tag:theconversation.com,2011:/fr/topics/health-funding-4871/articlesHealth funding – The Conversation2022-06-17T06:55:05Ztag:theconversation.com,2011:article/1852962022-06-17T06:55:05Z2022-06-17T06:55:05ZHospital funding deal sets a tight deadline for real reform, and the clock’s ticking<figure><img src="https://images.theconversation.com/files/469410/original/file-20220617-23-mb5gej.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C1000%2C666&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/doctors-running-surgery-567330295">Shutterstock</a></span></figcaption></figure><p>At the urging of the premiers, Prime Minister Anthony Albanese <a href="https://www.abc.net.au/news/2022-06-17/national-cabinet-covid-health-funding-extended/101160740">on Friday agreed</a> to extend current public hospital funding until the end of the year. </p>
<p>The federal government will keep paying for 50% of new costs, up from the usual 45% in pre-pandemic times. The limit on how much costs can go up each year has also been suspended. The extension will cost A$760 million.</p>
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<p>The premiers have long argued for a permanent 50:50 share of new public hospital costs. They have pointed to growing demand for hospital care, new costs from the pandemic, and the fact that states only get about <a href="https://www.abs.gov.au/statistics/economy/government/taxation-revenue-australia/2020-21/55060DO002_202021.XLSX">one third</a> of the nation’s taxes. </p>
<p>The decision kicks the can down the road. In the next few months, the prime minister and premiers will need to forge a new deal for health reform that breaks a long-standing stalemate.</p>
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Read more:
<a href="https://theconversation.com/video-albanese-holds-his-first-national-cabinet-185290">VIDEO: Albanese holds his first National Cabinet</a>
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<h2>New funding should reshape the system</h2>
<p>The states need help to meet rising costs, but this shouldn’t just mean shifting more of the financial burden onto the federal government while ignoring the underlying causes. </p>
<p>Instead, any further extension of funding should reshape the health-care system, shifting care out of hospitals and keeping people well so they don’t need hospital care in the first place.</p>
<p><a href="https://theconversation.com/remind-me-how-are-hospitals-funded-in-australia-177915">Activity-based funding</a> for public hospitals was introduced nation-wide a decade ago. It funds hospitals based on the number and mix of patients they treat, using the average cost of care. That gives hospitals an incentive to bring their costs down, and it has worked well.</p>
<p>But demand for care is rising as the population grows bigger, older and sicker. That means new funding must help keep people out of hospital, not just tamp down hospital costs once they get in the door.</p>
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Read more:
<a href="https://theconversation.com/remind-me-how-are-hospitals-funded-in-australia-177915">Remind me, how are hospitals funded in Australia?</a>
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<h2>We need to shift care away from hospitals</h2>
<p>The quickest way to do this is to move care, providing it at home, and virtually, when it is safe to do so, in a <a href="https://theconversation.com/what-is-hospital-in-the-home-and-when-is-it-used-an-expert-explains-167359">hospital-in-the-home</a> model.</p>
<p>Evidence shows there’s <a href="https://onlinelibrary.wiley.com/doi/abs/10.5694/mja12.10480">no place like home</a> when it comes to hospital care: patients prefer it, it improves outcomes, frees up beds and slashes brick-and-mortar spending. </p>
<p>Other countries and some states in Australia are expanding in-home care. The federal government should push this further by tying a significant share of new funding to these models.</p>
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<a href="https://images.theconversation.com/files/469419/original/file-20220617-11-mb5gej.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Older couple sitting on sofa during telehealth appointment with doctor or screen" src="https://images.theconversation.com/files/469419/original/file-20220617-11-mb5gej.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/469419/original/file-20220617-11-mb5gej.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=374&fit=crop&dpr=1 600w, https://images.theconversation.com/files/469419/original/file-20220617-11-mb5gej.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=374&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/469419/original/file-20220617-11-mb5gej.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=374&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/469419/original/file-20220617-11-mb5gej.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=470&fit=crop&dpr=1 754w, https://images.theconversation.com/files/469419/original/file-20220617-11-mb5gej.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=470&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/469419/original/file-20220617-11-mb5gej.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=470&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">Care can be provided at home and virtually, when it is safe to do so.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/using-ehealth-telemedicine-services-home-couple-1857484306">Shutterstock</a></span>
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<p>Knee replacements are a good example. In other countries, patients increasingly have a one-day hospital stay for their surgery, with preparation and recovery supported at home. The results are <a href="https://www.sciencedirect.com/science/article/pii/S1877056819302853">much better</a> than staying in hospital for multiple days, which remains the standard in Australia.</p>
<p>Some emergency department care can also be moved out of hospitals. The Albanese government’s promised investment in urgent care centres is a welcome <a href="https://theconversation.com/labors-urgent-care-centres-are-a-step-in-the-right-direction-but-not-a-panacea-181237">step</a> in this direction. Once these urgent care centres are established, new funding for growing hospital demand could be used to refine the model and set up more clinics. </p>
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Read more:
<a href="https://theconversation.com/labors-urgent-care-centres-are-a-step-in-the-right-direction-but-not-a-panacea-181237">Labor’s urgent care centres are a step in the right direction – but not a panacea</a>
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<h2>We need to keep people healthy</h2>
<p>The harder way to keep people out of hospital is to keep them healthy. New hospital funding can help here too, by paying for hospital staff to spend more time supporting GP clinics. </p>
<p>Waiting times to see a public hospital specialist were long before the pandemic and have blown out since. Many GP referrals to specialists, and many emergency departments visits, could be avoided by hospital specialists advising GPs, helping them to keep patients well. </p>
<p>These changes won’t help the bottom line immediately, but ultimately, freeing up hospital beds and better management of chronic disease will cut costs, waiting times and pressure on the health-care workforce. More importantly, it will mean a healthier population.</p>
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Read more:
<a href="https://theconversation.com/waiting-for-better-care-why-australias-hospitals-and-health-care-are-failing-104862">Waiting for better care: why Australia’s hospitals and health care are failing</a>
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<h2>The clock is ticking on broader reform</h2>
<p>Public hospital funding is just one piece of the health reform puzzle that the Commonwealth and states will have to solve together under a new health reform agreement. </p>
<p>Equity remains a burning problem, with big gaps in care access and outcomes for people who are <a href="https://grattan.edu.au/report/not-so-universal-how-to-reduce-out-of-pocket-healthcare-payments/">poorer</a>, live in rural areas, or for Aboriginal and Torres Strait Islander people. Closing these gaps – and explicit funding and accountability for them – should be a key focus.</p>
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Read more:
<a href="https://theconversation.com/first-nations-people-in-the-nt-receive-just-16-of-the-medicare-funding-of-an-average-australian-183210">First Nations people in the NT receive just 16% of the Medicare funding of an average Australian</a>
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<p>Solving health worker shortages will take a shared plan that brings together training places, clinical placements, migration and <a href="https://grattan.edu.au/report/unlocking-skills-in-hospitals-better-jobs-more-care/">new workforce models</a>. </p>
<p>Since preventing disease is a shared responsibility, all governments should agree how they will align their work with Labor’s proposed
<a href="https://theconversation.com/how-should-an-australian-centre-for-disease-control-prepare-us-for-the-next-pandemic-184149">centre for disease control</a>.</p>
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Read more:
<a href="https://theconversation.com/how-should-an-australian-centre-for-disease-control-prepare-us-for-the-next-pandemic-184149">How should an Australian 'centre for disease control' prepare us for the next pandemic?</a>
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<p>Perhaps most importantly, the new agreement should be clear on the overarching goals of the health system and how we will measure progress and value as a nation. </p>
<p>Striking a new funding and reform deal by the end of the year is a big challenge, but these reforms are long overdue, so a sense of urgency is welcome. </p>
<p>Too much of the federal-state health-care debate is about how much each side should spend. It would be a wasted opportunity if our political leaders came back again in six months without a long-term plan about how to fund and improve the system.</p><img src="https://counter.theconversation.com/content/185296/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Peter Breadon 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.</span></em></p>It would be a wasted opportunity if our political leaders came back again in six months without a long-term plan about how to fund and improve the system.Peter Breadon, Program Director, Health and Aged Care, Grattan InstituteLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1851942022-06-17T02:20:08Z2022-06-17T02:20:08ZMore funds for aged care won’t make it future-proof. 4 key strategies for sustainable growth<figure><img src="https://images.theconversation.com/files/469381/original/file-20220617-17-ueh3x5.jpg?ixlib=rb-1.1.0&rect=68%2C103%2C5673%2C3716&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://media.gettyimages.com/photos/sad-old-woman-looks-out-the-window-from-home-waiting-for-the-end-of-picture-id1318200521?s=2048x2048">Getty </a></span></figcaption></figure><p>The government costs of providing subsidised aged care for around <a href="https://www.gen-agedcaredata.gov.au/www_aihwgen/media/ROACA/21520-Health_Report-on-the-Operation-of-the-Aged-Care-Act-2020%e2%80%932021.pdf">1.5 million seniors</a> are set to blow out, while earnings for providers are <a href="https://opus.lib.uts.edu.au/bitstream/10453/157405/2/UARC_Aged%20Care%20Sector%20Mid%20Year%20Report%202021-22.pdf">dropping</a>. Aged care delivers many essential services to senior Australians from meals, transport and help at home, to 24/7 nursing and personal care in aged care homes.</p>
<p>This week, the governor of the Reserve Bank, Phillip Lowe, <a href="https://twitter.com/abc730/status/1536868590145531904">warned</a> Australia is on track to spend more on things like disability services, aged care and defence than what taxes can pay for:</p>
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<p>There are increasing demands on the public purse. It’s harder to find out how we’re going to pay for that.</p>
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<p>He told ABC viewers this was a discussion the nation needed to have.</p>
<p>In a paper <a href="https://opus.lib.uts.edu.au/handle/10453/158194">released today</a>, we argue the sustainability of the aged care system needs such a national discussion. </p>
<p>The paper raises serious questions about whether the system can survive the measures needed to address the:</p>
<ul>
<li>current unacceptable quality and safety of some services</li>
<li>unmet demand for home-based services</li>
<li>low wages and poor conditions of the workforce and </li>
<li>high number of providers operating at a loss. </li>
</ul>
<p>The sector already costs taxpayers <a href="https://budget.gov.au/2022-23/content/bp1/download/bp1_2022-23.pdf">A$27 billion per year</a> and it accounts for 1.2% of the economy (GDP). This is expected to nearly double to 2.1% within 40 years.</p>
<p>While demand for subsidised services is high and rising, many parts of the system need improvement. The federal budget can’t solve these problems by placing the entire burden on taxpayers.</p>
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<a href="https://images.theconversation.com/files/469382/original/file-20220617-15-k3i7lt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="older woman with female caregiver" src="https://images.theconversation.com/files/469382/original/file-20220617-15-k3i7lt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/469382/original/file-20220617-15-k3i7lt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=407&fit=crop&dpr=1 600w, https://images.theconversation.com/files/469382/original/file-20220617-15-k3i7lt.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=407&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/469382/original/file-20220617-15-k3i7lt.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=407&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/469382/original/file-20220617-15-k3i7lt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=512&fit=crop&dpr=1 754w, https://images.theconversation.com/files/469382/original/file-20220617-15-k3i7lt.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=512&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/469382/original/file-20220617-15-k3i7lt.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=512&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">Improving career pathways could create a more engaged workforce.</span>
<span class="attribution"><a class="source" href="https://image.shutterstock.com/image-photo/photo-elderly-woman-her-caregiver-600w-313075607.jpg">Shutterstock</a></span>
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Read more:
<a href="https://theconversation.com/fixing-the-aged-care-crisis-wont-be-easy-with-just-5-of-nursing-homes-above-next-years-mandatory-staffing-targets-184238">'Fixing the aged care crisis' won't be easy, with just 5% of nursing homes above next year's mandatory staffing targets</a>
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<h2>A gloomy outlook</h2>
<p>Looking forward, the aged care system will not be “self-correcting”. </p>
<p>Australia’s population is ageing. The number of people aged 85 and older is <a href="https://treasury.gov.au/sites/default/files/2021-06/p2021_182464.pdf">projected to triple</a> to 1.9 million by 2060-61. </p>
<p>This will increase the demand for aged care services and staff and will coincide with an additional necessary lift in staffing to improve the quality of services. </p>
<p>At the same time, the proportion of the population of working age will decline.</p>
<p>Aged care will have to compete with the rest of the economy for skilled staff by offering more attractive wages and conditions. Providers will need more funding to meet these rising costs, especially given that around 60% of aged care homes are <a href="https://opus.lib.uts.edu.au/bitstream/10453/157405/2/UARC_Aged%20Care%20Sector%20Mid%20Year%20Report%202021-22.pdf">already operating at a loss</a>.</p>
<p>Despite this, the government’s <a href="https://treasury.gov.au/sites/default/files/2021-06/p2021_182464.pdf">budget</a> is not only stressed now, but projections from the 2021 Intergenerational Report show budget deficits and government debt will be stretching out for at least the next 40 years. </p>
<p>To add to the gloom, our analysis, and that of the <a href="https://actuaries.logicaldoc.cloud/download-ticket?ticketId=2d440b61-8c9a-4187-bcc5-762981943f46">Actuaries Institute</a>, suggests the aged care budgetary impact could be even more severe than government projections.</p>
<p>Budgetary pressures are not the only concern. Other dimensions of the sustainability challenge include the:</p>
<ul>
<li>future availability of a skilled workforce</li>
<li>viability of high-quality providers and services</li>
<li>need to maintain community satisfaction with service standards.</li>
</ul>
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Read more:
<a href="https://theconversation.com/quality-costs-more-very-few-aged-care-facilities-deliver-high-quality-care-while-also-making-a-profit-178022">Quality costs more. Very few aged care facilities deliver high quality care while also making a profit</a>
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<h2>More than money – 4 key strategies</h2>
<p>Our paper offers four broad strategic approaches to addressing these issues. </p>
<p><strong>1. Slow the level of demand</strong></p>
<p>An often overlooked first strategy is to reduce the growth in demand for subsidised aged care services. Sound investment in primary care, such as more funding for nurse practitioners, physiotherapists and other allied health workers, can help older people improve their health and well-being and maintain their independence for longer.</p>
<p><strong>2. Improve services and health</strong></p>
<p>A second approach is to take a closer look at the effectiveness of the current range of subsidised services. For instance, the delivery of more restorative care would help more people regain and retain their independence. This could reduce the need for some ongoing services and produce better outcomes for those in need, at a lower overall cost.</p>
<p><strong>3. Improve efficiency and workforce engagement</strong></p>
<p>The efficiency of service delivery by providers also deserves closer examination. Evidence <a href="https://opus.lib.uts.edu.au/handle/10453/158194">shows</a> a highly trained and engaged workforce is much more productive and delivers improved standards of care. </p>
<p>At the same time, by improving career pathways for aged care workers, staff turnover costs can be reduced and the need for short-term agency replacements can be lessened.</p>
<p><strong>4. Balance private and public costs</strong></p>
<p>Finally, the balance between the private and public costs of the aged care subsidies should be reassessed.</p>
<p>There has to be a safety net for the many senior Australians who need care and yet are living on low incomes and have few assets. However, the overall level of consumer contributions to care services <a href="https://www.health.gov.au/sites/default/files/documents/2021/08/ninth-report-on-the-funding-and-financing-of-the-aged-care-industry-july-2021.pdf">amounts to</a> less than 10% of total care costs. The national debate needs to reach broad consensus on what is a fair and reasonable contribution from seniors who have higher incomes and wealth.</p>
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Read more:
<a href="https://theconversation.com/how-to-complain-about-aged-care-and-get-the-result-you-want-180036">How to complain about aged care and get the result you want</a>
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<h2>Planning for the future of aged care</h2>
<p>While greater funding from taxpayers and better-off consumers is inevitable, a more sustainable future needs to be achieved through the adoption of multiple interconnected strategies like these. The nature, scale and timing of such strategies should be at the heart of a national conversation about the elders of our society today and tomorrow. </p>
<p>At stake is the sustainable delivery of safe, high-quality services from viable and responsive providers and highly skilled and engaged staff. But these need to be at a cost that can be afforded by current and future generations.</p>
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Read more:
<a href="https://theconversation.com/todays-aged-care-falls-well-short-of-how-wed-like-to-be-treated-but-there-is-another-way-177067">Today's aged care falls well short of how we'd like to be treated – but there is another way</a>
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<img src="https://counter.theconversation.com/content/185194/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Michael Woods is Professor of Health Economics at the UTS Centre for Health Economics Research and Evaluation. He is a policy adviser to the UTS Ageing Research Collaborative which received support to undertake this independent research.</span></em></p><p class="fine-print"><em><span>The UTS Ageing Research Collaborative acknowledges that this independent report was commissioned by the Aged and Community Care Providers Association (ACCPA) in collaboration with Anglicare Australia, BaptistCare, Catholic Health Australia and UnitingCare Australia, with the support of COTA Australia and National Seniors Australia
Nicole Sutton is the current Treasurer of the Palliative Care Association of N.S.W.</span></em></p>While demand for subsidised services is high and rising, many parts of the system need improvement. The federal budget can’t solve these problems by placing the entire burden on taxpayers.Michael Woods, Professor of Health Economics, University of Technology SydneyNicole Sutton, Senior Lecturer in Accounting, University of Technology SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1833352022-05-19T05:06:52Z2022-05-19T05:06:52ZA budget for the ‘squeezed middle’ – but will it be the political circuit-breaker Labour wants?<figure><img src="https://images.theconversation.com/files/464129/original/file-20220518-17-xiocwy.jpg?ixlib=rb-1.1.0&rect=8%2C8%2C5383%2C3581&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Getty Images</span></span></figcaption></figure><p>One way to make sense of Finance Minister Grant Robertson’s fifth <a href="https://www.beehive.govt.nz/release/budget-2022-secure-future-difficult-times">budget speech</a> was to see it as a political performance working on different levels. </p>
<p>First, Labour needs this budget to do an immediate job – address concern with the cost of living. Following two years of pandemic-dominated politics, Robertson had to tell a compelling story about his plans for tackling mounting fuel, food and other prices. </p>
<p>Reminding people that some of this is beyond the government’s control is not a winning strategy. Handing out something tangible was imperative today – hence a NZ$1 billion cost-of-living package, including a one-off $350 cash payment for some 2.1 million low- and middle-income earners, and extended public transport subsidies and fuel excise cuts.</p>
<p>But the government also wants a reset in its head-to-head with a resurgent National Party. Many voters have moved on from the pre-Omicron phases of the pandemic. And with a genuine contest looming at next year’s election, Labour and the Greens will be hoping today’s announcements serve as a political circuit-breaker.</p>
<p>Some of the big-ticket items – chiefly the health reforms and Emissions Reduction Plan – speak to the longer term. We can imagine the government will be closely watching the Australian federal election this weekend to see how much climate policy influences voters’ choices.</p>
<p>Finally, there may also be something deeper going on. As reaction to today’s budget rolls in, we’ll get a sense of New Zealanders’ ongoing appetite for a more active and engaged state. Here and internationally, the pandemic years have represented a break with small state orthodoxy. </p>
<p>And while Robertson reassured voters and markets that this is a prudent, sustainable budget (many governments would walk over broken political glass for a projected surplus in 2025), the National and ACT parties will seek to portray Labour as fiscally profligate. Whichever narrative prevails will go a long way to determining whether Robertson delivers a third-term budget.</p>
<p><strong>– Richard Shaw, Massey University</strong></p>
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<h2>The government in the economy</h2>
<p>Budgets are generally no longer a surprise – most things are telegraphed well in advance. This is deliberate as mistakes happen when households and businesses have to play “guess what the government is thinking”. </p>
<p>A slight surprise was the one-off cost-of-living payment to those earning under $70,000. While no doubt any extra money is welcome to those struggling, the amount does need to be put into context. At the median wage of about $57,000 a year, an extra $350 is equivalent to a 0.6% pay increase. Inflation in the first quarter of 2022 alone was 1.7% and 6.9% for the year, and this is a one-off payment – you don’t get that money on an ongoing basis. </p>
<p>This budget also entrenches a bigger government presence in the economy.</p>
<p>In 2016, core crown expenses of $74 billion equalled 29% of gross domestic product (GDP). Core expenses are projected to be $127 billion (about 33% of GDP) for the year ended June 2023, and $138 billion (31% of GDP) by 2026. At the same time, tax revenue has grown from $70 billion (27.5% of GDP) in 2016 to a projected $116 billion in 2023 (30% of GDP). </p>
<p>Tax revenue is projected to grow to $138 billion by 2026 – or by about 6% per year – by which point it will be around 31% of GDP and the government’s books will balance once again. Under the current expenditure settings, significant changes to tax thresholds or rates seem unlikely. </p>
<p><strong>– Stephen Hickson, University of Canterbury</strong></p>
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<h2>Leaving poor children behind</h2>
<p>The centrepiece of the budget’s cost-of-living response – a temporary three-month cash payment of $350 – targets families earning under $70,000. Cash injections, when targeted and adjusted appropriately, are important poverty tools, allowing families to plug gaps in vital expenditure.</p>
<p>The problem, however, is that such payments aren’t targeted progressively and bypass those who are really being “squeezed” – the lowest income families who are most likely being kept in poverty by our income assistance programmes, and who are not eligible for this cost-of-living payment. </p>
<p>Indeed, Treasury’s own estimates predict that, while all families’ incomes should increase in the next few years, middle-class families’ incomes are projected to increase at a faster rate than those at the bottom of the income distribution.</p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/the-cost-of-living-crisis-means-bolder-budget-decisions-are-needed-to-lift-more-nz-children-out-of-poverty-181466">The cost of living crisis means bolder budget decisions are needed to lift more NZ children out of poverty</a>
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<p>We shouldn’t be surprised by the most vulnerable families being forgotten in the budget announcements today. The government had announced changes to benefit rates (decried by child poverty experts at the time as not enough) ahead of the budget and signalled this was already “enough”. </p>
<p>But the announcement that child support payments will go directly to parents on benefits (rather than being paid by the other liable parent to the government) is a welcome change that will lift some children out of poverty and reduce another punitive barrier to supporting the well-being of families that don’t fit the nuclear norm.</p>
<p>By the government’s own budget projections, the already modest child poverty targets set last year won’t be put back on track. In fact, they’ll fall well short of estimates based on a relative measure of income before housing costs are included, and only just squeeze into the margin of error on a measure of fixed income after housing costs are included – a short-term target that was easily met last year.</p>
<p>This budget will be remembered as the first to demonstrably leave poor children behind.</p>
<p><strong>– Kate Prickett, Te Herenga Waka — Victoria University of Wellington</strong></p>
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<h2>No step-change on climate change</h2>
<p>With the announcement of the Emissions Reduction Plan on Monday, there were only a few surprises left for budget day: an additional $47 million went to climate adaptation, $16 million for community-based renewable energy, a $73 million top-up for the Warmer Homes programme, and $132 million to extend the public transport fare reduction for two months, or longer for Community Services cardholders. </p>
<p>Otherwise, the budget confirmed fiscal commitments we already knew, such as the ten-fold boost to decarbonisation funding at $678 million, and $350 million for cycleways and public transport. The ERP proposal for mission-led “climate innovation platforms” appears to be unfunded.</p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/air-of-compromise-nzs-emissions-reduction-plan-reveals-a-climate-budget-thats-long-on-planning-short-on-strategy-181478">Air of compromise: NZ's Emissions Reduction Plan reveals a climate budget that’s long on planning, short on strategy</a>
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<p>All up, the transport sector receives $1.3 billion, energy $692 million and agriculture $380 million. As a complement to the Emissions Trading Scheme, this policy mix is expected to reduce emissions by 95 to 228 metric tons over the next three emissions budgets until 2035.</p>
<p>But what about the government’s hints that, after underwhelming investment on climate action in past years, 2022 would be the year of the climate budget? If we exclude the extraordinary spending of the COVID-19 Response and Recovery Fund, then ordinary spending on climate-related initiatives through the budget process has only gently increased. </p>
<p>Building on <a href="https://theconversation.com/new-zealands-covid-19-stimulus-is-a-lost-opportunity-to-move-towards-a-low-emissions-economy-155838">earlier analysis</a>, we estimate that at least $3 billion was allocated to climate-positive initiatives in 2022, compared to $1.4 billion in 2020 and $2.8 billion in 2021. Without a doubt, this year’s climate-related expenditure is more coherent and targeted, but not obviously a step-change.</p>
<p><strong>– David Hall and Nina Ives, Auckland University of Technology</strong></p>
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<h2>A mixed bag for health</h2>
<p>Health was a clear focus of the budget ahead of the health system restructure. The $1.8 billion funding increase for year one, with $1.3 billion in the second year, will give the system a needed boost as it adapts to the reforms. The last thing we need is a seriously underfunded system unable to cope in a period of significant change.</p>
<p>Aside from the additional operational funding, the budget was a bit of a mixed bag for health. Mental health services received a significant boost, including for <a href="https://www.beehive.govt.nz/release/195000-children-set-benefit-more-mental-health-support">school-based mental health and well-being support</a> and <a href="https://www.beehive.govt.nz/release/next-steps-specialist-mental-health-and-addiction-services">specialist mental health and addiction services</a>. These initiatives are important for the government to deliver on improving well-being.</p>
<p>Additional funding for air and road ambulance services will be important in maintaining and improving service quality. The $191 million in additional Pharmac funding over two years will also be welcome news for many. However, it’s still likely to leave some people disappointed, as the budget doesn’t give clear directions on what that additional funding will be spent on. </p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/why-the-budget-should-treat-public-health-like-transport-vital-infrastructure-with-long-term-economic-benefits-180322">Why the budget should treat public health like transport – vital infrastructure with long-term economic benefits</a>
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<p>The equity pay deal with support workers is <a href="https://theconversation.com/collapse-of-negotiations-with-care-workers-shows-little-has-changed-in-how-the-government-views-the-work-of-women-183025">set to expire</a>, so it was good to see further commitment of $40 million per year. However, there was no specific response to <a href="https://www.stuff.co.nz/national/health/128653422/striking-allied-health-workers-say-we-need-to-be-valued">calls for improved pay</a> for allied health workers.</p>
<p>Health workforce development has been allocated additional funding to support the delivery of kaupapa Māori and Pacific services. This and other initiatives will be important for health equity. However, the budget doesn’t offer further specific commitment to overcoming the <a href="https://www.1news.co.nz/2022/04/17/nz-needs-more-locally-trained-doctors-medical-school-professor/">shortage of general practitioners</a>. The need for a third medical school in New Zealand is becoming increasingly urgent.</p>
<p>Overall, more funding for health is always going to make things look better than less funding. The big questions now lie in how successful the overall reforms of the health system will be.</p>
<p><strong>– Michael Cameron, University of Waikato</strong></p><img src="https://counter.theconversation.com/content/183335/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>David Hall is affiliated with the Forestry Ministerial Advisory Group. </span></em></p><p class="fine-print"><em><span>Michael P. Cameron receives funding from Te Hiringa Hauora/Health Promotion Agency.</span></em></p><p class="fine-print"><em><span>Kate C. Prickett, Nina Ives, Richard Shaw, and Stephen Hickson 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>Our experts weigh up the winners and losers in a budget that had to balance an immediate cost-of-living crisis with long-term ambitions for health and climate change.Richard Shaw, Professor of Politics, Massey UniversityDavid Hall, Senior Lecturer in Social Sciences and Public Policy, Auckland University of TechnologyKate C. Prickett, Director of the Roy McKenzie Centre for the Study of Families and Children, Te Herenga Waka — Victoria University of WellingtonMichael P. Cameron, Associate Professor in Economics, University of WaikatoNina Ives, Climate change PhD student, Auckland University of TechnologyStephen Hickson, Economics Lecturer and Director Business Taught Masters Programme, University of CanterburyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1832142022-05-18T20:59:01Z2022-05-18T20:59:01ZLGBTIQ+ and unsure how to vote? Here are what the major parties are promising on health<figure><img src="https://images.theconversation.com/files/463838/original/file-20220518-19-sydn3n.jpg?ixlib=rb-1.1.0&rect=0%2C4%2C1000%2C661&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/young-queer-couple-laughing-together-indoors-2037503012">Shutterstock</a></span></figcaption></figure><p>About one in three LGBTIQ+ voters are not sure who to vote for, or are considering changing who they vote for, this federal election, according to <a href="https://equalityaustralia.org.au/wp-content/uploads/2022/04/Rainbow-votes-report.pdf">a survey</a> by Equality Australia.</p>
<p>So, if you are lesbian, gay, bisexual, trans, intersex, queer or otherwise part of the rainbow community, you might be wondering what the major parties have to offer you. </p>
<p>Health care and LGBTIQ+ issues are among the top concerns for the <a href="https://equalityaustralia.org.au/wp-content/uploads/2022/04/Rainbow-votes-report.pdf">roughly 850,000</a> LGBTIQ+ Australians eligible to vote this election. So let’s look at what each party has promised on health.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/marriage-equality-was-momentous-but-there-is-still-much-to-do-to-progress-lgbti-rights-in-australia-110786">Marriage equality was momentous, but there is still much to do to progress LGBTI+ rights in Australia</a>
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</p>
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<h2>Labor</h2>
<p>Improving health and <a href="https://www.alp.org.au/policies/aged-care">aged care</a> are central Labor platforms this election. Labor <a href="https://www.alp.org.au/policies/medicare-and-your-health">plans to</a> make it easier to see a doctor, set up <a href="https://theconversation.com/labors-urgent-care-centres-are-a-step-in-the-right-direction-but-not-a-panacea-181237">urgent care clinics</a>, and cut costs of medications. </p>
<p><a href="https://assets.nationbuilder.com/lgbtihealth/pages/982/attachments/original/1652661610/LGBTIQ__Health_Australia_-_ALP_Response.pdf?1652661610">Labor</a> <a href="https://www.lgbtiqhealth.org.au/electionsurvey">has promised</a> to consult more with LGBTIQ+ people about their health needs. It will support the national LGBTIQ+ mental health and support hotline, <a href="https://qlife.org.au/">QLife</a>, with a one-off grant to help the service reach more people. Labor also wants to set up a new taskforce to end Australia’s HIV epidemic.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/463829/original/file-20220518-20-v3cvl3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Distressed person curled up on sofa looking at smartphone" src="https://images.theconversation.com/files/463829/original/file-20220518-20-v3cvl3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/463829/original/file-20220518-20-v3cvl3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/463829/original/file-20220518-20-v3cvl3.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/463829/original/file-20220518-20-v3cvl3.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/463829/original/file-20220518-20-v3cvl3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/463829/original/file-20220518-20-v3cvl3.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/463829/original/file-20220518-20-v3cvl3.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">Labor has promised to expand an LGBTIQ+ support hotline, and to consult on health-care needs.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/portrait-beautiful-young-woman-depressed-facial-1452798530">Shutterstock</a></span>
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<p>LGBTIQ+ people would benefit from a stronger health system, but there is not much detail on how Labor’s health reforms would make health care more inclusive for LGBTIQ+ Australians. </p>
<p>Also missing from Labor’s health commitments is specific support for transgender people. Its <a href="https://alp.org.au/media/2594/2021-alp-national-platform-final-endorsed-platform.pdf">2021 national platform</a> said it wanted to ban gay conversion practices and unnecessary medical treatment of <a href="https://ihra.org.au/18106/what-is-intersex/">intersex people</a>, but these have not been election promises this year.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/yes-words-can-harm-young-trans-people-heres-what-we-can-do-to-help-176788">Yes, words can harm young trans people. Here's what we can do to help</a>
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</p>
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<h2>The Greens</h2>
<p>The Greens have also focused on affordable health care this election. They want to <a href="https://greens.org.au/platform/health">expand Medicare</a> to <a href="https://theconversation.com/the-greens-want-medicare-to-cover-a-trip-to-the-dentist-its-a-grand-vision-but-short-on-details-181239">include dental</a> and mental health care by reinvesting private health insurance rebates into the public system. </p>
<p>Out of all the major parties, The Greens have made the most LGBTIQ+ specific commitments this election. They <a href="https://assets.nationbuilder.com/lgbtihealth/pages/982/attachments/original/1652661609/LGBTIQ__Health_Australia_-_Greens_Response.pdf?1652661609">propose</a> A$285 million “to ensure all LGBTIQ+ people have access to holistic and comprehensive health services regardless of whether they live in a capital city or a rural town”. There will be funding for LGBTIQ+ community-run organisations, health services and research.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/463832/original/file-20220518-18-v3cvl3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Man with hand on other man's shoulder sitting in front of female health worker" src="https://images.theconversation.com/files/463832/original/file-20220518-18-v3cvl3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/463832/original/file-20220518-18-v3cvl3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=401&fit=crop&dpr=1 600w, https://images.theconversation.com/files/463832/original/file-20220518-18-v3cvl3.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=401&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/463832/original/file-20220518-18-v3cvl3.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=401&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/463832/original/file-20220518-18-v3cvl3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=504&fit=crop&dpr=1 754w, https://images.theconversation.com/files/463832/original/file-20220518-18-v3cvl3.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=504&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/463832/original/file-20220518-18-v3cvl3.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=504&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">The Greens have promised access to holistic and comprehensive health services for LGBTIQ+ people.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/gloomy-cheerless-man-being-involved-thoughts-597648815">Shutterstock</a></span>
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<p>The Greens will dedicate funding to cover out-of-pocket costs for trans people accessing gender affirming health care. </p>
<p>They also plan to commit $132 million to act on <a href="https://ihra.org.au/darlington-statement/">The Darlington Statement</a>, which advocates for intersex people.</p>
<p>All these commitments might seem ambitious. But they are supported by <a href="https://www.latrobe.edu.au/arcshs/publications/private-lives/private-lives-3">research</a> and <a href="https://www.lgbtiqhealth.org.au/beyond_urgent_national_lgbtiq_mhsp_strategy">recommendations</a> from LGBTIQ+ organisations.</p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/surgery-to-make-intersex-children-normal-should-be-banned-76952">Surgery to make intersex children 'normal' should be banned</a>
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</em>
</p>
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<h2>Coalition</h2>
<p>The Liberal Party <a href="https://www.liberal.org.au/strengthening-australias-world-class-health-system">promises</a> support for primary and preventative health care, expansion of telehealth services, more funding for public and private hospitals, and cost cuts for private health insurance. </p>
<p>Its women’s health platform is based on an almost $54 million commitment to “make it easier for more Australians to become parents”. <a href="https://www.liberal.org.au/our-plan/supporting-senior-australians?gclid=CjwKCAjwj42UBhAAEiwACIhADgPsBsGNB7lY0BEwmpbvJAP1JcckgP0S5HiJJVWnJucZsk7NedOroBoC6jAQAvD_BwE">Aged care</a> is also a big feature of its platform, as is mental health.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/463835/original/file-20220518-15-lmu0oi.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Two women with young child sitting on sofa" src="https://images.theconversation.com/files/463835/original/file-20220518-15-lmu0oi.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/463835/original/file-20220518-15-lmu0oi.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/463835/original/file-20220518-15-lmu0oi.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/463835/original/file-20220518-15-lmu0oi.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/463835/original/file-20220518-15-lmu0oi.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/463835/original/file-20220518-15-lmu0oi.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/463835/original/file-20220518-15-lmu0oi.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">The Liberal Party has promised funding to help more Australians become parents.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/happy-multiethnic-female-couple-their-adorable-1061247518">Shutterstock</a></span>
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<p>The Coalition <a href="https://assets.nationbuilder.com/lgbtihealth/pages/982/attachments/original/1652661608/LGBTIQ__Health_Australia_-_Coalition.pdf?1652661608">assures voters</a> it is “committed to supporting the mental health of the LGBTIQ+ community – particularly the LGBTIQ+ youth – as demonstrated by the ongoing investment in child and youth mental health and LGBTIQ+ specific programs and services”. </p>
<p>The Liberal Party recently announced a <a href="https://www.liberal.org.au/latest-news/2022/05/05/additional-support-mental-health-and-wellbeing-lgbtiq-communities">$4.2 million funding boost</a> over three years for national services to support LGBTIQ+ mental health.</p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/politics-with-michelle-grattan-on-katherine-deves-a-hung-parliament-and-the-new-silence-about-covid-181496">Politics with Michelle Grattan: On Katherine Deves, a hung parliament, and the new silence about COVID</a>
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<p>However, the Coalition has a patchy history when it comes to LGBTIQ+ health. Liberal and National Party members have opposed marriage equality and LGBTIQ+ inclusive sex education. </p>
<p>Some Coalition members <a href="https://theconversation.com/as-parliament-returns-for-2022-the-religious-discrimination-bill-is-still-an-unholy-mess-176362">recently supported</a> religious exemptions allowing discrimination against LGBTIQ+ staff and transgender students in faith-based schools. </p>
<p>Liberal Party candidate for Warringah, Katherine Deves, is vocally opposed to transgender women participating in women’s sport. Prime Minister Scott Morrison has defended Deves, <a href="https://www.theguardian.com/australia-news/2022/may/10/katherine-deves-backtracks-on-apology-for-comments-about-transgender-children">wrongly saying</a> “gender reversal surgery for young adolescents” is a “significant issue”.</p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/im-a-pediatrician-who-cares-for-transgender-kids-heres-what-you-need-to-know-about-social-support-puberty-blockers-and-other-medical-options-that-improve-lives-of-transgender-youth-157285">I’m a pediatrician who cares for transgender kids – here’s what you need to know about social support, puberty blockers and other medical options that improve lives of transgender youth</a>
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<h2>Call to focus on the real issues</h2>
<p>Research shows <a href="https://www.latrobe.edu.au/__data/assets/pdf_file/0007/598804/from-blues-to-rainbows-report-sep2014.pdf">discrimination</a> and lack of access to <a href="https://theconversation.com/i-will-euthanise-myself-before-i-go-into-aged-care-how-aged-care-is-failing-lgbti-people-131306">inclusive services</a> are the main contributors to the <a href="https://www.latrobe.edu.au/__data/assets/pdf_file/0010/1198945/Writing-Themselves-In-4-National-report.pdf">increased risk</a> of mental health problems and suicide LGBTIQ+ people face.</p>
<p>Labor and the Coalition make big promises to fund and support mental health. But these efforts are undermined by both parties’ support for <a href="https://www.smh.com.au/politics/federal/labor-commits-to-religious-freedom-and-lgbtq-protections-but-no-timeline-20220509-p5ajrs.html">religious discrimination</a> and their lack of leadership on transgender inclusion in health care and in public life more broadly.</p>
<p>When it comes to LGBTIQ+ issues this election, most have played out in the mainstream media as the “transgender issue”. However, this misses some of the real issues that matter to this community – freedom from discrimination and access to quality health care.</p><img src="https://counter.theconversation.com/content/183214/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Ruby Grant is a board member of LGBTIQ+ advocacy group, Equality Tasmania. She has previously received research funding from the Tasmanian Government. </span></em></p>But are the major parties really focusing on the right issues?Ruby Grant, Senior Lecturer in Sociology, University of TasmaniaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1733262021-12-12T19:10:07Z2021-12-12T19:10:07ZOlder Australians are already bamboozled by a complex home-care system. So why give them more of the same?<figure><img src="https://images.theconversation.com/files/436564/original/file-20211209-138695-pibcvi.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C1000%2C666&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/health-visitor-combing-hair-senior-woman-1222015342">Shutterstock</a></span></figcaption></figure><p>More than <a href="https://www.aihw.gov.au/reports/australias-welfare/aged-care">a million older Australians</a> need care at home each year. <a href="https://www.health.gov.au/sites/default/files/documents/2021/08/ninth-report-on-the-funding-and-financing-of-the-aged-care-industry-july-2021.pdf">More than 1,000 agencies</a> provide services to them.</p>
<p>Despite the federal government allocating <a href="https://www.health.gov.au/initiatives-and-programs/aged-care-reforms/a-generational-plan-for-aged-care">significant extra funds to home care</a> in the last budget, there is still a raft of problems with current home-care arrangements.</p>
<p>As we show in <a href="https://grattan.edu.au/report/unfinished-business-practical-policies-for-better-care-at-home/">our new report</a>, “Unfinished business: practical policies for better care at home”, the federal government is placing too much emphasis on expanding the market of services, and not enough on supporting people to access timely and quality services.</p>
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Read more:
<a href="https://theconversation.com/explainer-what-is-a-home-care-package-and-who-is-eligible-112405">Explainer: what is a home care package and who is eligible?</a>
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<p>Home care support ranges from help with personal care and cleaning the house, to provision of mobility aids, and transport to social events and medical appointments. </p>
<p>People who need care at home can explore options via the federal government’s <a href="https://www.myagedcare.gov.au/">myagedcare</a> website. Then they can get assessed, find a local provider to suit their needs, and manage their own care.</p>
<p>But this system is <a href="https://www.ingentaconnect.com/contentone/tpp/ijcc/2020/00000004/00000003/art00006">impersonal and cumbersome</a>.</p>
<p>Assessment of people’s needs is divorced from planning their services. Older people get little advice and support to find services, and people who need more intensive and complex care often have to wait for more than a year.</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1339011873237131264"}"></div></p>
<p>Administrative and coordination costs for the <a href="https://www.aihw.gov.au/reports/australias-welfare/aged-care">200,000 people who get home care packages</a> are high, hourly service charges are unregulated, and there is more than <a href="https://www.stewartbrown.com.au/images/documents/StewartBrown_-_ACFPS_Financial_Performance_Sector_Report_June_2021.pdf">A$1.6 billion in unspent funds</a> that could be used to provide services.</p>
<p>The number of private services has grown dramatically, with little oversight of quality and value for money.</p>
<p>At the same time, home-care workers <a href="https://www.smh.com.au/politics/federal/canberra-told-to-pay-up-to-get-aged-care-workers-a-25-per-cent-rise-20210705-p586x9.html">remain poorly paid and under-valued</a>. Training is patchy, work is often insecure, and there’s insufficient supervision, support and staff development.</p>
<p>Not surprisingly, it is increasingly difficult to recruit and retain aged-care workers.</p>
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<strong>
Read more:
<a href="https://theconversation.com/confused-about-aged-care-in-the-home-these-10-charts-explain-how-it-works-113923">Confused about aged care in the home? These 10 charts explain how it works</a>
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<h2>What’s wrong with the extra funding?</h2>
<p>The federal government’s response to the landmark <a href="https://agedcare.royalcommission.gov.au/">Royal Commission into Aged Care</a> was substantial, but it doesn’t change the fundamentals of the home-care system. It expands a market that is not working for older people.</p>
<p>The government is putting its faith in a centrally regulated market model, dominated by private and non-government home-care businesses.</p>
<p>Even with the massively increased home-care funding, the market may still not provide enough to reduce waiting times for services to less than a month, as the royal commission recommended.</p>
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<a href="https://images.theconversation.com/files/436568/original/file-20211209-137612-sxaiia.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Elderly lady using laptop at home" src="https://images.theconversation.com/files/436568/original/file-20211209-137612-sxaiia.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/436568/original/file-20211209-137612-sxaiia.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=431&fit=crop&dpr=1 600w, https://images.theconversation.com/files/436568/original/file-20211209-137612-sxaiia.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=431&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/436568/original/file-20211209-137612-sxaiia.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=431&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/436568/original/file-20211209-137612-sxaiia.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=542&fit=crop&dpr=1 754w, https://images.theconversation.com/files/436568/original/file-20211209-137612-sxaiia.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=542&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/436568/original/file-20211209-137612-sxaiia.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=542&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">Older people will still have to navigate a complex system and make market choices largely on their own.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/asian-old-woman-using-computer-69690976">Shutterstock</a></span>
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<p>There are currently almost <a href="https://gen-agedcaredata.gov.au/www_aihwgen/media/Home_care_report/Home-Care-Data-Report-1st-Qtr-2021-22.pdf">75,000 waiting for the home care support they need</a>, with some having waited up to nine months.</p>
<p>We calculate that up to 15% more home-care places than planned could be needed just to clear the waiting list. We call on the federal government to keep waiting times to 30 days or less.</p>
<p>The government’s budget package does include additional support to help older people navigate their way through the home-care system. But assessment, care finding, and care coordination will continue to be fragmented.</p>
<p>In the main, older people will still have to navigate a complex system and make market choices on their own.</p>
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Read more:
<a href="https://theconversation.com/budget-package-doesnt-guarantee-aged-care-residents-will-get-better-care-160611">Budget package doesn't guarantee aged-care residents will get better care</a>
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<h2>We need to go local to provide the best support</h2>
<p>Australia needs a new home care model – one that provides much more personalised support to help older people get the services they need and that manages local service systems on their behalf.</p>
<p>It’s difficult to see this being done without establishing effective regional aged-care offices. These offices need to provide a one-stop shop for older people. Yet they also need to have the authority and responsibility to develop and manage local services to make sure older people can get what they need.</p>
<p>The federal government is aware of this problem, but its response is tepid – <a href="https://www.health.gov.au/sites/default/files/documents/2021/05/governance-pillar-5-of-the-royal-commission-response-strengthening-regional-stewardship-of-aged-care.pdf">a trial</a> of small, regional offices of up to ten people to plan, monitor and solve problems. But those regional offices have no responsibility for supporting older people, and no authority to manage service providers on their behalf.</p>
<p>We recommend the federal government establish a network of regional aged-care offices across Australia to plan and develop services, hold funds, pay providers, and administer service agreements for individual older people who need care. These offices should include assessment teams and care finders, to help people who are trying to navigate the home-care system.</p>
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<strong>
Read more:
<a href="https://theconversation.com/as-home-care-packages-become-big-business-older-people-are-not-getting-the-personalised-support-they-need-113183">As home care packages become big business, older people are not getting the personalised support they need</a>
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<p>Good quality home care depends on a well-qualified, secure and valued workforce. Again, the federal government is aware of this problem and has introduced a limited set of workforce reforms. But it has not yet agreed to support improved pay and conditions, minimum qualification standards or a full registration scheme for personal-care workers.</p>
<p>The government should develop and implement a revitalised workforce plan for aged care as part of the <a href="https://www.health.gov.au/initiatives-and-programs/aged-care-reforms/aged-care-legislative-reform">new Aged Care Act</a>. Personal-care workers should be registered and hold suitable minimum qualifications. </p>
<p>The government should also make it clear it will fund the outcomes of the <a href="https://www.fwc.gov.au/cases-decisions-orders/major-cases/work-value-case-aged-care-industry">Fair Work Commission</a> review of fair pay and conditions for aged-care workers, with a ruling expected next year.</p>
<p>As Australia’s population continues to age, many more people with complex needs will need care. The vast majority of them will prefer to be supported at home. Massively expanding home-care services without much stronger market management, and a much more secure workforce, is a risk Australia shouldn’t take.</p><img src="https://counter.theconversation.com/content/173326/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Stephen Duckett is a member of the board of directors of the Brotherhood of St Laurence which, among other services, is a provider of aged care. He is also chair of the board of directors of the Eastern Melbourne Primary Health Network. Grattan Institute began with contributions to its endowment of $15 million from each of the Federal and Victorian Governments, $4 million from BHP Billiton, and $1 million from NAB. In order to safeguard its independence, Grattan Institute’s board controls this endowment. The funds are invested and contribute to funding Grattan Institute's activities. Grattan Institute also receives funding from corporates, foundations, and individuals to support its general activities, as disclosed on its website.</span></em></p><p class="fine-print"><em><span>Hal Swerissen is a non Executive Director of the Murray PHN and the Bendigo Kangan Institute. He is a Fellow in the Health Program at GRATTAN Institute.</span></em></p>Australia needs a new home-care model – one that provides much more personalised support to help older people get the services they need and that manages local service systems for them.Stephen Duckett, Director, Health and Aged Care Program, Grattan InstituteHal Swerissen, Emeritus Professor, La Trobe University, and Fellow, Health Program, Grattan InstituteLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1415232020-06-30T19:10:38Z2020-06-30T19:10:38ZThe updated deal for pharmacists will help recognise their role as health experts, not just retailers<p>Australia’s <a href="https://www1.health.gov.au/internet/main/publishing.nsf/Content/New-7th-Community-Pharmacy-Agreement">7th Community Pharmacy Agreement</a>, which comes into force today and lasts five years, will see the government provide A$16 billion for dispensing subsidised medicines and A$1.15 billion for other services such as diabetes support.</p>
<p>The agreement was struck between the federal government, industry peak body the Pharmacists’ Guild and, for the first time, the <a href="https://www.psa.org.au">Pharmaceutical Society of Australia</a>, which represents Australia’s <a href="https://www.pharmacyboard.gov.au/About/Statistics.aspx">31,000 registered pharmacists</a>.</p>
<p>If you are a consumer, the new deal is a reassuring continuation of essential existing subsidies. Prescription medications accessed under the Pharmaceutical Benefits Scheme (<a href="https://www.pbs.gov.au/pbs/home;jsessionid=4jsuwyz06dyu1dhj761nqmhc5">PBS</a>) will still be available from your local chemist. There will be a bit more government support for some other services provided by pharmacies, especially to Indigenous people. There is continuing recognition of the need to locate a community pharmacy within reach of most people. </p>
<p>If you are a pharmacist, the agreement finally gives you a little recognition as a professional with years of training and high standards, as distinct from corporations with chains of chemist stores.</p>
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Read more:
<a href="https://theconversation.com/explainer-what-is-the-community-pharmacy-agreement-38789">Explainer: what is the Community Pharmacy Agreement?</a>
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<h2>What’s in the agreement?</h2>
<p>The <a href="https://theconversation.com/explainer-what-is-the-community-pharmacy-agreement-38789">Community Pharmacy Agreement</a> is one of the building blocks of the Australian health system, which is notably fairer and more effective than that in the United States. The underpinning expectation is that the federal government will <a href="https://theconversation.com/explainer-how-is-the-price-of-medicine-decided-in-australia-83633">subsidise</a> prescription medicines under the PBS. We all benefit if everyone can afford those treatments. </p>
<p>Markets are imperfect. In an <a href="https://theconversation.com/relaxing-pharmacy-ownership-rules-could-result-in-more-chemist-chains-and-poorer-care-122628">unregulated</a> environment we would see pharmacies clustering in areas of high population – just like fast food shops – and not serving other areas such as outer suburbs and rural Australia.</p>
<p>The succession of Community Pharmacy Agreements, authorised under the <a href="https://austlii.edu.au/cgi-bin/viewdb/au/legis/cth/consol_act/nha1953147/">National Health Act</a>, uses regulation to avert this kind of market failure. The rules mean you cannot set up a pharmacy to compete with another nearby pharmacy, apart from under exceptional circumstances, thus ensuring the commercial viability of each pharmacy.</p>
<h2>Where’s the community?</h2>
<p>The “community” label is sometimes misunderstood. It doesn’t mean your local chemist is run by volunteers, the local council, or the federal government. Instead, it means the pharmacy operates on a commercial basis for people in the community. It is distinct from dispensing of medications by hospitals, which typically restrict what they offer to current patients and have a different business model.</p>
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<img alt="" src="https://images.theconversation.com/files/344695/original/file-20200630-103661-15ynk9w.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/344695/original/file-20200630-103661-15ynk9w.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=337&fit=crop&dpr=1 600w, https://images.theconversation.com/files/344695/original/file-20200630-103661-15ynk9w.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=337&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/344695/original/file-20200630-103661-15ynk9w.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=337&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/344695/original/file-20200630-103661-15ynk9w.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=424&fit=crop&dpr=1 754w, https://images.theconversation.com/files/344695/original/file-20200630-103661-15ynk9w.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=424&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/344695/original/file-20200630-103661-15ynk9w.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=424&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Pharmacies are a vital part of the community.</span>
<span class="attribution"><a class="source" href="https://commons.wikimedia.org/wiki/File:Elliston_Pharmacy,_2017_(01).jpg">Bahnfrend/Wikimedia Commons</a>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span>
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<p>Each pharmacy serving the community must be supervised by a pharmacist – a health practitioner who has undergone extensive training and meets the relevant professional criteria. Pharmacists are supervised under the <a href="https://www.ahpra.gov.au/About-AHPRA/What-We-Do/Legislation.aspx">National Health Practitioner Regulation Law</a> and associated <a href="https://www.pharmacyboard.gov.au">Pharmacy Board</a>.</p>
<p>The dispensing of medicine in community pharmacies needs to be supervised by pharmacists, although pharmacies can be owned by non-practitioners. The ongoing shift to corporate ownership is contentious, as pharmacies move away from being analagous to the “friendly family doctor” and towards a business model that emphasises selling jelly beans, “wellness” products and fluffy toys alongside medications. That model is not good for public health, and not necessarily good for the pharmacists themselves (more on this point later).</p>
<h2>What’s the significance of the new agreement?</h2>
<p>The agreement is important for three reasons. </p>
<p>First, and most importantly, it retains existing arrangements regarding distribution of pharmacies. Those arrangements have been criticised by entrepreneurs, often represented by the <a href="https://www.guild.org.au/news-events/news/2020/the-seventh-community-pharmacy-agreement">Pharmacy Guild</a>, which is the equivalent of industry peak bodies such as the Minerals Council of Australia.</p>
<p>The latest version of the agreement provides for updating of government payments to wholesalers and retailers of prescription medications – in other words, continued subsidisation of products under the PBS and support for the pharmaceutical supply chain. </p>
<p>There is little point in subsidising payments by consumers if there are no supplies in the warehouses for distribution to the pharmacies. That is an issue of concern amid a pandemic. Streamlining of processes under the agreement will make it easier for pharmacies to receive payments to dispense medicines subsidised under the PBS and the <a href="https://www.dva.gov.au/health-and-treatment/help-cover-healthcare-costs/manage-medicine-and-keep-costs-down/concessional">Repatriation Pharmaceutical Benefits Scheme</a>, which helps Australia’s veterans and predates the wider PBS.</p>
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Read more:
<a href="https://theconversation.com/pay-pharmacists-to-improve-our-health-not-just-supply-medicines-124641">Pay pharmacists to improve our health, not just supply medicines</a>
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<p>There will be support for pharmacy services in regional, rural and remote areas, although past <a href="https://ajp.com.au/news/community-pharmacies-in-rural-and-remote-australia-are-on-the-brink-of-extinction/">concerns</a> about the viability of pharmacies in the bush mean it is uncertain whether this support will be sufficient.</p>
<p>Second, the agreement also provides support – mainly in the form of payments under the <a href="https://www.ndss.com.au/">National Diabetes Services Scheme</a> and the <a href="https://www1.health.gov.au/internet/publications/publishing.nsf/Content/nmp-guide-medmgt-jul06-contents%7Enmp-guide-medmgt-jul06-guidepr3">Dose Administration Aids</a> program – for advice by pharmacists regarding ongoing testing by consumers with diabetes and assistance to seniors. </p>
<p>There is also increased funding of programs aimed at boosting Aboriginal and Torres Strait Islander peoples’ access to medicines. </p>
<p>Finally, the agreement belatedly and weakly acknowledges the Pharmaceutical Society of Australia.</p>
<p>The society’s involvement in the agreement is important because health services are not just about profit. Corporate imperatives to maximise the use of floor space by selling <a href="https://theconversation.com/government-decision-not-to-ban-homeopathy-sales-from-pharmacies-is-a-mistake-96114">non-therapeutic</a> products are potentially at odds with both professional practice and consumer benefit. </p>
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Read more:
<a href="https://theconversation.com/pharmacists-should-drop-products-that-arent-backed-by-evidence-12646">Pharmacists should drop products that aren't backed by evidence</a>
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<p>The latest agreement expands the existing remuneration to pharmacy owners for pharmacists to provide health advice. This is likely to be a useful supplement, rather than a major revenue source. In the coming years we can expect to see claims by health economists and calls for greater support.</p>
<p>The Pharmaceutical Society’s involvement is more broadly relevant because the latest agreement provides for remuneration of advising by professionals. Community pharmacists are a first port of call for many people with health issues. Problems with the interaction of multiple medications mean we need accessible professional expertise. </p>
<p>Rewarding such service to the community means pharmacists, self-employed or otherwise, can concentrate on health, not jellybeans and complementary products.</p><img src="https://counter.theconversation.com/content/141523/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Bruce Baer Arnold 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.</span></em></p>The new Community Pharmacy Agreement will make it easier for Australia’s pharmacists to spend time providing expert health advice to customers rather than focusing on retail revenues.Bruce Baer Arnold, Assistant Professor, School of Law, University of CanberraLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1342822020-03-23T18:27:14Z2020-03-23T18:27:14ZCoronavirus vaccine must be affordable and accessible<figure><img src="https://images.theconversation.com/files/322021/original/file-20200320-22614-1613lp5.jpg?ixlib=rb-1.1.0&rect=17%2C296%2C5973%2C3691&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Globally, billions of dollars in public funds have been committed for COVID-19 vaccine development. It's crucial that the resulting vaccine be accessible to all.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/virus-vaccine-development-vaccines-against-coronavirus-1630332622">(Shutterstock)</a></span></figcaption></figure><p>The race is on to develop a vaccine to protect against COVID-19. <a href="https://donortracker.org/German-funding-CEPI-vaccine-development-efforts-COVID-19">Germany</a>, the <a href="https://www.congress.gov/bill/116th-congress/house-bill/6074/text">United States</a>, the <a href="https://ec.europa.eu/commission/presscorner/detail/en/IP_20_474">European Union</a> and <a href="https://www.kff.org/global-health-policy/issue-brief/donor-funding-for-the-global-novel-coronavirus-response/">others</a> have collectively committed more than a billion dollars. </p>
<p>On March 11, Canada announced it would provide <a href="https://pm.gc.ca/en/news/news-releases/2020/03/11/prime-minister-outlines-canadas-covid-19-response">$275 million</a> toward the research and development of some of the world’s most promising candidate vaccines, diagnostics and therapeutics, among other public health and clinical research.</p>
<p><a href="https://www.cbc.ca/news/health/drugs-government-funded-science-1.4547640">Public funds are the backbone of the underlying science</a> that’s needed to develop the medical tools that we need and use. But today there is little indication — and no requirement — that the billions of public dollars being spent will result in a vaccine or treatment for COVID-19 that is affordable. </p>
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<img alt="" src="https://images.theconversation.com/files/322023/original/file-20200320-22622-1squugx.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/322023/original/file-20200320-22622-1squugx.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=462&fit=crop&dpr=1 600w, https://images.theconversation.com/files/322023/original/file-20200320-22622-1squugx.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=462&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/322023/original/file-20200320-22622-1squugx.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=462&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/322023/original/file-20200320-22622-1squugx.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=580&fit=crop&dpr=1 754w, https://images.theconversation.com/files/322023/original/file-20200320-22622-1squugx.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=580&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/322023/original/file-20200320-22622-1squugx.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=580&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Prime Minister Justin Trudeau holds a news conference on March 13, 2020 announcing federal funding to address the health and economic impact of COVID-19.</span>
<span class="attribution"><span class="source">THE CANADIAN PRESS/Fred Chartrand</span></span>
</figcaption>
</figure>
<p>Instead, governments appear poised to let the private market sort out the details of <a href="https://www.statnews.com/2020/02/27/azar-coronavirus-affordable-trump/">who gets access and at what price</a>. Their logic is that public funding should be used to support early stage discovery, but that the research should ultimately transferred to private companies in order to be fully developed and priced based on what the market can bear. This logic, whether for COVID-19 or for any other disease, is flawed.</p>
<p>For its $275 million investment, Canada has yet to announce what safeguards it will enact to ensure that the vaccines, diagnostics and therapeutics it develops are affordable and accessible to the people and health systems that need them. Given the massive public contributions being made, governments must ensure that the return on these investments comes in the form of lifesaving health services that are free for patients and affordable for health systems — not in the form of high profits for private companies. This is not only the ethical thing to do, it’s also what makes sense as a matter of global public health policy.</p>
<h2>Lessons from the Ebola vaccine</h2>
<p>Canada has recent experience in developing a vaccine that the world needed. The rVSV-ZEBOV vaccine for Ebola was <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5662448/">developped by researchers</a> working at the National Microbiology Laboratory in Winnipeg in the early 2000s. Yet the vaccine was only approved for use by the <a href="https://www.ema.europa.eu/en/news/first-vaccine-protect-against-ebola">European Medicines Agency</a> and the <a href="https://www.fda.gov/news-events/press-announcements/first-fda-approved-vaccine-prevention-ebola-virus-disease-marking-critical-milestone-public-health">U.S. Food and Drug Administration</a> in the fall of 2019, nearly 20 years after it was first developed and many years after the completion of <a href="https://doi.org/10.1016/S0140-6736(16)32621-6">the clinical trial showing it was effective</a>.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/322022/original/file-20200320-22590-1arekoe.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/322022/original/file-20200320-22590-1arekoe.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/322022/original/file-20200320-22590-1arekoe.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/322022/original/file-20200320-22590-1arekoe.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/322022/original/file-20200320-22590-1arekoe.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/322022/original/file-20200320-22590-1arekoe.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/322022/original/file-20200320-22590-1arekoe.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">The National Microbiology Laboratory in Winnipeg, where Canadian scientists developed the rVSV-ZEBOV vaccine for Ebola, is shown in 2009 file photo.</span>
<span class="attribution"><span class="source">THE CANADIAN PRESS/John Woods</span></span>
</figcaption>
</figure>
<p>Why the delay? For a long time, there was simply no financial interest from the private sector in moving it forward — Ebola outbreaks occur in countries that can’t afford the prices that make vaccine development lucrative for pharmaceutical companies. </p>
<p>As the Canadian government shopped around for a private sector partner to develop and commercialize the vaccine, <a href="https://doi.org/10.1503/cmaj.170704">there was little interest</a>. One company with no previous experience bringing a vaccine to market acquired the rights in 2010 for $205,000 and has since sub-licensed the vaccine to Merck for US$50 million after having apparently done <a href="https://www.statnews.com/2020/01/16/public-science-behind-merck-ebola-vaccine/">little to advance the development of the vaccine</a> despite being contractually obligated to do so.</p>
<p>As a colleague put it recently in <a href="https://openparliament.ca/committees/health/42-1/115/dr-aled-edwards-5/only/">testimony to Parliament’s Standing Committee on Health</a>, there is no law of physics that says that the private pharmaceutical industry has to do research and development of lifesaving drugs and vaccines. In fact, the private sector has shown itself to be remarkably out-of-step with many global public health priorities, walking away from research and development of things we all need — <a href="https://www.nytimes.com/2019/12/25/health/antibiotics-new-resistance.html">like new antibiotics</a>. They have, however, become adept at demanding high prices under the threat of <a href="https://lifesciencesontario.ca/news/new-federal-drug-pricing-rules-are-already-delaying-medicine-launches-and-costing-jobs-in-canada-survey-reveals/">delaying the launch of new medicines</a> if these pricing demands aren’t met.</p>
<h2>Public funds don’t guarantee accessible drugs</h2>
<p>It is essential that we learn the lessons from the Ebola vaccine and many other discoveries that have been supported by public funds and get it right, not only with COVID-19 but with our whole approach to publicly funded health innovation. Governments around the world play an integral role in supporting the science that leads to discovering lifesaving technologies. </p>
<p>In Canada alone, researchers in publicly funded labs have discovered an Ebola vaccine, <a href="https://www.theglobeandmail.com/news/national/canada-150/insulin-the-canadian-discovery-that-has-saved-millions-of-lives/article35537847/">insulin</a>, the <a href="https://www.bcmj.org/articles/john-hopps-and-pacemaker-history-and-detailed-overview-devices-indications-and">cardiac pacemaker</a>, a <a href="https://www.canada.ca/en/national-research-council/news/2017/12/vaccine_to_preventdeadlyinfectionsincanadasnorthreachesmanufactu.html">vaccine for haemophilus influenzae</a> and many others.</p>
<figure class="align-left ">
<img alt="" src="https://images.theconversation.com/files/322025/original/file-20200320-22622-g2v1sr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/322025/original/file-20200320-22622-g2v1sr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=735&fit=crop&dpr=1 600w, https://images.theconversation.com/files/322025/original/file-20200320-22622-g2v1sr.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=735&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/322025/original/file-20200320-22622-g2v1sr.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=735&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/322025/original/file-20200320-22622-g2v1sr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=923&fit=crop&dpr=1 754w, https://images.theconversation.com/files/322025/original/file-20200320-22622-g2v1sr.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=923&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/322025/original/file-20200320-22622-g2v1sr.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=923&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">An electron microscope image of SARS-CoV-2, the coronavirus that causes COVID-19.</span>
<span class="attribution"><span class="source">NIAID-RML file photo via AP</span></span>
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<p>While Canada and other governments have supported this important work by directing funding towards universities and research institutes, these funding models generally fail to capture the process from discovery through to use, and instead rely on universities or the researchers themselves to figure out how to get their game-changing discoveries to patients. </p>
<p>Historically, they’ve done this by <a href="https://cihr-irsc.gc.ca/e/50439.html">commercializing their discoveries via the private sector</a>, giving one company exclusive rights to do the subsequent development of the technologies and then to control the sale and price of them when they become a product — with no safeguards or assurances to ensure that patients would have affordable access once the drug or vaccine hits the market.</p>
<p>This no-strings-attached approach to science is foolhardy in an era of patients dying because health systems can’t afford drugs that now routinely cost <a href="https://www.theglobeandmail.com/canada/british-columbia/article-rare-diseases-expensive-drugs-health-canada-showdown-coming/">hundreds of thousands of dollars for some conditions</a>, and where companies are already gearing up to massively profit off of COVID-19 vaccines and therapeutics. </p>
<p>As these new medical tools are developed, licensed and become commercially available, there is a real risk that, given the way the biomedical innovation system works today, they may be rendered inaccessible to those who need them. This should be unacceptable to Canadians, considering the significant public investment that’s been made.</p>
<h2>Making access a priority</h2>
<p>Canada can get this right. We have world-class scientists who by all accounts have promising <a href="https://www.canada.ca/en/institutes-health-research/news/2020/03/government-of-canada-funds-49-additional-covid-19-research-projects-details-of-the-funded-projects.html">candidate vaccines and therapeutics</a> for COVID-19 in the works. We should support their work with public funds through Canada’s research granting councils and other mechanisms. </p>
<p>But we should not blindly accept that the only way these productive, world-class scientists can get their vaccines and therapeutics to patients is by selling them to pharmaceutical companies without negotiating access for patients and health systems upfront. We need safeguards that ensure that if the public paid for it, Canadians and everyone else around the world who needs it will be able to access it quickly and affordably, at a fair price. Public funds should deliver medicines and vaccines that are affordable for the public.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/coronavirus-weekly-expert-analysis-from-the-conversation-global-network-133646">Coronavirus weekly: expert analysis from The Conversation global network</a>
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</em>
</p>
<hr>
<p>Canada may not even have to depend on commercial partners to bring medical innovation from the lab bench to the patient’s bedside. The experience of the Ebola vaccine’s development shows that public sector researchers did much of the heavy lifting in the development and even manufacturing of early batches of the vaccine. We have experts in clinical trials in our hospitals, universities and vaccine research groups who are more than capable of doing the necessary clinical trials to develop and deliver new health technologies quickly and affordably.</p>
<p>We can do health research and development differently, in a way that prioritizes access and affordability for patients and ends the profiteering off sick people in times of crisis. Let’s get to work.</p><img src="https://counter.theconversation.com/content/134282/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jason Nickerson has received funding in the past from the Canadian Institutes of Health Research (CIHR), the Bill and Melinda Gates Foundation, and the Canadian Foundation for Healthcare Improvement (CFHI), the University of Ottawa, and the Canadian Society of Respiratory Therapists (CSRT). He is employed by Doctors Without Borders/Médecins Sans Frontières (MSF). </span></em></p>Canada is investing millions to develop COVID-19 treatments, but there are no safeguards to ensure that those vaccines and medications will be affordable and accessible to the people who need them.Jason Nickerson, Humanitarian Affairs Advisor, L’Université d’Ottawa/University of OttawaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1325812020-03-11T19:18:23Z2020-03-11T19:18:23ZThe coronavirus pandemic is forcing us to ask some very hard questions. But are we ready for the answers?<figure><img src="https://images.theconversation.com/files/319007/original/file-20200306-106594-1vgqfkw.jpg?ixlib=rb-1.1.0&rect=1%2C0%2C997%2C556&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-illustration/coronavirus-disease-flu-outbreak-coronaviruses-influenza-1621997023">Shutterstock</a></span></figcaption></figure><p>The global coronavirus pandemic poses immediate, wide-ranging ethical challenges for governments, health authorities, health workers and the public.</p>
<p>At the heart of these challenges is how best to respond to COVID-19 urgently, yet safely and fairly.</p>
<p>How do we ensure rapid development and delivery of vaccines and other medicines, ethically and with proper oversight? How do we ration and distribute limited healthcare resources? How many of our personal freedoms are we willing to forgo to contain the pandemic?</p>
<p>How do we do this while protecting the vulnerable?</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/why-public-health-officials-sound-more-worried-about-the-coronavirus-than-the-seasonal-flu-132733">Why public health officials sound more worried about the coronavirus than the seasonal flu</a>
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<h2>This situation is unique</h2>
<p>We ask these hard questions in a <a href="https://www.who.int/docs/default-source/coronaviruse/situation-reports/20200219-sitrep-30-covid-19.pdf?sfvrsn=3346b04f_2">unique and rapidly changing</a> environment, with the <a href="https://gisanddata.maps.arcgis.com/apps/opsdashboard/index.html#/bda7594740fd40299423467b48e9ecf6">number of cases</a> and <a href="https://www.marketwatch.com/story/coronavirus-fatality-rates-vary-wildly-depending-on-age-gender-and-medical-history-some-patients-fare-much-worse-than-others-2020-02-26">deaths</a> due to COVID-19 rising daily, and with increased global mobility leading to unstoppable transmission across borders.</p>
<p>The urgency of the situation is even forcing us to rethink <em>how</em> we answer these questions.</p>
<p>Traditionally, we make ethical decisions after <a href="https://link.springer.com/chapter/10.1007/978-94-015-9924-5_13">open dialogue</a> to <a href="https://www.academia.edu/2522689/Paul_Komesaroff._2008._Experiments_in_love_and_death_Medicine_postmodernism_microethics_and_the_body">achieve mutual understanding</a>.</p>
<p>Such dialogue is placed under stress <a href="https://www.researchgate.net/publication/299463625_Agamben_the_exception_and_law">in times of crisis</a> where, because decisions have to be made rapidly, authorities seek to suspend or dispense with time-honoured checks and balances. </p>
<p>However, it is precisely in these potentially dangerous situations that we most need nuanced ethical conversations.</p>
<p>Here are three key examples of the ethical challenges we face.</p>
<h2>1. How do we develop new drugs quickly yet safely?</h2>
<p>The first is how to balance the unknown risks associated with developing a vaccine or other drugs with the need for a response rapid enough to limit spread of the virus.</p>
<p>Part of that challenge is to ensure there is enough oversight of clinical trials when we are also accelerating the delivery of new therapies.</p>
<p>We will have to decide whether it is appropriate to <a href="https://www.ncbi.nlm.nih.gov/books/NBK441674/">accept higher levels of risk</a> to research participants and patients when the stakes are higher.</p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/infecting-healthy-people-in-vaccine-research-can-be-ethical-and-necessary-116263">Infecting healthy people in vaccine research can be ethical and necessary</a>
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<p>As well as the risks there are also potential benefits.</p>
<p>It has taken many years to construct an <a href="https://www.nhmrc.gov.au/about-us/publications/national-statement-ethical-conduct-human-research-2007-updated-2018">elaborate framework</a> to ensure clinical research is conducted ethically.</p>
<p>However, under the pressure of the current emergency we may be able to find ways to reduce bureaucracy and red tape, speed up decision-making and make the system more responsive.</p>
<p>These changes may serve us well in the future, when we return to “business as usual”.</p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/heres-why-the-who-says-a-coronavirus-vaccine-is-18-months-away-131213">Here's why the WHO says a coronavirus vaccine is 18 months away</a>
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<h2>2. How prepared are we to give up some personal freedoms?</h2>
<p>Balancing our personal freedoms – such as freedom of movement and the right to choose or decline medical treatment – with limiting the spread of disease is another major challenge.</p>
<p>We have seen disturbing images from Wuhan in China of officials apparently <a href="https://www.dailymail.co.uk/news/article-7980883/Video-shows-officials-protective-suits-dragging-suspected-coronavirus-carriers-homes.html">detaining citizens</a> walking along the street, or dragging them from their homes.</p>
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<iframe width="440" height="260" src="https://www.youtube.com/embed/SLirQXbJrNA?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">How prepared are we to give up our personal freedoms, such as the right to choose or decline medical treatment?</span></figcaption>
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<p>Australia has announced <a href="https://www.abc.net.au/news/2020-03-02/laws-introduced-to-help-detain-coronavirus-sufferers-in-sa/12017386">plans for legislation</a> allowing people to be detained or isolated when they are said to pose a threat to public safety.</p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/explainer-what-are-the-australian-governments-powers-to-quarantine-people-in-a-coronavirus-outbreak-132877">Explainer: what are the Australian government's powers to quarantine people in a coronavirus outbreak?</a>
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<p>At the same time, community organisations are mobilising to protect and support vulnerable members of society by providing <a href="https://www.lentilasanything.com/">food or other services</a>. Health practitioners will continue to serve their patients with courage and dedication, even when this places them in danger. </p>
<p>How can we ensure such ethical values prevail over increasing authoritarian power? </p>
<p>How much of our personal freedom will we be prepared to give up in support of public health demands? Will we accept self-quarantine at home or isolation in a medical facility? Will we allow authorities to enter people’s homes and arrest infected people? </p>
<p>There is a great risk the emergency measures introduced will continue and be absorbed into everyday practice when the crisis ends. Will we be able to prevent this?</p>
<h2>3. How do we allocate scarce resources?</h2>
<p>Finally, there is the question of <a href="https://www.ncbi.nlm.nih.gov/pubmed/19223051">how best to</a> <a href="https://www.ncbi.nlm.nih.gov/books/NBK54169/">allocate scarce resources</a>, such as drugs, access to intensive care treatments, personal protective equipment, staff and research funding.</p>
<p>As the number of cases increases globally the number of critically ill patients will quickly exceed the available facilities, requiring us to make difficult choices.</p>
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<em>
<strong>
Read more:
<a href="https://theconversation.com/coronavirus-should-frontline-doctors-and-nurses-get-preferential-treatment-132385">Coronavirus: should frontline doctors and nurses get preferential treatment?</a>
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<p>We will <a href="https://www.who.int/csr/resources/publications/WHO_CDS_EPR_GIP_2007_2c.pdf">have to decide</a> who is treated where, who has access to scarce drugs or technologies, how and for whose benefit health professionals and emergency services are deployed, and how food, protective clothing and other items are rationed.</p>
<p>Medical professionals have long been familiar with such discussions, which are now likely to become more routine.</p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/how-do-we-choose-who-gets-the-flu-vaccine-in-a-pandemic-paramedics-prisoners-or-the-public-74164">How do we choose who gets the flu vaccine in a pandemic – paramedics, prisoners or the public?</a>
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<h2>What lies ahead?</h2>
<p>We will need to <a href="https://academic.oup.com/ct/article/17/4/329/4098654">make these decisions</a> in a <a href="https://www.oxfordscholarship.com/view/10.1093/019925043X.001.0001/acprof-9780199250431">democratic way with public involvement</a>, rather than leaving them to experts or government authorities. </p>
<p>We will need to struggle to preserve the ethical values of mutual respect and responsibility, fairness, and care for vulnerable members of society, which may be difficult in our present harsh and uncompromising times.</p>
<p>There are no easy solutions to satisfy everyone. However, at least we can start talking about these issues. For now, maybe that’s the best we can do.</p><img src="https://counter.theconversation.com/content/132581/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>How do we develop new drugs quickly yet safely? How prepared are we to give up some personal freedoms? And how do we allocate scarce resources? These are just some of the tough questions we face.Paul Komesaroff, Professor of Medicine, Monash UniversityIan Kerridge, Professor of Bioethics & Medicine, Sydney Health Ethics, University of SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1246412019-10-10T04:53:39Z2019-10-10T04:53:39ZPay pharmacists to improve our health, not just supply medicines<figure><img src="https://images.theconversation.com/files/296159/original/file-20191009-3867-dvwfmu.jpg?ixlib=rb-1.1.0&rect=1%2C5%2C997%2C660&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Pharmacists receive no financial incentive to counsel patients about how to take their medicines. That needs to change.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/experienced-pharmacist-counseling-female-customer-modern-530265058?src=VfnYpYXbVyVUTGL1OYG9QA-1-0">from www.shutterstock.com</a></span></figcaption></figure><p>When you have a medicine dispensed at your local pharmacy under the
<a href="http://www.pbs.gov.au/">Pharmaceutical Benefits Scheme</a> (PBS), two things happen. The federal government determines how much the pharmacy receives for dispensing your medicine. It also decides what you need to pay. </p>
<p>This so-called fee-for-service funding means pharmacies maximise their revenue if they dispense many prescriptions quickly.</p>
<p>Rather than fast dispensing, it would be better for patients and the health-care system if the funding model paid pharmacists for improving the use of medicines, not just for supplying them. </p>
<p>This is possible, according to our research <a href="https://www.publish.csiro.au/AH/AH18201">published recently</a> in the Australian Health Review. And it should be considered as part of the next <a href="https://www1.health.gov.au/internet/main/publishing.nsf/Content/New-7th-Community-Pharmacy-Agreement">Community Pharmacy Agreement</a>, which outlines how community pharmacy is delivered over the next five years.</p>
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<strong>
Read more:
<a href="https://theconversation.com/explainer-what-is-the-community-pharmacy-agreement-38789">Explainer: what is the Community Pharmacy Agreement?</a>
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<h2>Dispensing medicine is more complex than it looks</h2>
<p>Dispensing medications may seem simple but this can be misleading: it includes both commercial and professional functions. </p>
<p>Under the PBS, the pharmacy receives a handling fee and mark-up on the cost of the drug to cover the commercial cost of maintaining the pharmacy and stock. </p>
<p>It also receives a dispensing fee for the pharmacist’s professional activities. These include reviewing the prescription to ensure it is legal and appropriate, taking into account factors such as your age, whether you are pregnant and which medicines you’ve been prescribed before; creating a record of the dispensing; labelling the medicine; and counselling you, including providing a medicine information leaflet if needed.</p>
<p>Higher dispensing fees are paid for medicines needing greater levels of security (such as controlled drugs including opioids) and for medicines the pharmacist must make up (such as antibiotics in liquid form).</p>
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Read more:
<a href="https://theconversation.com/health-check-is-it-ok-to-chew-or-crush-your-medicine-39630">Health Check: is it OK to chew or crush your medicine?</a>
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<p>But for the vast majority of PBS prescriptions, a pharmacy receives the same basic dispensing fee, currently <a href="http://www.pbs.gov.au/info/healthpro/explanatory-notes/front/fee">A$7.39</a>.</p>
<p>If you have a medicine dispensed for the first time, if it has a complicated dose, or it carries particular risks such as side effects or interactions, a pharmacist is professionally obliged to provide counselling matched to the risk. The more detailed the counselling, the greater the time needed. </p>
<p>However, at present, the dispensing fee to the pharmacy does not change depending on the level of counselling you need. Indeed, the current funding model is a <em>disincentive</em> for the pharmacist to spend time with you explaining your medicine. That’s because the longer they spend counselling, the fewer prescriptions they can dispense, and the fewer dispensing fees they receive.</p>
<h2>What could we do better?</h2>
<p>Performance-based funding, in which payment is adjusted in recognition of the efforts of the service provider or the outcomes of the service delivered, is becoming <a href="https://www.sciencedirect.com/science/article/abs/pii/S0168851013000183">more common</a> in health care and <a href="http://www.euro.who.int/__data/assets/pdf_file/0020/271073/Paying-for-Performance-in-Health-Care.pdf">can correct</a> some of the volume-related issues mentioned above. </p>
<p>It’s already being used in Australia. For instance, GPs are paid a <a href="https://www.humanservices.gov.au/organisations/health-professionals/services/medicare/practice-incentives-program">Practice Incentives Program</a> (PIP) to encourage improvements in services in areas such as asthma and Indigenous health. </p>
<p>However, performance-based funding has yet to be used for pharmacists’ dispensing in Australia. </p>
<p>We propose dispensing fees should be linked to the effort pharmacists make to promote improved use of medicines. This is based on the principle that counselling means <a href="https://www.healthaffairs.org/doi/full/10.1377/hlthaff.2013.1398">people are more likely to take their medications</a> as prescribed, which improves their health. </p>
<p>In other words, pharmacists would receive higher dispensing fees when more counselling is required or if counselling leads to patients taking their medications as prescribed.</p>
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<a href="https://images.theconversation.com/files/296160/original/file-20191009-3894-nireuq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/296160/original/file-20191009-3894-nireuq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/296160/original/file-20191009-3894-nireuq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/296160/original/file-20191009-3894-nireuq.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/296160/original/file-20191009-3894-nireuq.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/296160/original/file-20191009-3894-nireuq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/296160/original/file-20191009-3894-nireuq.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/296160/original/file-20191009-3894-nireuq.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">Pharmacists who spend longer counselling, for instance if someone’s health status has changed, should be rewarded for it.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/432551314?src=2-kqvJbHWH34nwt6dQsUpw-1-8&size=medium_jpg">from www.shutterstock.com</a></span>
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<p>Dispensing fees could be linked to the actual time taken to dispense a prescription: the longer the time, the higher the fee. The time taken would depend on the nature of the drug; the complexity of the patient’s treatment; recent changes in the patient’s health status or other medicines that need to be taken into account; consultation with the prescribing doctor; and the level of advice and education provided. </p>
<p>A blended payment model could include a fee-for-service payment for commercial processes and a performance-linked payment for professional functions.</p>
<p>The most experience with performance-based payments to pharmacy <a href="https://www.ncbi.nlm.nih.gov/pubmed/28844583">is in the United States</a>, where evidence is developing of patients taking their medicine as prescribed and lower total health-care costs. </p>
<p>In England, the government’s <a href="https://www.england.nhs.uk/primary-care/pharmacy/pharmacy-quality-payments-scheme/pqs/">Pharmacy Quality Scheme</a> is similar to the Australian Practice Incentives Program for GPs. It funds improved performance in areas such as monitoring use of certain drugs and patient safety.</p>
<p>There is some <a href="https://ahha.asn.au/system/files/docs/publications/deeble_issues_brief_no_5_partel_k_can_we_improve_the_health_system_with_pay-for-performance.pdf">concern</a> about performance-linked payments. Performance targets need to be achievable without being onerous. And performance needs to be clearly linked to the payment being made, but not if other services suffer.</p>
<h2>Incentives could apply to you too</h2>
<p>Cost is a barrier to some people taking their medicines <a href="https://www.pc.gov.au/research/ongoing/report-on-government-services/2017/health/rogs-2017-volumee.pdf">with over 7%</a> of Australians delaying or not having prescriptions dispensed due to cost.</p>
<p>However, there is currently no financial incentive for you to have a <a href="https://www.healthdirect.gov.au/generic-medicines-vs-brand-name-medicines">generic</a> (non-branded) medicine dispensed, which would save on PBS expenditure. So it makes sense for generic medicines to be a lower cost to you.</p>
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Read more:
<a href="https://theconversation.com/health-check-how-do-generic-medicines-compare-with-the-big-brands-42472">Health Check: how do generic medicines compare with the big brands?</a>
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<p>There is also currently no financial incentive for you to take your medicine as prescribed, which would likely improve your health and save the health budget in the long run. We are not aware of any country varying patient charges based upon this, although there are ways of monitoring if people take their medicines as directed.</p>
<p>However, countries such as New Zealand and the United Kingdom have lower or no patient prescription charges, minimising costs as a barrier to patients taking their medicine. </p>
<h2>What would need to happen?</h2>
<p>Dispensing a prescription should be an invitation for the pharmacist to interact with you and help you with advice on the effective and appropriate use of your medicine. At present, there is no incentive, other than professionalism, for pharmacists to add such value. </p>
<p>The proposed changes would require a major restructure to the funding of dispensing to provide incentives that are equitable and transparent and that did not adversely affect disadvantaged, rural and Indigenous people.</p>
<p>There would need to be agreement on <a href="https://ahha.asn.au/system/files/docs/publications/deeble_issues_brief_no_5_partel_k_can_we_improve_the_health_system_with_pay-for-performance.pdf">reliable and valid</a> performance measures and reliable information systems.</p>
<p>However, funding based on a professional service model rather than a dispensing volume model would support your pharmacist to provide greater benefit to you and the health-care system.</p><img src="https://counter.theconversation.com/content/124641/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>John Jackson is a Fellow of the Pharmaceutical Society of Australia and of the Society of Hospital Pharmacists of Australia and conducts research into pharmacy practice at Monash University Faculty of Pharmacy and Pharmaceutical Sciences.</span></em></p><p class="fine-print"><em><span>Ben Urick conducts research into performance-based pharmacy payment models at the University of North Carolina. He also consults with Pharmacy Quality Solutions, an IT vendor in the United States which supports performance-based community pharmacy payment models. Additionally, he is affiliated with the Pharmacy Quality Alliance, a medication-related quality measure developer, as a scientific advisor. </span></em></p>Pharmacies are paid a set amount to dispense most medicines, so the more they dispense, the greater their income. But there’s a better way to pay pharmacists and improve health care at the same time.John Jackson, Researcher, Faculty of Pharmacy and Pharmaceutical Sciences, Monash UniversityBen Urick, Research Assistant Professor, University of North Carolina at Chapel HillLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1218032019-08-20T05:17:45Z2019-08-20T05:17:45ZYouth discounts fail to keep young people in private health insurance<figure><img src="https://images.theconversation.com/files/288652/original/file-20190820-123749-1sn8r0a.jpg?ixlib=rb-1.1.0&rect=66%2C11%2C7271%2C4891&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Many young people see private health insurance as an unnecessary expense.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/792108373?src=JXjo4EIt_ph4IylSUXQv_g-1-7&size=huge_jpg">Yuricazac/Shutterstock</a></span></figcaption></figure><p>It was a key plank of what was dubbed the <a href="https://parlinfo.aph.gov.au/parlInfo/genpdf/chamber/hansardr/1804b2ba-3f8e-4c54-abff-2dea8c0ce814/0035/hansard_frag.pdf;fileType=application%2Fpdf">most significant package of private health insurance reforms in more than a decade</a>. From April 1 this year, private health insurers have been permitted to offer a youth discount – lower premiums for people under 30.</p>
<p>But the early signs are not good. New data <a href="https://www.apra.gov.au/publications/private-health-insurance-statistics">released today by the private health insurance regulator</a> show 7,000 fewer young people (25 to 29 year olds) were insured on June 30, 2019 than three months earlier when the new discount regime started.</p>
<p>In the three years to June 30, 2018, an average of about 2,100 young people dropped private health insurance every month. For the first six months of this year, the decline was 1,700 a month.</p>
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Read more:
<a href="https://theconversation.com/premiums-up-rebates-down-and-a-new-tiered-system-what-the-private-health-insurance-changes-mean-114086">Premiums up, rebates down, and a new tiered system – what the private health insurance changes mean</a>
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<p>So the new policy may have stemmed the bleeding, but young people are still leaving private health insurance. This does not augur well for the future of private health insurance. </p>
<p>It’s time to consider a bold option to encourage young people to stay in private health insurance, which reduces their premium costs based on their likelihood of getting sick. </p>
<h2>Lower health risks but the same costs</h2>
<p>As we pointed out in a recent <a href="https://grattan.edu.au/report/the-history-of-private-health-insurance/">Grattan Institute working paper</a>, the industry fears a death spiral where young and healthy people drop out of insurance, forcing up premiums for everyone left, then more young and healthy people drop out, premiums go up again, and the cycle continues.</p>
<p>Australian private health insurance is based on <a href="https://www.jstor.org/stable/43199730?seq=1#page_scan_tab_contents">community rating</a>. This means insurers must charge all consumers the same premium for the same product: they are not permitted to discriminate based on health risk (such as age, gender, health status, or claims history); and they cannot refuse to insure an individual.</p>
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<img alt="" src="https://images.theconversation.com/files/288655/original/file-20190820-123716-lnf43n.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/288655/original/file-20190820-123716-lnf43n.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/288655/original/file-20190820-123716-lnf43n.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/288655/original/file-20190820-123716-lnf43n.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/288655/original/file-20190820-123716-lnf43n.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/288655/original/file-20190820-123716-lnf43n.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/288655/original/file-20190820-123716-lnf43n.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">
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<span class="caption">Older people are much more likely to use private health insurance yet everyone pays the same premiums.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/751342633?src=nQlns4AG1tl-3qRdpw5G2g-1-17&size=huge_jpg">Rawpixel.com/Shutterstock</a></span>
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<p>Community rating is designed to enable higher-risk people to take out private health insurance, by forcing lower-risk people to cross-subsidise them. It means lower-risk people have to contribute more than what their expected use would require. </p>
<p>But faced with a higher-than-fair premium, low-risk people – typically the young and the healthy – make an economically rational decision to drop their private insurance. Hence the death spiral.</p>
<h2>Discounts don’t cut it</h2>
<p>Australia already has a so-called <a href="https://link.springer.com/article/10.1007/s10754-005-6602-6">lifetime community ranking</a>, under which people who take out private health insurance after their 31st birthday pay higher premiums – an additional 2% per year for each year they defer taking out insurance.</p>
<p>The April 1 changes introduced a reverse scheme, under which people can get a discount of 2% for each year they join before they turn 30, up to a maximum discount of 10%. </p>
<p>But even with the full 10% discount, a 25 year old will still be paying significantly more than they would with a risk-rated premium.</p>
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<strong>
Read more:
<a href="https://theconversation.com/going-to-the-naturopath-or-a-yoga-class-your-private-health-wont-cover-it-110699">Going to the naturopath or a yoga class? Your private health won't cover it</a>
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<p>So the relentless downward trend continues. In the year to June 2019, the number of 25 to 29 year olds with private health insurance dropped 28,000, about 6%. The previous year it was also 6%. The year before that it was 5%. </p>
<p>In fact, for every quarter for the last four years there has been fewer 25 to 29 year olds insured at the end of each quarter than at the beginning of the quarter.</p>
<p>Although it may be too early to declare the new youth discount policy a complete failure, the government and industry need to consider bolder policies.</p>
<h2>A better way to attract young people</h2>
<p>Community rating may have had its day, given that under Medicare, everyone who needs health insurance automatically has it through the public system. </p>
<p>It’s time to consider shifting to risk rating, starting with people under 30. A risk rating based on age could halve young people’s private health insurance premiums and encourage more Australians to stay in private health insurance.</p>
<p>People aged 25 to 29 use health care much less than the rest of the insured population. In 2018-19, the average benefit payments for that group were A$708 per member compared to A$1,363 per member for the whole population. </p>
<p>If there were no cross-subsidies from 25 to 29 year olds, their premiums would be 52% of the average, community-rated premium.</p>
<p>This would dramatically reduce premiums for young people and increase the attractiveness of private health insurance. </p>
<p>As 25 to 29 year olds only comprise 4% of the insured population, adjusting premiums for this group is unlikely to have a measurable impact on premiums for other people with insurance in the short run, and may have a long run benefit if it attracts people aged 30 to 39 into insurance.</p>
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<img alt="" src="https://images.theconversation.com/files/288656/original/file-20190820-123720-10r01n3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/288656/original/file-20190820-123720-10r01n3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/288656/original/file-20190820-123720-10r01n3.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/288656/original/file-20190820-123720-10r01n3.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/288656/original/file-20190820-123720-10r01n3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/288656/original/file-20190820-123720-10r01n3.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/288656/original/file-20190820-123720-10r01n3.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">
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<span class="caption">Moving from a community rating to a risk rating could halve private health insurance premiums for young people.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/427841167?src=1cwyQAe64TuokMzm-k5a5Q-1-38&size=huge_jpg">GaudiLab/Shutterstock</a></span>
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<p>Under this reform, funds would have to manage the transition from a risk-rated premium for a 29 year old to a community-rated premium for a 30 year old. </p>
<p>This might involve full risk rating for 25 year olds and a blended approach – partial risk rating – for people over 25, so that the rate for 29 year olds does not involve too big a jump to a community rated premium at age 30. </p>
<p>But if developing a phasing-in plan is beyond insurers’ skill set, then private health insurance is in even more dire straits than the trend data reveals.</p>
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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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<img src="https://counter.theconversation.com/content/121803/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Grattan Institute began with contributions to its endowment of $15 million from each of the Federal and Victorian Governments, $4 million from BHP Billiton, and $1 million from NAB. In order to safeguard its independence, Grattan Institute’s board controls this endowment. The funds are invested and contribute to funding Grattan Institute's activities. Grattan Institute also receives funding from corporates, foundations, and individuals to support its general activities, as disclosed on its website.</span></em></p>Young people continue to cancel their private health insurance despite discounts to entice them to stay. Instead, we should reduce their premiums based on their likelihood of needing health care.Stephen Duckett, Director, Health Program, Grattan InstituteLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1168942019-06-26T19:36:39Z2019-06-26T19:36:39ZMedical crowdfunding supports the wealthy and endangers privacy – here’s how to make it more ethical<figure><img src="https://images.theconversation.com/files/281246/original/file-20190625-81770-89gapa.jpg?ixlib=rb-1.1.0&rect=80%2C134%2C5910%2C3529&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Crowdfunding platforms could create opportunities to partner individual campaigns with philanthropic organizations that address background causes of health-care gaps.</span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><p>Medical crowdfunding is a fast-growing practice in which online platforms are used to raise money for health-related needs. GoFundMe.com, the largest platform for medical crowdfunding, has <a href="https://www.gofundme.com/about-us">raised $5 billion since 2010</a> and is currently <a href="https://www.gofundme.com/start/medical-fundraising">raising over $750 million annually</a> for medical expenses.</p>
<p>People use donated funds for a wide range of health-related needs, including direct medical care, prescriptions, medical equipment and the costs of travel to hospitals. </p>
<p>Donations from medical crowdfunding have allowed tens of thousands of people to afford medical care in a number of countries, saving lives in the process. </p>
<p>However, this practice raises serious ethical concerns around who benefits from it and how it impacts others. Medical crowdfunding is not likely to disappear any time soon. As a <a href="https://bioethics.hms.harvard.edu/person/associates/glenn-cohen">group of researchers</a> who have been <a href="https://www.crowdfundingforhealth.org/">studying this phenomenon</a>, we would like to share some evidence on its less favourable impacts and some suggestions for how to address them.</p>
<h2>Promoting inequality</h2>
<p>Medical crowdfunding is <a href="https://www.theguardian.com/lifeandstyle/2019/may/20/when-survival-is-a-popularity-contest-the-heartbreak-of-crowdfunding-healthcare">most likely to benefit people with large and relatively wealthy social networks</a> who are media savvy and who can create sympathetic or engaging stories for prospective donors. </p>
<p>If these traits are most common in relatively privileged people, then medical crowdfunding will entrench or exacerbate socioeconomic inequality.</p>
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<img alt="" src="https://images.theconversation.com/files/281248/original/file-20190625-81762-7jbi7v.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/281248/original/file-20190625-81762-7jbi7v.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=376&fit=crop&dpr=1 600w, https://images.theconversation.com/files/281248/original/file-20190625-81762-7jbi7v.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=376&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/281248/original/file-20190625-81762-7jbi7v.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=376&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/281248/original/file-20190625-81762-7jbi7v.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=473&fit=crop&dpr=1 754w, https://images.theconversation.com/files/281248/original/file-20190625-81762-7jbi7v.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=473&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/281248/original/file-20190625-81762-7jbi7v.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=473&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Crowdfunding is less likely to occur in remote Northern Indigenous communities, such as Iqaluit, Nunavut, where health needs are often greatest.</span>
<span class="attribution"><span class="source">THE CANADIAN PRESS/Sean Kilpatrick</span></span>
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<p>There is good reason to think this is happening. For example, our research has shown that in Canada, <a href="http://dx.doi.org/10.1136/bmjopen-2018-026365">people crowdfunding for health-related needs</a> tend to be from areas with high incomes, high levels of education and high rates of home ownership.</p>
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Read more:
<a href="https://theconversation.com/more-than-one-in-100-nunavut-infants-have-tb-94104">More than one in 100 Nunavut infants have TB</a>
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</p>
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<p>To address this, crowdfunding platforms should <a href="https://newsroom.fb.com/news/2017/11/facebook-social-good-forum/">create resources to develop crowdfunding skills</a> among campaigners. They can also follow the lead of <a href="https://watsi.org/">organizations like Watsi</a> and highlight disadvantaged groups on platform webpages and use donation pooling to distribute donations more equitably. </p>
<p>These platforms should also create opportunities for groups to assist those most in need and find ways to connect potential donors to such campaigns.</p>
<h2>Masking injustice</h2>
<p>Some people crowdfund because their care needs are not being met through the health-care system or private insurance. Donated funds can help to address these immediate needs but not the issues creating underlying problems and so may make the <a href="http://dx.doi.org/10.1136/medethics-2016-103933">causes of health-care needs less apparent</a>.</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1107997733632253952"}"></div></p>
<p>Crowdfunding platforms should create opportunities to partner individual campaigns with philanthropic organizations that address background causes of health-care gaps. They can also share anonymized data with governments and health-care providers to identify patterns of need. This information can be used to advocate for reforms.</p>
<p>Campaigners should write about injustices they have experienced that led them to campaign for donated funds in their posted stories. They can also identify groups, political leaders or agencies that can be called upon to remedy these problems. <a href="https://doi.org/10.1371/journal.pone.0215805">Journalists reporting on campaigns</a> should also highlight background causes of health-care gaps in their news stories.</p>
<p>Raising awareness of these injustices can be effective in creating change. For example, <a href="https://www.cbc.ca/news/canada/nova-scotia/nova-scotia-lung-transplant-toronto-1.5061400">Natalie Jarvis could not afford the expense of relocation</a> in preparation for lung transplantation surgery. She faced having to crowdfund these expenses or being transferred to palliative care. Public outrage at this story helped prompt her home province of Nova Scotia to <a href="https://www.cbc.ca/news/canada/nova-scotia/health-care-lung-transplants-travel-allowance-1.5111969">increase the travel allowance for this and other treatments</a>.</p>
<h2>Undermining privacy</h2>
<p>Medical crowdfunding campaigners are rewarded for sharing emotionally gripping stories that disclose personal information. They are also encouraged to use the recipient’s real name and share their diagnostic details, health status and treatment needs and plans, even for incapacitated adults and minors. </p>
<p>Doing so comes at a <a href="https://doi.org/10.1177/1461444816667723">significant cost to personal and medical privacy</a>. Browsing through medical crowdfunding campaigns online quickly reveals highly personal health details, images of recipients surrounded by medical equipment and information about their friends and family.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/281247/original/file-20190625-81737-3j3v9p.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/281247/original/file-20190625-81737-3j3v9p.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/281247/original/file-20190625-81737-3j3v9p.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/281247/original/file-20190625-81737-3j3v9p.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/281247/original/file-20190625-81737-3j3v9p.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/281247/original/file-20190625-81737-3j3v9p.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/281247/original/file-20190625-81737-3j3v9p.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">Research shows that in Canada, medical crowdfunding is carried out by those with high incomes, high levels of education and high rates of home ownership.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<p>To address this potential loss of privacy, crowdfunding platforms should require campaigners to receive documented consent from recipients to share their information where possible. They should also advise campaigners to be especially cautious when sharing information on behalf of minors or adults who cannot give consent.</p>
<p>Campaigners and other members of the public also need better advice from platforms and privacy advocates on privacy issues and how to protect privacy, such as by blurring faces in photos.</p>
<h2>Seeking unproven interventions</h2>
<p>Some campaigns seek funding for medical interventions that are unapproved for use by government regulators or are not scientifically demonstrated to be safe and effective. These campaigns often make unsupported claims about safety and efficacy.</p>
<p>Crowdfunding platforms should encourage campaigners to be cautious about the claims they make when requesting funds for unproven interventions. Platforms could even alert campaigners to the potential risks of such treatments. They should also enable anonymized data exchanges with groups like the <a href="http://www.isscr.org/">International Society for Stem Cell Research</a> and the <a href="https://www.fda.gov/consumers/consumer-updates/fda-warns-about-stem-cell-therapies">United States Food and Drug Administration</a> to better understand and react to crowdfunding for unproven interventions.</p>
<p>There is <a href="https://www.statnews.com/2018/08/06/crowdfunding-for-unproven-stem-cell-procedures-wastes-money-and-spreads-misinformation/">evidence that some businesses selling unproven interventions</a> steer clients toward crowdfunding. Platforms should use lists of problematic clinics or treatments to screen campaigns at risk of misinforming donors. They should also consider <a href="https://www.ft.com/content/f2c17eaa-4afb-11e9-bbc9-6917dce3dc62">banning fundraising for specific providers and dangerous interventions</a>.</p><img src="https://counter.theconversation.com/content/116894/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jeremy Snyder receives funding from the Greenwall Foundation and the Canadian Institutes of Health Research. </span></em></p><p class="fine-print"><em><span>Glenn Cohen has served as a bioethics consultant for Otsuka Pharmaceuticals on its digital medicine portfolio.</span></em></p><p class="fine-print"><em><span>Valorie A. Crooks holds the Canada Research Chair in Health Service Geographies (funded by the Canada Research Chair Secretariat) and a Scholar Award funded by the Michael Smith Foundation for Health Research. </span></em></p><p class="fine-print"><em><span>Peter Chow White 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.</span></em></p>Medical crowdfunding raises billions of dollars annually – mostly for those who already have good jobs and own their own homes.Jeremy Snyder, Professor, Faculty of Health Sciences, Simon Fraser UniversityGlenn Cohen, Professor of Law, Harvard Kennedy SchoolPeter Chow White, Professor and Director of the School of Communication, Simon Fraser UniversityValorie A. Crooks, Full Professor, Simon Fraser UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/986962018-08-29T22:54:20Z2018-08-29T22:54:20ZWhy we need academic health science centres<figure><img src="https://images.theconversation.com/files/234004/original/file-20180829-86141-1gi9ah3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A few woefully underfunded academic health sciences centres are responsible for providing complex care to patients with life-threatening illnesses as well as training future doctors and testing the latest in new surgical techniques.</span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><p>Academic health science centres (AHSCs) are Canada’s high-performance vehicles for better health. </p>
<p>These are partnerships between a university with a medical school and its teaching hospital. While there are hundreds of hospitals in Canada, there are few AHSCs.</p>
<p>The doctors who work there are called academic physicians and they train Canada’s medical students and residents — providing the seed crop of doctors who will ultimately lead the provision of care to Canadians. They also provide complex care and perform research. </p>
<p>When well maintained, these medical centres propel us safely forward for years to come. However, if neglected and ignored, they may ultimately leave us sick and stranded at the roadside. </p>
<p>After assessing Canada’s AHSC, a national group called the Canadian Association of Professors of Medicine (CAPM) concluded that <a href="http://deptmed.queensu.ca/blog/?p=1724">it’s time to fill the tank, change the oil and provide some tender loving care.</a></p>
<p>I would argue that academic medicine is currently experiencing the best of worlds and the worst of worlds. We possess new and powerful diagnostic and therapeutic tools and are poised to deliver more innovative care. However, our ability to accomplish these goals is challenged by a number of sociological, demographic and governmental factors. </p>
<p>This article aims to highlight these challenges, not as a complaint, rather to identify potholes in the road so that they can be avoided or repaired and we can accelerate our progress forward.</p>
<h2>Research and specialized facilities</h2>
<p>Academic health sciences centres conduct research — in the form of <em>clinical trials</em> (to test new drugs, devices and diagnostics), <em>population health studies</em> (to understand diseases at the population level) and <em>translational research</em> (to move basic science to the bedside and back again). </p>
<p>Research is a form of critical inquiry and discovery that generates the evidence upon which medical practise is based. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/234006/original/file-20180829-86135-1g1o9ql.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/234006/original/file-20180829-86135-1g1o9ql.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/234006/original/file-20180829-86135-1g1o9ql.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/234006/original/file-20180829-86135-1g1o9ql.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/234006/original/file-20180829-86135-1g1o9ql.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/234006/original/file-20180829-86135-1g1o9ql.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/234006/original/file-20180829-86135-1g1o9ql.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">Academic health science centres test the latest surgical techniques.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<p>These doctors are also the experts who provide complex care for patients with life-threatening illnesses — including advanced surgeries, transplantation, catheter-based interventions to treat heart attacks and stroke and so much more. They also test the latest surgical techniques and interventions and evaluate new forms of molecular diagnostics.</p>
<p>The ASHC is also home to specialized and expensive core facilities including clinical laboratories, pharmacies and radiology programs (think PET scanners and MRIs) and interventional rooms (including robotic surgery suites, catheterization laboratories and the like) that support the community. </p>
<h2>Congested hospital wards</h2>
<p>To put into perspective how unique these organizations are, we can look at the numbers. Out of approximately 231 hospital sites in Ontario, only 16 are acute care academic centres and only five are fully-fledged AHSCs with medical schools. </p>
<p>These are located at McMaster University, University of Ottawa, Queen’s University, University of Toronto and Western University. Such classifications are however complicated, because the Northern Ontario School of Medicine also has a school of medicine and many of the features of an AHSC.</p>
<p>A 2010 report from the National Task Force on the Future of Canada’s Academic Health Sciences Centres concluded that <a href="http://www.healthcarecan.ca/wp-content/themes/camyno/assets/document/Reports/2010/External/EN/ThreeMissions_EN.pdf">AHSCs provide the majority of complex care in Canada</a>. </p>
<p>However, one of the problems we face is the influx of Canada’s aging population of baby boomers into hospitals. Many of these people require alternate levels of care (ALC) and social support, rather than acute, tertiary care. But Canada lacks a <a href="https://theconversation.com/how-to-solve-canadas-wait-time-problem-96170">comprehensive senior care network</a> and in many hospitals in Ontario, <a href="http://deptmed.queensu.ca/blog/?p=1326">ALC’s occupy 10 to 20 per cent of acute-care beds.</a> </p>
<p>This, along with challenges such as the opioid crisis and homelessness, is congesting emergency departments and overcrowding inpatient wards. This compromises delivery of quality care and challenges physician wellness.</p>
<h2>‘What makes dollars makes sense’</h2>
<p>Academic health science centres are poorly understood by government. Often, to cater to public opinion, the government focuses on enhancing outpatient care, ignoring the <a href="http://deptmed.queensu.ca/blog/?p=1563">importance of accessing state of the art, innovative care</a>.</p>
<p>Compensation models are also misaligned with services provided. Most doctors in the community are paid on what we call a “fee for service” (FFS) payment plan. This means that they bill for each patient they see, for the service rendered. </p>
<p>This model disproportionately rewards clinical activity, particularly procedural activities, while <a href="http://deptmed.queensu.ca/blog/?p=1563">failing to fund many important and time-consuming consultative services, and not funding research and educational activities at all</a>. </p>
<p>At its worst this can lead to a culture where, “what makes dollars makes sense.” </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/234011/original/file-20180829-86144-5681qd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/234011/original/file-20180829-86144-5681qd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=375&fit=crop&dpr=1 600w, https://images.theconversation.com/files/234011/original/file-20180829-86144-5681qd.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=375&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/234011/original/file-20180829-86144-5681qd.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=375&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/234011/original/file-20180829-86144-5681qd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=471&fit=crop&dpr=1 754w, https://images.theconversation.com/files/234011/original/file-20180829-86144-5681qd.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=471&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/234011/original/file-20180829-86144-5681qd.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=471&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">An anti-fentanyl advertisment is seen on a sidewalk in downtown Vancouver, Tuesday, April, 11, 2017. The opioid crisis is contributing to the congestion of emergency departments.</span>
<span class="attribution"><span class="source">THE CANADIAN PRESS/Jonathan Hayward</span></span>
</figcaption>
</figure>
<p>Training pipeline goals at medical schools are also misaligned. While Canada needs large numbers of general practitioners, AHSCs need highly specialized physicians — cardiologists and cardiac surgeons, neurosurgeons and neurologists, gastroenterologists and general surgeons, nephrologists and transplant surgeons, laboratory medicine specialists, anaesthetists and radiologists. A focus on training more general internists is also important to the sustainability of our health-care system. </p>
<p>Finally, Canada lacks a funding mechanism to support the training of our most advanced learners, who are referred to as “fellows.” These are the doctors that go on to provide complex care such as coronary angioplasty, endovascular therapy for stroke, transplant medicine or catheter-based treatment of heart arrhythmias. </p>
<p>In the absence of fellowship funding, Canadian AHSCs rely increasingly on importing international medicine graduates to staff their hospitals.</p>
<h2>No funding for outstanding research</h2>
<p>Finally, we have inadequate research funding models. The creation of a clinician scientist takes approximately three additional years of postgraduate medical training. This is followed by five years as a junior faculty member, during which substantial time protection and mentorship are required. </p>
<p>This is difficult to provide when the rate of success for research proposals at Canada’s agency for funding biomedical research — the Canadian Institute of Health Research (CIHR) — is below 15 per cent. </p>
<p>Due to lack of funds, CIHR has been rejecting 80 to 90 per cent of funding applications, including those deemed outstanding by peer review. CIHR was intended to have a budget equal to one per cent of public health spending, but this has not kept up with health expenditures or inflation.</p>
<p>The <a href="http://www.sciencereview.ca/eic/site/059.nsf/eng/home">2017 Naylor report</a>, from the expert panel on Canada’s Fundamental Science Review notes: </p>
<blockquote>
<p>“Canada ranks well globally in higher education expenditures on research and development as a percentage of GDP, but is an outlier in that funding from federal government sources accounts for less than 25 per cent of that total, while institutions now underwrite 50 per cent of these costs with adverse effects on both research and education.” </p>
</blockquote>
<p>The report recommended an increase in CIHR funding of, “$485 million, phased in over four years, directed to funding investigator-led research.” However, while some of the report’s recommendations were taken up in the 2018 Federal budget, many outstanding grants will continue to be unfunded.</p>
<h2>The future is a federally-funded network</h2>
<p>Alternate funding plans (AFPs) need to be considered, which reward activities in education, research and clinical care equally. </p>
<p>AHSCs also need more research funding — to enable the next wave of researchers to <a href="https://www.policyschool.ca/wp-content/uploads/2016/03/funding-medical-research-zwicker-emery.pdf">save lives</a>. To achieve this they need an improved budget structure. </p>
<p>We should also create a federally funded network of accredited AHSCs. Although health care is primarily provincially funded, the federal government’s funding via the Canada Health Transfer accounts for approximately a quarter of the health-care budget. </p>
<p>Federal funding is both discretionary and growing (at a rate of around six per cent per year). This funding could be used selectively to develop, advance and unify a national network of AHSCs, in which academic departments of medicine could thrive. </p>
<p>With such investment we would certainly see benefits beyond improved health care.</p><img src="https://counter.theconversation.com/content/98696/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Stephen Archer receives research funding from CIHR, the Canada Foundation for Innovation, the Ontario Ministry of Research Innovation and The William J Henderson Foundation .</span></em></p>Canada’s systems of health funding, medical training and physician compensation need an overhaul – to support vital centres of medical research and complex care.Stephen L Archer, Professor, Head of Department of Medicine, Queen's University, OntarioLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1009482018-08-02T04:16:32Z2018-08-02T04:16:32ZDoctors’ fees shouldn’t just be transparent, they should be fair and reasonable<figure><img src="https://images.theconversation.com/files/230349/original/file-20180802-136655-yr7zxw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">High fees are prohibitive for many people who need to see a specialist.</span> <span class="attribution"><span class="source">From shutterstock.com</span></span></figcaption></figure><p>Out-of-pocket costs is a hot-button issue. It is on the agenda for a health ministers’ meeting this week, where the Victorian health minister will <a href="http://www.abc.net.au/news/2018-08-02/vic-medical-bill-shock-first-appointment-transparent-coag/10062418">push the Commonwealth</a> for more transparency about doctors’ fees. </p>
<p>The Medical Board of Australia is also finalising consultations on its <a href="http://www.medicalboard.gov.au/News/Current-Consultations.aspx">draft Code of Conduct</a> for doctors this week, which also emphasises that fees should be transparent. </p>
<p>Of course fees should be transparent, but that’s not good enough. Doctors, and especially specialists, should also be required to set fees that are “fair and reasonable”.</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>From <a href="http://health.gov.au/internet/main/publishing.nsf/Content/Quarterly-Medicare-Statistics">January to March</a>, only 30.8% of visits to specialists were bulk-billed, and the average out-of-pocket costs for those not bulk-billed was A$87.62 for each visit. </p>
<p>The visit to the specialist may lead to further costs such as diagnostic imaging (such as X-rays, ultrasounds and <a href="https://theconversation.com/the-science-of-medical-imaging-magnetic-resonance-imaging-mri-15030">MRI scans</a>), where 78.2% of services are bulk-billed and the average out-of-pocket is A$104.56. The alternative to these high charges is referral to a public hospital outpatient clinic, but the <a href="https://theconversation.com/getting-an-initial-specialists-appointment-is-the-hidden-waitlist-99507">wait between a referral and an appointment</a> can be very long indeed. </p>
<p>The <a href="http://www.abs.gov.au/ausstats/abs@.nsf/mf/4839.0">Australian Bureau of Statistics</a> estimated that in 2016-17 about 815,000 people missed out on seeing a specialist because of cost. That amounts to one out of every 14 people who needed to see a specialist. </p>
<p>Unlike other aspects of health disadvantage, people in metropolitan areas report higher rates of skipping specialist consultation:</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/230348/original/file-20180802-136655-l3laog.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/230348/original/file-20180802-136655-l3laog.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/230348/original/file-20180802-136655-l3laog.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/230348/original/file-20180802-136655-l3laog.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/230348/original/file-20180802-136655-l3laog.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/230348/original/file-20180802-136655-l3laog.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/230348/original/file-20180802-136655-l3laog.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/230348/original/file-20180802-136655-l3laog.png?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"></span>
</figcaption>
</figure>
<p>What are doctors’ ethical obligations when it comes to fee-charging? The draft Code says doctors should:</p>
<ul>
<li><p>ensure that your patients are informed about your fees and charges </p></li>
<li><p>be transparent in financial and commercial matters.</p></li>
</ul>
<p>But, as I argue in a <a href="https://grattan.edu.au/news/good-medical-practice-needs-to-be-founded-on-patients-rights/">Grattan Institute submission to the Medical Board</a>, this is too weak. The medical profession in Australia is out of step with consumer expectations, and with practices in other professions. </p>
<p>The legal profession, for example, has a statutory obligation to charge “<a href="http://www5.austlii.edu.au/au/legis/nsw/consol_act/lpul333/s172.html">costs that are no more than fair and reasonable in all the circumstances</a>”. The Legal Profession Uniform Law in NSW also sets out factors which may affect fees, such as “the quality of the work done” and the “level of skill, experience, specialisation and seniority” of the lawyers involved.</p>
<p>Fees charged by medical practitioners, especially specialists, have recently been the subject of media criticism, notably by medical journalist <a href="http://www.abc.net.au/news/health/2018-05-28/how-out-of-pocket-medical-costs-can-get-out-of-control/9592792">Dr Norman Swan on ABC TV’s Four Corners</a>. So they should be. </p>
<p><a href="https://onlinelibrary.wiley.com/doi/full/10.1002/hec.3317">Academic studies</a> have also shown that specialist fees – especially surgeons’ fees – vary wildly.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/why-it-costs-you-so-much-to-see-a-specialist-and-what-the-government-should-do-about-it-81998">Why it costs you so much to see a specialist – and what the government should do about it</a>
</strong>
</em>
</p>
<hr>
<p><a href="https://www.theguardian.com/australia-news/2018/jan/03/greg-hunt-to-investigate-exorbitant-out-of-pocket-medical-expenses">Policy responses</a> have been based on the assumption that the problem is confined to a small number of specialists charging egregious fees. </p>
<p>If this were the case, it could be argued that these doctors were operating outside professional norms. But the evidence shows it’s not unusual for fees to be <a href="https://www.mja.com.au/journal/2017/206/4/variation-outpatient-consultant-physician-fees-australia-specialty-and-state-and">significantly in excess</a> of even the Australian Medical Association (AMA) rate. The AMA rate is significantly above the Medicare rebate but is often regarded by medical practitioners as the appropriate fee to charge.</p>
<p>This can be an acute problem for some of the most vulnerable Australians: patients with several chronic diseases – such as diabetes, heart disease and depression – who are excessively billed by each of their medical practitioners several times a year.</p>
<p>Under the draft Code of Conduct, these doctors could not be seen as acting unprofessionally if they had simply informed their patients of the proposed fees. </p>
<p>Doctors, especially specialists, have a lot of power in these circumstances. Patients are often reluctant to shop around for a different specialist, if they have been referred to a specific specialist and have initiated contact with that specialist.</p>
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<img alt="" src="https://images.theconversation.com/files/230350/original/file-20180802-136661-1jm9tip.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/230350/original/file-20180802-136661-1jm9tip.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/230350/original/file-20180802-136661-1jm9tip.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/230350/original/file-20180802-136661-1jm9tip.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/230350/original/file-20180802-136661-1jm9tip.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/230350/original/file-20180802-136661-1jm9tip.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/230350/original/file-20180802-136661-1jm9tip.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">
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<span class="caption">Diagnostic imaging, such as a CT scan, is a further cost that often follows specialist fees.</span>
<span class="attribution"><span class="source">From shutterstock.com</span></span>
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<p>An obligation to be transparent is a necessary but not sufficient ethical obligation for contemporary medical practice. The draft Code says doctors should</p>
<blockquote>
<p>not exploit patients’ vulnerability or lack of medical knowledge when providing or recommending treatment or services</p>
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<p>But an obligation to not exploit patients’ vulnerability is not enough. The Code should be expanded to include a specific obligation on doctors to set fair fees.</p>
<p>This is not to dismiss the transparency obligation as irrelevant. Rather, the Code needs to supplement an obligation to disclose fees (transparency) with an obligation not to exploit patients financially.</p>
<h2>Better transparency provisions</h2>
<p>The existing transparency obligation should also be tightened. Too often, patients do not learn of the proposed fees until their initial visit to a specialist. </p>
<p>Patients may be able to discover the out-of-pocket costs associated with the initial consultation when making the booking, but probably not the out-of-pockets for any procedures which might be recommended. By then, the patient may not be able to assess properly whether they want to continue with this specialist.</p>
<p>And in some situations – particularly with anaesthetists – the fee discussion can take place at the time of an operation or procedure, leaving the patient with no effective choice at all.</p>
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<em>
<strong>
Read more:
<a href="https://theconversation.com/how-much-seeing-private-specialists-often-costs-more-than-you-bargained-for-53445">How much?! Seeing private specialists often costs more than you bargained for</a>
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<p>It is therefore important that the transparency of fees is timely. Indicative fees for procedures could be revealed on specialists’ websites, for example, so that patients (and their general practitioners) could make informed decisions before committing to their first consultation.</p>
<p>The Medical Board should tighten its Code of Conduct for doctors. If it doesn’t, too many Australian patients will continue to pay unfair, even exorbitant, fees.</p><img src="https://counter.theconversation.com/content/100948/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Grattan Institute began with contributions to its endowment of $15 million from each of the Federal and Victorian Governments, $4 million from BHP Billiton, and $1 million from NAB. In order to safeguard its independence, Grattan Institute’s board controls this endowment. The funds are invested and contribute to funding Grattan Institute's activities. Grattan Institute also receives funding from corporates, foundations, and individuals to support its general activities as disclosed on its website.</span></em></p>Yes, doctors’ fees should be transparent, but that requirement alone doesn’t go far enough to combat “bill shock”. Specialists should also be required to set fees that are “fair and reasonable”.Stephen Duckett, Director, Health Program, Grattan InstituteLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/861312017-10-23T19:09:00Z2017-10-23T19:09:00ZAssisted dying is one thing, but governments must ensure palliative care is available to all who need it<figure><img src="https://images.theconversation.com/files/191333/original/file-20171023-26647-1jl33ig.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">While assisted dying is contentious, access to palliative care should not be.</span> <span class="attribution"><span class="source">Rustle/Shutterstock</span></span></figcaption></figure><p>Assisted dying moved one step closer to reality in Victoria last week with the authorising bill <a href="http://www.abc.net.au/news/2017-10-20/voluntary-assisted-dying-bill-vote-in-victorian-parliament/9066506">passing the lower house</a> with a comfortable 47-37 majority. Throughout the debate, many MPs spoke of terrible personal experiences of the deaths of family members. Such harrowing stories were also present in submissions to the <a href="https://www.parliament.vic.gov.au/lsic/inquiry/402">parliamentary inquiry</a> into end-of-life choices, that recommended an assisted dying regime leading to the bill.</p>
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<em>
<strong>
Read more:
<a href="https://theconversation.com/victoria-may-soon-have-assisted-dying-laws-for-terminally-ill-patients-81401">Victoria may soon have assisted dying laws for terminally ill patients</a>
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<p>These terrible deaths were most often used to argue in favour of the need for assisted dying. Yet they occurred in a state that prides itself on the quality of its end-of-life services. While assisted dying is contentious, access to palliative care should not be. </p>
<h2>Palliative care in Australia</h2>
<p>Palliative care’s purpose is to enhance the quality of life for patients and their carers. It also aims to fulfil choices about care style and location for those approaching death. Politicians regularly express their support for palliative care. Yet, there is often a chasm between such positive rhetoric and actual delivery.</p>
<p>The gap isn’t new. A 2012 <a href="https://www.aph.gov.au/Parliamentary_Business/Committees/Senate/Community_Affairs/Completed_inquiries/2010-13/palliativecare/report/index">Senate review</a> expressed concern at the “variance in the standard and quality of palliative care” across Australia. In April 2017, the <a href="http://www.audit.nsw.gov.au/news/palliative-care">New South Wales Auditor General</a> was scathing in her criticisms of the state’s services, and in 2015 the <a href="https://www.audit.vic.gov.au/report/palliative-care">Victorian Auditor General</a> highlighted “room for improvement” – this in a state recognised as having the gold standard in palliative care. </p>
<p>A report by the <a href="https://grattan.edu.au/report/dying-well/">Grattan Institute</a> in 2014 also identified a need for better end-of-life services across Australia.</p>
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<em>
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Read more:
<a href="https://theconversation.com/palliative-care-should-be-embraced-not-feared-59162">Palliative care should be embraced, not feared</a>
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<p>The 2010 <a href="https://www.health.gov.au/internet/main/publishing.nsf/Content/EF57056BDB047E2FCA257BF000206168/$File/NationalPalliativeCareStrategy.pdf">National Palliative Care Strategy</a> – that sets out areas to focus on in palliative care – is a worthy, well-received document, saying all the right things. But a <a href="http://www.health.gov.au/internet/main/publishing.nsf/content/EF57056BDB047E2FCA257BF000206168/$File/Evaluation%20of%20the%20National%20Palliative%20Care%20Strategy%202010%20Final%20Report.pdf">review of the strategy</a> conducted at the end of 2016 found little evidence states had used it in developing their frameworks for delivering services. It also found limited accountability or evaluation mechanisms and little detail about vulnerable populations.</p>
<p>The most recent data on palliative care in Australia is incomplete. Although there is information on the provision of <a href="https://www.aihw.gov.au/reports/palliative-care-services/palliative-care-services-in-australia/contents/admitted-patient-palliative-care">hospital-based palliative care</a>, there is no information about services provided by community-based palliative care organisations.</p>
<p>What statistical information we have about the extent to which palliative care services meet patient and carer needs comes from voluntary reporting based on meeting certain benchmarks. These include targets such as having 60% of patients with moderate to severe pain at the beginning of the care period, reduced to absent or mild pain at the end of the period.</p>
<p>It is unlikely organisations that don’t participate have outcomes as good as those that do, so this suggests what we see here may be at the upper end of outcomes. And even then, what we see is not so good.</p>
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<h2>Palliative care and assisted dying</h2>
<p>The advisory panel set up by the Victorian government to set out the framework for the state’s assisted dying regime did not make explicit recommendations about palliative care. But it did <a href="https://www2.health.vic.gov.au/about/publications/researchandreports/ministerial-advisory-panel-on-voluntary-assisted-dying-final-report">note</a></p>
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<p>A person has the right to be supported in making informed decisions about their medical treatment and should be given, in a manner that they understand, information about medical treatment options, including comfort and palliative care.</p>
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<p>Provision of information is one thing, but access to services is another. Again the panel has nice words, stating </p>
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<p>every person approaching the end of life should have access to quality care to minimise their suffering and maximise their quality of life. </p>
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<p>But this rhetoric is not given any force in the panel’s recommendations.</p>
<p>When Victoria’s upper house, the Legislative Council, makes its decision about the assisted dying legislation, it should also ensure every terminally ill person in the state can get good quality palliative care if they want it.</p>
<p>The <a href="https://www.parliament.vic.gov.au/lsic/article/3098">Victorian government’s response</a> to the report of the parliamentary inquiry, that recommended legalising assisted dying, has been strong on support for enhanced palliative care. This welcome rhetoric now needs to be translated into effective policies – and more money.</p>
<h2>Funding for palliative care</h2>
<p>Palliative care is an important part of end-of-life care. A 2010 <a href="http://www.nejm.org/doi/pdf/10.1056/NEJMoa1000678">study in the prestigious New England Journal of Medicine</a> showed that people who received palliative care as they were nearing death actually lived longer than those who pursued aggressive treatment. A <a href="https://grattan.edu.au/report/dying-well/">Grattan Institute report</a> in 2014 showed increasing investment in palliative care would lead to better care and could save money.</p>
<p>One would think governments would do all they could to ensure palliative care is available to all who need it, and to put funding of palliative care on a sound footing. Sadly, that is not the case in Australia today.</p>
<p>In Victoria, funding for <a href="https://www2.health.vic.gov.au/hospitals-and-health-services/patient-care/end-of-life-care/palliative-care/palliative-care-funding-data">out-of-hospital palliative care</a> is currently allocated according to a formula, based loosely on the notional population served by the relevant palliative care organisation. What that means is if a palliative care organisation provides more services, or looks after more people who are at the end of their life, it does not get extra money. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/why-the-seemingly-tidy-leaked-proposal-for-hospital-funding-may-be-a-problem-policy-78461">Why the seemingly tidy, leaked proposal for hospital funding may be a problem policy</a>
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<p>There is no incentive for these organisations to seek out and help people who might benefit from palliative care. It is possible Victorians are missing out on palliative care because of this poor funding design.</p>
<p>Although state budgets are limited, the lid on palliative care funding should be lifted. The risk of a budget blow out is slim. After all, palliative care is for the dying, and <a href="https://www.bdm.vic.gov.au/research-and-family-history/research-and-data-services">the number of deaths is increasing very slowly</a> – about 2% (1,000 deaths) each year.</p>
<p>Funding for palliative care should be put on the same basis as funding for most other parts of the health-care system; that is, palliative care organisations should get paid for the services they actually provide. Unlike other parts of the system, palliative care funding should be uncapped, with the aim that everyone who needs palliative care gets it, and no one is excluded because of budget limitations in a particular service.</p>
<p>Of course, removing the cap on funding should be accompanied by a push to ensure the money is not wasted on inefficient or poor quality services. A new funding regime should be based on the requirement services are provided at or below national efficiency benchmarks. A broad suite of indicators should be used to assess the performance of palliative care organisations. The results should be published regularly, with bonuses paid to good performers.</p>
<p>The Victorian parliamentary debate about assisted dying has been emotional. But whatever the parliament ultimately decides, our politicians should commit to making palliative care available to all who are terminally ill.</p><img src="https://counter.theconversation.com/content/86131/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Grattan Institute began with contributions to its endowment of $15 million from each of the Federal and Victorian Governments, and $4 million from BHP Billiton. In order to safeguard its independence, Grattan Institute’s board controls this endowment. The funds are invested and Grattan uses the income to pursue its activities.</span></em></p>One would think governments would do all they could to ensure palliative care is available to all who need it. This is not the case in Australia today.Stephen Duckett, Director, Health Program, Grattan InstituteLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/826232017-08-28T02:44:58Z2017-08-28T02:44:58ZThe opioid epidemic is finally a national emergency – eight years too late<figure><img src="https://images.theconversation.com/files/183347/original/file-20170824-18740-l5137a.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">People without ID, like Steven Kemp, are sometimes turned away from the country's already threadbare system of drug treatment centers.</span> <span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/APTOPIX-Addicted-Without-ID/adcb4b23ab414c9dba8220d049ded453/25/0">Matt Rourke/AP Photo</a></span></figcaption></figure><p>“It has been many long, hard, agonizing battles for the last few years and you fought like a warrior every step of the way. Addiction, however, won the war. To the person who doesn’t understand addiction, she is just another statistic who chose to make a bad decision.”</p>
<p>Despite working nearly two decades as an addiction scientist, I cannot read <a href="https://www.facebook.com/notes/kathleen-errico/kelsey-grace-endicott-eulogy/10154023124488818/">Kelsey Grace Endicott’s mother’s eulogy</a> without crying. The opioid epidemic has turned those who lost their lives to addiction into statistics, while leaving their families in sorrow. </p>
<p>Overdose deaths in the U.S. have tripled since 2000, with 52,404 deaths in 2015 as the highest ever recorded. While the Centers for Disease Control and Prevention (CDC) has yet to release official statistics for 2016, <a href="https://www.nytimes.com/interactive/2017/06/05/upshot/opioid-epidemic-drug-overdose-deaths-are-rising-faster-than-ever.html">early estimates</a> put the number of deaths at as many as 65,000.</p>
<p>In a speech on October 26, President Trump declared the opioid epidemic a national emergency. Nearly a decade into this epidemic, this national emergency was declared at least eight years too late. Policymakers have missed opportunities to implement strategies scientifically demonstrated to reduce overdose deaths and help people recover.</p>
<p>His announcement was vague on details and did not specify how much money would be dedicated to reducing overdose deaths. The President restated many initiatives that have already been initiated and focused on supply-reduction efforts that, while important, do little for the millions of Americans who are struggled with opioid addiction. We have proven prevention and treatment services that we need to significantly expand, and states need the money to do this. </p>
<h1>The right treatments</h1>
<p>Declaring the opioid epidemic a <a href="http://www.npr.org/sections/health-shots/2017/08/11/542767898/president-trump-to-declare-national-opioid-emergency">national emergency</a> expands the availability of federal funding; frees up public health workers to address the issue; and makes it possible to remove regulatory barriers to lifesaving medications. </p>
<p><a href="http://wchstv.com/news/raw-news/raw-news-sessions-addresses-opioid-problems-at-west-virginia-summit">In a speech on May 11</a>, Attorney General Jeff Sessions suggested that tools like “Just Say No” and Drug Abuse Resistance Education (DARE) can help fight the opioid epidemic. </p>
<p>However, <a href="https://www.ncbi.nlm.nih.gov/pubmed/10450631">addiction science</a> has repeatedly proven that such drug prevention programs are <a href="https://www.scientificamerican.com/article/why-just-say-no-doesnt-work/">ineffective</a>. Some would argue that we are biologically wired to try new things, so education alone is not sufficient to prevent repeated drug use. </p>
<p>Prevention efforts are part of the solution, but we need more immediate solutions for people already ensnared by addiction. <a href="http://www.huffingtonpost.com/entry/naloxone_b_1475812.html">Naloxone</a>, known by the brand name Narcan, is usually the only thing that can prevent death when someone has overdosed on opioids. Science has <a href="http://www.nejm.org/doi/full/10.1056/NEJMra1202561">unequivocally demonstrated</a> that naloxone can reverse an opioid overdose, if administered in time and in an adequate dose. </p>
<p>When patients with opioid use disorders are treated with FDA-approved medications like methadone and buprenorphine, they not only reduce their use of opioids but they are also less likely to overdose. When these drugs are used to treat addiction, they are referred to as medication-assisted treatment. Medication-assisted treatment helps many people, particularly early in recovery, when otherwise their brains seem to focus only on using more drugs. In fact, <a href="http://ctndisseminationlibrary.org/protocols/ctn0030.htm">a National Institute on Drug Abuse study</a> found that only about 7 percent of patients can stop using opioids without buprenorphine.</p>
<p>We need drugs like naloxone and buprenorphine to prevent deaths and help people recover from addiction. In the past few years, state governments have taken significant steps to remove regulatory barriers and expand community access to naloxone.</p>
<p>But policies are infrequently aligned with addiction science. In 2015, only 11 percent of <a href="https://www.samhsa.gov/data/sites/default/files/report_2716/ShortReport-2716.pdf">people who needed addiction treatment</a> received it. There are not enough medication-assisted treatment treatment slots available: A recent study estimated that the U.S. was short 1.3 million treatment slots for medication-assisted treatment in 2012. Demand has <a href="http://ajph.aphapublications.org/doi/pdf/10.2105/AJPH.2015.302664">only increased since then</a>. </p>
<p>There is an entrenched belief that people choose to use drugs and that this choice reflects a moral failing. Even the director of the U.S. Department of Health and Human Resources – which cites medication-assisted treatment as part of its strategy – <a href="https://www.hhs.gov/about/news/2017/06/19/sec-price-meets-opioid-addiction-specialists-providers-and-treatment-facilities-stakeholders-readout.html">has been quoted saying</a>: “If we’re just substituting one opioid for another, we’re not moving the dial much.”</p>
<h1>Moving too slowly</h1>
<p>Early on, everyone believed that the epidemic was fueled by widely available <a href="http://www.latimes.com/opinion/op-ed/la-oe-hari-prescription-drug-crisis-cause-20170112-story.html">prescription pain relievers</a>. Books like <a href="http://johntemplebooks.com/books/american-pain/">“American Pain”</a> by John Temple described “drug tourists” routinely traveling from states like Kentucky and West Virginia to Florida, where millions of prescription pills were dispensed at “pill mills.” </p>
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<p>Such overprescribing and doctor-shopping <a href="https://www.cdc.gov/drugoverdose/pdf/hhs_prescription_drug_abuse_report_09.2013.pdf">did contribute</a> to the current epidemic. States <a href="https://www.cdc.gov/media/releases/2017/p0706-opioid.html">have been successful</a> at dispensing fewer prescription opioids, but this doesn’t help the nearly 2.6 million Americans <a href="https://www.samhsa.gov/data/sites/default/files/NSDUH-FFR1-2015/NSDUH-FFR1-2015/NSDUH-FFR1-2015.pdf">already addicted</a>, or the 329,000 who report currently using heroin. </p>
<p>And, since 2014, it has become clear that the epidemic is no longer just about prescription opioids. In addition, heroin is frequently mixed or substituted with <a href="http://www.herald-dispatch.com/_recent_news/dealer-behind-huntington-s-overdoses-sentenced-to-years-in-prison/article_4e22304c-2398-11e7-bcd1-97ce0311d81c.html">powerful synthetic opioids</a> like fentanyl or carfentanil. They require far more of the overdose reversal drug naloxone than is routinely dispensed in communities.</p>
<p>Meanwhile, in <a href="http://www.npr.org/2017/06/29/534916080/ohio-town-struggles-to-afford-life-saving-drug-for-opioid-overdoses">poor and rural areas</a>, community resources for public services are being <a href="https://www.nbcnews.com/news/us-news/too-many-bodies-ohio-morgue-so-coroner-gets-death-trailer-n733446">exhausted</a> by the costs of the epidemic.</p>
<p>Areas that have been disproportionately impacted by the epidemic, like West Virginia, have woefully inadequate access to harm-reduction services like syringe exchange programs and specialty addiction treatment. A clinic at our university that dispenses buprenorphine has more than 600 people on its waiting list. We will soon open a second clinic that will help reduce but not eliminate the waiting list. </p>
<p>A bill passed by President Obama, <a href="https://www.samhsa.gov/newsroom/press-announcements/201612141015">the 21st Century Cures Act</a>, is making approximately US$1 billion in funding available to help states combat the opioid epidemic. But, as <a href="https://www.vox.com/science-and-health/2017/8/1/15746780/opioid-epidemic-end">Dr. Keith Humphreys at Stanford University</a> has said: This is not enough. We likely need <a href="https://www.nytimes.com/2017/06/30/health/drug-treatment-opioid-abuse-heroin-medicaid.html?mcubz=1">50 times that</a>, as Ohio spent $1 billion in 2016 on the opioid epidemic. </p>
<h1>Fighting back</h1>
<p>It can be hard to grasp the devastation of the opioid epidemic. As the President’s Commission on Combating Drug Addiction and the Opioid Crisis <a href="https://www.whitehouse.gov/sites/whitehouse.gov/files/ondcp/commission-interim-report.pdf">has described it</a>, in the scale of deaths, it’s like the September 11 terrorist attacks happening every three weeks. A national emergency would have been declared 10 years ago if such a disaster occurred every three weeks. And it can be even harder to imagine the emotional turmoil and the depth of sorrow felt by the families who’ve lost their daughters, sons, brothers, sisters, mothers and fathers. </p>
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<span class="caption">Joe Fitzpatrick looks at a portrait of his daughter, Molly, at an exhibit honoring those who have died in New Hampshire’s opioid epidemic.</span>
<span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/Angels-of-Addiction/90769b4151664523b3effc0158f9c704/23/0">Holly Ramer/AP Photo</a></span>
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<p>I think it’s fair to say that we all want a simple solution – something that we can wrap our arms around. Something that can be done in one legislative session. But that has not worked and it will not work, just as declaring a national emergency is not enough. </p>
<p>Addiction scientists know what needs to be done to turn the tide. While we may not understand every aspect of the epidemic and certainly need more research to understand these <a href="https://www.brookings.edu/bpea-articles/mortality-and-morbidity-in-the-21st-century">deaths of despair</a>, we are eager to collaborate with communities to find empirically informed solutions, such as medication-assisted treatment. The President’s <a href="https://www.whitehouse.gov/ondcp/presidents-commission/members">Commission on Combating Drug Addiction and the Opioid Crisis</a> consists of four politicians and one addiction scientist. It might help to start by asking an expert, rather than politicians, what should be done.</p>
<p><em>This is an updated version of an article originally published on August 27, 2017.</em></p><img src="https://counter.theconversation.com/content/82623/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Erin Winstanley receives funding from the Hilton Foundation, CDC, and NIH. </span></em></p>President Trump declared the opioid epidemic a national emergency. But we need to do a lot more to prevent this crisis from escalating even further.Erin Winstanley, Associate Professor of Pharmacy, West Virginia UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/817772017-08-08T14:02:55Z2017-08-08T14:02:55ZA ‘learning disabilities commissioner’ without a learning disability is a waste of time<p>Calls to appoint a commissioner to look after the interests of people with learning disabilities have been growing louder since the shocking story of <a href="http://www.bbc.co.uk/news/uk-40252200">Ian Shaw</a> became national news. Shaw, 34, was diagnosed with terminal cancer last year after spending nine years in secure hospitals where his condition wasn’t spotted. Now there is talk of installing a commissioner to “uphold the rights” of people with learning disabilities. But unless the government plans to give this job to a person who is actually learning disabled, then I believe this would be another dead end. Instead of being left out of the process, people with learning disabilities should be at the heart of the solution.</p>
<p>The calls are being led by Stephen Bubb, who believes a commissioner could be charged with monitoring, and holding to account, all services which look after people with learning disabilities. Bubb authored the 2014 NHS England report – <a href="https://www.england.nhs.uk/wp-content/uploads/2014/11/transforming-commissioning-services.pdf">Winterbourne View: Time for Change</a> – which explored the shortcomings in care and support for people with learning disabilities in the UK. The report followed a string of scandals that emerged from Winterbourne View, a publicly-funded private hospital in Gloucestershire. </p>
<p>The <a href="http://www.bbc.co.uk/news/uk-england-bristol-14181646">scandal there</a> was first exposed in 2011 by an undercover reporter who revealed the psychological and physical abuse people with learning disabilities were facing. The hospital was subsequently shut down. Despite the Care Quality Commission receiving a <a href="http://www.cqc.org.uk/news/releases/cqc-report-winterbourne-view-confirms-its-owners-failed-protect-people-abuse">series of warnings</a> about mistreatment at Winterbourne, the complaints received were never followed up.</p>
<p>Bubb made ten recommendations in his report, including the recommendation that there should be a legal charter of rights for people with learning disabilities and their families. He later suggested that a commissioner would help to “<a href="https://www.theguardian.com/social-care-network/2016/feb/22/learning-disability-commissioner-bubb-report-winterbourne-view">protect and promote</a>” the rights of people with learning disabilities. But if a role for a learning disabilities commissioner was created, would someone with learning disabilities be appointed? Despite there being more than a million people with learning disabilities (although the number is rising and there are many who are not accounted for), it is very unlikely that one of these people would be. Bubb’s report fails to get to grips with the need to take action and make a difference in the lives of people with learning disabilities in order to give them the chance of achieving such a position. </p>
<h2>Serious failings in care</h2>
<p>And despite the case of Winterbourne being well known, private companies continue to be paid over <a href="https://uk.news.yahoo.com/uk-policy-turns-people-learning-101424436.html">one billion pounds by the NHS</a> to run mini-hospitals for people with learning disabilities. This despite <a href="https://theconversation.com/uk-policy-turns-people-with-learning-disabilities-into-commodities-study-reveals-80176">government policy</a> aiming to reduce them to ensure more people with learning disabilities are instead looked after in their own homes.</p>
<p><a href="https://www.theguardian.com/society/2017/jun/07/care-home-directors-convicted-over-devon-learning-disability-regime">Abhorrent crimes</a> are continuing to occur in the delivery of basic care. Earlier this month, a consultant psychiatrist admitted <a href="https://www.theguardian.com/society/2017/jun/07/care-home-directors-convicted-over-devon-learning-disability-regime">a string of failings</a> over the death of vulnerable teenager Connor Sparrowhawk, who drowned in a bath at an NHS care unit. </p>
<p>In addition, people with learning disabilities face regular physical, mental and <a href="https://www.thetimes.co.uk/article/cqc-covered-up-suspected-rape-in-care-home-hillgreen-care-8vnkxh07r">sexual abuse</a>, as well as hate crimes. A <a href="https://www.theguardian.com/society/2015/jun/17/learning-disabilities-rights-threatened-government-cuts-brian-rix-mencap">letter</a> to the Guardian, signed by more than 100 charities, said the shrinking of the welfare state risked leaving individuals cut off from their communities and work.</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"894483273811976196"}"></div></p>
<h2>Not the problem, the solution</h2>
<p>While Bubb’s report aims to highlight the challenges people with learning disabilities face, they themselves do not appear to be at the heart of the decision-making that is likely to take place on their behalf. People with learning disabilities do not need a government appointed commissioner. Instead, they need to be in full control of what happens to them.</p>
<p><a href="http://www.tandfonline.com/doi/full/10.1080/09687599.2016.1180871">My own research</a> suggests that people with learning disabilities are not helpless individuals. They are people who are fully engaged with their own lives, who understand how to make choices and have expertise in politics. They are able – when things are made accessible – to fully participate in the decision-making that affects their lives. This indicates that people with learning disabilities are not the problem but the solution.</p>
<p>If a commissioner was to be appointed, it makes sense that someone with learning disabilities should take that role. For example, people with learning disabilities experience <a href="https://www.mencap.org.uk/learning-disability-explained/research-and-statistics/health-research-and-statistics/health">health inequalities</a> and have worse health, on average, because of difficulties using the health service. By working harder to listen to the experiences of the learning disabled, a better understanding for health promotion and disability may emerge. In all aspects of life, people with learning disabilities should be making choices, sharing knowledge and participating at every level to ensure that they have control over their own destiny. </p>
<p>So unless the commissioner is learning disabled, I would suggest scrapping the idea completely. They are the experts on what is best for them and how they want to be included in society and they should be closely consulted about any kind of systemic changes. To avoid scandals like Winterbourne, people with learning disabilities should be respected as equal citizens.</p><img src="https://counter.theconversation.com/content/81777/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Michael Richards 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.</span></em></p>People with learning disabilities need to have a say in the government policy that rules their lives.Michael Richards, Lecturer in Applied Health and Social Care, Edge Hill UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/818342017-08-04T03:50:01Z2017-08-04T03:50:01ZGreg Hunt’s plan to reduce hospital admissions won’t work if he can’t measure successes and failures<p>The controversial issue of hospital funding will be up for discussion again today as state health ministers meet at the <a href="http://www.coaghealthcouncil.gov.au/Announcements/Meeting-Communiques1">COAG Health Council</a>. Earlier this week, <a href="http://www.theaustralian.com.au/national-affairs/health/rewards-to-reduce-crush-in-hospitals/news-story/6cfb38600f3c136c7099e97b841bc19c">The Australian newspaper reported</a> the federal health minister, Greg Hunt, might consider a ten-year funding deal with the states, rather than the normal five-year agreement. But this would depend on states agreeing to some of his proposals to reduce unnecessary spending and improve outcomes.</p>
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Read more:
<a href="https://theconversation.com/remind-me-again-whats-the-problem-with-hospital-funding-44965">Remind me again, what's the problem with hospital funding?</a>
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<p>These proposals are questionable. Hunt’s plan is reportedly to pay GPs for preventing chronically ill patients being hospitalised and to fine hospitals for re-admissions that could have been avoided. Deciding who gets the carrots and who gets the sticks is a brave endeavour. Even with the best evidence, attributing an “avoidable” hospitalisation to care provided by either GPs or hospitals overlooks patient co-operation. </p>
<p>Will GPs be paid for advising patients to reduce drinking, quit smoking and eat more healthily even if the patient ignores them and becomes yet another heart attack admission to hospital? Will the hospital’s legal expenses be paid when a patient who should be re-admitted isn’t because of scolding accountants? </p>
<p>And, most importantly, it’s unclear who will make these determinations and how “better outcomes” can be be measured. This is because it is impossible at the moment to measure the outcomes of health care in Australia.</p>
<h2>Information all over the place</h2>
<p>That’s not to say we don’t have data. <a href="https://academic.oup.com/intqhc/article-lookup/doi/10.1093/intqhc/mzr004">Data exist</a> for care provided by hospitals, GPs, specialists and allied health professionals, but in separate patient information systems and clinical registries – or both. To measure the outcomes, all this care must be compiled and assessed together, using reliable data. </p>
<p>In the hospital system, each state and territory is responsible for data collection. Clinical coders are employed to work with <a href="http://meteor.aihw.gov.au/content/index.phtml/itemId/181162">national minimum data sets</a> and <a href="https://www.accd.net.au/Icd10.aspx">standard classifications</a>. But coders can only work with the information doctors and nurses provide, and <a href="http://search.informit.com.au/fullText;dn=279243523881251;res=IELHEA">limitations of missing</a> <a href="http://journals.sagepub.com/doi/pdf/10.1177/1833358317721305">hospital data</a> are <a href="http://journals.sagepub.com/doi/pdf/10.1177/1833358316678957">well documented</a>. Hospital collections are funded by governments and costs are included in annual budgets.</p>
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Read more:
<a href="https://theconversation.com/new-proposed-health-data-report-misses-many-of-the-marks-73517">New proposed health data report misses many of the marks</a>
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<p>When it comes to general practice, there is no mandatory routine data collection. Medicare has information about attendance patterns, visit frequency and GP service items, but no details about the content of these visits – such as what conditions were managed or how each was managed. </p>
<p>Practices operate in silos, keeping their own records about their own patients. As with hospitals, patients may receive care from different practices, creating multiple records for the same individual in multiple facilities.</p>
<p>Given 87% of Australians <a href="https://ses.library.usyd.edu.au/bitstream/2123/15482/5/9781743325162_ONLINE.pdf">visited a GP</a> at least once in 2015-16, why there is no publicly funded, routine data collection is a good question. The Bettering the Evaluation and Care of Health (<a href="http://sydney.edu.au/medicine/fmrc/beach/">BEACH</a>) program actively collected nationally representative data from GPs for <a href="https://ses.library.usyd.edu.au/bitstream/2123/15482/5/9781743325162_ONLINE.pdf">18 years</a>. But the program lost funding in 2016 and data collection ceased, although the BEACH data are still <a href="http://sydney.edu.au/medicine/public-health/research/beach.php">current and available</a>.</p>
<h2>Electronic health records</h2>
<p>Collecting data from GPs’ electronic health records seems a practical solution. It’s timely, cost-effective and, with data-extraction tools available, should be reasonably simple. The National Prescribing Service (NPS) is using this method in its <a href="https://www.nps.org.au/medicine-insight">MedicineInsight</a> project, to produce data for quality improvement (for practices) and for aggregated data to inform government policy.</p>
<p>However, producing valid, reliable data from these records is anything but simple. Only about 71% of GPs have completely <a href="https://ses.library.usyd.edu.au//bitstream/2123/13765/4/9781743324530_ONLINE.pdf">paperless patient records</a>. The rest use a mix of electronic and paper records (25%) or paper records only (4%), which influences how representative the data may be. </p>
<p>Unlike research projects with clear participant denominators, the <a href="http://www.publish.csiro.au/PY/PY14071">number of patients will differ</a> depending on which day a data extraction is performed and the definition used to identify current patients.</p>
<p>There’s no regulation of GPs’ electronic health records. GPs use about eight different software products, but there are no nationally agreed and implemented standards for these. They have different data structures, terminology and classification systems (or none) and different data elements, labels and definitions. </p>
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<em>
<strong>
Read more:
<a href="https://theconversation.com/money-given-to-gps-from-ending-the-medicare-rebate-freeze-should-target-reform-76778">Money given to GPs from ending the Medicare rebate freeze should target reform</a>
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<p>There’s <a href="http://ahha.asn.au/system/files/docs/publications/deeble_institue_issues_brief_no_18.pdf">no standardised minimum data</a> set to specify what data should be recorded at every patient encounter. There are no data links between conditions and the management actions taken. </p>
<p>Links are crucial for managing outcomes. For instance, how can you assess care provision for diabetes if the care and condition aren’t linked in the records?</p>
<h2>The problem of missing data</h2>
<p>As with hospital collections, missing data are a problem. Extraction tools cannot extract what isn’t in the record. The absence of some data elements is easy to identify, such as a blank “age” field. But if a diagnosis, medication or test order is not entered, there’s no way to tell it’s missing. </p>
<p>Test results are also easy to miss. While there is a standard messaging language for <a href="http://www.hl7.org.au/">health systems</a>, its use isn’t mandatory. Many practices receive results by email or paper, scan and attach them, rather than directly populating the appropriate fields in the record.</p>
<p>The few published studies from MedicineInsight <a href="http://www.phcris.org.au/phplib/filedownload.php?file=/elib/lib/downloaded_files/conference/presentations/8147_conf_abstract_.pdf">acknowledge the limitations</a> of data completeness and accuracy in the electronic health records. The frustrations the researchers must be experiencing is justified given the number of years of calls to introduce standards to resolve these problems.</p>
<p>The true measurement of outcomes needs a system-wide approach, starting with a person-based health record that includes standardised data from all health providers. We are a long way from having reliable evidence to support the carrot-and-stick decisions being proposed.</p><img src="https://counter.theconversation.com/content/81834/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Joan Henderson was a member of the BEACH research team from 1999 until the program ceased in July 2016.</span></em></p>A plan to fine hospitals for avoidable hospitalisations and pay GPs to prevent them has many issues. The main problem is that it’s impossible to measure the outcomes of health care in Australia.Joan Henderson, Senior Research Fellow (Honorary)., University of SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/774622017-05-31T20:18:05Z2017-05-31T20:18:05ZAfter-hours GP home visits strain the budget (and don’t help emergency departments)<figure><img src="https://images.theconversation.com/files/170483/original/file-20170523-8883-1flsbdr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">After-hours home medical services are offered with bulk billing. But are they the best use of taxpayers' money?</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/520263562?src=aD11o6aSl2O2l414Kw3a-A-1-1&size=medium_jpg">from www.shutterstock.com</a></span></figcaption></figure><p>After-hours home medical services are a burden on our health budget and don’t ease the strain on emergency departments after all, new research shows.</p>
<p>The roll out of after-hours GP-type home visits is linked with as much as a ten-fold increase in Medicare claims in one jurisdiction. And rather than reducing the need to visit the emergency department, their rise in popularity has been accompanied by a slight <em>increase</em> in visits.</p>
<p>Our findings, published today in the <a href="http://www.racgp.org.au/afp/">Australian Family Physician</a> journal, question whether these convenient house calls are really the best use of taxpayers’ money.</p>
<h2>What are after-hours home medical services?</h2>
<p>The way people access GP-type services after their regular doctor’s surgery has closed for the day, or at weekends, has changed considerably in recent years. </p>
<p>In the past, if you called your GP after hours, you might hear a recorded message with the phone number of an after-hours medical service to attend. Alternatively, the message would recommend you go to the local emergency department.</p>
<p>But over the past five years, there has been a proliferation of after-hours medical services that come to you. These services advertise 100% bulk-billed consultations by GPs and other doctors in the home.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/170270/original/file-20170522-4471-4cqy65.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/170270/original/file-20170522-4471-4cqy65.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/170270/original/file-20170522-4471-4cqy65.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=301&fit=crop&dpr=1 600w, https://images.theconversation.com/files/170270/original/file-20170522-4471-4cqy65.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=301&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/170270/original/file-20170522-4471-4cqy65.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=301&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/170270/original/file-20170522-4471-4cqy65.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=379&fit=crop&dpr=1 754w, https://images.theconversation.com/files/170270/original/file-20170522-4471-4cqy65.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=379&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/170270/original/file-20170522-4471-4cqy65.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=379&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">After-hours medical services like this one offer bulk-billed home visits in the comfort of your own home.</span>
<span class="attribution"><a class="source" href="https://www.homedoctor.com.au/">Screen shot/National Home Doctor Service</a></span>
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<h2>A blow-out in Medicare claims</h2>
<p>Doctors can claim one of several Medicare items to reimburse them for providing care <a href="https://www.humanservices.gov.au/health-professionals/enablers/after-hours-incentive">after hours</a>. The precise item number depends on whether the service they provide is urgent, where they provide that service and the length of the consultation.</p>
<p>There’s been a <a href="https://theconversation.com/is-medicare-facing-a-cost-blowout-from-urgent-after-hours-care-rebates-60785">rapid growth</a> in claims <a href="http://www.smh.com.au/national/health/boom-in-afterhours-gps-raises-concerns-about-medicare-cost-blowout-20160511-gosr95.html">reported</a> for all after-hours Medicare items. And since 2014, claims for these items increased <a href="http://www.aph.gov.au/%7E/media/Committees/clac_ctte/estimates/add_1617/Health/Answers/SQ17_000203.pdf">five times</a> faster than the rate of standard GP consultations.</p>
<p><a href="https://theconversation.com/is-medicare-facing-a-cost-blowout-from-urgent-after-hours-care-rebates-60785">Attention has focused</a> on Medicare <a href="http://www.health.gov.au/internet/main/publishing.nsf/Content/mbsprimarycare-changes-to-medicare-primary-care-items-qanda">item 597</a>, the key item number for such, “urgent” after-hours consultations.</p>
<p>We reviewed the <a href="http://medicarestatistics.humanservices.gov.au/statistics/mbs_item.jsp">Medicare statistics website</a> from 2010/11, when these after-hours services started to be launched. In the period since then until 2015/16 the number of claims for item 597 increased by 170%.</p>
<p>This growth has naturally affected Medicare expenditure. In the five years before 2010/11, <a href="http://medicarestatistics.humanservices.gov.au/statistics/mbs_item.jsp">annual expenditure</a> on item 597 increased from A$55 million to A$72 million, a 29% increase. But in the next five years, expenditure increased to A$197 million, a 136% increase.</p>
<h2>What’s driving this increase?</h2>
<p>So what’s driving this increase, not only in the number of Medicare claims, but how much they cost the taxpayer?</p>
<p>We examined whether there was any truth in <a href="http://www.smh.com.au/national/health/boom-in-afterhours-gps-raises-concerns-about-medicare-cost-blowout-20160511-gosr95.html">media reports</a> suggesting the emergence of after-hours home medical services was largely responsible.</p>
<p>We identified key dates when the services were set up or expanded in Western Australia (WA), Tasmania, Australian Capital Territory (ACT) and Northern Territory (NT). Then we tracked changes in quarterly Medicare rebates against item 597 in each jurisdiction.</p>
<p>All jurisdictions had rapid and substantial increases in claims for item 597 after services in their area were set up or expanded.</p>
<p>To illustrate this, we charted the growth in claims from the quarter before the services were established up to the second quarter of 2016.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/170458/original/file-20170523-7354-rmd704.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/170458/original/file-20170523-7354-rmd704.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/170458/original/file-20170523-7354-rmd704.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=311&fit=crop&dpr=1 600w, https://images.theconversation.com/files/170458/original/file-20170523-7354-rmd704.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=311&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/170458/original/file-20170523-7354-rmd704.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=311&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/170458/original/file-20170523-7354-rmd704.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=391&fit=crop&dpr=1 754w, https://images.theconversation.com/files/170458/original/file-20170523-7354-rmd704.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=391&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/170458/original/file-20170523-7354-rmd704.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=391&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">All jurisdictions had rapid and substantial increases in claims for item 597 after services in their area were set up or expanded.</span>
<span class="attribution"><span class="license">Author provided</span></span>
</figcaption>
</figure>
<p>In the ACT, there was a 1,057% increase in claims since the second quarter of 2014; Tasmania saw a 521% increase since the fourth quarter of 2014; in WA there was a 348% increase since the second quarter of 2012; and for the NT, a 219% increase since the first quarter of 2015 was reported.</p>
<h2>Impact on emergency department visits</h2>
<p>Supporters of after-hours home medical services <a href="http://www.namds.com/wp-content/uploads/2017/01/NAMDS-Medicare-Benefits.pdf">say</a> the growth in Medicare claims associated with these services <em>reduces</em> government expenditure. This is because
fewer people use emergency departments.</p>
<p>A recent <a href="http://www.namds.com/wp-content/uploads/2017/01/Deloitte-Report-Analysis-of-after-hours-primary-care-pathways-1.pdf">report</a> by Deloitte Access Economics, commissioned by the National After-Hours Medical Deputising Service, estimated A$724 million in savings over four-years due to reduced emergency department presentations. This estimate was based on the assumption that 25% of “avoidable GP-type” emergency department presentations would receive care through after-hours home visiting medical services instead. However, there is no evidence to support this assumption.</p>
<p>According to the latest <a href="http://www.aihw.gov.au/publication-detail/?id=60129557372">report</a> from the Australian Institute of Health and Welfare, emergency department presentations in all states <em>increased</em> between 2011/12 and 2015/16 by 2.7%.</p>
<p>Indeed, both emergency presentations and, as we have shown, Medicare claims for item 597 are increasing.</p>
<p>Recently released <a href="http://www.aph.gov.au/%7E/media/Committees/clac_ctte/estimates/add_1617/Health/Answers/SQ17_000203.pdf">Senate Estimates documents</a> provide interesting reading. An estimated 180,000 people received three or more “urgent” consultations from an after-hours home visiting medical service between 2014 and 2016. Of these, more than 10,000 had no contact with a regular GP.</p>
<p>If these services are truly meeting previously unmet demand for urgent medical care, then we should see a decrease in emergency department presentations. However, this is not occurring.</p>
<h2>What’s behind these figures?</h2>
<p>What we are likely observing is clever marketing, using multiple channels – like web-based advertising, YouTube videos, flyers in pharmacies – to fuel demand for these new services.</p>
<p>Another potential reason for the increased claims for item 597 relates to reimbursement. As the rate for urgent after-hours consultations is higher than non-urgent consultations, some doctors or businesses may be tempted to claim an urgent consultation.</p>
<h2>What needs to happen next?</h2>
<p>There is no definition of “urgent” in the Medicare Benefits Schedule as doctors are well-placed to decide what’s urgent. However, greater scrutiny of claims against item numbers for urgent consultations, such as regular audits, may be warranted.</p>
<p>As part of wider Medicare reforms, the federal health department and Royal Australian College of General Practitioners are <a href="http://health.gov.au/internet/main/publishing.nsf/Content/98C1ED2053EF2A8CCA25811B002759EC/$File/Agreement%20RACGP.pdf">aiming to</a> set up a new after-hours rebate structure and will also review after-hours billing practices.</p>
<p>The <a href="http://www.health.gov.au/internet/main/publishing.nsf/content/mbsreviewtaskforce">Medicare Benefits Schedule review</a> is also expected to publish its recommendations about after-hours medical care soon.</p><img src="https://counter.theconversation.com/content/77462/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Barbara de Graaff receives funding from Primary Health Tasmania to evaluate primary health care in the after-hours.. </span></em></p><p class="fine-print"><em><span>Mark Nelson 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.</span></em></p>After-hours home medical services cost the taxpayer dearly and don’t reduce emergency department visits, according to new research.Barbara de Graaff, Postdoctoral Research Fellow, Health Economics, University of TasmaniaMark Nelson, Head, Discipline of General Practice, University of TasmaniaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/775552017-05-12T04:44:23Z2017-05-12T04:44:23ZDon’t be fooled, the Medicare Guarantee Fund provides no real guarantee<figure><img src="https://images.theconversation.com/files/169065/original/file-20170512-32610-1s6hk32.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The Medicare Guarantee Fund appears to be no more than an accounting trick.</span> <span class="attribution"><span class="source">from shutterstock.com</span></span></figcaption></figure><p>Treasurer Scott Morrison pulled a health-related rabbit out of his hat on budget night, announcing the government will “<a href="http://www.budget.gov.au/2017-18/content/speech/html/speech.htm">guarantee</a>” the future of Medicare. </p>
<p>It will do this by allocating revenue from the recently increased (from 2% to 2.5%) Medicare levy, after paying for the National Disability Insurance Scheme (NDIS), into a <a href="http://www.health.gov.au/internet/ministers/publishing.nsf/content/budget2017-mediarel-hunt002.htm">Medicare Guarantee Fund</a>. </p>
<p>The government will then cover the shortfall to cover the costs of Medicare – defined in these budget announcements as a combination of expenditure from the Medicare Benefits Schedule (MBS) and Pharmaceutical Benefits Scheme (PBS). In <a href="http://www.budget.gov.au/2017-18/content/speech/html/speech.htm">Morrison’s words</a>: </p>
<blockquote>
<p>Proceeds from the Medicare levy will be paid into the fund. An additional contribution from income tax revenue will also be paid into the Medicare Guarantee Fund to make up the difference.</p>
</blockquote>
<p>Based on the sketchy information so far available, this fund appears to be no more than an accounting trick. The size of the fund will be determined each year based on projected MBS and PBS expenditure. The balancing item, which is the extra proportion of non-NDIS revenue, will also be adjusted each year in line with those expenditure projections. </p>
<p>The guarantee part is that only the MBS and PBS expenditures can be paid from the fund, “<a href="http://sjm.ministers.treasury.gov.au/media-release/049-2017/">by law</a>”. This might sound good, but don’t be fooled. The Medicare Guarantee Fund is nothing more than a rebadging exercise: it changes the badge on a policy in the hope people might think it is a new policy. </p>
<p>It merely provides an additional line in the budget papers, supplementing information that was already there for MBS and PBS expenditure, albeit separately. And by defining Medicare as MBS and PBS expenditure, the government has seamlessly airbrushed public hospitals out of the picture.</p>
<h2>What is Medicare?</h2>
<p>Until budget night this week, most people would have thought of Medicare as the medical services and public hospital scheme, and probably still do. </p>
<p>When Medicare was introduced in 1984, it changed funding arrangements for medical services and public hospitals, removing or reducing financial barriers to access to these services. It did not touch PBS arrangements. </p>
<p>It may now be appropriate to add the PBS as a third component of Medicare, as it is about access to health care. But the PBS should be an addition to how Medicare is defined. It shouldn’t be used to airbrush public hospital access out of any Commonwealth definition of Medicare.</p>
<p>To put it more simply, the Medicare Guarantee Fund does not include the Commonwealth’s contribution to public hospital funding. But it does include the PBS, adopting a unique and idiosyncratic definition of Medicare. </p>
<p>The Medicare Guarantee Fund is being created using a partial statement of Medicare spending: if the public were to assume the Medicare Guarantee Fund is purely about a public commitment to Medicare, they would be misled.</p>
<p>So despite Morrison’s claims the fund will provide “transparency about what it really costs to run Medicare”, Medicare funding will actually be less transparent. </p>
<h2>What does the fund guarantee?</h2>
<p>The government probably hopes the Medicare Guarantee Fund will be its armour against a revised <a href="http://theconversation.com/mediscare-campaign-shows-the-power-of-negative-advertising-61990">Mediscare</a> campaign, like the one Labor ran before the 2016 election. The word “guarantee” linked with “Medicare” sounds good, costs nothing and does not bind the government in any way. But it may be enough to ward off the Mediscare vampires.</p>
<p>Mediscare resonated in 2016 because of the <a href="http://theconversation.com/is-medicare-under-threat-making-sense-of-the-privatisation-debate-61308">2014 budget decisions</a>. These were seen as a breach of trust as they were policies that had been explicitly ruled out in the previous election campaign.</p>
<p>The controversial 2014 budget proposals aimed to reduce Commonwealth expenditure by shifting costs onto consumers and onto states. One way of doing this was through <a href="http://theconversation.com/save-now-spend-later-why-co-payments-for-gp-visits-are-a-bad-idea-25823">co-payments</a> that required patients to make an out-of-pocket payment when they see a doctor.</p>
<p>Another cost-shifting policy was the <a href="http://theconversation.com/confused-about-the-medicare-rebate-freeze-heres-what-you-need-to-know-59661">Medicare rebate freeze</a>, which froze MBS rebates for visits to doctors at 2013 levels, despite inflation since then which has been tracking at <a href="http://www.abs.gov.au/ausstats/abs@.nsf/mf/6401.0">around 2% a year</a>. Since rebates are also paid to consumers, this was another example of a consumer cost shift, although the burden of this strategy probably fell on providers, particularly general practitioners. </p>
<p>Some of the 2014 changes (like the co-payment) required legislation to implement, while others (like the rebate freeze) could be implemented by administrative action without requiring parliamentary approval.</p>
<p>Importantly, none of the changes that required legislation were successful. The only changes in the 2014 budget that were eventually implemented were the ones that didn’t require legislation, such as the rebate freeze and draconian <a href="http://theconversation.com/federal-budget-2014-health-experts-react-26577">public hospital budget cuts</a>. These tore up a previous agreement under which the Commonwealth matched cost increases in public hospitals. </p>
<p>Even these two measures have now been partially wound back - the <a href="http://theconversation.com/another-day-another-hospital-funding-dispute-how-to-make-sense-of-todays-coag-talks-57058">hospital cuts before the 2016</a> election, and the rebate freeze in the 2017 budget.</p>
<h2>What should a Medicare guarantee look like?</h2>
<p>A Medicare guarantee worth its salt would be one that protects the public from the administrative assaults of the 2014 budget. This would involve enshrining in legislation the Commonwealth-state health care agreements – as well as the <a href="http://www.budget.gov.au/2013-14/content/bp3/html/bp3_03_part_2a.htm">“partnership” payments</a>, which are other Commonwealth grants to the states for health care – and introducing automatic indexation of Medicare rebates. </p>
<p>The Medicare Guarantee Fund as proposed in the 2017 budget does not do this. It provides no guarantee of policy stability, no guarantee of additional funding, and no guarantee that a future budget will not tear into the Medicare fabric in the way that characterised the 2014 debacle.</p><img src="https://counter.theconversation.com/content/77555/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Stephen Duckett does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond the appointment above.
Grattan Institute began with contributions to its endowment of $15 million from each of the Federal and Victorian Governments. In order to safeguard its independence, Grattan Institute’s board controls this endowment. The funds are invested and Grattan uses the income to pursue its activities.</span></em></p>The fund is nothing more than a rebadging exercise in the hope people might think it is a new policy. And it’s being used to airbrush public hospitals out of the Medicare picture.Stephen Duckett, Director, Health Program, Grattan InstituteLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/774702017-05-11T04:03:06Z2017-05-11T04:03:06ZMental health funding in the 2017 budget is too little, unfair and lacks a coherent strategy<figure><img src="https://images.theconversation.com/files/168842/original/file-20170511-21623-1k5y5qx.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Mental health remains chronically underfunded.</span> <span class="attribution"><span class="source">from shutterstock.com</span></span></figcaption></figure><p>This week’s federal budget allocated <a href="https://theconversation.com/budget-2017-sees-medicare-rebate-freeze-slowly-lifted-and-more-funding-for-the-ndis-experts-respond-77315">A$115 million in new funding</a> over four years. This is one of the smallest investments in the sector in recent years.</p>
<p>For instance, the <a href="http://www.carersvoice.com.au/assets/files/E-Bulletins/National%20Action%20Plan%20for%20Mental%20Health%202006-2011.pdf">Council of Australian Governments (CoAG)</a> added more than $5.5 billion to mental health spending in 2006. The <a href="http://www.aph.gov.au/about_parliament/parliamentary_departments/parliamentary_library/pubs/rp/budgetreview201112/mental">2011-12 federal budget</a> provided $2.2 billion in new funding.</p>
<p>This compounds a situation in which, in 2014-15, mental health received around <a href="http://www.aihw.gov.au/publication-detail/?id=60129557170">5.25% of the overall health budget</a> while representing <a href="http://www.aihw.gov.au/burden-of-disease/">12% of the total burden of disease</a>. There is no reason those figures should exactly match, but the gap is large and revealing. </p>
<p>They speak to the fact mental health remains chronically underfunded. Mental health’s share of <a href="http://www.aihw.gov.au/publication-detail/?id=60129557170">overall health spending</a> was 4.9% in 2004-05. Despite rhetoric to the contrary, funding has changed very little over the past decade. </p>
<p>We lack a coherent national strategy to tackle mental health. New services have been established this year, but access to them may well depend on where you live or who is looking after you. This is chance, not good planning.</p>
<h2>Hospital-based services</h2>
<p>The general focus of care when it comes to mental health remains hospital-based services. Inpatient – when admitted to hospital – and outpatient clinic care or in the emergency room <a href="https://mhsa.aihw.gov.au/resources/expenditure/">represent the bulk of spending</a>. (The Australian Institute of Health and Welfare includes hospital outpatient services under the heading “Community”, which makes definitive estimates of the proportion of funding impossible.)</p>
<p>Outside of primary care such as general practice, or Medicare-funded services (such as psychology services provided under a <a href="https://www.betterhealth.vic.gov.au/health/conditionsandtreatments/mental-health-care-plans">mental health care plan</a>), mental health services in the community are hard to find.</p>
<p>An encouraging aspect of this year’s budget is the government’s recognition of this deficiency. The largest element of new mental health spending was a commitment to establish a pool of $80 million to fund so-called <a href="http://www.health.gov.au/internet/budget/publishing.nsf/Content/budget2017-factsheet28.htm">psychosocial services</a> in the community. </p>
<p>As Treasurer Scott Morrison said in his <a href="http://www.budget.gov.au/2017-18/content/speech/html/speech.htm">budget speech</a>, this money is for:</p>
<blockquote>
<p>Australians with a mental illness such as severe depression, eating disorders, schizophrenia and post-natal depression resulting in a psychosocial disability, including those who had been at risk of losing their services during the transition to the NDIS.</p>
</blockquote>
<p>Yet, the money is <a href="http://www.health.gov.au/internet/budget/publishing.nsf/Content/budget2017-factsheet28.htm">contingent on states and territories</a> matching federal funds, meaning up to $160 million could be made available over the next four years if the states all chip in with their share of $80 million. But this commitment was made “noting that states and territories retain primary responsibility for CMH [community mental health] services”. Whether the states agree is another matter.</p>
<p>This new funding seems partly a response to the federal transfer of programs such as <a href="http://www.mhcc.org.au/policy-advocacy-reform/strengthening-relationships/partners-in-recovery.aspx">Partners in Recovery</a> and <a href="https://www.dss.gov.au/sites/default/files/documents/07_2013/part_c1_phams_guidelines_april_2013.pdf">Personal Helpers and Mentors</a> to the <a href="https://www.dss.gov.au/our-responsibilities/mental-health/programs-services/personal-helpers-and-mentors-phams">National Disability Insurance Scheme</a> (NDIS). Both these programs offered critical new capacity to community organisations to provide mental health services and better coordinate care.</p>
<p>Partners in Recovery was established in the 2011-12 budget with $550 million to be spent over five years. Personal Helpers and Mentors (along with other similar programs) was established in the same year with $270 million in funding over five years.</p>
<p>With these programs now (or soon to be) cordoned off to recipients of NDIS packages, the 2017 budget measure appears to be designed to offset their loss. However, not all states may choose to match the federal funds. And some may choose to do so but try to use new federal funds to reduce their own overall mental health spending. </p>
<p>States already <a href="http://www.health.gov.au/internet/main/publishing.nsf/content/mental-pubs-n-report13">vary in the types of services</a> they offer. All this raises the prospect that people’s access to, and experience of, mental health care is likely to vary considerably depending on where they live. In a budget espousing fairness, this is a recipe for inequity.</p>
<h2>Lack of coherent strategy</h2>
<p>The budget does attempt to improve the uneven distribution of mental health professionals by providing $9 million over four years to enable psychology services to rural areas though <a href="http://www.health.gov.au/internet/main/publishing.nsf/content/e-health-telehealth">telehealth</a>. It’s well known <a href="http://ruralhealth.org.au/sites/default/files/publications/nrha-mental-health-factsheet-2017.pdf">mental health services in the bush</a> are inadequate. </p>
<p>This investment seems sensible, but $9 million pales in comparison to spending on the <a href="http://www.health.gov.au/mentalhealth-betteraccess">Better Access Program</a>, which I <a href="http://medicarestatistics.humanservices.gov.au/statistics/mbs_item.jsp">have calculated</a> to be $15 million each week. This program provides Medicare subsidies for face-to-face mental health services under mental health care plans. While this program is available for those in rural areas, <a href="https://www.mja.com.au/journal/2015/202/4/better-access-mental-health-care-and-failure-medicare-principle-universality">accessing it is more difficult</a> than in cities.</p>
<p>This budget’s commitment to mental health shows a lack of an overarching strategy. Rather than offering a coherent approach to mental health planning, this budget continues Australia’s piecemeal, patchwork structure, where the system is driven mostly by who pays rather than what works or is needed. </p>
<p>The development of a national community mental health strategy would be most welcome now. This would demonstrate how the primary and tertiary mental health sectors will join up to provide the blend of clinical, psychological and social support necessary to finally enable people with a mental illness to live well in the community.</p>
<p>You could be forgiven for thinking that, albeit slowly, the <a href="http://www.aph.gov.au/Parliamentary_Business/Committees/Senate/Former_Committees/mentalhealth/report02/index">well-known problems</a> in mental health across Australia are being addressed. But the small pool of funding in this year’s budget says otherwise. And the lack of coherent strategy is a shame. You can’t complete a jigsaw puzzle if you keep adding new pieces.</p><img src="https://counter.theconversation.com/content/77470/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Sebastian Rosenberg is a co-opted member of the Executive of the Australian Health Care Reform Alliance</span></em></p>The latest federal budget leaves mental health chronically underfunded, with inequitable access to services, and without a clear national strategy.Sebastian Rosenberg, Senior Lecturer, Brain and Mind Centre, University of SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/722592017-02-01T08:13:15Z2017-02-01T08:13:15ZSobering health stats in latest Productivity Commission report<figure><img src="https://images.theconversation.com/files/155094/original/image-20170201-12649-wemiz8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The latest snapshot of Australian health funding reveals who's footing the bill, among other worrying health statistics.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/567154324?size=medium_jpg">from www.shutterstock.com</a></span></figcaption></figure><p>New health minister <a href="https://theconversation.com/whats-in-store-for-new-health-minister-greg-hunt-71344">Greg Hunt</a> probably choked over his breakfast cereal this morning as he read the blandly titled <a href="http://www.pc.gov.au/research/ongoing/report-on-government-services/2017/health">Report on Government Services 2017</a>, released by the <a href="http://www.pc.gov.au/">Productivity Commission</a> today. </p>
<p>As if he did not have enough on his plate pondering the <a href="https://theconversation.com/confused-about-the-medicare-rebate-freeze-heres-what-you-need-to-know-59661">Medicare rebate freeze</a>, which hits the <a href="https://theconversation.com/if-gps-pass-on-cost-from-rebate-freeze-poorer-sicker-patients-will-be-hardest-hit-71805">poor and sickest the most</a>, the future of <a href="https://theconversation.com/private-health-insurance-carrot-and-stick-reforms-have-failed-heres-why-38501">private health insurance</a> and the long-term fate of <a href="https://theconversation.com/another-day-another-hospital-funding-dispute-how-to-make-sense-of-todays-coag-talks-57058">public hospital funding</a>, the report puts another difficult set of issues onto his desk.</p>
<p>Australia <a href="https://theconversation.com/australian-health-care-where-do-we-stand-internationally-30886">performs relatively well</a> in health when compared to other countries. But those data are about averages and broad measures.</p>
<p>When you dig down into the data, the report reveals serious problems, notably in the areas of out-of-pocket health expenses, potentially avoidable early deaths, Indigenous health and state-by-state differences in health outcomes.</p>
<h2>The markers of a good health system</h2>
<p>The Productivity Commission report, which is prepared with the help of Commonwealth and state and territory governments, identifies the desired outcomes of the health system as:</p>
<ul>
<li>Australians are born and remain healthy</li>
<li>receive appropriate high quality and affordable primary and community health services</li>
<li>receive appropriate high quality and affordable hospital and hospital-related care</li>
<li>have positive health care experiences that take account of individual circumstances and care needs</li>
<li>have a health system that promotes social inclusion and reduces disadvantage, especially for Aboriginal and Torres Strait Islander people</li>
<li>have a sustainable health system.</li>
</ul>
<p>The report includes data on most of those outcomes, sometimes with adequate time series to track progress (or lack of progress), sometimes with state/territory level breakdowns and sometimes allowing comparisons of outcomes for Indigenous and non-Indigenous Australians.</p>
<p>These comparisons reveal serious policy issues the health minister would probably have preferred to avoid.</p>
<h2>Out-of-pocket costs</h2>
<p>Australians pay more <a href="https://theconversation.com/many-australians-pay-too-much-for-health-care-heres-what-the-government-needs-to-do-61859">out-of-pocket for health care than many countries</a>, resulting in access problems for a substantial minority. Drawing on <a href="http://www.aihw.gov.au/health-expenditure/">previously released data</a> from the Australian Institute of Health and Welfare, the report shows funding from non-government sources (mostly out-of-pocket costs) increased four-and-a-half times faster than government funding (6% vs 1.3%).</p>
<p>The increased out-of-pockets are a concern, affecting the costs faced by consumers in seeing both <a href="https://theconversation.com/how-much-seeing-private-specialists-often-costs-more-than-you-bargained-for-53445">private specialists</a> and <a href="https://theconversation.com/factcheck-have-average-out-of-pocket-costs-for-gp-visits-risen-almost-20-under-the-coalition-66278">general practitioners</a>.</p>
<h2>Potentially avoidable early deaths</h2>
<p>A key measure of health system performance is whether it improves our health and allows us to live longer in good health. While the report does not include some important outcome measures, such as whether consumer expectations are being met, it does report on what is happening with death rates, particularly death rates that health care interventions or preventive action could influence.</p>
<p>Despite all the hype about the benefits of <a href="https://theconversation.com/how-does-medical-research-deliver-value-for-money-1720">investing in medical research</a>, standardised rates for potentially avoidable early deaths have been unchanged for the past few years.</p>
<p>This raises questions about whether our medical research funding is <a href="https://theconversation.com/better-ways-to-spend-the-medical-research-future-fund-26685">wisely invested</a>, if more should be done on preventive health care and if new treatments with proven benefits are being <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3241518">implemented across all health care settings</a>.</p>
<h2>Indigenous health</h2>
<p>This report is yet another one to shine light on the tragedy of Indigenous health. In table after table in the report we see the stark differences in the outcomes for Indigenous compared to non-Indigenous Australians.</p>
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<p>The challenge of improving Indigenous health is immense. But this report puts it well and truly on the agenda of health minister Hunt and the new Indigenous health minister Ken Wyatt.</p>
<h2>State comparisons</h2>
<p>The report also allows comparisons between states. Australia’s <a href="https://www.jstor.org/stable/3330258?seq=1#page_scan_tab_contents">marble cake federalism</a> (a term used to describe multiple layers of government) means it is difficult to assign responsibility to one level of government and one minister for poor outcomes. This means health ministers in a number of states may have a spoiled breakfast too.</p>
<p>The Tasmanian health minister might want to ponder why there are more low birth-weight babies born in Tasmania compared to other states (rate for <1,500g is 1.3% in Tasmania vs 1% for all Australia, 7.7% vs 6.4% for <2,500g).</p>
<p>The Victorian health minister might ponder why 51% of young male Victorians (aged 18-24) are overweight or obese compared to an Australian prevalence of 44%. </p>
<p>The Queensland health minister might want to reflect on why more non-Indigenous Queenslanders smoke (using age-sex standardised rates) than the Australian average (17% vs 16%). </p>
<p>In South Australia, the health minister might ask why there are ten more potentially avoidable deaths per 100,000 population than in Western Australia (non-Indigenous population only).</p>
<h2>A treasure trove</h2>
<p>The Productivity Commission’s report is a treasure trove of information. A similar report has been published every year for the past 20 years but, unfortunately, shining light on these differences among states and between Indigenous and non-Indigenous Australians has not led to a narrowing of differences.</p>
<p>The relevant ministers need to take ownership of the problems raised in the report and start addressing them rather than wringing hands, or worse, ignoring or denying them.</p>
<p>Minister Hunt should table the report at the next health ministers’ meeting, focusing on where each state could make improvements.</p>
<p>Accountability for outcomes may also require the Productivity Commission to be more direct in its media strategy when the report is released. Non-government organisations have a role to play too, bringing to the public’s attention where there is scope for improvement.</p>
<p>It will be a tragedy if we allow these very comprehensive – and quite expensive – reports just to moulder on shelves rather than addressing the issues identified.</p><img src="https://counter.theconversation.com/content/72259/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Grattan Institute began with contributions to its endowment of $15 million from each of the Federal and Victorian Governments. In order to safeguard its independence, Grattan Institute’s board controls this endowment. The funds are invested and Grattan uses the income to pursue its activities
Stephen Duckett is a member of the South Australian Health Performance Council. Dr Duckett 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 the appointment above.</span></em></p>The latest Productivity Commission health report reveals some serious problems with out-of-pocket health expenses as well as disparities between Indigenous and non-Indigenous health.Stephen Duckett, Director, Health Program, Grattan InstituteLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/684282016-11-30T19:18:29Z2016-11-30T19:18:29ZHow e-cigarettes could ‘health wash’ the tobacco industry<figure><img src="https://images.theconversation.com/files/146181/original/image-20161116-13555-1ac2es0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Classifying e-cigarettes as a nicotine replacement therapy could help the tobacco industry influence health policy.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/237371161?src=sql-LWcr4laxp9REXUUEgA-1-22&id=237371161&size=medium_jpg">from www.shutterstock.com</a></span></figcaption></figure><p>The evidence that e-cigarettes help people quit smoking was described in the World Health Organisation’s (WHO) recent <a href="http://www.who.int/fctc/cop/cop7/FCTC_COP_7_11_EN.pdf">report</a> as “scant and of low certainty”. Predictably, this triggered the latest <a href="https://www.theguardian.com/society/2016/nov/04/vaping-does-not-help-people-stop-smoking-says-who-report">round</a> of claims and counterclaims in an ongoing, and often acrimonious, dispute about the potential of e-cigarettes.</p>
<p>This lack of definitive evidence about either their efficacy or their long term health effects, outlined by the WHO, is echoed by <a href="http://www.thelancet.com/journals/lanres/article/PIIS2213-2600(15)00521-4/abstract">others</a>, including Australia’s <a href="https://www.nhmrc.gov.au/guidelines-publications/ds13">National Health and Medical Research Council</a>.</p>
<p>Regulatory authorities outside Australia have classified e-cigarettes as medical devices or smoking cessation aids, similar to nicotine replacement therapy, like patches or gums. So far tobacco companies are the only actors to successfully gain medical licences for such products, although none have yet come to market.</p>
<p>But the decision to seek medical approval for their products may have serious consequences.</p>
<p>It may allow the industry to reclaim a role in health policy, part of a wider strategy by tobacco companies to rebrand themselves as nicotine companies with a key role in the fight against smoking.</p>
<p>By positioning themselves as “part of the solution”, rather than the essence of the problem, the tobacco industry is seeking to claw back from its pariah status and to re-engage in the policy process.</p>
<p>Policy makers who would shun overtures from Big Tobacco may nonetheless be prepared to meet with “nicotine companies” and producers of smoking cessation devices. This offers tobacco companies a significant opportunity to shape regulatory debates surrounding their core cigarette businesses, potentially undermining effective tobacco control policies which have driven declining smoking rates in Australia and elsewhere.</p>
<h2>How are e-cigarettes regulated?</h2>
<p>The lack of definitive evidence about either e-cigarettes’ efficacy or long term health effects underlies the Australian government’s decision to implement a near-complete ban.</p>
<figure class="align-left ">
<img alt="" src="https://images.theconversation.com/files/145692/original/image-20161114-9081-8kyo63.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/145692/original/image-20161114-9081-8kyo63.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=776&fit=crop&dpr=1 600w, https://images.theconversation.com/files/145692/original/image-20161114-9081-8kyo63.JPG?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=776&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/145692/original/image-20161114-9081-8kyo63.JPG?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=776&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/145692/original/image-20161114-9081-8kyo63.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=975&fit=crop&dpr=1 754w, https://images.theconversation.com/files/145692/original/image-20161114-9081-8kyo63.JPG?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=975&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/145692/original/image-20161114-9081-8kyo63.JPG?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=975&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">E-cigarette shop, Paris (supplied).</span>
</figcaption>
</figure>
<p>Current <a href="http://www.racgp.org.au/afp/2015/june/e-cigarettes-and-the-law-in-australia/">regulations</a> prohibit the sale, supply and possession of e-cigarettes containing nicotine. Regulation of the use of e-cigarettes in public places, their marketing and promotion varies by state, adding a further level of legal uncertainty.</p>
<p>People can import e-cigarettes as an unapproved therapeutic good with a prescription. However, most vapers (e-cigarette users), are unlikely to visit doctors to access products readily available over the internet. Many vapers also reject the idea they are sick and need to be cured.</p>
<p>Australia’s position differs from that of other jurisdictions. The European Union, for example, allows e-cigarettes to be sold as licensed medical devices or as non-medical products if they meet certain criteria set out in the 2014 <a href="http://ec.europa.eu/health/tobacco/products/revision/index_en.htm">Tobacco Products Directive</a>.</p>
<p>In the UK, British American Tobacco is the only company so far to have obtained a medical licence for an electronic nicotine delivery device, although its Voke brand is not yet on the market. This opens the possibility that UK patients could be prescribed tobacco industry products on the National Health Service.</p>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/145689/original/image-20161114-9077-f8nh9u.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/145689/original/image-20161114-9077-f8nh9u.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=660&fit=crop&dpr=1 600w, https://images.theconversation.com/files/145689/original/image-20161114-9077-f8nh9u.JPG?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=660&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/145689/original/image-20161114-9077-f8nh9u.JPG?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=660&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/145689/original/image-20161114-9077-f8nh9u.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=829&fit=crop&dpr=1 754w, https://images.theconversation.com/files/145689/original/image-20161114-9077-f8nh9u.JPG?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=829&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/145689/original/image-20161114-9077-f8nh9u.JPG?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=829&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Vype advert, UK (supplied).</span>
</figcaption>
</figure>
<p>In 2013, British American Tobacco subsidiary Nicovations applied to the Australian Therapeutic Goods Administration (TGA) to have Voke licensed as part of its “<a href="http://www.abc.net.au/news/2014-10-02/tobacco-giant-wants-e-cigarettes-classed-as-medicine/5786508">medicines-based approach</a>” to reduce the harms from smoking. When the TGA refused to evaluate its application, Nicovations successfully took the issue to the <a href="http://www.judgments.fedcourt.gov.au/judgments/Judgments/fca/single/2016/2016fca0394">Federal Court</a>, which in April 2016 <a href="http://www.smh.com.au/federal-politics/political-news/federal-court-forces-drug-regulator-to-consider-nicotine-inhaler-case-20160421-goc3kx.html">ruled</a> the TGA was required to consider the company’s submission.</p>
<p>Another British American Tobacco brand, Vype, which is not regulated as a medical device, is sold in UK pharmacies alongside nicotine replacement products. It is being positioned – both physically and symbolically – as a smoking cessation tool.</p>
<h2>Do we need products to help us stop smoking?</h2>
<p>Current debates on e-cigarettes occur in a context in which quitting smoking has become defined as a treatable medical condition and the best way to stop smoking is to buy a manufactured remedy. This situation is the result of aggressive promotion by pharmaceutical companies that manufacture nicotine replacement therapies and other pharmacotherapy. </p>
<p>Despite the <a href="http://jamanetwork.com/journals/jama/article-abstract/1812969">reality</a> that the overwhelming majority of ex-smokers quit without using pharmaceutical products, the manufacturers of nicotine replacement therapy have successfully shaped perceptions around how smokers quit, both in Australia and internationally.</p>
<p>Tobacco companies’ investment in e-cigarettes builds on the medicalisation of smoking cessation. While some companies have invested in developing medical devices, the vast majority of tobacco companies’ “next generation” products, including e-cigarettes, are carefully differentiated from existing nicotine replacement therapies. They are positioned as smoking substitutes rather than overtly medical treatments. </p>
<p>Indeed, the development of medical products may be intended to draw attention to the availability of non-medical substitutes, which are targeted at smokers who do not see themselves as unwell or in need of treatment but may be attracted by substitute products.</p>
<p>Niconovum USA, Inc, a subsidiary of Reynolds American, provides a particularly explicit example through production of Zonnic nicotine gum and other products. As Niconovum’s president <a href="http://ajph.aphapublications.org/doi/full/10.2105/AJPH.2016.303456">said</a> recently:</p>
<blockquote>
<p>Many smokers do not see smoking as a medical condition and, thus, have not been reached by traditional nicotine replacement therapy marketing and channels of distribution.</p>
</blockquote>
<p>The current developments in smoking cessation and the evolving corporate strategy of Big Tobacco means we need to be clear about the key issues and participants in current smoking cessation debates. </p>
<p>The marketing of e-cigarettes as smoking cessation products will reinforce misconceptions among policy makers and the wider public that some form of medical or non-medical replacement product is required to quit smoking. It will also reinforce the idea that to drive quit rates, it is both necessary and legitimate to engage with the producers of these products.</p>
<figure class="align-left ">
<img alt="" src="https://images.theconversation.com/files/145694/original/image-20161114-9048-1ebr979.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/145694/original/image-20161114-9048-1ebr979.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=799&fit=crop&dpr=1 600w, https://images.theconversation.com/files/145694/original/image-20161114-9048-1ebr979.JPG?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=799&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/145694/original/image-20161114-9048-1ebr979.JPG?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=799&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/145694/original/image-20161114-9048-1ebr979.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1004&fit=crop&dpr=1 754w, https://images.theconversation.com/files/145694/original/image-20161114-9048-1ebr979.JPG?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1004&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/145694/original/image-20161114-9048-1ebr979.JPG?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1004&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Smoking cessation products display, UK (suppplied).</span>
</figcaption>
</figure>
<p>Investment by tobacco companies in e-cigarettes raises important concerns regarding the renormalisation of the industry, and the impact on tobacco control policies. It, may, for instance, allow tobacco companies to reposition themselves as key partners in the health policy process in ways <a href="https://responsibilitydeal.dh.gov.uk/">similar</a> to the alcohol and food industries.</p>
<p>While meetings between governments and the tobacco industry are precluded by <a href="http://www.who.int/tobacco/wntd/2012/article_5_3_fctc/en/">Article 5.3</a> of the <a href="http://www.who.int/fctc/text_download/en/">Framework Convention on Tobacco Control</a>, tobacco companies will be able to argue such restrictions do not extend to their e-cigarette subsidiaries. </p>
<p>Despite strategies to rebrand themselves as nicotine companies and technological innovators, the core business of the tobacco industry, and its sources of profit, remains firmly focused on conventional tobacco products.</p>
<p>As such, governments should approach e-cigarettes and their producers with caution. Tobacco companies, including their subsidiaries, must be viewed as tobacco companies in all contexts, and governments should adhere to internationally accepted norms of non-engagement.</p><img src="https://counter.theconversation.com/content/68428/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Ross MacKenzie receives funding from the National Institutes of Health. He he has previously worked on research projects funded by the Rockefeller Foundation, and Cancer Council NSW.</span></em></p><p class="fine-print"><em><span>Benjamin Hawkins receives funding from the US National Institute of Health (Grant No. R01-CA091021).</span></em></p>Classing e-cigarettes as quit smoking aids could help rebrand the tobacco industry as a legitimate player in health policy. Here’s why we should be concerned.Ross MacKenzie, Lecturer in Health Studies, Macquarie UniversityBenjamin Hawkins, Lecturer in Global Health Policy, London School of Hygiene & Tropical MedicineLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/690412016-11-22T04:50:57Z2016-11-22T04:50:57ZFixing an ailing Obamacare: four ways to address rising costs and less choice<figure><img src="https://images.theconversation.com/files/146695/original/image-20161121-30364-1ble1ts.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">How might US president-elect Donald Trump address Obamacare's rising costs? </span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/154183421?src=DKwbS5YekkQdg9M4VlTpZA-1-4&id=154183421&size=medium_jpg">from www.shutterstock.com</a></span></figcaption></figure><p>Repealing <a href="https://theconversation.com/explainer-what-is-obamacare-18642">Obamacare</a> was central to both <a href="https://www.donaldjtrump.com/policies/health-care/">Donald Trump’s</a>, and the <a href="https://prod-cdn-static.gop.com/static/home/data/platform.pdf">Republican party’s</a>, policy platforms. The President-elect has since <a href="https://www.theguardian.com/us-news/2016/nov/12/donald-trump-appears-to-soften-stance-on-range-of-pledges">softened</a> his stance and there are several Republican proposals to replace Obamacare with a more viable alternative.</p>
<p>Obamacare involves establishing state insurance marketplaces (or exchanges) on which people buy insurance. These are like price comparison websites on which people can buy subsidised insurance. People can also get insurance through their employers or directly from insurers. </p>
<p>All people must have insurance (under threat of penalty) and insurers cannot refuse people with pre-existing conditions or charge them more. Most state marketplaces work independently, with different plans available to residents of different states. In offering insurance, companies must spend at least 80% of premiums on healthcare and quality improvement.</p>
<p>Key criticisms of Obamacare have included rising premiums and fewer available policies. Repealing Obamacare without a replacement could have “<a href="https://www.linkedin.com/pulse/lets-look-affordable-care-act-nick-gerhart">devastating consequences</a>”, according to the Iowa Insurance Commissioner. People’s insurance would be disrupted and insurers would face losses as sick people rush to have procedures before their cover ends. </p>
<p>So what has led to Obamacare’s problems, what needs to be addressed and what might alternatives to Obamacare look like?</p>
<h2>Rising premiums, less choice</h2>
<p>Obamacare has become decreasingly popular in recent years. Insurance premiums will <a href="http://fortune.com/2016/10/25/obamacare-insurance-premiums-2017-healthcare/">reportedly</a> rise by 25% in 2017. Subsequently, <a href="https://www.washingtonpost.com/news/the-fix/wp/2016/11/10/the-13-most-amazing-things-in-the-2016-exit-poll/">almost half</a> of exit poll respondents in the US election thought Obamacare “went too far”. Insurers too argue they are <a href="http://thehill.com/policy/healthcare/276366-insurers-warn-losses-from-obamacare-are-unsustainable">losing money</a> on Obamacare. A 2016 McKinsey & Co <a href="http://healthcare.mckinsey.com/2014-individual-market-post-3r-financial-performance">report</a> indicates insurers lost money in 41 states on Obamacare exchanges in 2014. </p>
<p>Insurance companies too are withdrawing from Obamacare marketplaces and instead choosing to focus on employer sponsored plans. So, some states also have <a href="http://www.nytimes.com/2016/10/25/us/some-health-plan-costs-to-increase-by-an-average-of-25-percent-us-says.html">fewer insurance options</a>. UnitedHealthcare is withdrawing from most Obamacare marketplaces and remaining in only a <a href="http://www.bloomberg.com/news/articles/2016-04-19/unitedhealth-profit-beats-estimates-fueled-by-tech-unit-optum">handful</a> of states in 2017. <a href="http://money.cnn.com/2016/08/15/news/economy/aetna-obamacare/">Aetna</a> will stop offering insurance in 11 of the 15 states it serves.</p>
<p>The <a href="https://www.cbo.gov/sites/default/files/114th-congress-2015-2016/reports/51385-HealthInsuranceBaseline.pdf">Congressional Budget Office</a> indicates subsidies from the government to consumers will amount to US$43 billion in 2016. These subsidies increase as premiums increase, squeezing health care budgets further. This is clearly not sustainable given the existing budget deficit. </p>
<p>The Republican party has detailed replacement plans for Obamacare. <a href="https://abetterway.speaker.gov/_assets/pdf/ABetterWay-HealthCare-PolicyPaper.pdf">A Better Way</a> and the <a href="http://www.finance.senate.gov/chairmans-news/burr-hatch-upton-unveil-obamacare-replacement-plan">CARE Act</a> both maintain key features, including that insurers cannot refuse people with preexisting conditions (the preexisting condition rule).</p>
<p>However, they both propose increasing premiums for people who have not maintained continuous coverage. The idea is to encourage people to sign up while healthy, the first issue that an Obamacare replacement needs to address.</p>
<h2>1. Get healthy people into insurance</h2>
<p>Efforts to get healthy people into insurance, and to reward them for keeping up their policies, are intended to enable companies to insure sick people without going bankrupt. </p>
<p>Obamacare’s current “individual mandate”, which states that everyone must buy insurance or face a penalty, is meant to facilitate this.</p>
<p>However, too many healthy people pay the penalty rather than buy insurance. While the overall percentage of people without insurance <a href="http://www.cdc.gov/nchs/data/nhis/earlyrelease/earlyrelease201609_01.pdf">decreased</a> between 2012 and the first quarter of 2016, this varied across different age ranges. As the graph shows, in percentage terms, more 25-34 year olds are uninsured than are 35-44, or 45-64 year olds. Thus, in percentage terms, older (generally sicker) people make up an increasing portion of enrolees, increasing risk and forcing companies to charge higher premiums to remain solvent.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/146646/original/image-20161119-19345-tpebpt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/146646/original/image-20161119-19345-tpebpt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/146646/original/image-20161119-19345-tpebpt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=264&fit=crop&dpr=1 600w, https://images.theconversation.com/files/146646/original/image-20161119-19345-tpebpt.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=264&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/146646/original/image-20161119-19345-tpebpt.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=264&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/146646/original/image-20161119-19345-tpebpt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=331&fit=crop&dpr=1 754w, https://images.theconversation.com/files/146646/original/image-20161119-19345-tpebpt.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=331&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/146646/original/image-20161119-19345-tpebpt.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=331&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Percentage of uninsured people by age group.</span>
<span class="attribution"><span class="source">Center for Disease Control</span></span>
</figcaption>
</figure>
<p>President-elect Trump seems to want to keep the preexisting conditions component. However, this could be unviable given the current lack of young, healthy, enrolees. The government would need to enforce the individual mandate either through increased penalties for people not taking up a policy or to persuade people to sign up.</p>
<p>Australia and Republican proposals could give some guidance. Australia’s <a href="http://www.privatehealth.gov.au/healthinsurance/incentivessurcharges/lifetimehealthcover.htm">Lifetime Health Cover</a> program, as well as the previously mentioned alternatives, Better Way and CARE Act, allow insurance companies to charge higher premiums to people who have not maintained continuous coverage.</p>
<p>The Republican proposals also reduce the required level of care insurance companies must offer, thereby reducing premium costs and attracting more people to insurance. The CARE Act forces people who do not enrol into a default low cost insurance program, which provides coverage for only a limited range of conditions.</p>
<h2>2. Address fragmented marketplaces</h2>
<p>Insurance companies can sell insurance via employer based plans, on Obamacare marketplaces and/or directly to consumers. A total of <a href="https://www.cbo.gov/sites/default/files/114th-congress-2015-2016/reports/51385-HealthInsuranceBaseline.pdf">155 million</a> people under 65 get their insurance from employment based plans; <a href="https://www.cbo.gov/sites/default/files/114th-congress-2015-2016/reports/51385-HealthInsuranceBaseline.pdf">12 million</a> buy their insurance on the marketplaces; <a href="https://www.cbo.gov/sites/default/files/114th-congress-2015-2016/reports/51385-HealthInsuranceBaseline.pdf">9 million</a> buy it outside the marketplaces (directly from insurers). </p>
<p>Compared with those on employer-sponsored plans, people who buy insurance on the exchange tend to qualify for government subsidies and tend to be sicker and poorer. The Blue Cross Blue Shield <a href="http://www.bcbs.com/healthofamerica/newly_enrolled_individuals_after_aca.pdf">reports</a> new enrolees after Obamacare tend to have higher rates of some diseases and use more medical services.</p>
<p>Insurance companies can mitigate having to insure excess numbers of sick people on Obamacare marketplaces by focusing on employer-linked plans. This reduces choice on the marketplace.</p>
<p>Some states have tried to address this problem through incentives and penalties. Alaska has a <a href="https://blog.cms.gov/2016/08/11/building-on-premium-stabilization-for-the-future/">reinsurance</a> type program to help insurers meet the costs of high cost patients. Nevada <a href="https://www.healthinsurance.org/nevada-state-health-insurance-exchange/">mandates</a> insurers participate in its exchange. Australia too has a <a href="http://www.pc.gov.au/__data/assets/pdf_file/0006/156678/57privatehealth.pdf">reinsurance arrangement</a> to help insurance companies burdened with bad risks. The Better Way proposal would have a US$25 billion high risk pool. Such incentive measures could help to increase exchange participation without risking insurance companies’ solvency. </p>
<p>Trump potentially has a similar policy. His policy platform <a href="https://www.donaldjtrump.com/policies/health-care/">refers to</a> establishing “high-risk pools to ensure access to coverage for individuals who have not maintained continuous coverage”. This might help to alleviate the stresses created by retaining the preexisting condition clause.</p>
<h2>3. Allow interstate purchases</h2>
<p>People can generally only buy insurance form their home state’s marketplace due to the McCarran-Ferguson Act (1945), which allows states to regulate health insurance plans within their borders.</p>
<p>Some markets have few insurance companies, and <a href="http://www.nytimes.com/2016/10/25/us/some-health-plan-costs-to-increase-by-an-average-of-25-percent-us-says.html">reportedly</a>, will only have one marketplace offering in 2017. This gives little choice for their residents.</p>
<p><a href="https://www.donaldjtrump.com/policies/health-care/">Trump’s solution</a> is to allow “people to purchase insurance across state lines, in all 50 states”. This will not solve the issue of healthy people going without insurance and increasing the risk pool, but will increase choice. Increased competition also risks further eroding any profitability for insurance companies.</p>
<h2>4. Relax the 80/20 rule</h2>
<p>The <a href="https://www.healthcare.gov/health-care-law-protections/rate-review/">80/20 rule</a> says insurance companies must spend at least 80% of all premium revenue on medical care and actions to improve the quality of care; they must spend <a href="https://www.healthcare.gov/health-care-law-protections/rate-review/">at least 85%</a> when selling insurance to large groups.</p>
<p>The 80/20 rule can be problematic because there’s a debate about whether the government is entitled to regulate companies’ profitability.</p>
<p>The rule also limits competition in individual marketplaces. This is because a firm can participate in a marketplace only if it can keep its overheads low enough to spend 80% of revenue on health care. This is possible only if both (1) it has relatively low costs, and (2) it has enough customers to generate economics of scale. Small insurers lack economies of scale, so could not participate. </p>
<p>Insurers unsure about whether a marketplace will be profitable will be deterred because there is no guarantee they could retain enough premium revenue to remain solvent. </p>
<p>The government might not want to enable rampant profiteering. However, relaxing the 80/20 rule could encourage more insurers to enter the insurance marketplaces. </p>
<h2>Where to from here and will Trump’s position help?</h2>
<p>Trump’s Obamacare position is evolving and his policy platform is vague. He states that he intends to “repeal and replace” Obamacare yet the form of that replacement is unclear.</p>
<p>Trump indicated he supported the rule that insurance companies must accept people with preexisting conditions and to allow adult children to remain on their parents’ insurance policies. Trump also wants to increase choice by allowing people to buy insurance across state lines, which does not itself solve the problem of unhealthy people flocking to Obamacare marketplaces.</p>
<p>Retaining Obamacare is untenable unless Trump retains, and enforces, the individual mandate. However, his policies regarding the individual mandate are unclear. The obvious solutions are to increase penalties for noncompliance and imposing a loading for failing to maintain continuous coverage. A reinsurance plan, similar to that in Australia, or in Alaska, might help mitigate the impact of high-risk customers.</p>
<p>Ultimately, the choice comes down to enforcing the individual mandate more stridently, potentially allowing higher premiums for those who fail to maintain continuous coverage, or watching Obamacare fail.</p><img src="https://counter.theconversation.com/content/69041/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Mark Humphery-Jenner 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.</span></em></p>Alternatives to Obamacare look to address rising premiums and less consumer choice. What options does the US have and how could they work?Mark Humphery-Jenner, Associate Professor of Finance, UNSW SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/642282016-10-30T19:06:52Z2016-10-30T19:06:52ZSurgery isn’t always the best option, and the decision shouldn’t just lie with the doctor<figure><img src="https://images.theconversation.com/files/142121/original/image-20161018-12454-11m0fyv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Weighing up the evidence for surgery is just one thing to consider before going under the knife.</span> <span class="attribution"><a class="source" href="http://www.shutterstock.com/dl2_lim.mhtml?src=G5r9D6sZtKvWkj3xzKlPTw-1-19&id=210890980&size=medium_jpg">from www.shutterstock.com</a></span></figcaption></figure><p>Surgeons often decide to perform procedures because that’s what’s usually done, it’s what they’re taught, it sounds logical or it fits with observations from their own practice.</p>
<p>If the surgeon’s decision is in line with evidence from scientific studies, there’s little problem. But if the two conflict, either the surgeon’s opinion or the evidence is wrong.</p>
<p>The best way to test whether surgery works (particularly when the outcome is subjective, such as with pain) is to compare it with a sham or placebo procedure. The idea is to keep the patients and those who measure the effectiveness “blinded” to which treatment is given.</p>
<p>A <a href="http://www.bmj.com/content/348/bmj.g3253">review of studies</a> comparing surgery to sham or placebo surgery showed surgery was no better than placebo in just over half of the studies. And in studies where surgery was better than placebo, the difference was generally small.</p>
<p>As an example, two studies compared placebo surgery to keyhole surgery (arthroscopy) of the knee in patients with degenerative conditions (arthritis, meniscus tears and catching and clicking). Both studies showed no important difference in surgery outcomes between the two groups.</p>
<h2>What about other options?</h2>
<p>We don’t always need to compare surgery with a sham. Sometimes comparing surgery with non-surgical treatment (like physiotherapy or medications) is more appropriate.</p>
<p>One <a href="http://journals.plos.org/plosone/article?id=10.1371%2Fjournal.pone.0096745">study</a> looked at all orthopaedic surgical procedures performed on more than 9,000 patients in three hospitals over three years. Only half the procedures were compared with non-operative treatment. And of that half, about half were no better than not operating.</p>
<p>So there are two problems in surgery: an evidence gap (in which there’s a lack of high quality evidence) and an evidence-practice gap (where there’s high quality evidence that a procedure doesn’t work, yet is still performed).</p>
<p>Part of the problem is that operations are often introduced before there’s good quality evidence of their effectiveness in the real world. The studies comparing them to non-operative treatment or placebo often come much later – if at all.</p>
<h2>When should surgery be funded?</h2>
<p>Doctors should not perform surgical procedures and taxpayers should not have to cover their cost until there’s high quality evidence they work. It should be unethical for surgeons to introduce a new technique without studying whether or not <a href="http://www.ncbi.nlm.nih.gov/pubmed/24484092">it works</a>.</p>
<p>Unfortunately, the opposite is true: ethical approval is not required before surgeons can start performing new procedures, but it is required to study the effectiveness of that procedure.</p>
<p>Often, procedures surgeons consider effective are later shown not to be.</p>
<p>In the US in the 1980s, a new procedure for the lung disease emphysema touted removing some lung tissue. Animal studies and (non-comparative) human studies were encouraging. So the procedure became common. </p>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/142124/original/image-20161018-12459-vq1dx6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/142124/original/image-20161018-12459-vq1dx6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/142124/original/image-20161018-12459-vq1dx6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=399&fit=crop&dpr=1 600w, https://images.theconversation.com/files/142124/original/image-20161018-12459-vq1dx6.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=399&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/142124/original/image-20161018-12459-vq1dx6.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=399&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/142124/original/image-20161018-12459-vq1dx6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=501&fit=crop&dpr=1 754w, https://images.theconversation.com/files/142124/original/image-20161018-12459-vq1dx6.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=501&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/142124/original/image-20161018-12459-vq1dx6.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=501&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Weighing up the evidence for surgery could shed light on whether it should be funded.</span>
<span class="attribution"><a class="source" href="http://www.shutterstock.com/dl2_lim.mhtml?src=lfFyW8Ym2fcj54AIiy-Tfw-1-0&id=89667058&size=medium_jpg">from www.shutterstock.com</a></span>
</figcaption>
</figure>
<p>Some surgeons called for a trial comparing the procedure to non-operative treatment. But proponents of the procedure said this would deprive many people of the procedure’s benefits, the effectiveness of which was obvious.</p>
<p>Medicare in the US decided only to fund the surgery if patients took part in a trial comparing it to non-surgical treatment. The <a href="http://www.nejm.org/doi/full/10.1056/NEJMoa030287#t=article">trial</a> was done and the surgery was found wanting, with no overall benefit over non-operative treatment. The trial cost the government some money, but much less than paying for the procedure for decades until someone else studied it.</p>
<p>This type of solution should be considered in Australia: new procedures should only be funded by the public if they are performed as part of a trial to adequately test their effectiveness.</p>
<p>Once evidence is available, the key is using it to make good decisions about the effectiveness of a particular procedure for an individual patient. So how should surgeons do that? The answer lies in measuring the right outcomes to begin with and then making shared decisions.</p>
<h2>How do we know if surgery works?</h2>
<p><a href="http://www.theaustralian.com.au/national-affairs/health/budget-2016-healthcare-waste-costs-20bn-a-year/news-story/37475d4c7c3a7adfcd65b8216b8ed015">Billions</a> are spent worldwide on surgical procedures that may not be <a href="https://www.mja.com.au/journal/2012/197/10/over-150-potentially-low-value-health-care-practices-australian-study">effective</a>. But how should we define effectiveness?</p>
<p>There is a growing acceptance that doctors should partner with patients to identify outcomes important to them. These might include avoiding complications and an unexpectedly long stay in hospital. But they should also consider longer-term quality of life, disability and <a href="https://www.ncbi.nlm.nih.gov/pubmed/25689756">survival</a>.</p>
<p>This is important when a good operation might be a bad choice. Some medical conditions herald a terminal decline in health, for which living longer is not as good as living well. A good operation may also be a bad choice in cases where attempts at prolonging life are futile.</p>
<h2>Sharing decisions</h2>
<p>Shared decision-making takes into account beliefs, preferences and views of the patient as an expert in what is right for them, supported by clinicians who are the experts in effective therapeutic options.</p>
<p>Patients should have the opportunity to ask further questions when deciding whether to go ahead with surgery to see if surgery is consistent with their values and lifestyle goals. For the critically ill, frail or confused, this discussion should often include the person’s spouse, family or next of kin.</p>
<p>The right decisions in surgery are patient-centred, based on good evidence, clearly communicated and made in a supportive environment. Everyone – doctors, other health professionals, the patient, sometimes their family, and the public – have a right and a responsibility to be included.</p><img src="https://counter.theconversation.com/content/64228/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Ian Harris receives no direct payment or funding for research projects. He is an investigator on research projects funded by NHMRC, HCF Research Foundation, AO Trauma Asia Pacific, Lincoln Centre, UNSW, Arthritis Australia, AOA Research Foundation, MAA and SIRA</span></em></p><p class="fine-print"><em><span>Professor Paul Myles receives research funding from the NHMRC and the Australian and New Zealand College of Anaesthetists. </span></em></p>There’s often limited evidence for many common types of surgery. Understanding what makes good evidence is the key to deciding what’s best for you.Ian Harris, Professor of Orthopaedic Surgery, UNSW SydneyProfessor Paul Myles, Chair of the Department of Anaesthesia and Perioperative Medicine, Monash UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/623822016-07-19T14:10:07Z2016-07-19T14:10:07ZIt will take more than $36 billion every year to end AIDS<figure><img src="https://images.theconversation.com/files/131093/original/image-20160719-7903-1mu176c.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">South African HIV rights group, the Treatment Action Campaign, marching through Durban, calling for antiretroviral access for all. </span> <span class="attribution"><span class="source">International AIDS Society/Rogan Ward</span></span></figcaption></figure><p>In the past 15 years, the global community has provided <a href="http://journals.lww.com/aidsonline/Abstract/2016/06010/Tracking_development_assistance_for_HIV_AIDS___the.18.aspx">US$109.8 billion</a> in development assistance to curb HIV/AIDS. Several international aid organisations created in this period have been instrumental in galvanising the resources needed to combat the epidemic. </p>
<p>But meeting the UNAIDS <a href="https://theconversation.com/hiv-aids-and-90-90-90-what-is-it-and-why-does-it-matter-62136">90-90-90</a> targets – that 90% of HIV positive people will know their status, 90% of those people will be on antiretrovirals and 90% will be virally suppressed by 2020 – will require major changes in how programmes are delivered and financed. </p>
<p>Maintaining and scaling up the <a href="https://secure.jbs.elsevierhealth.com/action/getSharedSiteSession?rc=1&redirect=http%3A%2F%2Fwww.thelancet.com%2Fjournals%2Flancet%2Farticle%2FPIIS0140-6736%2815%2960658-4%2Ffulltext%3Frss%253Dyes&code=lancet-site">funding of AIDS efforts</a> in the next 20 years to end the epidemic is crucial.</p>
<p>The challenge is that since 2010 development assistance for HIV has <a href="http://www.healthdata.org/policy-report/financing-global-health-2015-development-assistance-steady-path-new-global-goals">remained nearly constant</a>. <a href="https://secure.jbs.elsevierhealth.com/action/getSharedSiteSession?rc=1&redirect=http%3A%2F%2Fwww.thelancet.com%2Fjournals%2Flancet%2Farticle%2FPIIS0140-6736%2815%2960658-4%2Ffulltext%3Frss%253Dyes&code=lancet-site">Researchers estimate</a> that $36 billion is needed annually to achieve the United Nations goals. </p>
<p>Current epidemiological and financial trends suggest there’s a major risk of a substantial shortfall in the funds required to sustain life-saving antiretroviral programmes. </p>
<h2>The three phases of the epidemic</h2>
<p>The number of people living with HIV/AIDS steadily increased to 38.8 million in 2015, according to the 2015 <a href="http://www.thelancet.com/pdfs/journals/lanhiv/PIIS2352-3018(16)30087-X.pdf">Global Burden of Disease</a> study.</p>
<p>The unfolding global HIV pandemic has advanced through three phases. In the first phase, 1981 to 1997, HIV moved from being ranked as the 39th leading cause of death worldwide to the 11th. </p>
<p>In the second phase, from 1998 to 2005, incidence declined by 25.4%. But because of the lag between infection and mortality, the number of deaths caused by HIV increased. </p>
<p>In the third phase, from 2005 to 2015, the mass scaling of prevention of mother-to-child transmission and antiretrovirals – particularly in low-income sub-Saharan Africa – led to several developments. These included declining HIV mortality, a stagnation in the decline of global incidence rates and steadily rising prevalence. These global patterns mask well documented but extraordinary heterogeneity across countries. </p>
<p>The need for HIV programmes, particularly antiretroviral ones, keeps growing. This is due to both the sustained high number of infections and the success of antiretrovirals in extending the lifespan of people living with HIV.</p>
<h2>Dealing with the financing gap</h2>
<p>Enormous progress has been made in reducing HIV deaths. This is particularly true in low-income countries. But this is mainly because programmes that prevent mother-to-child transmission and antiretroviral interventions, largely funded through development assistance for HIV, have been expanded. </p>
<p>This scaling up has been fuelled by the increase in development assistance for HIV from <a href="http://www.healthdata.org/policy-report/financing-global-health-2015-development-assistance-steady-path-new-global-goals">$1.3 billion</a> in 2000 to <a href="http://dx.doi.org/10.1016/S0140-6736(16)30168-4">$10.8 billion</a> in 2015. </p>
<p>UNAIDS and other international development agencies hope that the <a href="http://www.unaids.org/en/resources/documents/2014/JC2686_WAD2014report">growing need for funding</a> will be partly solved by <a href="http://www.unaids.org/en/resources/documents/2016/2016HighLe%2030%20velMeeting">expanded health spending</a> in low-income countries.</p>
<p>But the scarcity of adequate funds to provide antiretrovirals to people living with HIV – together with the possibility of rising drug resistance to existing antiretroviral treatments – will make achieving the goal to <a href="http://www.unaids.org/en/resources/documents/2014/JC2686_WAD2014report">end AIDS by 2030</a> extremely difficult.</p>
<p>In middle-income countries, increased commitments to funding health programmes from national budgets could fill the gap. </p>
<p>But domestic resources won’t be sufficient in low-income countries where, as in eastern and some southern sub-Saharan African countries, HIV rates are the highest.</p>
<p>Researchers have projected that <a href="http://www.sciencedirect.com/science/article/pii/S0140673616301672">government health expenditure</a> in southern sub-Saharan Africa is going to increase from $30.8 billion in 2015 to $53.1 billion in 2030.</p>
<p>Meeting the needs of people living with HIV will require a combination of the following evidence-informed strategies:</p>
<ul>
<li><p>concentrating development assistance for HIV in these low-income countries;</p></li>
<li><p>improving the efficiency of HIV programmes; </p></li>
<li><p>increasing domestic financing; </p></li>
<li><p>lowering the cost of treatment (including the prices of antiretrovirals); and </p></li>
<li><p>reducing future incidence through more concerted efforts. </p></li>
</ul>
<p>Development assistance efforts will also need to be scaled up if the free flow of low-cost generic drugs is hampered. </p>
<p>The World Health Organisation now <a href="http://www.who.int/hiv/pub/guidelines/arv2013/en/">recommends</a> universal <a href="http://www.who.int/hiv/pub/arv/policy-brief-arv-2015/en/">antiretroviral treatment for all</a> people with HIV.</p>
<p>In 2015, only <a href="http://www.who.int/gho/hiv/epidemic_response/ART_text/en/">41% of people living with HIV</a> were receiving antiretroviral therapy. But the 90-90-90 goals imply that 81% should be receiving antiretrovirals and 73% will have viral suppression. No country has achieved this yet. To do so, antiretroviral coverage will need to be extended to at least 15.5 million additional people by 2020. This implies an addition of 3.1 million per year between 2015 and 2020, while ensuring complete treatment adherence.</p>
<p>It will require concerted efforts to scale up detection of new infections to meet the target of 90% of people knowing their status. The targeted expansion in antiretroviral therapy coverage would play an important part in reducing the still high number of people dying from HIV.</p>
<p>But such expansion has enormous cost implications in an era when even maintenance of coverage in some low-income settings could be at risk in the presence of declining development assistance for health. </p>
<p>Increased antiretroviral coverage might also play a part in <a href="http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0011068">reducing population transmission</a> of HIV and therefore <a href="http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(08)61697-9/abstract">incidence</a>. The quality of antiretroviral therapy embodied in the third 90 target of the UNAIDS strategy remains a major issue, as does the potential role of other care in extending survival.</p><img src="https://counter.theconversation.com/content/62382/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Charles Shey Wiysonge 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.</span></em></p>Current epidemiological and financial trends suggest there’s a major risk of a substantial shortfall in the funds required to sustain life-saving antiretroviral programmes.Charles Shey Wiysonge, Professor of Clinical Epidemiology at the Faculty of Medicine and Health Sciences, Stellenbosch UniversityLicensed as Creative Commons – attribution, no derivatives.