tag:theconversation.com,2011:/au/topics/specialists-22666/articlesspecialists – The Conversation2023-08-27T20:04:42Ztag:theconversation.com,2011:article/2116802023-08-27T20:04:42Z2023-08-27T20:04:42ZDoes private health insurance cut public hospital waiting lists? We found it barely makes a dent<figure><img src="https://images.theconversation.com/files/544122/original/file-20230823-29-hhssuv.jpg?ixlib=rb-1.1.0&rect=0%2C1%2C1000%2C664&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/blur-image-patients-hospital-waiting-see-1142067620">Shutterstock</a></span></figcaption></figure><p>The more people take up private health insurance, the <a href="https://www.aph.gov.au/parliamentary_business/committees/senate/community_affairs/completed_inquiries/1999-02/pubhosp/report/c05">less pressure</a> on the public hospital system, including <a href="https://www.privatehealthcareaustralia.org.au/australians-sign-up-to-private-health-insurance-in-record-numbers-to-avoid-hospital-waiting-lists/#:%7E:text=%22Private%20health%20insurance%20is%20the,and%20keep%20pressure%20off%20premiums.">shorter waiting lists</a> for surgery. That’s one of the key messages we’ve been hearing from government and the private health insurance industry in recent years.</p>
<p>Governments <a href="https://www.privatehealth.gov.au/health_insurance/surcharges_incentives/index.htm">encourage us</a> to buy private hospital cover. They tempt us with carrots – for instance, with subsidised <a href="https://www.ato.gov.au/Individuals/Medicare-and-private-health-insurance/Private-health-insurance-rebate/">premiums</a>. With higher-income earners, the government uses sticks – buy private cover or pay the <a href="https://www.ato.gov.au/Individuals/Medicare-and-private-health-insurance/Medicare-levy-surcharge/">Medicare Levy Surcharge</a>. These are just some of the <a href="https://www.health.gov.au/ministers/the-hon-greg-hunt-mp/media/delivering-australias-lowest-private-health-insurance-premium-change-in-21-years#:%7E:text=Home-,Delivering%20Australia's%20lowest%20private%20health%20insurance%20premium%20change%20in%2021,be%202.70%20percent%20in%202022">billion-dollar strategies</a> aimed to shift more of us who can afford it into the private system.</p>
<p>But what if private health insurance doesn’t have any meaningful impact on public hospital waiting lists after all?</p>
<p>That’s what we found in our <a href="https://melbourneinstitute.unimelb.edu.au/publications/working-papers/search/result?paper=4721936">recent research</a>. Our analysis suggests if an extra 65,000 people buy private health insurance, public hospital waiting lists barely shift from the average 69 days. Waiting lists are an average just eight hours shorter.</p>
<p>In other words, we’ve used hospital admission and waiting-list data to show private health insurance doesn’t make much difference.</p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/private-health-insurance-is-set-for-a-shake-up-but-asking-people-to-pay-more-for-policies-they-dont-want-isnt-the-answer-210981">Private health insurance is set for a shake-up. But asking people to pay more for policies they don't want isn't the answer</a>
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</em>
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<h2>What we did</h2>
<p>Our <a href="https://melbourneinstitute.unimelb.edu.au/publications/working-papers/search/result?paper=4721936">work</a> looked at data from 2014-2018 on hospital admissions and waiting lists for elective surgery in Victoria.</p>
<p>The data covered all Victorians who were admitted as an inpatient in all hospitals in the state (both public and private) and those registered on the waiting list for elective surgeries in the state’s public hospitals.</p>
<p>That included waiting times for surgeries where people are admitted to public hospitals (as an inpatient). We didn’t include people waiting to see specialist doctors as an outpatient.</p>
<p>The data was linked at the patient level, meaning we could track what happened to individuals on the waiting list.</p>
<p>We then examined the impact of more people buying private health insurance on waiting times for surgeries in the state’s public hospitals.</p>
<p>We did this by looking at the uptake of private health insurance in different areas of Victoria, according to socioeconomic status. After adjusting for patient characteristics that may affect waiting times, these differences in insurance uptake allowed us to identify how this changed waiting times.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/544142/original/file-20230823-23-lz4g5p.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Man lying in hospital bed with oxygen mask, holding hands of female friend or relative" src="https://images.theconversation.com/files/544142/original/file-20230823-23-lz4g5p.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/544142/original/file-20230823-23-lz4g5p.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/544142/original/file-20230823-23-lz4g5p.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/544142/original/file-20230823-23-lz4g5p.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/544142/original/file-20230823-23-lz4g5p.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/544142/original/file-20230823-23-lz4g5p.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/544142/original/file-20230823-23-lz4g5p.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">We looked at all people waiting for elective surgery.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/close-shot-wife-hands-family-praying-2344798261">Shutterstock</a></span>
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<h2>What we found</h2>
<p>In our sample, on average <a href="https://melbourneinstitute.unimelb.edu.au/__data/assets/pdf_file/0005/4721936/wp2023n09.pdf">44% of people</a> in Victoria had private health insurance. This is close to the national average of <a href="https://www.apra.gov.au/private-health-insurance-annual-coverage-survey">45%</a>. </p>
<p>We found that increasing the average private health insurance take-up from 44% to 45% in Victoria would reduce waiting times in public hospitals by an average 0.34 days (or about eight hours).</p>
<p>This increase of one percentage point is equivalent to 65,000 more people in Victoria (based on <a href="https://www.abs.gov.au/AUSSTATS/abs@.nsf/Lookup/3101.0Main+Features1Jun%202018?OpenDocument">2018 population data</a>) taking up (and using) private health insurance.</p>
<p>The effects vary slightly by surgical specialty. For instance, private health insurance made a bigger reduction to waiting times for knee replacements, than for cancer surgery, compared to the average. But again, the difference only came down to a few hours.</p>
<p>Someone’s age also made a slight difference, but again by only a few hours compared to the average wait.</p>
<p>Given the common situation facing public and private hospitals across all states and territories, and similar private health insurance take-up in many states, our findings are likely to apply outside Victoria. </p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/getting-an-initial-specialists-appointment-is-the-hidden-waitlist-99507">Getting an initial specialists' appointment is the hidden waitlist</a>
</strong>
</em>
</p>
<hr>
<h2>Why doesn’t it reduce waiting lists?</h2>
<p>While our research did not address this directly, there may be several reasons why private health insurance does not free up resources in the public system to reduce waiting lists:</p>
<ul>
<li><p>people might buy health insurance and not use it, preferring to have free treatment in the public system rather than risk out-of-pocket costs in the private system</p></li>
<li><p>specialists may not be willing to spend more time in the public system, instead <a href="https://onlinelibrary.wiley.com/doi/epdf/10.1111/1753-6405.12488">favouring working</a> in private hospitals </p></li>
<li><p>there’s a growing need for public hospital services that may not be available in the private system, such as complex neurosurgery and some forms of cancer treatment.</p></li>
</ul>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/with-surgery-waitlists-in-crisis-and-a-workforce-close-to-collapse-why-havent-we-had-more-campaign-promises-about-health-182327">With surgery waitlists in crisis and a workforce close to collapse, why haven’t we had more campaign promises about health?</a>
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</em>
</p>
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<h2>Why is this important?</h2>
<p>Government <a href="https://www.privatehealth.gov.au/health_insurance/surcharges_incentives/index.htm">policies</a> designed to get more of us to buy private health insurance involve a significant sum of public spending.</p>
<p>Each year, the Australian government spends about <a href="https://www.health.gov.au/ministers/the-hon-greg-hunt-mp/media/delivering-australias-lowest-private-health-insurance-premium-change-in-21-years#:%7E:text=Home-,Delivering%20Australia's%20lowest%20private%20health%20insurance%20premium%20change%20in%2021,be%202.70%20percent%20in%202022">$A6.7 billion</a> in private health insurance rebates to reduce premiums.</p>
<p>In the 2020-21 financial year, Medicare combined with state and territory government expenditure provided almost <a href="https://www.aihw.gov.au/reports/hospitals/australias-hospitals-at-a-glance/contents/spending-on-hospitals">$6.1 billion</a> to fund services provided in private hospitals.</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1691072564003520512"}"></div></p>
<p>There might be an argument for this public spending if the end result was to substantially take pressure off public hospitals and thereby reduce waiting times for treatment in public hospitals.</p>
<p>But the considerable effort it takes to encourage more people to sign up for private health insurance, coupled with the small effect on waiting lists we’ve shown, means this strategy is neither practical nor effective.</p>
<p>Given the substantial costs of subsidising private health insurance and private hospitals, public money might be better directed to public hospitals and primary care. </p>
<p>In addition, people buying private health insurance can skip the waiting times for elective surgery to receive speedier care. These people are often <a href="https://melbourneinstitute.unimelb.edu.au/__data/assets/pdf_file/0005/4682822/wp2023n08.pdf">financially well off</a>, implying unequal access to health care.</p>
<h2>What’s next?</h2>
<p>The Australian government is currently <a href="https://consultations.health.gov.au/medical-benefits-division/consultation-on-phi-studies/">reviewing</a> private health insurance.</p>
<p>So now is a good time for reforms to optimise the overall efficiency of the health-care system (both public and private) and improve population health while saving taxpayer money. We also need policies to ensure equitable access to care as a priority. </p>
<p>When it comes to reducing hospital waiting lists, we’ve shown we cannot rely on increased rates of private health insurance coverage to do the heavy lifting.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/do-you-really-need-private-health-insurance-heres-what-you-need-to-know-before-deciding-93661">Do you really need private health insurance? Here's what you need to know before deciding</a>
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</p>
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<img src="https://counter.theconversation.com/content/211680/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Yuting Zhang receives funding from the Australian Research Council, Department of Veterans' Affairs, the Victorian Department of Health, and National Health and Medical Research Council. In the past, Professor Zhang has received funding from several US institutes including the US National Institutes of Health, Commonwealth fund, Agency for Healthcare Research and Quality, and Robert Wood Johnson Foundation. She has not received funding from for-profit industry including the private health insurance industry.</span></em></p><p class="fine-print"><em><span>Jongsay Yong and Ou Yang do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Governments spend billions of dollars every year to encourage us to take up private cover. But our research shows this does little to reduce pressure on the public system.Yuting Zhang, Professor of Health Economics, The University of MelbourneJongsay Yong, Associate Professor of Economics, The University of MelbourneOu Yang, Senior Research Fellow, The University of MelbourneLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1445062020-09-28T19:58:41Z2020-09-28T19:58:41ZSpecialist referral rules haven’t changed much since the 70s, but Australia’s health needs sure have<figure><img src="https://images.theconversation.com/files/354199/original/file-20200822-22-1k8yxpa.jpg?ixlib=rb-1.1.0&rect=5%2C0%2C992%2C663&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/vintage-gray-telephone-on-hardwood-floor-212598148">Shutterstock</a></span></figcaption></figure><p>You have a chronic health condition and visit your specialist for an annual check-up, but the referral’s expired. You’re told to get a new referral from the GP to claim the Medicare rebate. You take the next afternoon off to see your GP, who gives you another 12 month referral and tells you they can’t backdate it. You’re out of pocket for the specialist fee and gap payment for your GP consultation. You’ll have to do it all again next year.</p>
<p><a href="https://forums.whirlpool.net.au/archive/2624403">Common issues like this</a> are highlighted in a <a href="https://ahha.asn.au/publication/health-policy-issue-briefs/deeble-brief-no-38-optimising-healthcare-through-specialist">new report</a> on the specialist referral system out today by the <a href="https://ahha.asn.au/deebleinstitute">Deeble Institute for Health Policy Research</a>, the research arm of the Australian Healthcare and Hospitals Association.</p>
<p>The report, which we co-authored, finds shortcomings in a broken referral system, plagued by <a href="https://www.aihw.gov.au/getmedia/023846dd-b30e-4149-a442-5dc0694aab26/aihw_phc_1.pdf.aspx">poor data</a> collection and wasted dollars.</p>
<p>Fixing these issues requires a better understanding of patients’ long-term needs and the health and economic consequences of the medical referral system. </p>
<h2>Chronic illness is more common now</h2>
<p>The rules about specialist referrals were developed in the <a href="https://parlinfo.aph.gov.au/parlInfo/search/display/display.w3p;adv=yes;orderBy=_fragment_number,doc_date-rev;page=0;query=%22referral%20system%22%20%221970%22%20Decade%3A%221970s%22%20Year%3A%221970%22;rec=0;resCount=Default">70s</a>, when acute illness was <a href="https://www.racgp.org.au/FSDEDEV/media/documents/Special%20events/Health-of-the-Nation-2019-Report.pdf">more common</a>.</p>
<p>Now <a href="https://www.aihw.gov.au/reports-data/health-conditions-disability-deaths/chronic-disease/overview">more people</a> each year are being diagnosed with a chronic illness, needing long-term specialist management.</p>
<p>They will often need multiple referrals, depending on how many specialists they see and when these referrals expire. This can be a <a href="https://chf.org.au/sites/default/files/chf_submission_to_mbs_review_final.pdf">frustrating</a> financial and logistical burden and can even cause some patients to delay treatment.</p>
<h2>Referrals can be too short</h2>
<p>Different types of health-care workers <a href="http://classic.austlii.edu.au/au/legis/cth/consol_reg/hir2018273/s96.html">can refer</a> you to specialists or consultant physicians. The duration of the referral ultimately <a href="http://classic.austlii.edu.au/au/legis/cth/consol_reg/hir2018273/s102.html">depends on who issues it</a>.</p>
<p>GPs commonly limit their referrals to <a href="https://www.racgp.org.au/FSDEDEV/media/documents/Running%20a%20practice/Practice%20resources/Referring-to-other-medical-specialists.pdf">fixed terms</a>, even though <a href="http://classic.austlii.edu.au/au/legis/cth/consol_reg/hir2018273/s102.html">indefinite referrals</a> are possible. Specialists can only issue referrals to other specialists for three months, and this rule poses serious challenges for many vulnerable people.</p>
<figure class="align-center ">
<img alt="A doctor handing a patient a referral letter" src="https://images.theconversation.com/files/360192/original/file-20200928-24-jcrbie.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/360192/original/file-20200928-24-jcrbie.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=397&fit=crop&dpr=1 600w, https://images.theconversation.com/files/360192/original/file-20200928-24-jcrbie.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=397&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/360192/original/file-20200928-24-jcrbie.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=397&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/360192/original/file-20200928-24-jcrbie.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=499&fit=crop&dpr=1 754w, https://images.theconversation.com/files/360192/original/file-20200928-24-jcrbie.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=499&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/360192/original/file-20200928-24-jcrbie.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=499&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">GPs can issue referrals with no time limit, but rarely do.</span>
<span class="attribution"><span class="source">Shutterstock</span></span>
</figcaption>
</figure>
<p><a href="https://www1.health.gov.au/internet/main/publishing.nsf/Content/19F237413A9086B6CA2580180019C0C4/$File/MBS-Review-Taskforce-Recommendations-Principles-and-Rules-Report.pdf">One example</a>, taken from a review of Medicare in 2016, is of cancer patients receiving different types of therapy, where the radiation oncology treatment lasts longer than three months. When the referral expires, the patient needs to obtain a new one to continue treatment.</p>
<p>Issues the review <a href="https://www1.health.gov.au/internet/main/publishing.nsf/Content/19F237413A9086B6CA2580180019C0C4/$File/Final%20first%20report%20of%20the%20MBS%20Principles%20and%20Rules%20Committee.pdf">identified</a> about the three month rule included difficulties providers had in interpreting the rules, leading to improper Medicare billing practices. This echoes <a href="https://www.abc.net.au/news/2014-05-13/annual-specialist-referrals-wasting-millions,-say-gps/5447822?nw=0">previous concerns</a>.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/explainer-what-is-medicare-and-how-does-it-work-22523">Explainer: what is Medicare and how does it work?</a>
</strong>
</em>
</p>
<hr>
<h2>Why are referrals stuck in the 70s?</h2>
<p>Regardless of the burden on patients, health-care workers and Medicare, both sides of government have shown little interest in changing the referral rules. </p>
<p>This is largely because of the general principles that sit behind them. These include the need to keep people away from expensive specialist care and the importance of <a href="http://www5.austlii.edu.au/au/legis/cth/num_reg_es/hir2018201801365289.html">GPs as gatekeepers</a> of the health system.</p>
<p>So, the purpose of a referral is to provide access to Medicare subsidies for specialist care. But the purpose of a referral expiring is actually to reconnect you with your GP, who then issues a new referral if you are receiving ongoing specialist care.</p>
<p>The referral system offers important economic benefits. But the burden of referral expiration and the limited referral pathways available for patients needs attention. Revising how referrals operate and improving the system of communication between care teams can overcome many associated challenges.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/specialists-are-free-to-set-their-fees-but-there-are-ways-to-ensure-patients-dont-get-ripped-off-97372">Specialists are free to set their fees, but there are ways to ensure patients don't get ripped off</a>
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</em>
</p>
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<h2>The referral system doesn’t always give good value</h2>
<p>We’re seeing a trend toward what’s called <a href="https://valuebasedcareaustralia.com.au/about/governance/">value-based care</a>. This is the idea <a href="https://grattan.edu.au/wp-content/uploads/2016/03/936-chronic-failure-in-primary-care.pdf">GPs</a> and <a href="https://evolve.edu.au/">specialists</a> should deliver effective and efficient patient care, taking into account the limited resources available.</p>
<p>But the current referral system can discourage this.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/7-lessons-for-australias-health-system-from-the-coronavirus-upheaval-141122">7 lessons for Australia's health system from the coronavirus upheaval</a>
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</em>
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<p>A recent example of the misuse of referrals is with Victoria’s <a href="https://www.dhhs.vic.gov.au/call-to-test-covid-19">Call-to-Test</a> program for COVID-19. This is designed to provide <a href="https://www.abc.net.au/news/2020-08-11/how-victorias-home-coronavirus-testing-will-work/12541296">about 200</a> vulnerable Melburnians access to nurse-led in-home COVID-19 testing each day. </p>
<p>People need a GP referral, unlike most government-run COVID-19 clinics around Australia. Victoria’s health department <a href="https://www.dhhs.vic.gov.au/call-to-test-covid-19#do-i-need-a-general-practitioner-gp-referral">says</a> a referral is needed so test results can be incorporated into treatment plans.</p>
<figure class="align-center ">
<img alt="A medicare card" src="https://images.theconversation.com/files/360193/original/file-20200928-18-5v1y9b.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/360193/original/file-20200928-18-5v1y9b.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/360193/original/file-20200928-18-5v1y9b.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/360193/original/file-20200928-18-5v1y9b.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/360193/original/file-20200928-18-5v1y9b.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/360193/original/file-20200928-18-5v1y9b.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/360193/original/file-20200928-18-5v1y9b.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">There is strong support from both consumers and health-care workers for improving the referral system.</span>
<span class="attribution"><span class="source">Shutterstock</span></span>
</figcaption>
</figure>
<p>But referrals, as a vehicle, don’t achieve this. Referrals relate to Medicare billing and they are not designed to facilitate GP follow-up care.</p>
<p>We estimate GP consultations to obtain the Call-to-Test referrals are likely to cost Medicare anywhere from A$10,300 a day (if GPs claim for a <a href="http://www9.health.gov.au/mbs/fullDisplay.cfm?type=item&q=91800&qt=ItemID#:%7E:text=91800%20%2D%20Additional%20Information&text=(c)%20implementing%20a%20management%20plan,providing%20appropriate%20preventative%20health%20care.&text=(b)%20the%20service%20must%20be,service%20may%20be%20bulk%2Dbilled._">shorter consultation</a> along with a <a href="http://www.mbsonline.gov.au/internet/mbsonline/publishing.nsf/Content/0C514FB8C9FBBEC7CA25852E00223AFE/$File/FAQ%20-%20COVID-19%20Bulk%20Billing%20Incentive%20-%20080520.pdf">bulk billing incentive</a>) up to a $17,560 a day (if GPs claim for a <a href="http://www9.health.gov.au/mbs/fullDisplay.cfm?type=item&q=91801&qt=item&criteria=91801">longer consultation</a>). This would be on top of the cost of any follow-up services after the test results are known, which is where the money is better spent.</p>
<h2>If not now, when?</h2>
<p>Rather than waiting until the next scheduled review of the <a href="https://www.legislation.gov.au/Details/F2020C00656">referral rules</a> in 2028, we can do better, sooner. There is strong <a href="https://chf.org.au/sites/default/files/chf_submission_to_mbs_review_final.pdf">consumer</a> and <a href="https://australian.physio/sites/default/files/submission/Submission_PreBudget_2015-16.pdf">clinician</a> support for a more efficient referral system. </p>
<p>Key legislative changes we’d like to see include expanding referral pathways and giving specialists the flexibility to extend referrals when needed, rather than letting them expire. </p>
<p>Consumer awareness of their referral rights is also needed. So too is compulsory and ongoing training for Medicare Benefit Schedule providers, administrators and Medicare staff who advise practitioners of the rules.</p>
<p>Supporting all of this, we need an independent inquiry and further research to ensure evidence-informed policies guide high-value, cost-effective care within the referral system.</p><img src="https://counter.theconversation.com/content/144506/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Christie M. Gardiner co-authored the report mentioned in this article but received no external funding for this. She does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.
Rebecca Haddock co-authored this article and the report mentioned in it. Rebecca is the director of the Deeble Institute for Health Policy Research, the research arm of the Australian Healthcare and Hospitals Association.</span></em></p><p class="fine-print"><em><span>Samantha Prime co-authored the report mentioned in this article, and was supported as a Deeble Institute for Health Policy Research Summer Scholar 2020 by the Australian Healthcare and Hospitals Association and HESTA.</span></em></p>Many more people need long-term specialist care, or are waiting a long time for elective surgery. These and other factors tell us we need to update how specialist referrals work.Christie M. Gardiner, Associate Lecturer of Law, University of NewcastleSamantha Prime, PhD Candidate | Health Policy, Systems & Services, Queensland University of TechnologyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1246382019-11-11T19:01:05Z2019-11-11T19:01:05ZDodgy treatment: it’s not us, it’s the other lot, say the experts. So who do we believe?<figure><img src="https://images.theconversation.com/files/296329/original/file-20191010-188797-1wp5mk4.jpg?ixlib=rb-1.1.0&rect=1%2C4%2C997%2C661&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Will my surgery work? Well, it depends on who you ask.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/concentrated-surgical-team-operating-patient-operation-1265400856?src=m2MZzzAzKRA2Zx3XNqfTmw-1-3">from www.shutterstock.com</a></span></figcaption></figure><p>Patients might not be getting the best advice about which treatments do or don’t work, according to our study published today. We found professional societies are more likely to call out other health professionals for providing low-value treatments rather than look in their own backyard.</p>
<p>Our study in <a href="https://doi.org/10.1186/s12913-019-4576-1">BMC Health Services Research</a> looked into recommendations under the global <a href="https://www.choosingwisely.org/">Choosing Wisely</a> public health campaign. We found professional societies are reluctant to publish recommendations against treatments and procedures that generate income for their members. </p>
<p>But they are much more comfortable at recommending against treatments that generate income for members of other professional societies.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/less-is-the-new-more-choosing-medical-tests-and-treatments-wisely-40756">Less is the new more: choosing medical tests and treatments wisely</a>
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</em>
</p>
<hr>
<h2>How does the Choosing Wisely campaign work?</h2>
<p>Choosing Wisely aims to reduce the use of medical tests, treatments and procedures that provide little-to-no benefit, or in some cases can harm.</p>
<p>It then recommends patients question their doctors about whether these so-called low-value tests, treatments or procedures are necessary.</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1171566184073854976"}"></div></p>
<p>To take part in the Choosing Wisely campaign, professional societies publish recommendations relevant to their members.</p>
<p>For example, a surgical society could list a surgical procedure of questionable effectiveness. A physiotherapy society could also list a poorly justified physiotherapy treatment. This ensures recommendations raise awareness of low-value care among the practitioners most likely to provide this care.</p>
<p>However, an <a href="https://www.nejm.org/doi/full/10.1056/NEJMp1314965">ongoing</a> <a href="https://www.bmj.com/content/351/bmj.h6760">concern</a> is whether professional societies focus on low-value care provided by their members or whether they tend to make recommendations for care provided by others, outside their own society.</p>
<p>Many low-value tests, treatments and procedures also generate substantial income for the practitioner who provides them. So societies might be reluctant to recommend against or “call out” these examples of low-value care because of fear of affecting their members’ bottom line.</p>
<h2>What did we do?</h2>
<p>To investigate these concerns, we evaluated all Choosing Wisely recommendations worldwide since the campaign began in 2012.</p>
<p>We reviewed 1,293 recommendations from eight countries, including Australia, to investigate the proportion of recommendations that target income-generating treatments. We also investigated whether recommendations on income-generating treatments were more likely to come from societies involved, or not involved, in providing this care.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/needless-treatments-spinal-fusion-surgery-for-lower-back-pain-is-costly-and-theres-little-evidence-itll-work-91829">Needless treatments: spinal fusion surgery for lower back pain is costly and there's little evidence it'll work</a>
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<p>Treatments or procedures that attract a fee-for-service and are performed outside a routine encounter with a practitioner were considered income-generating for the practitioner performing the treatment. Examples included arthroscopic surgery of the knee and shoulder, cesarean section, removing a breast lump and radiotherapy.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/296334/original/file-20191010-188797-7ohdv6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/296334/original/file-20191010-188797-7ohdv6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/296334/original/file-20191010-188797-7ohdv6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/296334/original/file-20191010-188797-7ohdv6.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/296334/original/file-20191010-188797-7ohdv6.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/296334/original/file-20191010-188797-7ohdv6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/296334/original/file-20191010-188797-7ohdv6.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/296334/original/file-20191010-188797-7ohdv6.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Radiotherapy was one of the treatments counted as income-generating, as part of our study.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/woman-receiving-radiation-therapy-treatments-breast-1097370944?src=J77SkxBy3P-8gXMxgs35Hg-1-0">from www.shutterstock.com</a></span>
</figcaption>
</figure>
<p>We then examined each recommendation and determined whether the society making the recommendation was targeting a treatment routinely provided by members of their society or members of another society. </p>
<p>There were over 230 professional societies with Choosing Wisely recommendations across medicine, surgery, diagnostic testing and allied health. Examples of professional societies from Australia included the: <a href="https://www.racgp.org.au/">Royal Australian College of General Practitioners</a>; <a href="https://www.surgeons.org/">Royal Australasian College of Surgeons</a>; <a href="https://australian.physio/">Australian Physiotherapy Association</a>; and <a href="https://www.rcpa.edu.au/">Royal College of Pathologists of Australasia</a>.</p>
<h2>Here’s what we found</h2>
<p>Overall, we found only 20% of Choosing Wisely recommendations target income-generating treatments. But more importantly, of these recommendations, most target treatments provided by practitioners that are not members of the society making the recommendation.</p>
<p>For example, the <a href="https://rheumatology.org.au/">Australian Rheumatology Association</a> <a href="http://www.choosingwisely.org.au/recommendations/ara">recommends against</a> arthroscopy for knee osteoarthritis, a surgical intervention that rheumatologists don’t perform (this is generally carried out by orthopaedic surgeons):</p>
<blockquote>
<p>Do not perform arthroscopy with lavage and/or debridement or partial meniscectomy for patients with symptomatic osteoarthritis of the knee and/or degenerate meniscal tear.</p>
</blockquote>
<p>Meanwhile, the <a href="https://www.aaos.org/Default.aspx?ssopc=1">American Academy of Orthopaedic Surgeons</a>, whose members perform arthroscopy, doesn’t recommend against the procedure. Instead, it <a href="https://www.choosingwisely.org/societies/american-academy-of-orthopaedic-surgeons/">points the finger</a> at clinicians who routinely provide insoles:</p>
<blockquote>
<p>Don’t use lateral wedge insoles to treat patients with symptomatic medial compartment osteoarthritis of the knee.</p>
</blockquote>
<h2>Why does it matter?</h2>
<p>Choosing Wisely aims to reduce waste in health care. But when societies mainly look for waste in fields other than their own, their recommendations are likely to have less impact. </p>
<p>To illustrate this, eight societies of orthopaedic surgeons have collectively published 48 Choosing Wisely recommendations. But only nine of these recommendations target low-value surgery routinely performed by orthopaedic surgeons. Most of these are from the <a href="https://www.orthopeden.org/">Netherlands Orthopaedic Association</a> (five out of nine recommendations).</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/antibiotics-for-colds-x-rays-for-bronchitis-internal-exams-with-pap-tests-the-latest-list-of-tests-to-question-56007">Antibiotics for colds, x-rays for bronchitis, internal exams with pap tests – the latest list of tests to question</a>
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</em>
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<p>By shying away from publishing recommendations that target ineffective and expensive interventions performed by their own members, professional societies are not acting in line with the spirit of the campaign. </p>
<p>Choosing Wisely could have a large impact on redirecting health-care spending from low-value care to recommended care, thereby improving the lives of millions. But for the campaign to realise its potential, ensuring future recommendations focus on the care provided by members of the society making the recommendation is a good place to start.</p>
<hr>
<p><em>Dr John Farey, a surgical registrar affiliated with the Institute for Musculoskeletal Health and the Sydney Local Health District, co-authored this article.</em></p><img src="https://counter.theconversation.com/content/124638/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Professional societies of doctors, surgeons or physiotherapists are more likely to recommend against treatments provided by others, our new research shows.Joshua Zadro, Postdoctoral Research Fellow, University of SydneyChristopher Maher, Professor, Sydney School of Public Health, University of SydneyIan Harris, Professor of Orthopaedic Surgery, UNSW SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1087402019-03-06T11:06:32Z2019-03-06T11:06:32ZWe need more than a website to stop Australians paying exorbitant out-of-pocket health costs<figure><img src="https://images.theconversation.com/files/262361/original/file-20190306-48444-hvs3fo.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">For some people, high out-of-pocket costs makes it difficult to see a doctor or fill a prescription.</span> <span class="attribution"><span class="source">From shutterstock.com</span></span></figcaption></figure><p>In an attempt to crack down on specialists charging exorbitant fees, the Morrison government <a href="http://www.health.gov.au/internet/ministers/publishing.nsf/Content/health-mediarel-yr2019-hunt035.htm">has pledged</a> to create a website listing individual specialists’ fees. </p>
<p>The website is voluntary and doctors will post their own fees. Patients will be able to compare doctors whose fees are listed, and the searchable website will have a special focus on the high fees in gynaecology, obstetrics and cancer services. </p>
<p>The announcement, made on Saturday, follows the release of a ministerial advisory committee’s <a href="http://www.health.gov.au/internet/main/publishing.nsf/Content/3A14048A458101B0CA258231007767FB/$File/Report%20-%20Ministerial%20Advisory%20Committee%20on%20Out-of-Pocket%20Costs.pdf">report on out-of-pocket costs</a>, which the government has had since November.</p>
<p>But while the website is a good first step, transparency alone is unlikely to be enough to ensure Australians aren’t forgoing care because of high costs. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/more-visits-to-the-doctor-doesnt-mean-better-care-its-time-for-a-medicare-shake-up-110884">More visits to the doctor doesn't mean better care – it's time for a Medicare shake-up</a>
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</em>
</p>
<hr>
<h2>What’s the problem?</h2>
<p>A central problem is the lack of transparency around out-of-pocket costs. Patients are typically unaware of the full out-of-pocket costs they might incur at the time of referral and admission. </p>
<p>The Consumers Health Forum’s <a href="https://chf.org.au/sites/default/files/20180404_oop_report.pdf">recent report</a> found Australian consumers face higher than average out-of-pocket costs compared to most countries. This translates into people often avoiding visiting a GP or specialist and failing to fill scripts due to cost.</p>
<p>A <a href="https://grattan.edu.au/wp-content/uploads/2014/07/Grattan_Institute_submission_-_inquiry_on_out-of-pocket_costs_-_FINAL.pdf">report from the Grattan Institute</a> using data from the Australian Bureau of Statistics shows many people already miss out on health care because of cost: 5% skip GP visits, 8% don’t go to a specialist, 8% don’t fill their prescription and 18% don’t go to the dentist. This will happen more if fees go up.</p>
<p>Those who avoid care because of cost are often those most in need, leading to concerns about equity of access. Delaying or foregoing care means when people do visit their doctor, their condition may be much worse than if they had presented earlier. This can affect long-term health outcomes and lead to higher costs over time.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/many-australians-pay-too-much-for-health-care-heres-what-the-government-needs-to-do-61859">Many Australians pay too much for health care – here's what the government needs to do</a>
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</em>
</p>
<hr>
<p>“Value” is also about providing information on the various options for care, including the evidence base of the treatments offered, waiting times for various providers, and how the quality of care might vary between the options. </p>
<p>Consumers, with the help of GPs where necessary, should be able to assess these trade-offs to arrive at a decision that works best for them. </p>
<p>But patients know little about the quality of care provided when they are offered treatment or even whether they will really get better as a result.</p>
<p>Significant numbers of procedures and treatments performed on patients in Australia are considered “low value care” – when treatments have little effect on health outcomes, and may even cause harm. <a href="https://qualitysafety.bmj.com/content/early/2018/08/06/bmjqs-2018-008338#block-system-main">Recent estimates</a> for New South Wales public hospitals suggest that between 11% and 20% of treatments involve low-value care.</p>
<p>These issues are being tackled through the <a href="http://www.choosingwisely.org.au/getmedia/042fedfe-6bdd-4a76-ae20-682f051eb791/Choosing-Wisely-in-Australia-2017-Report.aspx">Choosing Wisely</a> campaign which is increasing awareness of tests and treatments that are of low value and may cause harm. </p>
<p>The Medicare Benefits Schedule Review Taskforce is also reviewing how these procedures are funded through Medicare.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/262362/original/file-20190306-48447-5j0ldc.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/262362/original/file-20190306-48447-5j0ldc.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/262362/original/file-20190306-48447-5j0ldc.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/262362/original/file-20190306-48447-5j0ldc.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/262362/original/file-20190306-48447-5j0ldc.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/262362/original/file-20190306-48447-5j0ldc.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/262362/original/file-20190306-48447-5j0ldc.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">This website will make specialist fees publicly available to consumers – but only if the specialists choose to list their fees.</span>
<span class="attribution"><span class="source">From shutterstock.com</span></span>
</figcaption>
</figure>
<h2>Your right to know the costs of care</h2>
<p>What are your rights as a patient in relation to the costs of medical treatment?
At present, it seems consumers have very few. </p>
<p>There are no consistent enforceable guidelines on health-care providers to provide information on costs. <a href="https://protect-au.mimecast.com/s/Gb85CzvOL5hQ0lYKs4dl75?domain=urldefense.proofpoint.com">Voluntary codes of practice</a> are in place to encourage fee transparency but cannot be enforced.</p>
<p>The <a href="http://www.ombudsman.gov.au/making-a-complaint/private-health-insurance/informed-financial-consent">Commonwealth Ombudsman’s website</a> provides guidelines on informed financial consent in health care. Unfortunately these place the onus to gather the relevant information on the costs of care on consumers:</p>
<blockquote>
<p>You should ask your doctor, your health fund, and your hospital about any extra money you may have to pay out of your own pocket, commonly known as a “gap” payment. </p>
</blockquote>
<p>Health professionals should be required to provide information that will assist consumers make informed decisions. </p>
<h2>Why we need more than a website</h2>
<p>Gathering information on specialists’ fees and making sense of it is an enormous burden to place on vulnerable patients. This is especially the case for the elderly and those with little education who are reluctant to appear to question their trusted doctor.</p>
<p>We don’t know how effective a website of usually charged fees will be and who will use it. It’s possible it will advantage the rich by increasing their access to information, while not increasing access for poorer consumers. </p>
<p>Published fees may also be used by other doctors to set fees, and could potentially increase fees, if they see their prices are lower than others. </p>
<p>The onus should be on clinicians, and the system, to give patients easily accessible and digestible information as part of the service they provide.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/specialists-are-free-to-set-their-fees-but-there-are-ways-to-ensure-patients-dont-get-ripped-off-97372">Specialists are free to set their fees, but there are ways to ensure patients don't get ripped off</a>
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</em>
</p>
<hr>
<p>If health professionals cannot provide and interpret these costs to patients, we need to consider other trained workers – health “cost navigators” – who could advise patients as to how to decide on the best treatment for the best price.</p>
<p>The issues of out-of-pocket expenses are serious. They threaten the sustainability of our health system and adversely influence health. We need to ensure patients don’t face prohibitive costs that discourage them from treatment or force them into debilitating financial straits.</p><img src="https://counter.theconversation.com/content/108740/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Anthony Scott receives funding from the NHMRC, ARC, ANZ Health, and has previously conducted work for the Medibank Better Health Foundation. He receives funding from the NHMRC Partnership Centre for Health System Sustainability, which receives funding from the BUPA Research Foundation. Anthony Scott attended the workshop that helped form the content of this article.</span></em></p><p class="fine-print"><em><span>Peter Brooks organised the meeting with the Consumer Health Forum that developed a series of issue around out of pocket expenses some of which are the content of this article.
The authors would like to acknowledge the contribution of the Consumer Health Forum to the content of this article and in particular Ms Leanne Wells CEO of the CHF </span></em></p>Seeking and making sense of specialist fees is an unfair burden to place on vulnerable patients. A website might be helpful for some – but health professionals need to be held to higher account.Anthony Scott, Professor, The University of MelbournePeter Brooks, Professor, Centre for Health Policy, Melbourne School of Population and Global Health, The University of MelbourneLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/762192017-05-12T01:57:13Z2017-05-12T01:57:13ZDistrust of experts happens when we forget they are human beings<figure><img src="https://images.theconversation.com/files/168844/original/file-20170511-21593-t28wl.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">One of these is a human, the other not. Can you tell the difference? </span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/411319051?src=wSnv0OC0ynaSWAt1jzkdaw-1-37&size=huge_jpg">from www.shutterstock.com </a></span></figcaption></figure><p>In 2016, conservative, pro-brexit, British politician <a href="http://www.newsweek.com/michael-gove-sky-news-brexit-economics-imf-466365">Michael Gove announced</a> that people in England “…have had enough of experts with organisations from acronyms saying that they know what is best and getting it consistently wrong”.</p>
<p>In the US, Donald Trump famously <a href="https://www.theatlantic.com/international/archive/2017/01/trump-edelman-trust-crisis/513350/">doesn’t believe any expert </a> who doesn’t agree with him. Our most recent former Prime Minister Tony Abbott has also been <a href="https://www.crikey.com.au/2013/07/26/crikey-says-abbott-has-to-trust-someone/">accused</a> of having trust issues. </p>
<p>Growing distrust of experts is <a href="https://theconversation.com/please-dont-explain-hanson-2-0-and-the-war-on-experts-62106">linked with</a> changing social and political climates. But it also stems from misunderstandings about what experts are, and what their obligations to society entail. </p>
<p>At their heart, criticisms of experts often imply that they are servants, commodities or so vested in their field they can’t relate to reality. </p>
<p>To restore trust in experts, we need to remember they are, first and foremost, human beings. </p>
<h2>How detractors define and judge experts</h2>
<p>It’s probably safe to assume politicians are working from a relatively <a href="http://www.ewi.org.uk/membership_directory_why_join_ewi/whatisanexpertwitness">simple definition</a> of “expert”, such as: “an expert is a person with specialist knowledge not commonly held, or likely to be understood, by a layman.”</p>
<p>When people like Trump make assertions about the right and proper role of experts in public conversations, they appear to have an implicit list of infringements that experts must never transgress. </p>
<h3>Expressing values or opinions</h3>
<p>Detractors claim that when speaking as an expert, the things you say in public should be untainted by your values and opinions. In essence, you should be a passive conduit for information or facts. </p>
<p>University of Colorado Professor <a href="http://sciencepolicy.colorado.edu/about_us/meet_us/roger_pielke/">Roger Pielke</a> offers a subtle disdain for experts occupying this position when he critiques the “<a href="http://rogerpielkejr.blogspot.com.au/2015/01/five-modes-of-science-engagement.html">stealth issues advocate</a>”, a role “characterized by the expert who seeks to hide his/her advocacy behind a facade of science, either pure scientist or science arbiter.” </p>
<h3>Deviating from the straight and narrow</h3>
<p>Critics of experts believe that should you even <em>appear</em> to deviate from your role as a neutral presenter of facts (for example, by offering policy advice), you are no longer an expert and/or cannot be trusted. </p>
<p>This is typified by <a href="https://www.desmog.uk/2017/02/01/european-conservatives-shun-us-uk-climate-science-denier-s-anti-expert-rhetoric-incredibly-dangerous">Myron Ebell</a> when he was head of Donald Trump’s Environmental Protection Agency transition team. He said:</p>
<blockquote>
<p>[…] whenever you hear an environmental expert, think that he is an urban eco-imperialist.</p>
</blockquote>
<h3>Making mistakes</h3>
<p>Those who criticise experts assert that if you get something wrong, you are no longer an expert and/or cannot be trusted. <a href="https://www.theguardian.com/environment/2017/jan/30/green-movement-greatest-threat-freedom-says-trump-adviser-myron-ebell">Myron Ebell</a> referred to experts as “the expertariat”, saying:</p>
<blockquote>
<p>The people of America have rejected the expertariat, and I think with good reason because I think the expertariat have been wrong about one thing after another, including climate policy. </p>
</blockquote>
<p>All of these criticisms forget one thing: experts are human beings. </p>
<p>To suggest that the benefits of expertise can be delivered “value-free” is naive. Like all people, experts are influenced by politics and biases, emotions and beliefs. They are motivated, active agents who create, process and communicate knowledge. Experts are not passive conduits.</p>
<h2>The reality of the expert</h2>
<p>To consider the role of experts in public debates, I’m drawing on my own area of expertise: <a href="http://cpas.anu.edu.au/news-events/rod-lamberts-science-communication-frequently-public-occasionally-intellectual">science communication</a>. In the spirit of this article, I should note that I claim expertise here based on nearly 20 years of university-based research, practice, and teaching as well as my experience providing consultancies in Australia and around the globe. </p>
<p>In my realm, the most interesting grist for discussions around experts and trust turns up wherever science-<em>related</em> (but not always science-<em>based</em>) assertions are flung around in contests over socially contentious issues. </p>
<p><a href="https://theconversation.com/our-political-beliefs-predict-how-we-feel-about-climate-change-69435">Climate change action</a>, the acceptance of <a href="https://theconversation.com/perceptions-of-genetically-modified-food-are-informed-by-more-than-just-science-72865">genetically modified foods</a>, and <a href="https://theconversation.com/want-to-boost-vaccination-dont-punish-parents-build-their-trust-40094">compulsory childhood vaccination</a> are three classic examples where this regularly plays out in public.</p>
<p>Of course in examples like these, the role of expertise is not straightforward. For starters, exactly what constitutes pertinent specialist knowledge is itself up for debate. </p>
<p>Scientific aspects of disagreements about climate change, genetic modification or vaccination are regularly accompanied by arguments grounded in social, political, economic and religious concerns. And well they should be – these are not uni-dimensional issues. It’s not simply a matter of ‘getting some expertise’, it’s also about working out which expertise is relevant, and to whom.</p>
<p>In an ideal world, the evidence-based assertions of experts withstand evidence-based challenges, and are modified where they are found wanting. It’s through the open, honest, systematic contest of ideas among experts that the best ideas emerge. </p>
<p>Clearly the place of the expert in public conversations on these issues depends on many factors: the goal(s) of the conversation; the knowledge, interests and positions of the parties involved; and importantly, the types of people who might be ‘listening in’. </p>
<p>But more, it should also depend on what the experts themselves want to achieve. Like anyone else, experts have their own motives, even when overtly wearing their expert hat. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/168849/original/file-20170511-21613-150n3vh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/168849/original/file-20170511-21613-150n3vh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/168849/original/file-20170511-21613-150n3vh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/168849/original/file-20170511-21613-150n3vh.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/168849/original/file-20170511-21613-150n3vh.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/168849/original/file-20170511-21613-150n3vh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/168849/original/file-20170511-21613-150n3vh.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/168849/original/file-20170511-21613-150n3vh.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Yes, I’m wearing my scientist hat but I’m also a human being.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/634641254?src=u_rKdO-eHmSU9eYxpcJO5g-2-48&size=huge_jpg">Shutterstock</a></span>
</figcaption>
</figure>
<p>Traditionally, an expert’s motivation for participating in public conversations as an expert will be rooted in a desire to inform, guide, advise or warn based on their specialist knowledge. </p>
<p>But equally – and often simultaneously – they could be driven to participate because they want to engage, inspire or entertain. They themselves may also hope to learn from their participation in a public conversation. </p>
<p>Or maybe they just want to be noticed (and there’s nothing wrong with that).</p>
<h2>So, what’s the place of experts in public conversations?</h2>
<p>Assessing the actions of experts using criteria that downplay, and even ignore, the fact that they are people makes it easier to admonish them and dismiss their expertise because they dare to have opinions, to make mistakes, or to pick a side. </p>
<p>US Navy Professor <a href="http://thefederalist.com/author/tomnichols/">Tom Nichols</a> says <a href="http://thefederalist.com/2014/01/17/the-death-of-expertise/">we live in</a>:</p>
<blockquote>
<p>[…] a manic reinterpretation of “democracy” in which everyone must have their say, and no one must be “disrespected”. </p>
</blockquote>
<p>This is a place where, at the extremes, positions put forward by experts are deemed suspect <em>because</em> they come from experts. </p>
<p>In a world where facts and logic are considered malleable, and where powerful, influential interest groups cast doubt on the notion of expertise <em>itself</em>, it’s the <a href="http://cpas.anu.edu.au/news-events/rod-lamberts-science-communication-frequently-public-occasionally-intellectual">place of the expert in public conversations</a> to help turn this tide. </p>
<p>It’s my opinion that the expert should strive to be seen as <em>more</em> human, to embody at every opportunity their position as a part of society, as a person who has interests and opinions <em>and also</em> expertise. </p>
<p>How they choose to do this, however, should be up to them.</p><img src="https://counter.theconversation.com/content/76219/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Rod Lamberts currently receives funds from DIIS, and has in the past received ARC funding. </span></em></p>Experts may be dismissed when they express values, offer advice or make mistakes. But these expectations are unreasonable and unhelpful.Rod Lamberts, Deputy Director, Australian National Centre for Public Awareness of Science, Australian National UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/567302016-04-11T03:44:23Z2016-04-11T03:44:23ZWhy emergency care in Africa needs to become a specialised course<figure><img src="https://images.theconversation.com/files/117862/original/image-20160407-16260-i7rb9z.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">An ambulance arrives to evacuate casualties from a fire at the Nakumatt supermarket in Kenya.</span> <span class="attribution"><span class="source">Reuters/Antony Njuguna</span></span></figcaption></figure><p>The young patient was wheeled into our emergency centre by the ambulance service. He had sustained what appeared to be a severe head and pelvis injury and possibly also a spinal one. </p>
<p>Our emergency care team leapt into action. They took over his breathing, placing a tube through his mouth into his lungs. We splinted his pelvis and rapidly replaced the blood he had lost. In no time we were heading to the CT scanner with a fully stabilised patient.</p>
<p>Earlier that evening I sutured a three-year-old’s face after an unwelcome encounter at home that resulted in a broken window and an unsightly cut. She may recall the accident that led to the injury but not her hospital experience nor any traces of the wound. I gave her a light sedation and used a combination of fine sutures and skin glue to close the wound.</p>
<p>Before that, I treated a would-be mother who suffered a miscarriage. I also slowed down a young man’s heart that was beating too fast and treated another person’s acute asthma attack.</p>
<p>Each patient could safely go home after the emergency centre treatment. Each had a follow-up arrangement at their usual primary care doctor. My trauma patient couldn’t go home – at least not today. But he did get the best chance at a good outcome thanks to the presence of the specialised emergency care team in the emergency centre.</p>
<h2>Inadequate training on offer</h2>
<p>This scenario can be replicated by very few African emergency centres. But it did form part of my daily routine when I trained and worked as a specialist in emergency medicine at an English hospital. There, this level of emergency care is considered standard.</p>
<p>In contrast, emergency centres in South Africa – including privately operated ones – are mainly staffed by general practitioners and early career medical officers, who are largely non-specialists. Elsewhere in Africa, emergency centres may be staffed by clinical officers, who are not quite doctors but able to provide more advanced care than a nurse.</p>
<p>Undergraduate courses in most of Africa, and certainly in South Africa where I work, largely skimp on emergency care training. And the two- to three-day courses – usually a prerequisite to work in an emergency centre – mainly cover aspects of resuscitation. The result is that emergency centres are staffed with clinicians who either do not practice emergency medicine full-time or are only trained to deal with a small section of specialised emergency care. </p>
<p>There are currently five universities in South Africa that offer specialist training in emergency medicine. The first was established in 2003. But the trickle of specialists produced annually has not yet tangibly filtered down into the health-care system. There are only nine similar offerings on the rest of the continent.</p>
<p>In contrast, emergency medicine as a speciality has existed in developed countries such as Canada, the US, United Kingdom, Australia and New Zealand, and in parts of Western Europe for between 20 and 45 years. </p>
<h2>Africa needs emergency care specialists</h2>
<p>African countries make up more than half of the <a href="https://www.cia.gov/library/publications/the-world-factbook/rankorder/2066rank.html">top 20 countries</a> that have the highest annual death rates. </p>
<p>The two biggest contributing factors are: a lack of attention to prevention at the one end, and emergency care at the other.</p>
<p>Injury related deaths are <a href="http://www.who.int/healthinfo/global_burden_disease/projections/en/">projected to overtake</a> HIV-related deaths by 2030. Noncommunicable causes of death such as acute strokes and heart attacks have steadily increased over the past decade, overtaking the slowing tide of infectious causes of death such as HIV, tuberculosis and malaria.</p>
<p>An emergency care epidemic from injuries and noncommunicable diseases has been quietly filling the room just as HIV and tuberculosis were being ushered out. With proper emergency care only haphazardly practiced, health practitioners are ill prepared to cope with the stresses this will place on an already resource-limited and overburdened health-care system.</p>
<p>From what is known internationally about the ideal standard of emergency care, Africans appear to be getting a raw deal. This is the same whether you are attending a dilapidated public “casualty” department or a tidy private emergency centre. </p>
<p><a href="http://mybroadband.co.za/news/business/157603-why-discovery-is-so-expensive.html">Private medical aid providers admit</a> to this service failure. They point to inappropriate decisions taken by inexperienced doctors working in private emergency centres as one of the key reasons for rising private health-care costs in South Africa. This effect is likely to be similar, if not worse, in public emergency centres staffed by doctors with a similar scope. </p>
<p>Emergency medicine as a speciality involves providing specialist-level care for all acute illnesses or injuries for any age group, whether in or outside the hospital. It means having neurologist, cardiologist, surgical and a whole host of other specialist skills sets available in the emergency centre, with the safety and convenience of not having to wait longer than needed. The knock-on effect is reduced mortality, morbidity and cost. </p>
<p>By providing specialist input early in the patient journey, diagnoses are made sooner, appropriate treatment is started earlier and admissions are made appropriately. This leads to timely care, less complications and earlier discharge – often from the emergency centre. </p>
<p>As shown by multiple <a href="http://www.jogh.org/documents/issue201602/jogh-06-020304.pdf">studies</a> it is really that simple: by investing in the front end of acute care, savings (in more ways than one) are made downstream for both patients and health-care systems. </p>
<p>It is paramount to incorporate proven local solutions into African emergency care because Western solutions don’t face the same resource restrictions. </p>
<p>African countries could, for example, take a leaf out of <a href="http://www.sciencedirect.com/science/article/pii/S2211419X12000067">HIV’s success story</a>. As with antiretroviral treatment, emergency care is a front-end solution that has an effect on nearly every part of the health-care system. And stakeholders from every part of the health-care system need to be involved to set up and maintain the service. </p>
<p>But to achieve any of this, health-care leaders in the public and private sector need to be mobilised as advocates.</p><img src="https://counter.theconversation.com/content/56730/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Stevan Bruijns receives funding from the National Research Foundation as a rated researcher. He is the editor-in-chief for the African Journal of Emergency Medicine, an open-access journal affiliated with the African Federation for Emergency Medicine, a not-for-profit organisation supporting emergency care across Africa</span></em></p>Few African emergency centres are able to provide comprehensive emergency care because they are staffed by general practitioners.Stevan Bruijns, Senior lecturer in the Division of Emergency Medicine, University of Cape TownLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/506642015-11-19T04:24:48Z2015-11-19T04:24:48ZThe big data challenge and how Africa can benefit<figure><img src="https://images.theconversation.com/files/102326/original/image-20151118-14214-1vxrw3o.png?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The Large Hadron Collider is playing a key role in enabling the collection of big data. </span> <span class="attribution"><span class="source">Supplied</span></span></figcaption></figure><p><a href="https://theconversation.com/explainer-what-is-big-data-13780">Big data</a> has become some sort of celebrity. Everybody talks about it, but it is not clear what it is. To unpack its relevance to society it is important to backtrack a bit to understand why and how it came to be this ubiquitous problem.</p>
<p>Big data is about processing large amounts of data. It is associated with multiplicities of data formats stored somewhere, say in a <a href="http://searchcloudcomputing.techtarget.com/definition/cloud-computing">cloud</a> or in distributed computing systems. </p>
<p>But the ability to generate data systematically outpaces the ability to store it. The amount of data is becoming so big and is produced so fast that it cannot be stored with current technologies in a cost effective way. What happens when big data becomes too big and too fast?</p>
<h2>How fundamental science contributes to society</h2>
<p>The big data problem is yet another example of how the methods and techniques developed by scientists to study nature have had an impact on society. The techno-economic fabric that underlies modern society would be unthinkable without these contributions.</p>
<p>There are numerous examples of how findings intended to probe nature ended up revolutionising life. Big data is intimately intertwined with fundamental science and continues to evolve with it.</p>
<p>Consider just a few examples: what would life be without electricity or electromagnetic waves? Without the fundamental studies of <a href="http://www.phy.pmf.unizg.hr/%7Edpaar/fizicari/xmaxwell.html">Maxwell</a>, <a href="http://www.nobelprize.org/nobel_prizes/physics/laureates/1925/hertz-bio.html">Hertz</a> and other physicists on the nature of <a href="http://www.merriam-webster.com/dictionary/electromagnetism">electromagnetism</a> we would not have radio, television or other forms of wave mediated communication, for that matter.</p>
<p>Modern electronics is based on materials called <a href="http://dictionary.reference.com/browse/semiconductor">semi-conductors</a>. What would life today be without <a href="http://www.thefreedictionary.com/electronics">electronics</a>? The invention of transistors and eventually of integrated circuits is based entirely on the work scientists have done by thoroughly studying semi-conductors.</p>
<p>Modern medicine relies on countless techniques and applications. These range from x-rays, medical imaging physics and nuclear magnetic resonance to other techniques such as radiation therapeutic and nuclear medicine physics. Modern medicine and research would be unthinkable without techniques that were initially conceived for scientific research purposes.</p>
<h2>How the information age came about</h2>
<p>The big data problem initially emerged as a result of the need for scientists to communicate and exchange data.</p>
<p>At the European laboratory <a href="http://home.cern/">CERN</a> in 1990, internet pioneer <a href="http://www.w3.org/People/Berners-Lee/">Tim Berners-Lee</a> suggested a browser called <a href="http://www.w3.org/People/Berners-Lee/WorldWideWeb.html">WorldWideWeb</a>, leading to the first web server. The internet was born. </p>
<p>The internet has magnified the ability to exchange information and learn, leading to a proliferation of data.</p>
<p>The problem isn’t only about volume. The time lapsing between the generation and processing of information has also been greatly reduced.</p>
<p>The <a href="http://home.cern/topics/large-hadron-collider">Large Hadron Collider</a> has pushed the boundaries of data collection to limits never seen before.</p>
<p>When the project, and its experiments, were being conceived in the late 1980s scientists realised that new concepts and techniques needed to be developed to deal with streams of data that were bigger than had ever been seen before. </p>
<p>It was then that concepts that contributed to cloud and distributed computing were developed.</p>
<p>One of the main tasks of the Large Hadron Collider is to observe and explore the <a href="http://home.cern/topics/higgs-boson">Higgs boson</a>, a particle connected with the generation of mass of fundamental particles, by means of colliding protons at high energy. </p>
<p>The probability of finding a Higgs boson in a high-energy proton-proton collision is extremely small. For this reason it is necessary to collide many protons many times every second. </p>
<p>The Large Hadron Collider produces data flows of the order of petabytes every second. To give an idea of how big a petabyte is, the entire written works of mankind from beginning of written history, in all languages, can be stored in about 50 petabytes. An experiment at the Large Hadron Collider generates that much data in less than one minute.</p>
<p>Only a small fraction of the data produced is stored. But even this has already reached the exabyte scale (one thousand times a petabyte) leading to new challenges in distributed and cloud computing.</p>
<p>The <a href="http://www.ska.ac.za/about/index.php">Square Kilometre Array</a> (SKA) in South Africa will start generating data in the 2020s. SKA will have the processing power of about 100 million PCs. The <a href="https://www.skatelescope.org/">data</a> it collects in a single day would take nearly two million years to play back on an iPod.</p>
<p>This will produce new challenges for the correlation of vast amounts of data.</p>
<h2>Big data and Africa</h2>
<p>The African continent often lags behind the rest of the world when it comes to embracing innovation. Nevertheless big data is increasingly being seen as a solution to tackling poverty on the continent.</p>
<p>The private sector has been the first to get out of the starting blocks.
The bigger African firms are, naturally, more likely to have big data projects. In Nigeria and <a href="http://www.africanbusinessreview.co.za/technology/1783/Big-Data-in-Africa:-IBM-Dissects-a-Developing-Trend-in-a-Developing-Market">Kenya</a> at least 40% of businesses are in the planning stages of a big data project compared with the global average of 51%. Only 24% of medium companies in the two countries are planning big data projects.</p>
<p>Rich rewards can be reaped from harnessing big data. For example, healthcare organisations can benefit from <a href="http://www.hissjournal.com/content/2/1/3">digitising</a>, combining and effectively using big data. This could enable a range of players, from single-physician offices and multi-provider groups to large hospital networks, to deliver better and more effective services. </p>
<p>Grasping the challenge of managing big data could have big economic spin-offs too. With economies becoming more and more sophisticated and complex the amount of data generated increases rapidly. As a result, in order to improve these complex processes it is necessary to process and understand increasing volumes of data. With this labour productivity is enhanced. </p>
<p>But for any of these benefits to become reality, Africa needs specialists who are proficient in big data techniques. Universities on the continent need to start teaching how big data can be used to find solutions to scientific problems. A sophisticated economy requires specialists who are skilled in big data techniques.</p><img src="https://counter.theconversation.com/content/50664/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Bruce Mellado receives funding from the DST, NRF and the University of the Witwatersrand. </span></em></p>Big data is about processing large amounts of data. It is often associated with multiplicities of data. But the ability to generate data outpaces the ability to store it.Bruce Mellado, Professor of Physics, University of the WitwatersrandLicensed as Creative Commons – attribution, no derivatives.