Dr J VOLUME 23 ? ISSUE 1 ? AUTUMN 2005
http://www.injuryupdate.com.au/image...SUdebateSH.pdf

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 it is struggling, an
opposition will probably have enough
momentum to bring the government
down. If a country is in recession,
the blame gets well and truly pointed
at the man in charge, rather than it
being seen as a problem caused by
the collective stupidity of the nation?s
businesses and individuals.

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
scally accountable. The downside is
that there are many other important
things going on in people?s lives than
their nancial well being, which the
government can inuence but for
which it is 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 more
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 that, while
we have become wealthier, our quality
of life has declined in ways which
have reduced it by as much as the
extra money has improved it.

A list of ways in which our quality of
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 rates
of divorce and children being brought
up by single parents; (2) the decline
in the actual number of children
because of declining fertility; (3) the
decline in the exercise that 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 because
people don?t have nearly as much
connection with each other any more.
The tradesperson who does work at
your house is now different every time,
you never seem to get to speak to the
same person twice in any business you
deal with (eg, your bank), you spend
half your time reading emails and
receiving letters from people you don?t
actually know.

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 media
broadcasts of crime almost incessantly,
we have become paranoid about
walking the streets at night and living
in dwellings on the ground oor, 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 we were surveying 100
people (a la Family Feud), the top
answer, with, say, 82 responses, would
be that ?people are lazy?. Second top
answer, with 16 responses, would be
that ?people don?t have enough time to
exercise?. Unfortunately no one would
think to answer ?the government has
provided too many disincentives for
people to exercise and not enough
incentives?.

I am fascinated by the fact that, when
the current account decit blows out,
people blame the government (and not
individual spending habits); yet, when
the stomach of the average person
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 nger
at fat and inactive people and blame
them for their own predicament.

I denitely 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
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
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 it can
affect these sorts of things? Well what
about the fact that, when they brought
the GST in, they made fresh food GST-
free but packaged food GST-liable?
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 at-rate GST (ie, 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.

Why is there community rating for
private health insurance (meaning
that everyone pays basically the same
premiums)? Again, the government
line will be that it doesn?t want to
discriminate against people who have
chronic illnesses, and it wants to keep
the system as simple as possible. But
this 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 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
regularly run, swim and cycle.

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%.
A simple system would have its merits,
but how can you justify differential
rates of import duty which actually
encourage people to buy the less safe,
less environmentally-friendly option?
What 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 the same rebate paid 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 higher rebates 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.

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 since then it has kept
payments to sports physicians equal
to or lower than all other recognised
doctors. If you ask the HIC or Health
Department why this is the case, their
only answer is a 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
ofcial 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 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. In the survey of 100 people
on the question of ?who should pay
most for the medical care of someone
injured playing sport?? the top answer
would be, ?the injured individual, as it
was a self-inicted problem?. But if the
survey was ?who should pay for the
medical care of someone who suffers
a heart attack??, the top answer would
be ?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 people?s
fault when they get injured doing
it, not something for which they are
credited for by our government for
staying healthy. Whenever it suits the
government, they will say that systems
should be as simple as possible. What
is the government explanation for
the paradox that a patient needing
a referred 30 minute consultation to
manage inactivity-caused hypertension
receives a government rebate of
$108.85, yet a patient needing a
referred 30 minute consultation to
manage an activity-caused sports
injury receives a government rebate
of $49.80? Is this anything other than
a systemic incentive for people to not
exercise?

Obviously I have a personal bias as
a sports physician in seeing that my
patients and those of other doctors get
paid an equal Medicare rebate. I am
prepared to toe 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, they would
lose most of their female members.
So the ACSP is at a stalemate with
the AMA, who could be our most
important advocate if there was
an AMA policy for something as
simple as equal pay for equal work.
Unfortunately, the AMA is anything but
committed to this (because its
members who get more lucrative
rebates don?t want the status quo
changed) and, because it is 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 (as far
as I can see) greater exercise in the
community, there is again less voice
making this issue a relevant one for the
government.

Based on the time lag between
the knowledge that smoking was
a killer and government policy to
discourage smoking, we are probably
looking at another decade before the
governments of the day get serious
with pro-exercise policies. I am only
aware of one exercise policy in the
life of the Howard government,
which has been (belatedly) to
encourage schools nancially to
have a minimum number of physical
education classes. By comparison, it
is much more committed to funding
schools based on whether they are in
marginal electorates than whether they
encourage sport. It has sat on its hands
while local councils have demolished
local playgrounds in order to reduce
public liability premiums.
The Coalition at the last election didn?t
have an exercise policy, whereas the
Opposition was prepared to devote
a couple of million to a ?program? to
encourage people to exercise, although
there was nothing revolutionary in
their policy statement. One of the
next big planned Federal Government
initiatives is 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 universities will fall
into disrepair or need to be closed
down, because -- surprise surprise
-- university students aren?t going
to want to pay voluntary fees. If the
government made income tax or the
Medicare levy voluntary, then hardly
any one would pay it either. The
Government seems to be oblivious
to the fact that its policies can and do
affect the amount that people exercise.
But until the people are prepared
to make this a political issue, there
is unfortunately no incentive for the
Government to act.


Table 1- Medicare rebates for 30 minute consultations in the ofce 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