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Health minister ‘deeply concerned’ by podiatric surgery revelations amid industry push for Medicare funding
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Key points
- Health Minister Mark Butler says podiatric surgeon investigation ‘deeply concerning’.
- Many patients do not know podiatric surgeons are not medical doctors yet perform complex and invasive surgeries.
- Podiatric surgeons rejected for Medicare funding in 2016, 2020.
- Key training college now lobbying department for Medicare funding.
The controversial training college for podiatric surgeons is lobbying for millions of dollars in taxpayer-funded subsidies, even as Health Minister Mark Butler branded revelations about the industry’s standards “deeply concerning”.
Podiatric surgeon services are not covered by Medicare or most private health funds, so patients are often left out-of-pocket, with invoices seen by this masthead ranging from $2000 to $8000 for procedures that can be completed for free in the public hospital system.
The Australasian College of Podiatric Surgeons (ACPS) has been rejected at least two times, in 2015 and 2020, for public funding by the independent body that assesses applications for Medicare cover, the Medical Services Advisory Committee (MSAC).
The committee rejected data provided by the college to justify an “unmet need” for expanding taxpayer-funded foot and ankle procedures and found they failed to establish “non-inferiority” of their services compared to orthopaedic surgeons.
A joint investigation by this masthead and 60 Minutes revealed patients around the country have been left deformed and feeling misled about the qualifications of podiatric surgeons. Podiatric surgeons can lawfully use titles “surgeon” and “doctor” and lawfully perform invasive surgeries despite not having medical degrees.
Health Minister Mark Butler on Tuesday said he was “deeply concerned” about the reports and looked forward to the findings of a Podiatry Board of Australia review into the sector which was launched following questions from this masthead.
Former AHPRA investigator David Gardner says healthcare regulation is broken in Australia. Credit: Janie Barrett
Butler said the review would examine all aspects of the regulatory framework for podiatric surgeons, including “qualifications, regulation, training, and how titles are understood”.
“With the review expected to be open for public submissions later this month, anyone with experiences such as those highlighted are encouraged to make a submission,” Butler said.
Butler declined this masthead’s request for an interview, and did not respond to questions about the outcome of the “rapid review” he launched earlier this year into past efforts to reform the Australian Health Practitioner Regulation Agency.
Former AHPRA investigator turned lawyer David Gardner said the problems with podiatric surgeons expose failures in healthcare regulation across the board, from accrediting courses to investigating complaints.
“What is the relationship between AHPRA and the Australasian College of Podiatric Surgeons?”
AHPRA was created in 2010 and was the beginning of a national scheme to regulate healthcare. One of its key duties is approving education courses for health practitioners. For podiatric surgeons, AHPRA accredited training provided by the Australasian College of Podiatric Surgeons (ACPS) which allows graduates to use the term “surgeon”. AHPRA then set up the Podiatry Accreditation Committee to assess standards and monitor training. Former ACPS president Mark Gilheany was appointed as deputy chair of the committee, which the AOA claims creates a conflict of interest by allowing the college to assess its own courses.
‘Not satisfied’
Currently, there is no Medicare funding for podiatric surgeons and only certain aspects of their treatment is covered by a minority of private health funds.
The ACPS, which acts as both a training organisation and lobby group for podiatric surgeons, has repeatedly pushed for Medicare funding to cover surgical treatments for conditions such as hammer and claw toes, heel pain, nerve problems and non-cancerous tumours in the foot and ankle.
It argues increasing affordability for podiatric surgeon services would relieve pressure on the public health system and provide an alternative to orthopaedic surgeons. However, the committee found there was uncertainty around the “unmet need” for these services following applications from 2015 and 2020.
As part of the 2015 application, the college conducted a telephone survey with 10 orthopaedic surgeons to “gauge wait times for appointments and procedures”, which indicated shorter wait times for podiatric surgeons – although the results of these were rejected by the committee.
“MSAC was concerned that the survey was not conducted independently, the representativeness of the sample of orthopaedic surgeons was uncertain, and the comparability of the surgeons’ case mix was also uncertain,” it found.
The college produced a report by Access Economics in 2008 which predicted an enormous rise in demand for foot and ankle procedures that could not be met by the current healthcare system. The MSAC similarly rejected this – claiming the “prediction of unmet need” was “overstated”.
The college provided testimonials from positive patients in its submissions, which the committee found may not be representative of the wider population, and in any event, “their usefulness was limited by the lack of long-term follow-up in the data”.
Responding to the rejection of the 2015 application, the college said the committee’s conclusions were “disappointing” and their position had either been “misinterpreted” or “significant levels of robust evidence that supports the college’s application have been ignored”.
The college lashed out at the “apparent discrimination against a surgical specialty who have significant and robust data supporting their clinical practice”.
In its 2020 application, the college reduced the number of procedures it proposed should be covered by Medicare, and sought to improve its evidence, but it was again rejected on similar grounds.
The committee noted “extensive input” from consumers – 49 submissions were made supporting the industry – but found “deficiencies” in research on patient outcomes and preferences.
“After carefully assessing all of the available data, MSAC still could not be satisfied that podiatric surgeons could deliver the same or better clinical outcomes than orthopaedic surgeons,” it found, noting this did not necessarily confirm inferiority.
The committee criticised a “lack of prospective, comparative, large scale, robust studies … and sometimes dated evidence” presented by the college.
The committee noted the “risk of reporting bias” in the college’s database that tracks complication rates, claiming the quality was further limited by “the short 30-day follow up” and added the “overall quality” of other studies was “very low, with high risk of bias”.
The MSAC found that if public funding was provided to podiatric surgeons, this could have flow-on effects to the rest of the medical industry – as podiatric surgeons are unable to manage post-operative infection, they would require referral to a medical practitioner.
In response to this rejection, the college said it was again “extremely disappointed”, claiming the college has provided “significant evidence that stands up to the rigorous challenges set by the MSAC”.
The Department of Health and Aged Care confirmed its officials had met with the college after it submitted a fresh submission for Medicare funding in February this year.
Former college president Robert Hermann uploaded a video in July titled “Why podiatric surgery should be funded by Medicare”, saying the industry was “committed to the highest standards” and criticising “groups” who wanted better protection for titles doctor and surgeon.
“Such groups seek a return to old-fashioned silos and outdated hierarchical structure of healthcare,” he said.
Hermann, who has since been replaced as college president, said the department had advised the most recent application was “doable” but needed a decision by government to proceed.
Butler did not answer questions about the status of this application. A department spokesperson said it would require a government budget decision.
“The independence and integrity of MSAC is critical to ensuring that evidence-based services that deliver quality clinical outcomes and value for money are listed on the MBS,” the spokesperson said.
The Podiatry Board of Australia (PBA) has launched an independent review of podiatric surgeons, after receiving an uptick in complaints from patients about procedures, or communication from practitioners. This followed questions from this investigation about podiatric surgeons.
“Some of those complaints can be everything from poor communication, where the patient maybe hasn’t felt heard or hasn’t been able to understand the information that’s been provided to them,” PBA chair Cylie Williams said.
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