, which will be interesting.
Felicity:Yeah.
Paul:So thanks, Felicity, and thanks everyone for listening.
Felicity:Thanks, Paul.