Sneak preview of Dr J

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Since I'm on the physical activity bandwagon, here is Dr J. in the edition coming up in Autumn Sport Health:

The paradigm change needed on physical activity

The phrase “it’s the economy, stupid” was made famous during Bill Clinton’s 1992 Presidential campaign and it seems to be very much a truism today in Western countries. Basically the logic behind this slogan it is that if the economy is cruising along well, enough swinging voters will be happy with an incumbent leader to vote him back in, but if the economy is struggling then an opposition will probably have enough momentum to bring the government down. If a country is in a recession, the blame gets well and truly pointed at the man in charge, rather than it being seen as being a problem caused by the collective stupidity of the nation’s businesses and individuals. In fact, for all the huff and puff and soul searching that the Federal Labor party went through after their last election defeat, their problem can be summed up in two statements: (1) there was a benign economic environment at the time of the election (medium growth, low interest rates, low inflation, medium unemployment); (2) they failed to convince the public that the election should be decided on factors other than economic management. Every time the political debate in the last election turned to the economy, John Howard and Peter Costello trotted out 18% interest rates during the previous Labor government’s term and they stole the momentum.

The fact that the public is so willing to blame the government of the day for a bad economy (even when a recession might happen for reasons beyond government control) is a good thing in terms of keeping the government fiscally accountable. The downside is that there are many other important things going on in people’s lives, other than their financial well being, which the government can influence but which they are rarely held accountable for. We live in a much wealthier society today than that of 30 years ago, yet where statistical measures can be made about happiness, we are neither happier nor less happy than we were 30 years ago. Also statistically, richer people are happier than poor people, yet as a richer society we aren’t any happier than in the past. It seems to be that whilst we have become wealthier, our quality of life has declined in other ways which has reduced it by as much as the extra money has improved it.

A list of ways in which life may have become worse (for the average member of the community), many of which are inter-related, would include: (1) the increase in the divorce rate and rate of children being brought up by single parents; (2) despite the previous point, the decline in the actual number of children in society because of declining fertility; (3) the decline in amount of exercise people are doing; (4) the decreased perception of personal safety; (5) the increase in the number and size of cars on the road making more noise and spitting out more pollutants than ever; (6) the increase in the number of business and personal interactions that the average person has along with a corresponding decrease in personal connection involved in those interactions; (7) I don’t have to keep going, you can add a few more here of your own. Apologies for how I phrased point (6), but I wanted to bundle in something about how much worse life is for the fact that people don’t have nearly as much connection with each other any more. The tradesperson who does work at your house is now always a different person every time, you never seem to get to speak to the same person twice in any business you deal with (e.g. your bank), you spend half your time reading emails and receiving letters from people you don’t actually know. I think you all know what I mean and I think it pisses you all off as much as it does me.

Number (4) is interesting as apparently crime hasn’t really increased that much (if at all) over the past 30 years, but because we hear and see broadcasts of crime through the media almost incessantly, we have become far more paranoid about walking the streets at night and living in dwellings on the ground floor etc. An interesting analogy to this is that we should all be much happier now than we were 30 years ago because medical science has advanced so much, yet in terms of satisfaction it has been almost completely cancelled out by the increase in expectations of the health professions. We have much better ability to make a correct diagnosis in medicine, for example, yet patients are now livid if the correct diagnosis wasn’t made 10 minutes after the initial presentation, whereas 30 years ago there was more error in medicine but far more acceptance of error. The fact that our health is better hasn’t seemed to make us any happier.

Thanks for indulging me in 700 words of introduction, as the point of this column is to focus on our favourite topic of the moment which is the lack of exercise in the community. We know that people doing regular exercise are happier, that most people actually know this and that almost anyone can exercise, yet people are doing less exercise than ever. Why is this so? If this was Family Feud, in a survey of 100 people, the top answer, with 82 responses was that “People are lazy”. Second top answer, with 16 responses was that “People don’t have enough time to exercise”. If your answer was that “The government has provided too many disincentives for people to exercise and not enough incentives” you would probably have scored zero, unless Dr. J was part of the survey, in which case you might have cracked it for one point.

I am fascinated by the fact that when the current account deficit blows out that people blame the government (and not individual spending habits) and yet when the stomach of the average society member blows out, people blame individual eating and exercise habits (and not the government). OK, in certain circumstances, individuals have tried to blame someone else for their obesity (like the people who tried to take out a class action against McDonald’s) but most of the time we point the finger at fat and inactive people and blame them for their own predicament. However, despite this being the case now and having being the case as long as I can fathom (that fat people have been blamed for their own size) as a society we are still collectively getting fatter. Add to the list getting more depressed as fat people wallow in self-loathing because they feel (and get treated as if) their size is a personal failure issue.

I definitely don’t want this column to be an excuse for people who eat too much and who exercise too little to blame it on the government. What I want (and this is what I mean by paradigm shift) is for the government of the day to become accountable for more of the things going on in our society than the economy. Such as the average amount of exercise that people are doing, such as the number of divorces in society, such as the size of cars on our roads. Because I believe the government of the day actually can affect things like the amount of exercise that people do and the amount of junk food that people eat etc. What’s that, you don’t think that they can affect these sorts of things? Well what about when they brought the GST in, the fact that they made fresh food GST free but packaged food subject to GST, wasn’t this a good move? The answer is that it was a very good move and it almost certainly contributes a degree towards healthy eating, but it doesn’t really go far enough. Why is there the same GST on a salad at McDonald’s and a Big Mac at McDonald’s? Obviously the answer the government would give is that it is simpler to comply with a flat rate GST (i.e. it makes economic sense). It just doesn’t make sense if you were a government who was getting scored on whether people had healthy diets.

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Why is there community rating for private health insurance (meaning that everyone pays basically the same premiums)? Again the government line will be that they don’t want to discriminate against people who have chronic illnesses, and they want to keep the system as simple as possible. But this system effectively means that there is a government subsidy in the private health system for cigarette smokers, for people who don’t exercise and for people who are overweight (and a government penalty in the same system for non-smokers, for exercising individuals and for those with normal body weight). This is because if the insurance companies had their way, they would penalise smokers (after risk rating them) and penalise people who were overweight. They would also probably penalise people who played either no sport (or very high risk sports like football) and give lower premiums to people who run, swim and cycle. The government just won’t let them because of the laws that they have passed. The problem is that you don’t hear the opposition complaining about having the laws changed, because they don’t think that people are going to change their vote with a concerted government campaign to get everyone healthier.

The government line that exceptions shouldn’t be made with tax and levies and the like breaks down very quickly when you try to mark them on some of my previously mentioned measures of societal well-being. For example, the import duty in Australia on most passenger cars is 10% but the import duty on 4-wheel drive vehicles is 5%. Obviously in this system the government is happy to have a split rate of duties, with the expressed aim of …..encouraging more people to buy 4WD vehicles. It is lucky that the government hasn’t signed the Kyoto protocol, in which case they would have to go to the bother of also increasing the levy on 4WD vehicles. This would affect the economy in a very bad way, of course, by decreasing GDP spent on petrol etc. etc.

What about if you want to visit a doctor under Medicare, what kind of rebate will the government pay you? Obviously the system could be ‘simple’ and pay the same rebate for the same length consultation for every type of doctor. Maybe this wouldn’t be ‘fair’ though. For example, surgeons can make lucrative amounts of money (much of which is subsidised by health insurance) from operating, so perhaps it is fair that patients of physicians deserve more rebate from their consultations than the patients of surgeons. Psychiatrists can legally see more than one patient at the same visit, so when this happens, it is perhaps fair that each patient receives a lower Medicare rebate.

Table 1- Medicare rebates for 30 minute consultations in the office with various doctors

Type of doctor Medicare rebate for half-hour initial consultation in office
Consultant physician (including cardiologist, endodcrinologist, rheumatologist, occupational physician, rehabilitation physician) $108.85
Psychiatrist $62.40
Surgeon $61.75
VR-General practitioner $58.55
Sports physician $49.80

Why is it that patients of sports physicians receive lower rebates than any other recognised doctors in the Medicare system (Table 1)? In 1998 the Howard government recognised that the ACSP had appropriate standards for training and registering sports physicians, yet in the time period since it has kept payments to sports physicians equal to or lower than all other recognised doctors. If you call up anyone in the HIC or Health Department and ask why this is the case, they will only answer it with an sentence that does not make any sense, such as “the sports physician rebate is lower than the GP rebate because sports physicians work in a specialised area, but the sports physician rebate is lower than the specialist rebate because sports physicians aren’t specialists”. I know anyone reading this would think that this statement came from George Orwell’s 1984, but this is actually the official health department reason why sports physician rebates are so low compared to other doctors. Perhaps a more truthful reason may be that the relative values of various doctors were determined in the actual year of 1984, when the current Medicare schedule came into existence, and neither the government nor the AMA has ever wanted them changed.

The only real conclusion is that the current government in Australia doesn’t care to support either sports physicians or people who are exercising and the sad fact is that most of society doesn’t think it is an issue for the government either. We surveyed 100 people on the question of “Who should pay most for the medical care of someone injured playing sport?” and, top answer was, with 68 responses, “the injured individual, as it was a self-inflicted problem”. Next question, “Who should pay for the medical care of someone who suffers a heart attack?”, top answer, with 62 responses, was “the government (Medicare), as this is a terrible, unavoidable disease”. Of course in the medical profession we know that exercise could prevent a large proportion of heart attacks, but exercise is only ever someone’s fault when they get injured doing it, not something which individuals can be credited for (by our government) for staying healthy. The question that the Family Feud survey will never ask, unless we really do have a paradigm shift, is “Why are heart attacks caused by inactivity the responsibility of the government, whereas activity itself is not the responsibility of the government?”

Obviously I have a personal bias as a sports physician in seeing that my patients get paid an equal Medicare rebate to the patients of other doctors. I am prepared to tow the line of the medical profession and the AMA and not ever claim that I personally am being paid by Medicare, only that my patients are (and I am billing my patients). But I will go on the record as saying that, as a sports physician, I am being unfairly discriminated against by the Medicare system. The AMA claims that it is not in the business of telling doctors what to charge (or what the government should rebate), so it is not interested in the fact that sports physicians have much lower rebates than other doctors. If Medicare paid an $80 rebate for a consultation with a male doctor and a $60 rebate for a consultation with a female doctor of the same type, do you think the AMA would get away with the line that female doctors weren’t being discriminated against because they were still free to charge their patients exactly what male doctors charge? If the AMA didn’t think this was an issue of the highest importance immediately then they would lose most of their female members. Unfortunately the ACSP is in a stalemate with the AMA, who could be our most important advocates even if they believed in something as simple as the concept of equal pay for equal work. Unfortunately the AMA is anything but committed to this issue and because they are indifferent to the lower rebates of sports physicians, most sports physicians refuse to pay membership fees to the AMA. With an important body like the AMA not interested in promoting either sports physicians or greater exercise, there is again less voice making this issue a relevant one for the government.

Unfortunately it is more doom and gloom than light at the end of the tunnel with respect to government encouragement of exercise. I am only aware of one exercise policy in the life of the Howard government, which has been (belatedly) to financially encourage schools to have a minimum number of physical education classes. By comparison, they are much more committed to funding schools based on whether they are in marginal electorates than whether they encourage sport. They have sat on their hands while local councils have demolished local playgrounds in order to reduce public liability premiums. The Federal coalition at the last election didn’t have an exercise policy, whereas the opposition were prepared to devote a couple of million to a “program” to encourage people to exercise, although there was nothing revolutionary in their policy statement. I hear that one of the next big Federal government initiatives will be to pass legislation to make all union and facility fees voluntary at universities. This will have the fantastic effect of meaning that many sports facilities at University will fall into disrepair or need to be closed down, because, surprise surprise, university students aren’t going to want to pay voluntary fees. The Labor opposition will fight the legislation, to no avail, but unfortunately it will be more because they want to preserve the existence of the “Marxist clubs” on university campuses than because they want more people to play sport. We now have a Federal government that is basically not interested in physical activity policies and an opposition party that is being led by an obese man, who is hardly going to ever take the government on regarding physical activity. Our society is in a sad state when a political party can rule out a candidate for leadership because she is an unmarried woman (presumably because the electorate won’t respect her economic credentials) but they have no qualms about appointing an obese man, because hardly any one in the electorate thinks that obesity and inactive have anything to do with the government.