Category Archives: healthcare

healthcare, policy, politics

Medical research fund is a distraction

Brilliant, but highly cynical politics. Tear down universal health care to fund the med tech industry.

http://www.theguardian.com/commentisfree/2014/may/23/joe-hockeys-medical-research-fund-is-nothing-more-than-a-distraction

Joe Hockey’s medical research fund is nothing more than a distraction

If we health and medical researchers do not stand up now, we will be left with the moral blight of having silently colluded in the destruction of universal healthcare

, , ,  ,

Scientist in laboratory.
‘We have known for decades that improving health in communities often relies on social change’. Photograph: Francois Lenoir/Reuters

Health is a basic requirement for an individual to lead a good life. Without health you have nothing; when we are sick, it’s difficult to work, to care for others, to participate in the things we enjoy. We seek treatment so we can get back to our normal lives.

Because health is so important to our wellbeing, there is widespread agreement— including among ethicists —that a fair and accessible healthcare system is something that we should pursue. And although the Australian healthcare system is far from perfect, it has provided universal access to healthcare for almost 40 years. A universal healthcare system – one that is open to everyone, whether or not they can afford to pay – is a basic feature of a good and just society.

Tony Abbott and Joe Hockey want us to panic about a “budget emergency”, including the idea that our current health system is unsustainable. Rising healthcare costs pose a challenge to governments everywhere. But this is not a new problem, and will not bring about economic or social catastrophe any time soon.

This amplified threat is being used to justify measures that are now well known: introducing co-payments for GP fees; disestablishing Medicare Locals; transferring health agencies to the department of health with reduced funding; and stripping $80bn in funding from the states, particularly in health and education. This will not only force the states to increase their own goods and services taxes, but reduce the public services they can afford to provide. It will end universal access to health care, make Medicare a mere “safety net”, overwhelm hospitals, and increase the inequities that are increasingly a feature of Australian society.

With breathtaking cynicism, the Coalition has also engaged in the oldest strategy in the magicians’ handbook: distraction. The rabbit they have pulled out of their hat is the $20bn medical research future fund, to be financed – they claim – largely through the new taxes and cuts in health services. This is supposed, we can only presume, to buy the quiescence of health and medical academics and researchers, and to distract citizens from the damage being done to our health system. Given that polls consistently show that Australians strongly support Medicare, it’s likely that the government has underestimated our ability to concentrate on what’s important. There are also strong ethical reasons why the Coalition’s proposed changes are unjustifiable.

Hockey encourages us to imagine that the medical research fund “may well save your life, or that of your parents, or perhaps even the life of your child”. Medical research is clearly a good, and has achieved remarkable breakthroughs in the last century. The medical research future fund may yield benefits. But, as any medical researcher knows, medical research is not a steady production line of cures. It is frequently incremental, with many dead ends, and scope for progress may in fact be diminishing.

More importantly, history shows that, without government intervention, the new treatments produced from medical research are often available only to those who can pay, broadening the gap between rich (who can afford top-shelf care) and poor (who receive little). This means the proposed cuts and fees will burden the least-well-off in the present to fund research that may benefit a few, likely wealthy, people in the future.

More fundamentally, we have known for decades that improving health in communities often relies on social change, rather than high-tech biomedical research. Ready access to GPs and other community-based health care, established vaccinations, good education, affordable healthy food: things like these make a big difference to population health. This is why Hockey’s championing of the medical research future fund as a panacea to service cuts is so offensive. Not only does it overstate the role of medical research in a just healthcare system, but it takes funding away from the agents of social transformation that can effectively and efficiently improve health.

Some health and medical researchers are organising against this unjust policy; others seem willing to support it. As health and medical researchers we could benefit from medical research future fund. But we believe that anyone who cares about the health of Australians is obliged to resist both the proposed healthcare changes, and the deceptive trick of linking them to the good of medical research.

If health and medical researchers do not stand up now, we will be left not only with a less coherent and less fair health care system, but with the moral blight of having silently colluded in the destruction of universal healthcare. Once destroyed, this will be almost impossible to claw back. We should reject this governments’ urgency rhetoric, lack of compassion for the least well-off, and rejection of solidarity and equity as fundamental Australian values.

Hockey and Abbott should put their rabbit back in their hat. We have not taken our eyes off the real issue: a fair health care system.

facts & data points, health market quality, healthcare, healthy habits, nutrition, policy, politics, rapid learning health systems

Health consequences of GST on fresh food

Audio:

http://www.abc.net.au/radionational/programs/rnfirstbite/potential-health-impacts-3a-gst-on-fresh-food/5467836

Would a GST on fresh food make Australians sicker?

Saturday 24 May 2014 9:31AM
Shopping at the market

In response to last week’s Federal Budget, debate grows around whether or not the GST should be broadened to include fresh food. Calls are coming from MPs, former leaders and even the chief executive of World Vision Reverend Tim Costello, for an ‘adult conversation’ about a consumption tax on fresh fruit and vegetables. However, Australian research has shown a 10 per cent tax on fresh fruit and vegetables could have dire public health consequences.

Please leave your comments on this story below and if you’d like to have the program delivered weekly subscribe here.

Guests

Dr Lennert Veerman
Senior Research Fellow, School of Population & Health, University of Queensland

Further Information

MJA Article on GST Veerman & Cobiac
Rev Tim Costello on RN Breakfast
Grattan Institute report Balancing Budgets

Credits

Presenter
Anita Barraud
Producer
Maria Tickle
cool, healthcare, healthy habits, management and leadership, meaning, nutrition, policy, politics, rapid learning health systems

Emeritus Professor Stephen Leeder AO – A Celebration!

 

http://sydney.edu.au/medicine/public-health/menzies-health-policy/news/pastevents.php

Emeritus Professor Stephen Leeder AO – A Celebration!

Thursday, 1 May 2014
MacLaurin Hall, Quadrangle Building, University of Sydney

Colleagues gathered to celebrate the remarkable career of Emeritus Professor Stephen Leeder AO.

Keynote presentations and discussion focussed on the following themes: Chronic Disease: An international epidemic; Medical Education; Public Health Education and Training for the 21st Century; and Health Policy.

Presentations

Chronic Disease: An international epidemic

Professor K. Srinath Reddy, President, Public Health Foundation of India (PHFI)

Professor Robert Cumming, Sydney School of Public Health, University of Sydney

Medical Education

Emeritus Professor John Hamilton AM OBE, University of Newcastle

Professor Bruce Robinson AM, Dean, Sydney Medical School, University of Sydney (see sound recording below)

Public Health Education and Training for the 21st Century

Dr Henry Greenberg, Special Lecturer in Epidemiology, Mailman School of Public Health

Professor Glenn Salkeld, Head, Sydney School of Public Health, University of Sydney

Health Policy

Dr Mary Foley, Secretary, NSW Health (see sound recording below)

Associate Professor James Gillespie, Deputy Director, Menzies Centre for Health Policy, University of Sydney (see sound recording below)

Dr Anne-marie Boxall, Director, The Deeble Institute for Health Policy Research (see sound recording below)

Ms Shauna Downs, PhD Candidate, Menzies Centre for Health Policy, University of Sydney

The Hon. Dr Neal Blewett AC (see sound recording below)

Distinguished Guest Speaker: The Hon. Jillian Skinner MP, Minister for Health and Minister for Medical Research (see sound recording below)

Sound Recordings

Chronic Disease: An international epidemic

Medical Education

Public Health Education and Training for the 21st Century

Health Policy

Dr Norman Swan in conversation with Emeritus Professor Stephen Leeder

Video Tributes

Professor Jeffrey D. Sachs, Director of The Earth Institute, Quetelet Professor of Sustainable Development, and Professor of Health Policy and Management at Columbia University

Simon & Trish Chapman

Flyer and Program

Event Flyer

Event Program

complex adaptive systems, health market quality, healthcare, policy, politics, rapid learning health systems

US healthcare costs are rising again and no one knows why (yet)

Cogent analysis of Obamacare and impacts on spending…

http://www.newrepublic.com/article/117452/rising-health-care-costs-what-it-means-economy-obamacare

Cause for Concern: Health-care costs are rising—and the experts aren’t sure why

By 

Last week’s news about Obamacare enrollment was great. But health care policy wonks have something else on their mind now: the cost of health care. It’s starting to rise more quickly than before. That could be a problem.

For the last four years or so, national health care expenditures—that is, all the money that Americans spend on medical services and supplies—has been growing at historically low rates. It’s gone up every year, as it almost always does, but only by 3 or 4 percent. That’s just a little bit more than inflation. Typically health care spending has risen more quickly. Sometimes, in the 1980s and again in the early 2000s, it’s risen much more quickly. Keep in mind that when national health care spending rises much more quickly than the economy is growing, you feel the impact—as relatively higher insurance premiums, higher out-of-pocket costs, and higher taxes to support government insurance programs. You may not have noticed it, but the recent slowdown has been good for your finances.

Rising health care costs via Altarum

Now the respite may be ending. You can see it in the latest monthly reports from the Altarum Institute, an Ann Arbor-based think-tank that monitors national health care spending. These reports, based on government data, are the equivalent of an early warning system for medical costs. They are one of the first places a spending spike would show up. According to Altarum, expenditures started to rise more quickly in the middle of 2013. Since then, the rate has gone up even more. Reports of rising costs have already gotten the attention of savvy health care observers in the media, like Philip Klein and Sarah Kliff. The question now is how long the trend will continue, how quickly spending will accelerate, what should be done about it—and, of course, what it means for Obamacare.

 

First economists have to figure out whether the recent reports are accurate. They may not be. The key evidence of accelerating health costs comes from monthly government statistics, particularly those produced by the Bureau of Economic Analysis. There’s a reasonable chance, three or four months from now, BEA will announce that costs haven’t been rising so quickly—in much the same way government sometimes revises unemployment statistics, upon learning there were more jobs than the initial data suggested. If that happens, analysts like those at Altarum will have to redraw that graph above and the outlook might look more encouraging.

But most experts I know are betting against that. For some time, they have expected health care costs to rise, because the primary factor in the slowdown was the economy. When unemployment is high and wages aren’t rising, you are less likely to consume more health care for the same reason that you are less likely to consume other goods—it costs money you might not have. You can’t avoid treatment for a heart attack, obviously. But the pills you take for a chronic condition? Getting somebody to look at a nagging, but tolerable pain? You might push that off until you had a little more cushion to pay for the co-pays and deductibles. That’s what people did during the recession. And now that the recession is over, they’re almost certainly starting to spend more again, partly to take care of those problems that they allowed to linger.

In fact, exactly one year ago Monday, an op-ed in the Washington Postpredicted that health care spending would start rising about now. The op-ed was from Drew Altman and Larry Levitt of the Kaiser Foundation, based on work they and their colleagues had done with the analysts at Altarum. Historically, they noted, health care spending followed economic growth, albeit with a time lag. So pretty soon after the economy picked up again, people would start spending more money on health care—until it was rising at about 7 percent rather than 4 percent. Sure enough, according to the latest Altarum analysis, annual growth in health care spending as of February was 6.7 percent. That would be the highest rate since late 2007, just before the recession started.

But the recession wasn’t the only reason health care spending stopped rising so quickly, which means there’s reason to think the long-term trajectory on medical spending really has come down—at least a little. The whole health care industry is in the midst of some pretty significant transformations right now. One of them is a change in the design of health plans, which are transferring more and more out-of-pocket costs onto individuals. That change has tended to slow down health care spending for the same reason that the recession did: It makes people more cost-conscious, because every bill is another direct hit on their wallets. Conservatives and economists tend to think this is a good thing, because it gives people “more skin in the game.” Liberals and public health experts tend to think this is a bad thing, because it gives people incentive not to get medical care they might need. Either way, it’s been happening.

Read More: Obamacare’s Very, Very Good DayAnother change is one taking place in the places where people get medical care, particularly hospitals. It’s a vast re-engineering project, one that attempts simultaneously to make systems run more smoothly and to pay closer attention to the issues that make people sick (or, at least, prevent them from getting better). One sign of this progress is a dramatic drop in hospital “readmissions” across the country—that is, patients going back to the hospital shortly after discharge, for the same reason they were admitted previously. (See the graph below.) This is no accident. It’s a product of “transitional care” programs that hospitals like Mount Sinai in New York started a few years ago. Basically, the hospitals identify which patients are at high risk for readmission, educate them while they are still in hospital, and then provide follow-up outpatient care once the patients have left.

Readmissions via Cutler

How real are these changes? And how widespread? Nobody is sure. But one encouraging sign is the trajectory of spending within the Medicare program. Seniors’ consumption of health care doesn’t track the economy so closely, since their fixed incomes vary less and Medicare (with supplemental policies) provides such comprehensive insurance. Sure enough, Medicare’s cost trajectory fell a few years ago—and it has stayed low even as the economy has recovered. As Peter Orszag, the economist and former Obama Administration official, noted recently at Bloomberg View, “Even though copayments and deductibles in Medicare are usually small, Medicare beneficiaries, too, seem to be having fewer elective procedures and unnecessary doctor visits. This year, for example, Medicare has seen a reduction in the number of costly hip, knee and other major joint replacements, which are sometimes more a choice than a necessity.”

One reason for this progress is the Affordable Care Act. The law’s critics predicted that it would make health care more expensive. And there’s one sense in which that’s certainly true. Because of Obamacare, more people will have insurance and more people who already had insurance will have more comprehensive coverage. All else equal, that means people are going to get more medical care, at least initially. That’s particularly true for people with medical problems that, for years, they deferred treating because they lacked the ability to pay their bills.

But Obamacare also has provisions that push costs in the other direction. There are cuts to what Medicare pays doctors, hospitals, and insurers who provide alternative private coverage. There are financial incentives that reward providers for becoming more efficient: Pretty much everybody agrees that hospitals wouldn’t be working so hard to reduce readmissions if Medicare didn’t penalize them for each patient readmitted. And then there is the “Cadillac tax”—which gradually reduces the financial advantages of very pricey health insurance. The tax doesn’t start for a few years but, already, employers are talking about readjusting their insurance plans to avoid hitting the threshold that would trigger the tax.

So what does that mean for the future? Over the last few weeks I’ve consulted a number of respected experts—including those at Altarum and the Kaiser Foundation, as well as leading economists like Amitabh Chandra and David Cutler. I’ve also consulted reports from the Congressional Budget Office. Their predictions vary, particularly when it comes to the effects of Obamacare. Chandra, for example, thinks the law has done very little to restructure medical care—he calls hopes for its success at cost control “aspirational.” Cutler, by contrast, thinks the law is having an effect already and is likely to have an even bigger one in the future. (The White House, naturally, has adopted the optimistic view as its own.) But pretty much all of these authorities agree on the general shape of things to come. Health care spending will acclerate for a little while, partly because of Obamacare’s coverage expansion but mostly because of the economic recovery. Then it will subside. It will, in other words, be like a wave: Spending will go up, crest, and then return to a lower level.

The good news is that, once the wave is done, year-to-year increases in health care spending should be significantly lower than the historical average. Economists like to talk about “excess growth”—that’s the difference between how quickly health care costs are rising and how fast the economy, measured as Gross Domestic Product, is growing. Over the last 50 years, excess growth has been about 2.6 percent. But the average in the last 20 years has been down to 1.6 percent, thanks to structural changes, some of which date back to the 1990s when insurers first started using managed care. There’s every reason to think that, once the economy fully recovers and Obamacare’s expansion is in place, health care spending will be back to rising at something like the level it was before.

Projected cost growth via KFF

The Kaiser-Altarum projection, for example, assumes excess growth will revert right back to 1.6 percent. (See graph above.) But that would still require some combination of signficantly higher taxes, higher deficits, or higher health insurance premiums in the future. Knocking even a tenth of a percentage point off of that would make a difference. Knocking a few tenths of a percentage point would make a big difference. Is that possible? Sure. But it would mean, first and foremost, standing by the Affordable Care Act’s cost cutting provisions. And the evidence on that front so far has been mixed.

Cuts to hospitals are taking place, for example. But the insurance industry recently won a reprieve on cuts for its Medicare plans. This is why conservative economists think Obamacare is likely to drive up government health spending—and, eventually, everybody’s health spending—no matter what the projections say. They are convinced Congress will never let the tough, cost-cutting provisions take effect, since those parts of the law inevitably take money out of the pockets of powerful special interests. This isn’t a crazy argument. Medicare’s official actuary has warned, repeatedly, that proposed Medicare cuts may be too harsh for the political system to sustain.

One challenge, then, is showing the mettle it takes to stand by those cuts. But it will take more than that to significantly reduce spending on medical care. The health care industry would have to find new ways to be more efficient—and consumers would have to become more intelligent shoppers—ideally in ways that don’t compromise the quality of care. The Affordable Care Act can be a catalyst for these changes: Among other things, it created a new “Center for Medicare and Medicaid Innovation” for introducing new ways of paying for treatments and supplies. But it’s not so hard to imagine such efforts failing to take hold—and leaving future generations with a huge bill.

One final note: It’s not always the case that spending more on health care is a bad thing. New or more treatments might alleviate suffering, reduce disability, or extend life—all of which have value. Providing insurance to more people, so that they are more secure financially, also has value. The reason to worry about high health care spending is that the extra money America spends doesn’t actually seem to buy America better health care. But, over the long run, the real goal of health care reforms should be a combination of restraining costs and improving quality.

Sometime this spring, Sylvia Burwell will have confirmation hearings to be Secretary of Health and Human Services. Republicans are sure to use those hearings as a chance to highlight everything they think is wrong with Obamacare. That’s fine. The purpose of confirmation hearings, after all, is to establish some democratic accountability. But it would be great if senators from both parties used the moment to ask her about what’s happening with health care costs and what, if anything, the government plans to do about it. As Cutler said a year ago, in an interview with the Harvard Gazette. “We have a lot of control over this, through policies in the Affordable Care Act and Medicare and Medicaid. It’s not easy—no change is ever easy—but if we continue to do the right things, like stressing efficiency and helping people choose less expensive alternatives, then we can make sure this trend continues.”

health market quality, healthcare, policy

Specialists gaming medicare

silly, pathetic behaviour…

http://www.abc.net.au/news/2014-05-13/annual-specialist-referrals-wasting-millions-say-gps/5447822

PDF: 223489955-The-response-From-Medicare

Specialists forcing patients back to GP for fresh referrals to charge higher fees: health industry

Specialist doctors could be raking in millions of dollars from Medicare by forcing chronically ill patients back to their GP for a fresh referral each year so they can then charge twice the fee.

An ABC investigation has found evidence of widespread concern in the health industry about the billing practices of some specialists, particularly dermatologists, ophthalmologists and cardiologists.

The Royal Australasian College of Physicians, which represents most specialists in Australia, declined to comment and said the issue of referrals was a matter for Medicare.

The Federal Government would not comment on whether specialist doctors are breaching regulations but there is a general concern in the health industry that the practice of routinely seeking a new referral every 12 months is a waste of money.

Some GPs have spoken out about the issue because they believe it is a misuse of patients’ time and appointments.

Central to their concerns is the practice of specialists refusing to accept ongoing or “indefinite” referrals. Some specialists only accept “standard” referrals, which expire after 12 months.

How it works

Initial attendance (Item 104):
Minimum charge by specialist: $85.55
You get back from Medicare*: $72.75

Subsequent attendance (Item 105):
Minimum charge by specialist: $43.00
You get back from Medicare*: $36.55
* Out of hospital

Initial attendance (surgery or hospital)
Minimum charge: $150.90
You get back from Medicare: $128.30

Subsequent attendance
Minimum charge: $75.50
You get back from Medicare: $64.20

Initial attendance (review and management plan)
Minimum charge: $263.90
You get back from Medicare: $224.35

Subsequent attendance
Minimum charge: $132.10
You get back from Medicare: $112.30

It means when a patient returns after 12 months with a new referral, the specialist can bill for another initial consultation, which is double the price of a subsequent consultation.

Ultimately, the taxpayer is billed three times: the double consultation and the visit back to the GP for the new referral.

In 2012-13, specialists charged Medicare almost $600 million for initial and subsequent visits, so specialists could potentially be reaping millions.

Medicare paid $347 million in initial consultations and $241 million on subsequent visits for the 2012-13 period.

GPs say the specialists are only supposed to ask for fresh referrals when a condition changes.

It has angered them at a time when the Government is considering slugging patients a co-payment to see the GP.

The ABC understands it has been a contentious issue between GPs and specialists for many years since guidelines changed to allow the writing of indefinite referrals.

Doctors speak out

Melbourne GP Owen Harris is part of a busy practice in St Kilda. He gets annoyed when he has written a patient an ongoing referral only to see them back at his desk 12 months later requesting a fresh one.

He says it wastes an appointment other patients could use.

“I think some specialists are being a bit greedy here and billing Medicare rather than following the requirements,” he said.

“It’s a waste of patients’ time, the GP’s time, and certainly Medicare’s money.”

Dr Harris emphasised it was not all specialists but said the practice was widespread, and particularly prevalent at busy city clinics where doctor turnover is high.

“Medicare is a difficult and complex system,” he said.

“Patients can’t possibly understand all the complexities. If they’re told by the clinic you must bring a new referral then they’re simply following that advice without knowing whether or not that’s true.”

Patients can’t possibly understand all the complexities … if they’re told by the clinic you must bring a new referral then they’re simply following that advice without knowing whether or not that’s true.

GP Dr Owen Harris

His concerns have been backed by the Royal Australian College of General Practitioners, who said they were aware of the issue and it was one that needed to be examined.

President Dr Liz Marles says it is common for a melanoma patient to return each year for a referral to a dermatologist for a skin check.

“This is an area that could certainly be explored in terms of increasing efficiency for the patient, the GP and the specialist to make sure we’re getting value for money,” she said.

Dr Marles says some GPs favour 12-month referrals so they can keep track of patients and hear back from specialists.

However she says specialists should be keeping GPs in the loop regardless of referrals.

The Australian Healthcare and Hospitals Association is also concerned given discussions about co-payments.

Chief executive Alison Verhoeven says it is one of the many anomalies in the health system costing money.

“This is an issue of governance,” she said. “It would be helpful if there were better guidelines.”

Patients critical of referral process

Auditor wrong on doctor visits


Fact Check examines Tony Shepherd’s claim that “Australians, on average, go to the doctor now 11 times per year”.

Melbourne man Peter Barton has an eye condition that requires timely treatment when it recurs intermittently.

His specialist has asked that he return to the practice each time it recurs.

“I just don’t understand that at a time when I need to see the specialist, where they want me to see them I’ve got to do this side trip to the GP first,” he said.

“It would be an hour-and-a-half round trip to the GP, on top of the time away at the actual specialist, it almost doubles the time for me to get my eye sorted. It’s frustrating.”

Debate over whether approach breaks the rules

Dr Harris says the Medicare rules are clear and that specialists are breaking them.

“There’s no reason for that to be happening and it isn’t something that should continue,” he said.

But a senior health industry source has told the ABC the laws and guidelines around the referral billing practices are actually quite vague.

“It all depends on the specific interpretation of very general rules,” they said.

“The spirit of the thing is a single course of treatment.”

A spokeswoman for the Department of Human Services did not comment on whether specialists were in breach of rules by refusing to accept indefinite referrals but said they monitor doctors over Medicare billing rates.

“A single course of treatment involves an initial attendance by a specialist and the continuing management [of that condition] until the patient is referred back to the referring practitioner,” she said.

“The issuing of a new referral does not necessarily mean a new course of treatment.”

facts & data points, health market quality, healthcare, policy, politics, rapid learning health systems

Anne-marie lays down the case in The Conversation

 

 

http://theconversation.com/the-state-of-australia-health-25920

The state of Australia: health

We’re unlikely to solve persistent challenges to the health system, such as ensuring equitable access to well-coordinated care, with quick fixes. AAP Image/Quentin Jones

In the lead-up to the budget, the story of crisis has been hammered home, but there’s more to a country than its structural deficit. So how is Australia doing overall? In this special series, ten writers take a broader look at the State of Australia; our health, wealth, education, culture, environment, well-being and international standing.

In the lead up to this year’s federal budget, the government has been telling us short-term budget pain is needed to secure our long-term economic future.

The release of the National Commission of Audit report last week reinforced the government’s message that we need to do something more than tinker around the edges to get our economy back into shape.

But is Australia’s health system so bad it needs some kind of shock therapy to ensure it meets our future needs?

How are we doing now?

In 2011-12, Australia spent 9.5% of GDP on health, just higher than the OECD average of 9.3%. Twenty years ago, Australia spent 7.1% of GDP on health, which was about the OECD average. These figures somewhat undermine the argument that we have a crisis in health spending.

When you take a look at the headline indicator for health status, life expectancy, Australians are doing fairly well by global standards. In 2011, the average life expectancy for all Australians was 82 years, making us the seventh longest-living people among OECD nations.

There are some concerns, however, that we might not be living such long lives in the future. In 2011, Australians drank a little more alcohol than the OECD average (ten versus 9.3 litres per person per year). And we’re also a lot fatter: 21% of the population report being obese, compared with an OECD average of 15%.

While these indicators and global comparisons are useful high-level measures of our health system’s effectiveness, we need to get beyond averages to find the true picture.

 

More Australians are obese than the OECD average. Olivier Le Moal/Shutterstock

 

Most people know – whether from personal experience or just watching the news – that our health system does not serve us all equally well. Some people cannot get access to essential health care, such as pharmaceuticals, general practitioners or dentists, when they need it simply because of cost.

Other people, especially those living in rural and remote areas, struggle to get access to services close to home.

And with some types of elective surgery and cancer services now predominately done in private hospitals, people without private health insurance can find themselves waiting for an excessively long time for treatment.

If the care you get depends to some extent on where you live, what you earn or whether or not you have private insurance, we have a problem with equitable access to care. And it’s a serious one too because there is strong evidence showing the people in most need of health care are the ones least able to afford it.

Getting timely access to care is one thing, but the quality of it matters too. In aninternational survey by the Commonwealth Fund, Australia’s performance was patchy on a series of quality measures.

When compared with seven other developed countries (including the United States, United Kingdom and New Zealand), Australia ranked sixth overall on a series measures looking at medical errors.

We ranked fourth on how well care was coordinated between different health professionals and third on how well care was centred around patient’s needs and preferences.

How we got here – past reforms

Medicare is the foundation of the Australian health system. The scheme, now 30 years old, is funded partly through our progressive tax system, and this is one of the key reasons our health system is considered to be relatively equitable. While Medicare has served us well, the time is right to consider reforms.

Medicare was originally developed to help people get access to basic medical and hospital care; in the 1960s when the scheme was conceived, most people suffered from relatively straightforward acute health conditions (infections, for instance, and traumatic injuries). Treatment from GPs, medical specialists and public hospitals was often all people needed to be cured.

Now, with more than seven million Australians having at least one chronic disease, people’s health needs are more complex. For some, a basic level of care might mean being treated by a GP, physiotherapist, dietitian, occupational therapist and an array of medical specialists. Medicare now funds a limited range of non-medical services, but much of what people need still falls outside its scope.

 

Australia’s 30-year-old Medicare system needs reform. AAP Image/Dave Hunt MEDICARE

 

Medicare also works on an insurance model, with patients reimbursed for each visit to the doctor, and doctors paid largely on a fee-for-service basis. This model works reasonably well for one-off visits to the GP, but provides few incentives for health-care providers to work co-operatively and ensure patients receive coordinated care.

Over the last 20 years or so, federal and state governments have tried many different ways of improving the coordination of care. Some focused on reforms to financing health care, for example, the coordinated care trials of the 1990s.

Others have tried to improve coordination by making changes to the governance of the health system at the local level – the more recent establishment of Medicare Locals is an example.

In some areas, the long struggle to improve the coordination of care is starting to pay off, but these successes have yet to be replicated cross the country.

What’s next?

The National Commission of Audit report recommended some major changes to the structure and operation of our health system, and a 12-month period to review some of the proposals it outlined. But before the government looks at them in any detail, it’s important to recognise the limits of what Medicare, or any health system, can do to improve the length and quality of people’s lives.

It is well established that health services are just one of many factors that influence health outcomes. Other important determinants of health include the social, economic and physical environment, and people’s individual characteristics and behaviours. To improve the health of Australians, governments will also need to make gains in some of these other areas that determine health outcomes.

Health systems, however, do have an influence on health outcomes. A large study of 136 countries found that there was a correlation between rates of death and certain health system variables. Countries with more doctors, lower out-of-pocket costs, and higher total expenditure, for example, had lower premature death rates at the national level.

 

When you take a look at the headline indicator for health status, life expectancy, Australians are doing fairly well. Mercy Health/Flickr, CC BY-NC-ND

 

While this study includes many less wealthy countries than Australia, it shows that the design and operation of our health system does matter, even to headline indicators such as mortality.

The Australian health system clearly has some problems that need to be addressed, but they are long-standing ones, and ones shared by most other OECD countries.

We are unlikely to solve persistent challenges, such as ensuring equitable access to well-coordinated care, with quick fixes (we have tried most of them before). Nor are they likely to be solved by reforms naïvely borne out of economic theory, or imported holus bolus from other countries.

To improve Australia’s health system, we need to carefully consider a range of reforms and evaluate their potential to solve the most important problems we face (and this is not overall health expenditure).

If we don’t, we will simply add to the growing pile of overly ambitious reform proposals that have fallen by the wayside and made no difference at all.

health market quality, healthcare, healthy habits, management and leadership, policy, politics, rapid learning health systems

Polypill Barriers

 

https://www.mja.com.au/insight/2014/16/polypill-barriers-remain

Polypill barriers remain

Nicole MacKee
Monday, 12 May, 2014
Polypill barriers remain

BARRIERS to the global availability of a polypill to prevent cardiovascular disease remain despite growing evidence of its clinical potential, according to former BMJ editor and long-term advocate of the polypill, Dr Richard Smith.

Dr Smith, who was in Melbourne last week to attend the Cardiovascular Combination Pharmacotherapy Global Summit, in conjunction with World Congress on Cardiology, said momentum was starting to gather with growing evidence of increased adherence and clinical benefit with the polypill — a fixed-dose combination of commonly used blood pressure and cholesterol-lowering medications, and aspirin.

“But in terms of actually getting it made available to lots of people, the progress is fairly slow because, although the big drug companies are the people who know how to get a drug on the market, they’re generally not interested”, Dr Smith told MJA InSight.

Dr Smith, director of the Ovations Chronic Disease Initiative, welcomed findings from the Single Pill to Avert Cardiovascular Events (SPACE) project that showed the polypill was associated with a 43% boost in patient adherence to medication at 12 months. (1) (2)

“That’s tremendously dramatic”, he said, of the research that was presented at the cardiology congress. “Generally, if you have people taking treatment for life … after a year [of starting therapy], you’ve only got about 50%̄60% of people [still] taking the treatment, so anything that can increase adherence is really important.”

The SPACE project, led by researchers from the George Institute for Global Health, analysed data from three clinical trials involving 3140 patients, including the Kanyini-GAP trial in Australia. (3)

Dr Ruth Webster, of the George Institute, said the polypill’s capacity to prevent cardiovascular events was “potentially massive”.

“In Australia, 50% of people who should be taking these combination medications don’t take them”, she said. “Globally at least 90% of people in lower income countries who would potentially benefit from these medications are not taking them.”

Dr Webster said the affordability of the polypill could ensure that its benefits were felt in low- as well as high-income nations.

“One of the key aims of the polypill has always been … to make it cheap so that patients can afford it”, said Dr Webster, adding that governments and health care organisations could use their buying power to ensure a cheap and effective pill was available globally.

Although a polypill is available in some Latin American and Asian countries, the UK, the US and Australia do not yet have one on the market.

Dr Webster said the George Institute was actively involved in efforts to have a polypill made available in Australia.

Dr Smith said that Iran was trialling providing the polypill to everyone over the age of 50 years who had at least one risk factor for cardiovascular disease. “The future is going to come not from Australia or Britain or the US, but from these kinds of countries, where … there’s much more to gain … as there are many people not being treated [at all]”, he said.

In addition to regulatory hurdles, cardiologists were also a barrier to polypill development, said Dr Smith, who recently wrote about the key barriers to polypill uptake in his BMJ blog. (4)

“[Cardiologists] think … that constantly titrating the drugs you give people, measuring their blood pressure regularly and their lipids … is a better way of doing things. But the problem is that we have this famous rule of halves — of all of the people at risk, half are not diagnosed; and of the half that are diagnosed, half are not treated; and the half that are treated, are not treated adequately”, he said. “So you end up with a very high proportion of people who are at risk who are not getting good treatment.

“The strongest argument for the polypill is how bad things are at the moment. Not just in low- and middle-income countries where, on the whole, they are terrible, but also in high-income countries because a lot of people are not getting adequate treatment.”

Dr Smith said the polypill had also faced opposition from public health experts concerned that giving people such a pill would discourage improvements in lifestyle and diet.

“But I think that’s a myth that’s been laid to rest because in three trials that have looked at lifestyle, people on the polypill don’t get fatter, they don’t smoke more, they don’t eat unhealthier diets”, he said.

1. Nature 2007; 450: 494-496
2. George Institute for Global Health: SPACE Project
3. BMC Public Health 2010; Online 5 August
4. BMJ Blogs 2014; Online 1 May

 

health market quality, healthcare, healthy habits, management and leadership, policy, politics, quotes & aphorisms, rapid learning health systems

Peter Baume on Money in Medicine

Former senator, doctor and colleague, Professor Peter Baume, used to say that:

“matters of principle usually turned out in politics to be matters of money, while matters of high principle usually turned out to be matters of lots of money.”

He could have been talking about matters of health policy.

Quoted by Steve Leeder

https://www.mja.com.au/insight/2014/16/stephen-leeder-policy-means-people

 

Stephen Leeder: Policy means people

Stephen Leeder
Monday, 12 May, 2014
Steve Leeder

SHOULD we pay more from our pockets for health care and less from the public purse?

What current institutions in health can we do without? Should prevention be a major concern of government or should it be left to the individual?

These questions should be addressed by a national government elected to oversee — among many things — the health of the nation.

Much health care in Australia is paid for from taxes. A long history explains why this is so, much of it expressing humane concern for people who are sick and assuring access to care for those who are not so well off financially.

Our politicians have choices — they can leave the health system as it is or they can try to change it by changing the underpinning policy. In seeking to make change they inevitably provoke the interest of those who stand to lose or gain as a result — doctors, nurses, patients, managers, insurers, pharmaceutical companies and many others.

So, whether they leave the system mostly in place and merely fiddle, or propose branch and root changes, politicians are engaging in policy decisions whether they recognise it or not (policy in this case being deciding how to apply resources available for health care).

These policy decisions affect people’s lives and are not trivial. For example, increasing theprivatisation of health care, as has been proposed in Queensland, carries costs for those least able to pay.

The more privatised the system, the less the needs of the poor and the marginal are met. This in turn means that society is changed and the values that it expresses — a fair go for all and concern for the weak — are hammered in the promotion of profit.

The results of a two-tiered health system are rapid access to quality care for the rich, who pay privately, and inferior care with long waiting times for the poor through a publicly funded safety net, a system well known in less developed countries.

Because it involves money, the health policy debate occurs in the context of other public policy discussions, most notably those that have to do with the Budget. Former senator, doctor and colleague, Professor Peter Baume, used to say that matters of principle usually turned out in politics to be matters of money, while matters of high principle usually turned out to be matters oflots of money. He could have been talking about matters of health policy.

As the word implies, policy has to do with the polis — the people. In a democracy the people expect their voices will be heard, alongside those of experts in health, the financial controllers and other interest groups. They also expect that changes to the system are canvassed with them before being announced and that they have a chance to have their say.

Optimally, a competitive, comprehensive statement of intent for health care would be provided by contestants for our vote at each election. This did not happen at the last federal election and we have not been canvassed about proposed changes.

Instead we have been bombarded in the past few weeks by government and the media about proposed cuts in tomorrow’s federal Budget, rumours of extinctions (eg, the Australian National Preventive Health Agency and Medicare Locals), increased costs to visit GPs and nothing much about our public hospital system.

It would be healthy if tomorrow’s Budget acknowledged the need for people-based health policy.

We should be presented with options that emanate from clear-headed policy thinking as well as a sound budget. The publication recently of the National Commission of Audit report is not reassuring. It focuses heavily on the supply side of the cost equation for health care but does not provide any insights into what can be done to achieve real efficiency through structural change. Instead, we just hear about rising charges through copayments and by forcing high-income earners out of Medicare and into private insurance schemes.

How to achieve more efficient (and generally more effective) care is left unconsidered. For example, in the Western Sydney Local Health District in the past 2 years, we have cut millions of dollars from our recurrent budget with an 8% increase in activity by attending to contracting, procurement and not using expensive part-time staffing from a budget of a mere $2.4 billion.

Let’s have less haste and hysteria, and more speed towards an efficient and humane health system, thank you.

 

Professor Stephen Leeder is the editor-in-chief of the MJA and professor of public health and community medicine at the University of Sydney. He chairs the Western Sydney Local Health District Board.

facts & data points, healthcare, policy

Obesity Society of Australia

good obesity and diabetes stats, otherwise fluff…

http://www.medicalobserver.com.au/news/govts-should-weigh-in-on-obesity

Govts should weigh in on obesity

22nd Apr 2014

THE release in 1997 of the National Health and Medical Research Council’s report, Acting on Australia’s Weight: a Strategic Plan for the Prevention of Overweight and Obesity, was supposed to be a watershed.

Associate Professor Tim Gill

Executive Officer, Australian and New Zealand Obesity Society

This was the first time a national agency anywhere in the world had produced a national action plan that recognised the seriousness of the growing obesity problem and set out a strategy to deal with it.

Great anticipation surrounded the level and vigour of action on treatment and obesity prevention it would stimulate.

Alas, after several years of procrastination, several government taskforces and innumerable additional reports (with mostly the same recommendations) the original report has been re-branded from Acting on Australia’s Weight to ‘Waiting on Australia to Act’ by health advocates frustrated by continued unwillingness by successive Australian governments to take up the tougher recommendations required.

All governments now acknowledge the seriousness of the public health problem of obesity and the financial and social burden of obesity-related conditions.

However, they proffer a confusing range of reasons for their unwillingness to act upon recommendations from their own expert committees.

Among the most perplexing rationales for inaction include: obesity is not a disease; we cannot act without certainty that this intervention will be effective; obesity is a lifestyle problem that requires personal rather than government action; and we do not want to create a nanny state.

In isolation, some of these justifications appear valid, especially when espousing a need for evidence-based policy and a desire to avoid causing unintended harm.

However, few stand up to critical analysis within the context of type of response required to make headway.

Since the release of Acting on Australia’s Weight, the prevalence on obesity has risen from 18.7% to 28.3% and now almost two-thirds of Australian adults are overweight or obese.

The predicted avalanche of weight-related chronic disease is beginning to emerge. The level of type 2 diabetes has more than doubled since 1995 and now affects 4.2% of the adult population.

Every day 280 Australians develop diabetes, and the Baker IDI Institute estimates there will be 2.5—3 million people with diabetes by 2025 and about 3.5 million by 2033. These sorts of figures should see governments eager to identify and support any action. Instead we have reached a point where the range of strategies acceptable to governments is narrowing. Potentially effective interventions have been ruled off the table as a consequence of a combination of political, philosophical and technical considerations.

It is true there are no easy or quick solutions to the problem of Australia’s expanding weight. It is also true that governments alone cannot solve this problem; it will take a concerted effort from individuals, communities, professionals, industry and all sectors of society.

Governments must provide leadership, however. This necessitates tough decisions in the face of corporate resistance and public self-interest that demonstrate commitment in tackling obesity and perceptions around this issue.

Telling people battling with genetic and physiological liabilities overlaid with an environment that promotes sedentary behaviour and overconsumption of food that they must take personal responsibility is not leadership.

But preparedness to embrace a range of structural, regulatory or fiscal reforms that have the potential to push the environment in a direction that supports appropriate behaviour change provides a clear indication of the government’s stance.

This display of leadership is likely to achieve more in terms of modelling and endorsement of additional action than the direct impact of the intervention itself. And that is the role of government.