18 December 2017
The Hon. Greg Hunt, MP
Minister for Health
PO Box 6022
House of Representatives
Canberra ACT 2600
RE: Reforms to the subsidisation of private health insurance rebates
I am contacting you on behalf of the Board of the Australian Register of Naturopaths and Herbalists (ARONAH) in response to the reforms to the private health insurance (PHI) rebates as announced by the Australian Government on 13th October 2017, specifically as they relate to the inclusion of naturopathy and Western herbal medicines on the list of health practices prohibited from inclusion in PHI policies that are eligible for PHI subsidies.
ARONAH was set up in 2009 to mirror the statutory regulated Boards administered by the Australian Health Practitioner Regulation Authority of the National Registration and Accreditation Scheme. As such, the constitution of ARONAH is based on the legislation of the National Law, and ARONAH works closely with national health regulators in this space. One of the key roles of ARONAH is to provide minimum standards of education and practice for the disciplines of naturopathy and western herbal medicine (WHM). This is because naturopathy and WHM are not regulated professions in Australia and do not currently fall under the National Registration and Accreditation scheme (NRAS), despite numerous calls by government (including the Commonwealth government) and non-government stakeholders over the last two decades.
ARONAH is concerned with the proposed PHI reforms and the significant impact they will have on the professions within our scope, particularly naturopathy. The exclusion of naturopathy and Western herbal medicine under these reforms was claimed to be based on claims of insufficient evidence of effectiveness, as informed by the recent NHMRC Natural Therapies Review. In the case of naturopathy, there are a number of legitimate concerns with this decision that may not have been fully considered by the Department of Health, particularly in the absence of statutory registration of naturopaths.
In the first instance, the professions in the NHMRC review included those that were not statutory regulated and all professions listed within the National Registration and Accreditation Scheme (NRAS) were excluded from the review. The ARONAH Board’s concern relates to basing policy decisions on assumptions. In this case, there is an inherent assumption that all registered professions have evidence of safety and effectiveness. The primary purpose of registration is public protection, which includes the protection of title and the establishment of defined minimum education and practice standards. If the narrow and restrictive criteria for evidence applied in the NHMRC review was applied to other professions currently listed within the NRAS, such as physiotherapy, surgery, general practice and chiropractic, as were chosen for naturopathy (i.e. only studies based on “whole-practice” research, rather than studies on individual naturopathic practices) it is almost certain that these professions would fail to demonstrate sufficient evidence of effectiveness in order to justify their inclusion in the PHI scheme. ARONAH would also like to note that the professions of naturopathy and Western herbal medicine have been assessed for evidence of effectiveness under the criteria used for establishing whether professions, when the government of Victoria assessed whether those professions should be registered (and which ultimately found that they should), noting that there was substantiated benefit of naturopathic and herbal medicine practices in a range of conditions. Thus, the decision to exclude NRAS-listed professions from Natural Therapies Review based on the assumptions of efficacy from exhaustive reviews, whilst using a more restrictive interpretation of interpretation for unregistered professions in the Review is neither fair nor equitable, and is a questionable basis for policy decisions.
Secondly, despite the erroneous basis by which naturopathy was defined for inclusion in the review, the NHMRC concluded that there was some evidence to suggest that naturopathic care was effective for the treatment of nationally important health conditions such as cardiovascular disease, anxiety, multiple sclerosis and musculoskeletal conditions. However, the review concluded that as the research was conducted in regulated jurisdictions (largely in North America, in settings where government licensure is in place), the transferability to Australia could not be confirmed. The particular concern in this instance was that, in the absence of consistent education and practice standards by all individuals practicing as a naturopath, there was no assurance that the outcomes of the North American studies would be reflected in Australia. However, ARONAH works closely with the naturopathic profession and naturopathic regulators in North America, and can confirm that properly qualified naturopaths in Australia are at a level commensurate with North American peers, a finding that was also noted in the very reference used by the Review to dismiss Australian naturopathic practice. ARONAH firmly believes that the use of this finding to remove naturopathic medicine from the list of services that can be included in PHI policies to be a highly inappropriate interpretation of the Review’s findings. It is ARONAH’s view that the Review should be used to support the development of regulation and minimum standards in the Australian profession and ensure that the highest standards of practice in Australia are the norm – particularly given the positive findings of the Review for trained naturopathic professionals internationally – rather than assessing the entire profession based on an assumption that its unregulated nature indicates the lowest level of training (which ARONAH and most professional associations do not recognise, and therefore are already ineligible for rebates under current PHI arrangements).
The proposed PHI reforms also may be seen as contradicting key performance indicators of a quality health care system. In particular, these changes could have a negative impact on patient experience (i.e. by disregarding patient preference, right to choice and patient-centeredness), population health outcomes (i.e. by discounting the importance of holism, wellbeing and prevention) and health care access (i.e. by discriminating a person from getting the services they need or desire) (references available on request). These reforms may also breach international standards and declarations, such as the World Health Organisation (WHO) traditional medicine strategy 2014-2023, which specifies that Member States (including Australia) should improve patient accessibility to natural therapy services, and facilitate the integration of natural therapies into the health system. Similarly, the United Nations International Covenant on economic, social and cultural rights (general comment no. 14) stipulates that the State should not prohibit or impede access to traditional preventive care, healing practices and medicines. With this in mind, the proposed reforms to the PHI scheme may in fact betray the best interests of consumers and the health care system, as well as contravene international standards.
Ultimately, had naturopathy been included in the NRAS the proposed PHI reforms would not have affected the profession. ARONAH would like to note that the inclusion of naturopathy and WHM in the NRAS has been supported by numerous State governments, yet has not yet been actioned due to delays in the implementation of various aspects of the NRAS (as has registration of other professions). ARONAH notes that every government review on the issue of naturopathic registration conducted in the last two decades has recommended that naturopathy be included in statutory regulatory schemes such as NRAS. This includes the Commonwealth’s Expert Advisory Committee on Complementary Medicine, which recommended registration of naturopathy. This sentiment was supported by the then Parliamentary Secretary of Health Christopher Pyne, who noted it was an issue that should be reviewed by State governments. In 2005 the Victorian government formally assessed the regulatory requirements for the professions of naturopathy and Western herbal medicine and found that based on the AHMAC criteria for regulation of health professions there was an unequivocal case for statutory registration of naturopathy and WHM. The Victorian government began the legislative process to enact registration for these professions. The governments of New South Wales and South Australia also noted the need for regulation of these professions, but noted that they would observe the first year of practical implication of naturopathic and WHM registration in Victoria before developing their own regulatory system. However, the advent of national registration (and NRAS) required all state governments to cease individual regulatory developments while NRAS was developed, and the Victorian government’s work on naturopathic registration was tabled with COAG for future action in 2007, where it has remained (unactioned) to this day. ARONAH’s representatives were assured by COAG in 2007 that naturopathic registration would be considered in the “third phase” of implementation of NRAS, whereby unregistered professions would be individually considered for inclusion in NRAS (the first two stages being the transfer of professions registered in every State and Territory, and the assessment of professions registered in some States and Territories). To date, however, there remains no formal pathway for inclusion of new profession under NRAS.
This delay has had clear implications for naturopathic and WHM practice. ARONAH itself was formed in response to government inaction on the issue of naturopathic and WHM registration. The lack of registration also creates clear inconsistencies in regulatory approaches (e.g. one form of herbal medicine practice [Chinese herbal practice] is registered, whilst the predominant form used in Australia is not). The recent review into NRAS and the Review of Unregistered practitioners also explicitly stated that lack of registered status should not disadvantage any health profession. However, under the PHI Review, naturopathy, despite a recognised evidence base (even by the Review), was considered to be an ineffective practice due solely to its unregulated status in Australia.
The Australian government has been unresponsive to its own reports and ongoing submissions and to ongoing lobbying by the naturopathic profession. This has impeded progress on establishing appropriate statutory registration for naturopaths. In the absence of this important public protection, ARONAH has endeavoured to meet the need for statutory registration by defining competency and education accreditation standards for the naturopathic profession. These standards have been developed through extensive benchmarking against other health professions registered in Australia under the NRAS. In addition, ARONAH aligned its standards closely with the North American naturopathic practice and education standards. To date, the ARONAH standards are being applied to register naturopaths in Australia and to accredit naturopathic degrees in order to protect the Australian public.
ARONAH is also concerned that the government may not have been aware of the quasi-regulatory role that the PHI sector had in the professions of naturopathy and WHM. PHI rebates required professional association membership (and therefore at least a minimal level of accountability and probity checking) and PHI-recognition was often used by third parties (e.g. employers) as a marker of practitioner suitability, in the absence of any other regulatory mechanism. This was partly because many PHI providers required standards above and beyond the minimal standards imposed by some professional associations. As it stands, naturopathy is now the only health profession trained to a government-accredited degree level that is excluded from the PHI sector. ARONAH is concerned that the current reforms in the unregulated environment will discourage potential practitioners from training in accredited programs and regress naturopathic standards. Already ARONAH is aware of potential students questioning the value of degree programs due to the removal of PHI recognition, and there has been a concerning development that a subsection of naturopaths have been encouraging others in the profession to remove themselves from professional associations given that they will no longer be a requirement for PHI recognition.
As we have highlighted above, there are serious concerns regarding the recent reforms to the subsidisation of PHI rebates in Australia, which potentially contravene international standards and declarations and are based on decisions and evidence that lacks transparency, fairness and equity.
Finally, the outcome of the proposed reforms for naturopathy is directly linked to an issue that the profession has been actively, repeatedly and consistently attempting to resolve with little or no support from the Australian government. As such, the outcome is directly influenced by a factor outside of the control of the profession, which is unjust and inappropriate.
I would like very much to meet to discuss this issue with you or someone from your office, to discuss potential evidence-based solutions that help to encourage patient choice and promote evidence-based effective care.
As such, I would be grateful if you could let me know the best person to contact in your office to make arrangements for a meeting, or please ask them to give me a call.
I welcome any questions you may have or an opportunity to discuss them at a mutually convenient time.
Ms Jackie Arbuckle,
Australian Register of Naturopaths and Herbalists