tag:theconversation.com,2011:/global/topics/health-financing-25186/articlesHealth financing – The Conversation2024-03-12T04:29:09Ztag:theconversation.com,2011:article/2255512024-03-12T04:29:09Z2024-03-12T04:29:09ZWhat will aged care look like for the next generation? More of the same but higher out-of-pocket costs<figure><img src="https://images.theconversation.com/files/581147/original/file-20240312-22-5zslsi.jpg?ixlib=rb-1.1.0&rect=70%2C462%2C6629%2C4003&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-talking-senior-woman-during-1937848606">pikselstock/Shutterstock</a></span></figcaption></figure><p>Aged care financing is a vexed problem for the Australian government. It is already underfunded for the quality the community expects, and costs will increase dramatically. There are also significant concerns about the complexity of the system. </p>
<p>In 2021–22 the federal government spent <a href="https://www.health.gov.au/resources/publications/final-report-of-the-aged-care-taskforce?language=en">A$25 billion</a> on aged services for around 1.2 million people aged 65 and over. Around 60% went to residential care (<a href="https://www.gen-agedcaredata.gov.au/topics/people-using-aged-care#:%7E:text=On%2030%20June%202022%2C%20approximately,and%203%2C500%20using%20transition%20care.">190,000 people</a>) and one-third to home care (<a href="https://www.gen-agedcaredata.gov.au/topics/people-using-aged-care#:%7E:text=On%2030%20June%202022%2C%20approximately,and%203%2C500%20using%20transition%20care.">one million people</a>).</p>
<p>The <a href="https://www.health.gov.au/resources/publications/final-report-of-the-aged-care-taskforce?language=en">final report from the government’s Aged Care Taskforce</a>, which has been reviewing funding options, estimates the number of people who will need services is likely to grow to more than two million over the next 20 years. Costs are therefore likely to more than double. </p>
<p>The taskforce has considered what aged care services are reasonable and necessary and made recommendations to the government about how they can be paid for. This includes getting aged care users to pay for more of their care. </p>
<p>But rather than recommending an alternative financing arrangement that will safeguard Australians’ aged care services into the future, the taskforce largely recommends tidying up existing arrangements and keeping the status quo.</p>
<h2>No Medicare-style levy</h2>
<p>The taskforce <a href="https://www.health.gov.au/resources/publications/final-report-of-the-aged-care-taskforce?language=en">rejected</a> the aged care royal commission’s recommendation to introduce a levy to meet aged care cost increases. A 1% levy, similar to the Medicare levy, could have raised around <a href="https://www.thenewdaily.com.au/finance/finance-news/2021/03/03/cost-of-aged-care-levy#:%7E:text=Overall%2C%20a%201%20per%20cent%20levy%20would%20raise,necessary%20to%20provide%20decent%20aged%20care%20for%20all.">$8 billion a year</a>.</p>
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Read more:
<a href="https://theconversation.com/governments-aged-care-report-proposes-older-australians-pay-more-but-eschews-a-levy-225462">Government's aged care report proposes older Australians pay more but eschews a levy</a>
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<p>The taskforce failed to consider the mix of taxation, personal contributions and social insurance which are commonly used to fund aged care systems internationally. The <a href="https://www.oecd.org/els/health-systems/Japan-OECD-EC-Good-Time-in-Old-Age.pdf">Japanese system</a>, for example, is financed by long-term insurance paid by those aged 40 and over, plus general taxation and a small copayment.</p>
<p>Instead, the taskforce puts forward a simple, pragmatic argument that older people are becoming wealthier through superannuation, there is a cost of living crisis for younger people and therefore older people should be required to pay more of their aged care costs. </p>
<h2>Separating care from other services</h2>
<p>In deciding what older people should pay more for, the taskforce divided services into care, everyday living and accommodation. </p>
<p>The taskforce thought the most important services were clinical services (including nursing and allied health) and these should be the main responsibility of government funding. Personal care, including showering and dressing were seen as a middle tier that is likely to attract some co-payment, despite these services often being necessary to maintain independence.</p>
<p>The task force recommended the costs for everyday living (such as food and utilities) and accommodation expenses (such as rent) should increasingly be a personal responsibility. </p>
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<img alt="Aged care resident eats dinner from a tray" src="https://images.theconversation.com/files/581169/original/file-20240312-18-2tr0gt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/581169/original/file-20240312-18-2tr0gt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/581169/original/file-20240312-18-2tr0gt.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/581169/original/file-20240312-18-2tr0gt.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/581169/original/file-20240312-18-2tr0gt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/581169/original/file-20240312-18-2tr0gt.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/581169/original/file-20240312-18-2tr0gt.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">Aged care users will pay more of their share for cooking and cleaning.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/elderly-lady-eating-healthy-lunch-bed-2146362593">Lizelle Lotter/Shutterstock</a></span>
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<h2>Making the system fairer</h2>
<p>The taskforce thought it was unfair people in residential care were making substantial contributions for their everyday living expenses (about 25%) and those receiving home care weren’t (about 5%). This is, in part, because home care has always had a muddled set of rules about user co-payments. </p>
<p>But the taskforce provided no analysis of accommodation costs (such as utilities and maintenance) people meet at home compared with residential care. </p>
<p>To address the inefficiencies of upfront daily fees for packages, the taskforce recommends means testing co-payments for home care packages and basing them on the actual level of service users receive for everyday support (for food, cleaning, and so on) and to a lesser extent for support to maintain independence. </p>
<p>It is unclear whether clinical and personal care costs and user contributions will be treated the same for residential and home care. </p>
<h2>Making residential aged care sustainable</h2>
<p>The taskforce was <a href="https://www.health.gov.au/resources/publications/final-report-of-the-aged-care-taskforce?language=en">concerned</a> residential care operators were losing $4 per resident day on “hotel” (accommodation services) and everyday living costs. </p>
<p>The taskforce recommends means tested user contributions for room services and everyday living costs be increased. </p>
<p>It also recommends that wealthier older people be given more choice by allowing them to pay more (per resident day) for better amenities. This would allow providers to fully meet the cost of these services. </p>
<p>Effectively, this means daily living charges for residents are too low and inflexible and that fees would go up, although the taskforce was clear that low-income residents should be protected. </p>
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Read more:
<a href="https://theconversation.com/we-need-a-new-way-to-pay-for-aged-care-but-it-cant-shut-out-those-on-low-incomes-212017">We need a new way to pay for aged care. But it can't shut out those on low incomes</a>
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<h2>Moving from buying to renting rooms</h2>
<p>Currently older people who need residential care have a choice of making a refundable up-front payment for their room or to pay rent to offset the loans providers take out to build facilities. Providers raise capital to build aged care facilities through equity or loan financing. </p>
<p>However, the taskforce did not consider the overall efficiency of the private capital market for financing aged care or alternative solutions. </p>
<p>Instead, it recommended capital contributions be streamlined and simplified by phasing out up-front payments and focusing on rental contributions. This echoes the royal commission, which found rent to be a more efficient and less risky method of financing capital for aged care in private capital markets. </p>
<p>It’s likely that in a decade or so, once the new home care arrangements are in place, there will be proportionally fewer older people in residential aged care. Those who do go are likely to be more disabled and have greater care needs. And those with more money will pay more for their accommodation and everyday living arrangements. But they may have more choice too.</p>
<p>Although the federal government has <a href="https://www.abc.net.au/news/2024-03-11/aged-care-task-force-hands-down-recommendations/103573554">ruled out an aged care levy</a> and <a href="https://www.abc.net.au/news/2024-02-15/no-plan-to-touch-aged-care-asset-test/103470442">changes to assets test on the family home</a>, it has yet to respond to the majority of the recommendations. But given the aged care minister chaired the taskforce, it’s likely to provide a good indication of current thinking.</p>
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Read more:
<a href="https://theconversation.com/lump-sum-daily-payments-or-a-combination-what-to-consider-when-paying-for-nursing-home-accommodation-207405">Lump sum, daily payments or a combination? What to consider when paying for nursing home accommodation</a>
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<p class="fine-print"><em><span>Hal Swerissen is Deputy Chair of the Bendigo Kangan Institute which provides training in aged care</span></em></p>Rather than bold reforms that will safeguard Australians’ aged care services into the future, the taskforce largely recommends tidying up and keeping the status quo. And getting users to pay more.Hal Swerissen, Emeritus Professor, La Trobe UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2192032023-12-05T19:25:50Z2023-12-05T19:25:50ZWhat is the hospital funding agreement politicians are talking about today?<p>National Cabinet meets today to discuss three big issues in Commonwealth-state financial relations: <a href="https://www.afr.com/politics/an-end-to-the-gst-guarantee-would-be-disastrous-20231129-p5enol">GST allocation</a>, National Disability Insurance Scheme (NDIS) funding, and a Commonwealth government proposal to kick-start negotiations on a new National Health Reform Agreement, to take effect in July 2025. </p>
<p>So what is the reform agreement? What are the chances it could result in better access to hospital care when Australians need it? And what does the GST have to do with it?</p>
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Read more:
<a href="https://theconversation.com/a-tussle-between-the-federal-and-state-governments-over-disability-supports-is-looming-what-should-happen-next-217839">A tussle between the federal and state governments over disability supports is looming. What should happen next?</a>
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<h2>What is the reform agreement?</h2>
<p>State and territory governments are responsible for running public hospitals, but <a href="https://www.aihw.gov.au/reports/health-welfare-expenditure/health-expenditure-australia-2021-22/data">about 40%</a> of public hospital funding comes from the Commonwealth government.</p>
<p>The National Health Reform Agreement is front and centre of any discussion about health funding. Negotiated every five years or so, it was originally designed to:</p>
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<li>increase the Commonwealth’s share of public hospital funding</li>
<li>introduce more transparency about how states spend this extra Commonwealth funding</li>
<li>drive efficiency in public hospital care.</li>
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<p>Its performance on all three objectives has been mixed. </p>
<p>Efficiency initially improved, but there has been back sliding and, even in the pre-COVID years, the average cost of a public hospital admission <a href="https://www.pc.gov.au/ongoing/report-on-government-services/2023/health/public-hospitals">increased faster than inflation</a>. </p>
<p>Transparency has been a double-edged sword, causing a heightened focus on the agreement and its formula, but de-emphasising the broader GST context.</p>
<p>The previous Commonwealth Liberal government reduced the planned increase in the Commonwealth share of public hospital funding in its first budget, and its share has <a href="https://johnmenadue.com/new-data-shows-the-commonwealth-government-is-not-pulling-its-weight-on-hospital-funding/">now declined to 41%</a>. </p>
<p>Tight state budgets and increasing costs per patient mean hospitals’ capacity has not expanded in line with population growth, resulting in poorer access and longer waiting times.</p>
<h2>Working out the Commonwealth’s fair share</h2>
<p>Under the <a href="https://www.health.gov.au/our-work/2020-25-national-health-reform-agreement-nhra">National Health Reform Agreement</a>, total Commonwealth funding to the states collectively will increase in line with total public hospital “activity” growth across all states. </p>
<p>“Activity” includes hospital admissions and outpatient activity (seeing a specialist in an outpatient clinic, for example) and is measured in “activity units” with a “national efficient price”. The price for each unit is currently <a href="https://www.ihacpa.gov.au/">set</a> at <a href="https://www.ihacpa.gov.au/resources/national-efficient-price-determination-2023-24">$6,032</a>.</p>
<p>The current formula is that the Commonwealth funds 45% of the costs of increases in hospital admissions, emergency department visits or outpatient attendances but only paid at the “national efficient price”. Total Commonwealth funding growth is capped at 6.5% each year.</p>
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<img alt="Hospital bed in corridor" src="https://images.theconversation.com/files/563504/original/file-20231204-21-tk0pd5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/563504/original/file-20231204-21-tk0pd5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/563504/original/file-20231204-21-tk0pd5.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/563504/original/file-20231204-21-tk0pd5.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/563504/original/file-20231204-21-tk0pd5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/563504/original/file-20231204-21-tk0pd5.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/563504/original/file-20231204-21-tk0pd5.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">Commonwealth hospital funding has declined.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/darkhaired-woman-middleaged-man-walk-along-2273073889">Shutterstock</a></span>
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<h2>But it’s often misunderstood</h2>
<p>Many commentators and government officials assume the same model applies for funding to each state. It doesn’t. Funding to each state is determined by a separate process (which we’ll get to in a moment). </p>
<p>This false assumption about the way the National Health Reform Agreement works for each state leads to complaints the agreement constrains good policy initiatives, rewards “volume not value” and encourages unnecessary hospitalisations. </p>
<p>Worse, it allows states to blame the agreement for their own mismanagement of their hospitals. </p>
<p>And it encourages fruitless discussions between Commonwealth and state officials about “reform projects” that typically go nowhere but can be used by politicians to hoodwink the public that big issues in the health sector are being addressed.</p>
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Read more:
<a href="https://theconversation.com/ambulance-ramping-is-a-signal-the-health-system-is-floundering-solutions-need-to-extend-beyond-eds-187270">Ambulance ramping is a signal the health system is floundering. Solutions need to extend beyond EDs</a>
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<h2>How funding to the states is really allocated</h2>
<p>Funding from the Commonwealth to the states must be considered at two levels: the National Health Reform Agreement and the GST.</p>
<p>If you look at the <a href="https://www.publichospitalfunding.gov.au/">national health funding body’s</a> website, you can see tables purporting to show how Commonwealth funding is allocated to <a href="https://www.publichospitalfunding.gov.au/public-hospital-funding-reports">health services across Australia</a>, down to the last dollar. This reflects the transparency objective of the National Health Reform Agreement.</p>
<p>These numbers are real. The dollars reported actually end up in state bank accounts. </p>
<p>However, the big picture is somewhat different, and this is where the GST comes in.</p>
<p>Money collected through the GST is allocated among the states based on need. The aim is to ensure each state has the capacity “to provide services and the associated infrastructure at the same standard”. </p>
<p>An independent body, the <a href="https://www.cgc.gov.au/about-us">Commonwealth Grants Commission</a>, assesses need, including the need for public hospital spending by states. It also assesses how states can raise money through taxes to meet their needs.</p>
<p>A <a href="https://www.cgc.gov.au/about-gst-distribution">state’s GST allocation</a> is based on the gap between its spending needs and its assessed revenue raising capacity. </p>
<p>Importantly, most Commonwealth grants, including the National Health Reform Agreement, are taken into account by the Grants Commission in a similar way to how it assesses the state’s ability to raise payroll tax or stamp duty. </p>
<p>The result is that a state’s funding under the National Health Reform Agreement is effectively reallocated back to the state, with a lag, not in line with the agreement’s formula, but rather in line with the GST formula (this is essentially based on the state’s population, weighted for factors such as age, the proportion living in remote locations, and the proportion of First Nations Australians).</p>
<p>The National Health Reform Agreement formula, although impressively precise, is somewhat of a fiction, providing a funding flow which is effectively overridden a few years later. </p>
<p>The reality therefore is that the principal impact of the National Health Reform Agreement is to determine the total <em>national</em> contribution the Commonwealth makes to public hospitals. </p>
<p>However, because states often assume the National Health Reform Agreement formula is real, it has a life of its own which can shape the health and hospital system for good or ill.</p>
<h2>What to watch for out of National Cabinet</h2>
<p>The entrails of today’s National Cabinet decision need to be examined carefully. The words may obscure what is really happening, but there are two factors to look for. </p>
<p>Most importantly, will the 6.5% cap be increased? If so, by how much? This determines the total amount of money the Commonwealth might be required to pay states. </p>
<p>And what will states commit to in exchange for any increase in the Commonwealth’s potential spending? A commitment to <a href="https://www.afr.com/policy/health-and-education/six-reforms-to-repair-the-ndis-20230425-p5d33n">work together (and share spending) on NDIS reform</a> may be on the cards here.</p>
<p>Funding commitments for specific “reform projects” send signals about what governments collectively think are important issues in the public hospital system such as joint commitments to improve efficiency or to expand access to digital services, such as telehealth.</p>
<p>For patients, an increase in the Commonwealth share and in the cap, provided it is coupled with tighter accountability for access (such as commitments to reducing waiting times for planned procedures), could lead to a much improved public hospital system. </p>
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Read more:
<a href="https://theconversation.com/how-does-australias-health-system-stack-up-internationally-not-bad-if-youre-willing-to-wait-for-it-218031">How does Australia's health system stack up internationally? Not bad, if you're willing to wait for it</a>
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<p class="fine-print"><em><span>Stephen 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 their academic appointment.</span></em></p>National Cabinet is meeting today to discuss hospital funding, and the interconnected issues of NDIS reform and GST allocation. But how are hospitals actually funded? And what’s GST got to do with it?Stephen Duckett, Honorary Enterprise Professor, School of Population and Global Health, and Department of General Practice, The University of MelbourneLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2179142023-11-30T07:18:00Z2023-11-30T07:18:00ZReform delay causes dental decay. It’s time for a national deal to fund dental care<p>A <a href="https://parlinfo.aph.gov.au/parlInfo/download/committees/reportsen/RB000078/toc_pdf/AsystemindecayareviewintodentalservicesinAustralia.pdf">Senate committee</a> has investigated why so many Australians are missing out on dental care and made 35 recommendations for reform. </p>
<p>By far the most sweeping is the call for universal coverage for essential dental care. The committee also proposed a suite of measures to get more dental care to groups who are missing out, including those in rural areas. </p>
<p>The government has three months to respond. It should lay out a plan to gradually expand coverage, while putting guardrails in place to make sure care is effective, efficient and equitable. </p>
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Read more:
<a href="https://theconversation.com/expensive-dental-care-worsens-inequality-is-it-time-for-a-medicare-style-denticare-scheme-207910">Expensive dental care worsens inequality. Is it time for a Medicare-style 'Denticare' scheme?</a>
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<h2>If Australians can’t pay, they miss out</h2>
<p>The <a href="https://parlinfo.aph.gov.au/parlInfo/download/committees/reportsen/RB000078/toc_pdf/AsystemindecayareviewintodentalservicesinAustralia.pdf">Senate committee report</a> follows <a href="https://parlinfo.aph.gov.au/parlInfo/download/committees/reportsen/RB000080/toc_pdf/Interimreport.pdf">more than a dozen</a> national inquiries and reports into dental care since 1998, many with similar findings.</p>
<p>Dental care was left out of Medicare from the start, due to opposition from dentists and <a href="https://johnmenadue.com/why-dental-care-was-excluded-from-medicare-and-why-it-should-now-be-included-an-edited-repost/">concerns</a> about cost. </p>
<p>Half a century later, Australia still funds oral health very differently to how we fund care for the rest of the body, with patients paying most of the cost themselves. </p>
<p>As a result, many people miss out on care. In <a href="https://www.abs.gov.au/statistics/health/health-services/patient-experiences/latest-release">2022-23</a>, 2.3 million Australians skipped or delayed necessary dental care because of the cost – 17.6% of people, up from 16.4% the year before.</p>
<p>People on lower incomes were much more likely to miss out. People living in the poorest areas are around three times as likely to wait more than two years between visits to the dentist, compared to people in the wealthiest areas. One in four report delaying care. </p>
<p>Even if you can afford to see a dentist, you might not be able to get in. Our analysis of census data shows there is one dentist for every 400 to 500 people in inner-city parts of most capital cities. But in Blacktown North in outer Sydney, there is only one dentist for every 5,100 people. </p>
<p>Regional areas fare even worse. There is only one for every 10,300 people in the northeast of Ballarat in Victoria. In some remote areas, there are no working dentists at all.</p>
<h2>Missing dental care can affect the whole body</h2>
<p>The consequences of missing dental care are serious. Around 80,000 hospital <a href="https://www.aihw.gov.au/reports/dental-oral-health/oral-health-and-dental-care-in-australia/contents/hospitalisations">visits</a> a year are for preventable dental conditions. </p>
<p>Oral health problems are also <a href="https://www.aihw.gov.au/reports/dental-oral-health/oral-health-and-dental-care-in-australia/contents/introduction">linked</a> to a range of chronic diseases affecting the rest of the body too, and may cause <a href="https://thenewdaily.com.au/life/2023/07/15/gum-disease-shrinks-your-brain/">damage</a> to the brain. </p>
<p>On top of that, there are costs from people not being able to work or study, leading to further economic costs of more than <a href="https://onlinelibrary.wiley.com/doi/pdfdirect/10.1111/j.1834-7819.2012.01718.x">half a billion</a> dollars a year. </p>
<p>Those numbers only hint at the individual suffering involved. Dental disease often means pain, embarrassment and stigma. </p>
<p>The Senate inquiry heard from one 30-year-old on a low income who couldn’t afford dental care for years. They skipped meals for months to save up enough money to go to the dentist, and were finally diagnosed with advanced gum disease. They now expect to lose teeth, which will affect them for the rest of their life.</p>
<h2>Dental problems are rising, spending is falling</h2>
<p>Compared to five years ago, more of us have untreated dental decay, are concerned about the appearance of our teeth, avoid food due to dental problems, and have toothaches. </p>
<p>Despite all this, government spending on dental health has been <a href="https://www.aihw.gov.au/getmedia/52d76196-5884-479c-93e5-12a17afbb2bb/aihw_den_231_costs_datatables_oralhealthanddentalcareinaustralia_tranche_6_17032023_1.xlsx.aspx">falling</a>. In the ten years to 2020-21, the federal government’s share of spending on dental services – excluding premium rebates – fell from 12% to 5%, while the states’ share fell from 10% to 9%.</p>
<p>Federal government spending on private health insurance rebates for dental care increased, but that doesn’t close the funding gap, and it doesn’t help the most vulnerable.</p>
<h2>Time for universal dental care</h2>
<p>Most submissions to the Senate inquiry supported major reform to expand coverage for dental care, as previous <a href="https://apo.org.au/sites/default/files/resource-files/2009-07/apo-nid17921.pdf">reviews</a>, <a href="https://agedcare.royalcommission.gov.au/sites/default/files/2021-03/final-report-volume-1.pdf">Royal Commissions</a> and a 2019 Grattan Institute <a href="https://grattan.edu.au/wp-content/uploads/2019/03/915-Filling-the-gap-A-universal-dental-scheme-for-Australia.pdf">report</a> have recommended. </p>
<p>Getting there will be costly. </p>
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Read more:
<a href="https://theconversation.com/worried-about-your-childs-teeth-focus-on-these-3-things-212870">Worried about your child's teeth? Focus on these 3 things</a>
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<p>The May <a href="https://budget.gov.au/content/bp2/download/bp2_2023-24.pdf">budget</a> kicked the can down the road by extending the current, inadequate funding for public dental services for another year. That funding will now stop in mid-2025, the same time that federal and state governments need to agree on a new National Health Reform Agreement – the biggest financial health deal in Australia.</p>
<p>With national health funding up in the air, there is an opportunity to finally work out a plan to expand dental coverage, starting in less than two years. </p>
<h2>Phasing, fairness and efficiency will be key</h2>
<p>Building a new, universal health care system is something Australia hasn’t done for generations. It will take more than simply expanding funding. Instead, governments should seize an historic opportunity to avoid the <a href="https://grattan.edu.au/wp-content/uploads/2022/12/A-new-Medicare-strengthening-general-practice-Grattan-Report.pdf">problems</a> in other universal coverage schemes. </p>
<p>First, dental coverage should ramp up gradually. The Senate committee <a href="https://parlinfo.aph.gov.au/parlInfo/download/committees/reportsen/RB000078/toc_pdf/AsystemindecayareviewintodentalservicesinAustralia.pdf">recommended</a> phasing in a universal scheme, and mentioned establishing a Seniors Dental Benefit Scheme, and expanding the Child Dental Benefits Schedule to cover all children over time. </p>
<p>Starting with these steps would allow time for the workforce, providers, and government funding to expand to care for more people, as Australia builds a universal scheme.</p>
<p>Second, policies should ensure care is available where it’s needed most. This means getting more dentists in <a href="https://content.vu.edu.au/sites/default/files/media/is-medicare-fair-cities-and-country-mitchell-institute.pdf">disadvantaged</a> and rural areas.</p>
<p>Even with more funding and broader coverage, some areas will struggle to attract dentists, particularly where there is a small population, few people who can afford fees and where clinics need to be set up from scratch. </p>
<p>The committee proposed incentives for providers in rural areas, new dental schools in regional universities, expanding rural medical student subsidies to dentistry and oral health, and better pay for clinicians in public dental clinics.</p>
<p>Third, given the <a href="https://www.pbo.gov.au/sites/default/files/2023-11/For%20publication%20PR-2023-367-Various%20policy%20options%20for%20reforming%20Commonwealth%20subsidies%20of%20dental%20services%20-%20PRR_0.pdf">huge costs</a> involved, care must be efficient and effective. The committee outlined some ways to get good value for money. It said the universal scheme should fund essential oral health care, which would exclude cosmetic dentistry, for example. And it wants regulations and funding changed so oral health therapists can do more. </p>
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Read more:
<a href="https://theconversation.com/collaborating-with-communities-delivers-better-oral-health-for-indigenous-kids-in-rural-australia-141038">Collaborating with communities delivers better oral health for Indigenous kids in rural Australia</a>
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<p>Governments and the public should also be able to see where the billions of dollars of new investment are going, and the difference it is making. </p>
<p>Participating public and private clinics should record the treatments they provide, how satisfied their patients are, wait times and their results. And clinics should commit to following evidence-based guidelines and using data to continually improve their care. </p>
<p>Successive governments have skimped on dental care even as demand has risen. But those savings are a false economy that causes unnecessary disease and entrenches inequality. Today’s proposal for an overhaul should be the last – it’s time to fill this gap in the health system.</p><img src="https://counter.theconversation.com/content/217914/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Peter Breadon's employer, Grattan Institute, has been supported in its work by government, corporates, and philanthropic gifts. A full list of supporting organisations is published at <a href="http://www.grattan.edu.au">www.grattan.edu.au</a>.</span></em></p><p class="fine-print"><em><span>Anika Stobart 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>Access to dental care in Australia is worse than ever and is simply unaffordable to many.Peter Breadon, Program Director, Health and Aged Care, Grattan InstituteAnika Stobart, Senior Associate, Grattan InstituteLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2127872023-10-06T00:43:44Z2023-10-06T00:43:44ZPeople with private health insurance save the government $550 a year, on average<figure><img src="https://images.theconversation.com/files/551923/original/file-20231003-21-e4wvn4.jpg?ixlib=rb-1.1.0&rect=505%2C18%2C3608%2C2732&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.pexels.com/photo/photo-of-woman-lying-in-hospital-bed-3769151/">Pexels/Andrea Piacquadio</a></span></figcaption></figure><p>The federal government has, for a long time, <a href="https://www.aph.gov.au/parliamentary_business/committees/senate/community_affairs/completed_inquiries/1999-02/pubhosp/report/c05">encouraged Australians</a> to get private health insurance, in an attempt to reduce the financial burden on the public health system.</p>
<p>To make private health insurance more attractive, the government has a strategy of carrots and sticks. Low-income and older people receive subsidies through “<a href="https://www.privatehealth.gov.au/health_insurance/surcharges_incentives/insurance_rebate.htm">premium rebates</a>”. High-income earners without the right policy face the Medicare Levy Surcharge, ranging from <a href="https://privatehealth.gov.au/health_insurance/surcharges_incentives/medicare_levy.htm">1 to 1.5%</a> of their taxable income.</p>
<p>The effectiveness of these subsidies is regularly debated, with questions about whether the <a href="https://www.health.gov.au/sites/default/files/documents/2022/03/budget-2022-23-portfolio-budget-statements.pdf">A$6.7 billion</a> of taxpayer money that subsidises private health insurance premiums could be better spent on Medicare or directly financing hospitals. </p>
<p>We set out to answer this question: do the savings from increased participation in private health insurance outweigh the costs the government incurs by subsidising private health insurance rebates?</p>
<p>Our <a href="https://consultations.health.gov.au/medical-benefits-division/consultation-on-phi-studies/supporting_documents/MLS%20and%20PHI%20Rebate%20Study%20%20Offset%20Analysis.pdf">analysis</a>, which was commissioned and funded by the Department of Health and Aged Care, found large benefits to the government, especially when older people sign up for private insurance. On average, the government saves about $554 for each person it helps with these subsidies a year. </p>
<p>But rebates can be better targeted for Australians who are more likely to need and use health services. </p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1703662498552172997"}"></div></p>
<h2>How did we work this out?</h2>
<p>To assess if the money spent on subsidising private health insurance pays off, we examined both the costs (from the premium rebate subsidies and the forgone tax from the Medicare Levy Surcharge) and the savings. </p>
<p>To calculate the savings we looked at how much money the government would spend if these people didn’t have private health insurance and used the public health system instead of the private system. We call this the “offset”.</p>
<p>This is a key metric for the success of the carrot and sticks, as it will be able to tell us the health-care costs saved by the government when someone has private insurance.</p>
<p>Using private health insurance spending data from 2019, we made assumptions that one day in a private hospital costs equal to one day in a public hospital, based on findings from the <a href="https://www.pc.gov.au/inquiries/completed/hospitals/report">Productivity Commission</a>.</p>
<p>We also factored in the government’s <a href="http://www.msac.gov.au/internet/msac/publishing.nsf/Content/Factsheet-03">75% Medicare Benefits Schedule fee contribution</a>, and <a href="https://theconversation.com/we-can-cut-private-health-insurance-costs-by-fixing-how-we-pay-for-hip-replacements-and-other-implants-121172">higher prices</a> for prostheses (for hip replacements and other implants) in the private system.</p>
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Read more:
<a href="https://theconversation.com/we-can-cut-private-health-insurance-costs-by-fixing-how-we-pay-for-hip-replacements-and-other-implants-121172">We can cut private health insurance costs by fixing how we pay for hip replacements and other implants</a>
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<p>On average, we found that private health insurance offsets public health-care costs by about $1,400 per person, with greater savings for older people than younger people, reaching $4,000 for those aged 75 and above.</p>
<p>To answer if the savings from private insurance take-up outweighs the costs incurred, we needed to take into account what the government spends to subsidise insurance. </p>
<p>We used the standard <a href="https://privatehealth.gov.au/health_insurance/surcharges_incentives/insurance_rebate.htm">premium rebate percentages</a> where a person aged 70 or above earning up to $90,000 attracts a 32.812% rebate, while a person aged under 65 making $105,001–$140,000 would receive a 8.202% rebate.</p>
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<img alt="Surgeon operates" src="https://images.theconversation.com/files/551938/original/file-20231004-17-8tgkzg.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/551938/original/file-20231004-17-8tgkzg.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=900&fit=crop&dpr=1 600w, https://images.theconversation.com/files/551938/original/file-20231004-17-8tgkzg.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=900&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/551938/original/file-20231004-17-8tgkzg.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=900&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/551938/original/file-20231004-17-8tgkzg.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1131&fit=crop&dpr=1 754w, https://images.theconversation.com/files/551938/original/file-20231004-17-8tgkzg.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1131&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/551938/original/file-20231004-17-8tgkzg.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1131&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">The savings were greater for older people, who were more likely to use health services.</span>
<span class="attribution"><a class="source" href="https://www.pexels.com/photo/woman-in-white-medical-scrub-4421551/">Anna Schvets/Pexels</a></span>
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<p>With an average annual private health insurance premium of $2,300, this would mean the government incurs costs ranging from $755 to $189.</p>
<p>As people who enrol in private insurance don’t have to pay the Medicare Levy Surcharge, which helps fund the public health system, we found that the forgone tax amounts range between $970 and $2,400 for single individuals subject to the penalty.</p>
<p>Combining the costs (from the premium rebate subsidies and the forgone tax from the Medicare Levy Surcharge), and subtracting the savings (the offsets), is how we find that the subsidies are a good financial deal for the government. The subsidies are less than the cost offset by about $554 per person who has private health insurance.</p>
<h2>Is there room for improvement?</h2>
<p>This raises a question: what if we could change these subsidies based on who costs more to provide health care for and who saves the government more money? As our findings reveal that some groups save the government more money than their subsidies cost, what should we do with the subsidies? If we increase their subsidies, it costs taxpayers more – unless more of them switch to private health insurance. </p>
<p>For instance, an individual aged 75+ earning $105,001 to $140,000 receives $1,877 in subsidies and offsets $5,268 in public health spending, saving the government $3,391. Given the roughly 6,000 people in this age group currently in private health insurance, only two additional enrolments would make it budget-neutral. </p>
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<em>
<strong>
Read more:
<a href="https://theconversation.com/private-health-insurance-is-set-for-a-shake-up-but-asking-people-to-pay-more-for-policies-they-dont-want-isnt-the-answer-210981">Private health insurance is set for a shake-up. But asking people to pay more for policies they don't want isn't the answer</a>
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<h2>How can the savings be used?</h2>
<p>A better way to subsidise private health insurance is to give extra subsidies to people who are sicker and need more medical care. These are known as “risk-adjusted subsidies”. </p>
<p>A risk-adjusted subsidy would be based on a person’s characteristics such as their age, gender, income, where they live and their health history (such as prior hospitalisations, or use of services). These are people who need private health insurance the most, and also would save the government the most money by having private insurance.</p>
<p>This subsidy could be computed by a formula that uses individual-level spending to figure out how much health care the person is likely to need and how much it’s expected to cost. </p>
<p>Existing <a href="https://www.nber.org/papers/w31052">work</a> in Australia has shown how this can be developed, while <a href="https://www.sciencedirect.com/book/9780128113257/risk-adjustment-risk-sharing-and-premium-regulation-in-health-insurance-markets">countries</a> such as the Netherlands, Germany, the United States and Switzerland show such a system is feasible. </p>
<p>The Australian health system, and private health insurance regulation in particular, is set for a shake-up, with the <a href="https://consultations.health.gov.au/medical-benefits-division/consultation-on-phi-studies/">Department of Health and Aged Care</a> seeking input on its options. Our research can help inform a path forward. </p>
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Read more:
<a href="https://theconversation.com/who-really-benefits-from-private-health-insurance-rebates-not-people-who-need-cover-the-most-212611">Who really benefits from private health insurance rebates? Not people who need cover the most</a>
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<img src="https://counter.theconversation.com/content/212787/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Francesco Paolucci has received funding from Horizon 2020, the National Health and Medical Research Council, the Medical Research Future Fund, the Australian Research Council, and The Department of Health and Aged Care.</span></em></p><p class="fine-print"><em><span>Josefa Henriquez has received funding from the Department of Health and Aged Care. </span></em></p>Yes, savings from increased participation in private insurance outweigh the costs the government incurs by subsidising private health insurance rebates. But rebates can be better targeted.Francesco Paolucci, Professor of Health Economics, University of Bologna, University of NewcastleJosefa Henriquez, Phd Candidate (Economics), University of NewcastleLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2050212023-05-10T02:57:27Z2023-05-10T02:57:27ZThe aged-care budget delivers for workers but meeting our future needs will require bold funding reforms<figure><img src="https://images.theconversation.com/files/525275/original/file-20230510-17-kqidgu.jpg?ixlib=rb-1.1.0&rect=191%2C382%2C6518%2C3702&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-talking-senior-woman-during-1937848606">Shutterstock</a></span></figcaption></figure><p>The 2023-24 federal budget takes a step in the right direction for aged care, with a much-needed pay boost for workers in the sector. </p>
<p>But there are major medium- to long-term challenges to overcome from cost increases. Despite a <a href="https://agedcare.royalcommission.gov.au/sites/default/files/2021-03/final-report-executive-summary.pdf">royal commission</a>, major commitments from a new government and significant additional funding, around two-thirds of residential aged providers and one-quarter of home care providers are <a href="https://www.health.gov.au/sites/default/files/2023-02/quarterly-financial-snapshot-of-the-aged-care-sector-quarter-1-2022-23-july-to-september-2022_0.pdf">losing money</a>.</p>
<p>If we’re going to have a functioning aged-care system in a decade or two that meets the needs of the ageing population, we need to consider bold reform to make it fit for purpose. </p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1653743243002253313"}"></div></p>
<h2>What’s the problem?</h2>
<p>Around <a href="https://www.gen-agedcaredata.gov.au/Topics/Spending-on-aged-care">60%</a> of government aged care funding is spent on residential care. Impersonal, large scale, “big box” aged-care institutions <a href="https://theconversation.com/australias-residential-aged-care-facilities-are-getting-bigger-and-less-home-like-103521">still dominate</a> the system. </p>
<p>But older people in residential care are still getting less than the mandated three hours and 20 minutes of <a href="https://www.health.gov.au/sites/default/files/2023-02/quarterly-financial-snapshot-of-the-aged-care-sector-quarter-1-2022-23-july-to-september-2022_0.pdf">care per day</a>. Only around <a href="https://www.health.gov.au/sites/default/files/2023-02/quarterly-financial-snapshot-of-the-aged-care-sector-quarter-1-2022-23-july-to-september-2022_0.pdf">$12 a day is spent on food</a>. The commitment to have a registered nurse in all residential-care facilities <a href="https://hellocare.com.au/home-care-reforms-delayed-and-exemptions-for-24-7-nurse-mandate/">won’t be met</a> in the time period promised. </p>
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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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<p>Not surprisingly, most people want care at home instead. There has been a <a href="https://www.gen-agedcaredata.gov.au/www_aihwgen/media/Home_care_report/Home-care-packages-program-data-report-1-October-31-December-2022.pdf">massive increase</a> in the number of home care packages in response. This part of the aged-care industry has proven much more profitable. </p>
<p>Even so, home care packages for more older people with more complex needs remain cumbersome and inefficient. Administrative costs are high, funding is too low for people with very complex needs and there are risks with the rapid introduction of new providers and the “uberisation” of services through new online platforms.</p>
<p>A new government <a href="https://www.theweeklysource.com.au/labor-defers-start-of-new-support-at-home-program-to-mid-2024/">Support at Home program</a> is due to reform and replace the existing home care packages, home support program, respite care and short-term restorative care program. But it has again been delayed – now until <a href="https://www.theweeklysource.com.au/federal-government-delays-support-at-home-again-and-cuts-2-2bn-from-residential-aged-care/">2025</a>. There are <a href="https://grattan.edu.au/report/unfinished-business-practical-policies-for-better-care-at-home/">ongoing concerns</a> about the design and implementation of the program.</p>
<p>A major underlying problem for aged care is that workers are undervalued. Pay is not competitive with the disability and health-care sector and providers struggle to get staff. Career structures, supervision and training are all underdone. </p>
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<img alt="Older man in his bedroom" src="https://images.theconversation.com/files/525276/original/file-20230510-29-qte7k8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/525276/original/file-20230510-29-qte7k8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/525276/original/file-20230510-29-qte7k8.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/525276/original/file-20230510-29-qte7k8.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/525276/original/file-20230510-29-qte7k8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/525276/original/file-20230510-29-qte7k8.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/525276/original/file-20230510-29-qte7k8.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">Home support changes have been delayed.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/elderly-indian-man-retirement-house-1014721636">Shutterstock</a></span>
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<h2>What’s in the budget for aged care?</h2>
<p>The Fair Work Commission <a href="https://www.fairwork.gov.au/newsroom/media-releases/2023-media-releases/march-2023/20230324-aged-care-award-increase-30-june">determined</a> that wages for direct care workers should be increased by 15%. The <a href="https://budget.gov.au/content/bp2/download/bp2_2023-24.pdf">budget includes</a> $12.4 billion for aged care, mainly to fund pay increases for 250,000 aged-care workers in residential and home care. </p>
<p>Daily payment rates for aged-care residents will increase by 17.6% to cover pay increases and inflation and an additional 9,500 home care packages will be introduced over the next year.</p>
<p>This year’s federal budget is a step in the right direction, particularly in improving pay rates for aged-care workers. But the medium to longer term future for aged care remains bleak without significant further reform. </p>
<h2>What’s missing from the budget?</h2>
<p>Demand will increase dramatically as <a href="https://cepar.edu.au/publications/working-papers/new-population-projections-australia-and-states-and-territories-particular-focus-population-ageing">the number of people over 80 grows</a>, the <a href="https://www.headsup.org.au/docs/default-source/default-document-library/combining-work-and-care-the-benefits-to-carers-and-the-economy-report.pdf?sfvrsn=88df524d_2#:%7E:text=With%20the%20proportion%20of%20Australia%E2%80%99s%20population%20aged%20over,informal%20carers%20relative%20to%20the%20growing%20older%20population.">availability of informal carers decreases</a> and <a href="https://onlinelibrary.wiley.com/doi/abs/10.1111/hsc.13187">community expectations increase</a>. And there are <a href="https://www.abc.net.au/news/2023-03-14/aged-care-crisis-residential-system-solution-older-australians/102067884">continuing concerns</a> about the way services are designed, organised and delivered.</p>
<p><a href="https://anmj.org.au/report-at-least-10-billion-more-needed-per-year-to-reform-aged-care/">Estimates</a> suggest Australia will need to increase aged-care spending by $10 billion a year to implement the aged care royal commissions recommendations. </p>
<p>It would <a href="https://www.actuaries.digital/2022/05/19/assessing-sustainable-aged-care-financing-in-australia/#Aged%20Care%20Funding">need to double</a> to around 3% of GDP to be in line with high-quality aged care in comparable OECD countries.</p>
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Read more:
<a href="https://theconversation.com/more-funds-for-aged-care-wont-make-it-future-proof-4-key-strategies-for-sustainable-growth-185194">More funds for aged care won't make it future-proof. 4 key strategies for sustainable growth</a>
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<p>Current funding is a complicated and unsustainable mix of Commonwealth government payments, means-tested user contributions and capital contributions for residential care. </p>
<p>Commonwealth payments are generated from general revenue. Effectively this is a pay-as-you-go model where today’s taxpayers meet the costs. Inevitably that means growth in spending is an ongoing political balancing act in the hurly burly of the annual budget process. There is no guarantee growth funding will be provided in the medium to longer term.</p>
<h2>What are the alternatives?</h2>
<p>There are <a href="https://agedcare.royalcommission.gov.au/sites/default/files/2020-06/consultation_paper_2_-_financing_aged_care_0.pdf">alternatives</a>, but none of them are likely in Australia. </p>
<p>A social insurance model like the transport accident, workers’ compensation and superannuation schemes could be introduced to fund aged care, at least in part. That would mean workers (and potentially their employers) would contribute to their potential future aged-care costs during their working lives. Social insurance models exist in Germany, Japan, Korea and the Netherlands. </p>
<p>In Australia, there have been calls for a superannuation levy on contributions to fund future aged-care costs. But this would fly in the face of the federal government’s intention to make it clear that the purpose of superannuation is to provide a decent retirement income rather than using it as a piggy bank to fund health and aged care.</p>
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<img alt="Older person eats a meal on a tray" src="https://images.theconversation.com/files/525277/original/file-20230510-27-w9n5kh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/525277/original/file-20230510-27-w9n5kh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/525277/original/file-20230510-27-w9n5kh.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/525277/original/file-20230510-27-w9n5kh.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/525277/original/file-20230510-27-w9n5kh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/525277/original/file-20230510-27-w9n5kh.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/525277/original/file-20230510-27-w9n5kh.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">One idea is for workers to contribute to their own aged care fund.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/elderly-lady-eating-healthy-lunch-bed-2146362593">Shutterstock</a></span>
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<p>An other alternative is wealth taxes to pay for aged care. The current capital contribution schemes for residential care (<a href="https://www.health.gov.au/our-work/residential-aged-care/managing-residential-aged-care-services/managing-accommodation-payments-and-contributions-for-residential-aged-care">Refundable Accommodation Deposit</a> and <a href="https://www.health.gov.au/our-work/residential-aged-care/managing-residential-aged-care-services/managing-accommodation-payments-and-contributions-for-residential-aged-care">Daily Accommodation Payment</a> schemes) are an inefficient, inequitable and half baked model. More equitable, targeted universal estate taxes could be introduced to fund aged care, but that would raise the politically uncomfortable spectre of death duties. </p>
<p>The most <a href="https://cass.anu.edu.au/news/most-australians-support-tax-levy-improve-aged-care">palatable option</a> to provide future growth funding for aged care would be the introduction of an aged-care levy as part of the general tax mix. A 1% levy, similar to the Medicare levy, would <a href="https://thenewdaily.com.au/finance/finance-news/2021/03/03/cost-of-aged-care-levy/#:%7E:text=Overall%2C%20a%201%20per%20cent%20levy%20would%20raise,necessary%20to%20provide%20decent%20aged%20care%20for%20all.">raise around $8 billion</a> a year.</p>
<p>While Treasury generally opposes hypothecated levies, levy revenue already partially funds health and disability care. It would be reasonably easy to introduce (<a href="https://cass.anu.edu.au/news/most-australians-support-tax-levy-improve-aged-care">and popular with the community</a>) for aged care.</p>
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Read more:
<a href="https://theconversation.com/overseas-recruitment-wont-solve-australias-aged-care-worker-crisis-189126">Overseas recruitment won't solve Australia's aged care worker crisis</a>
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<p class="fine-print"><em><span>Hal Swerissen 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 federal budget is a step in the right direction, particularly in improving pay rates for aged-care workers. But the medium- to long-term future remains bleak without further, significant reforms.Hal Swerissen, Emeritus Professor, La Trobe UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2045272023-05-09T23:01:37Z2023-05-09T23:01:37ZHealth budget has big changes – reviving our worn-out Medicare fee-for-service system and boosting bulk billing<p>There were four major changes for <a href="https://www.health.gov.au/resources/collections/budget-2023-24">health care in the 2023-24 budget</a>: prioritising primary care, funding to strengthen Medicare, cheaper access to common medicines, and new funding to keep the digital health system going. Many of these changes were <a href="https://federation.gov.au/national-cabinet/media/2023-04-28-strengthening-medicare">foreshadowed in recent weeks</a>.</p>
<p>The big news on budget night was a tripling of the bulk-billing incentive, a key plank to strengthen Medicare. </p>
<p>This payment was <a href="https://journals.sagepub.com/doi/abs/10.1258/1355819042349899?journalCode=hsrb">introduced in 2004</a> to encourage GPs to bulk bill pensioners, health care card holders and children. It provides an additional amount, of <a href="http://www9.health.gov.au/mbs/search.cfm?q=10990&sopt=I">around A$7</a> to <a href="http://www9.health.gov.au/mbs/search.cfm?q=10991&sopt=I">over $10</a> depending on GP location, on top of the ordinary Medicare rebate when the service is bulk billed. </p>
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<p>But bulk billing has since declined, from about 90% of attendances in early 2022 to <a href="https://www.health.gov.au/resources/publications/medicare-quarterly-statistics-state-and-territory-december-quarter-2022-23?language=en">about 80% a year later</a>. Bulk billing is unevenly distributed and in some low-income areas (<a href="https://theconversation.com/if-you-live-in-a-bulk-billing-desert-its-hard-to-see-a-doctor-for-free-heres-how-to-fix-this-204029">bulk-billing deserts</a>) fewer than 50% of people have all their GP attendances bulk billed. This causes uncertainty and people missing out on care.</p>
<p>A tripling of the bulk-billing incentive – described as the biggest investment in Medicare in 40 years – is hoped to stem, and possibly reverse, the decline. </p>
<p>However it’s unclear whether it will increase bulk billing. Practice owners could simply pocket the increased incentive for patients who are already bulk billed, leaving bulk billing rates unchanged. Or GPs could use the increased revenue from their existing bulk-billed patients to <a href="https://onlinelibrary.wiley.com/doi/abs/10.1002/hec.3572">reduce their hours of work</a>, rather than bulk billing more patients.</p>
<h2>1. Primary care is now a priority</h2>
<p>The most important change in the budget for health was symbolic: the government talked about primary care. Typically, health budgets are focused on hospitals, with primary care an afterthought, or worse: the target of budget cuts. </p>
<p>The 2023 budget starts the process of the primary care rebuild, modernising the system in response to the transition to a population with more people with multiple chronic conditions, such as diabetes, heart disease and depression.</p>
<p>In the lead up to the budget, Health Minister Butler <a href="https://www.health.gov.au/ministers/the-hon-mark-butler-mp/media/minister-for-health-and-aged-care-speech-national-press-club-2-may-2023?language=en">emphasised the centrality of primary care</a> to the health system. In addition to the rhetoric, this budget allocates real money to create a new foundation for primary care.</p>
<h2>2. Funding the plan to strength Medicare</h2>
<p>The second change is to fund what has been long discussed. Health Minister Butler signalled the focus on primary care as one of his first acts when he appointed the <a href="https://www.health.gov.au/committees-and-groups/strengthening-medicare-taskforce">Strengthening Medicare Taskforce</a>, which I was a member of. </p>
<p>The <a href="https://www.health.gov.au/resources/publications/strengthening-medicare-taskforce-report?language=en">taskforce report</a>, released late last year, sets out an ambitious blueprint for change. This budget includes the first down payment, of more than $1 billion new money in a full year. </p>
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Read more:
<a href="https://theconversation.com/new-medicare-reforms-wont-fix-everything-but-they-start-to-tackle-the-systems-biggest-problems-204800">New Medicare reforms won't fix everything but they start to tackle the system's biggest problems</a>
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<p>A key challenge for primary care policy is the reliance on fee-for-service payments. The budget addresses this by modernising the way the government pays for primary care in two critical ways:</p>
<p><strong>Patient enrolment</strong> </p>
<p>First, it introduces the concept of enrolment into the Australian primary care world. </p>
<p>Long part of primary care systems internationally, and regarded as one of the <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3948764/">key “building blocks” for good primary care</a>, enrolment involves a patient identifying a preferred GP as their main source of care. </p>
<p>Patient enrolment, dubbed MyMedicare, will mean the practice or GP has responsibility for the patient between visits, and therefore introduces a long-term relationship between patient and practitioner.</p>
<p><strong>Team-based health care</strong></p>
<p>The Strengthening Medicare Taskforce also recommended more multi-disciplinary or team-based primary care, involving nurses, physiotherapists and a range of other health providers and administrative supports. This is a somewhat back-to-the-future initiative as the 21st-century iteration of the <a href="https://www.sydney.edu.au/news-opinion/news/2014/11/05/whitlam--medibank-and-health-system-reform.html">Whitlam government’s community health program</a>.</p>
<p>The budget provides a significant increase in the <a href="https://www.health.gov.au/our-work/workforce-incentive-program">workforce incentive program</a>, which provides grants to practices to employ nurses, Aboriginal and Torres Strait Islander health workers and allied health professionals. </p>
<p>The program recognises that care for people with multiple chronic conditions requires the skills of a range of professions. Importantly, many general practices have already recognised this and are already providing team-based care.</p>
<p>The increased funding in this budget will reward that past behaviour, making these practices more viable, as well as encouraging an expansion in other practices.</p>
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<img alt="Clinician takes an elderly man's blood pressure with a machine" src="https://images.theconversation.com/files/525060/original/file-20230509-19-7udzig.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/525060/original/file-20230509-19-7udzig.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/525060/original/file-20230509-19-7udzig.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/525060/original/file-20230509-19-7udzig.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/525060/original/file-20230509-19-7udzig.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/525060/original/file-20230509-19-7udzig.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/525060/original/file-20230509-19-7udzig.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">The changes emphasise team-based care, using the skills of a range of health providers.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/elderly-man-having-blood-pressure-check-2246991347">Shutterstock</a></span>
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<h2>3. Extended prescription dispensing length</h2>
<p>The third budget change, <a href="https://www.health.gov.au/ministers/the-hon-mark-butler-mp/media/minister-for-health-and-aged-care-press-conference-26-april-2023?language=en">announced in April</a>, reduces prescription costs for medications by extending prescription quantities to two rather than one month’s supply for many common medications. </p>
<p>Despite <a href="https://www.smh.com.au/business/small-business/chemists-cry-poor-after-the-cornucopia-of-covid-19-20230427-p5d3nr.html">the tears and histrionics</a> of the Pharmacy Guild – the lobby group of pharmacy owners – the expert <a href="https://www.pbs.gov.au/industry/listing/elements/pbac-meetings/pbac-outcomes/2018-08/Increased-Dispensing-Quantity-List-of-Medicines-8-April-2019.pdf">Pharmaceutical Benefits Advisory Committee</a> recommended this modest change five years ago. </p>
<p>It doubles the amount of medication that may be dispensed under a single prescription, reducing patient co-payments and dispensing fees paid to pharmacists. It reduces government outlays by about $400 million a year and shows the government is prepared to take on a powerful stakeholder, despite the guild’s threats, <a href="https://www.afr.com/politics/federal/anthony-pratt-donates-nearly-4m-to-major-parties-20230130-p5cgn2">big political donations</a> and local campaigns. </p>
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<h2>4. Digital health time bomb</h2>
<p>Finally, the budget addresses a time bomb left by the previous government: digital health. </p>
<p>The Strengthening Medicare Taskforce identified contemporary digital health capacity as essential for a modern health system. Yet peculiarly, the previous government did not provide funding for the Digital Health Agency and My Health Record on an ongoing basis. It was due to expire on June 30 2023. </p>
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Read more:
<a href="https://theconversation.com/my-health-record-is-meant-to-empower-patients-but-with-little-useful-information-stored-is-it-worth-saving-199508">My Health Record is meant to empower patients – but with little useful information stored, is it worth saving?</a>
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<p>Some $250 million has been allocated in a full year <a href="https://www.medicalrepublic.com.au/whats-new-is-old-is-new-again-in-budget/91016">simply to keep the lights on and My Health Record ticking over</a>. </p>
<p>Although the current functionality and support for My Health Record leaves much to be desired, closing it down without replacement was never an option.</p>
<h2>What’s missing?</h2>
<p>The obvious omission relates to mental health. Although funding has been provided for more budget time bombs – programs which otherwise would have ended – and funding for additional places in psychology courses, mental health reform is still a work in progress.</p>
<p>The discontinuation of the COVID-related temporary extension of the Better Access program from a limit of ten to a limit of 20 mental health visits prompted <a href="https://theconversation.com/seeing-a-psychologist-on-medicare-soon-youll-be-back-to-10-sessions-but-we-know-thats-not-often-enough-194338">predictable criticism</a>, even though the program was <a href="https://insightplus.mja.com.au/2023/3/governments-better-access-initiative-must-change-to-prevent-a-mental-health-crisis/">demonstrably inequitable</a>. The government has recognised this gap, titling its mental health budget announcement “<a href="https://www.health.gov.au/resources/publications/laying-the-groundwork-for-mental-health-and-suicide-prevention-system-reform-budget-2023-24?language=en">laying the groundwork</a>”. </p>
<p>Overall, the health component of the 2023-2024 budget is well crafted. It signals a new priority for primary care and provides a new foundation for funding reform for the future. </p>
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Read more:
<a href="https://theconversation.com/seeing-a-psychologist-on-medicare-soon-youll-be-back-to-10-sessions-but-we-know-thats-not-often-enough-194338">Seeing a psychologist on Medicare? Soon you'll be back to 10 sessions. But we know that's not often enough</a>
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<p class="fine-print"><em><span>Stephen Duckett is Chair of the Board of Directors of Eastern Melbourne Primary Health Network and was a member of the Strengthening Medicare Taskforce </span></em></p>The big news on budget night was a tripling of the bulk-billing incentive. It’s hoped to stem the decline in bulk billing – but it’s unclear if it will increase it.Stephen Duckett, Honorary Enterprise Professor, School of Population and Global Health, and Department of General Practice, The University of MelbourneLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2048002023-05-02T10:58:54Z2023-05-02T10:58:54ZNew Medicare reforms won’t fix everything but they start to tackle the system’s biggest problems<figure><img src="https://images.theconversation.com/files/523712/original/file-20230502-28-w6y3xw.jpg?ixlib=rb-1.1.0&rect=40%2C200%2C3190%2C1940&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://photos.aap.com.au/">AAP/Tracey Nearmy</a></span></figcaption></figure><p>Federal Health Minister Mark Butler has long said Medicare is in the <a href="https://www.sbs.com.au/news/article/australias-gp-system-in-the-worst-shape-in-40-years-mark-butler-warns/iquhpkxx5">worst shape</a> it’s been in decades. Premiers have come to successive national cabinet meetings saying primary care is failing – and demanding reform and investment.</p>
<p>Fortunately, the policies Minister Butler <a href="https://www.health.gov.au/ministers/the-hon-mark-butler-mp/media/minister-for-health-and-aged-care-speech-national-press-club-2-may-2023">outlined</a> today at the <a href="https://www.health.gov.au/ministers/the-hon-mark-butler-mp/media/minister-for-health-and-aged-care-speech-national-press-club-2-may-2023">National Press Club</a> to strengthen Medicare live up to challenge. These reforms will be funded with a total of A$2.2 billion</p>
<p>They certainly won’t fix everything. But instead of kicking the can down the road, or just addressing superficial symptoms, they start to tackle some of the biggest challenges in general practice: outmoded technology, GPs working with little support, a broken funding model, and restrictive regulations. </p>
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Read more:
<a href="https://theconversation.com/health-and-housing-measures-announced-ahead-of-budget-and-ndis-costs-in-first-ministers-sights-204675">Health and housing measures announced ahead of budget, and NDIS costs in first ministers' sights</a>
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<h2>Diagnosing the problem</h2>
<p>There are many visible and urgent crises in health care, ranging from falling rates of bulk-billing to overwhelmed hospital emergency departments. But the minister zeroed in on the one big structural failure driving many of these problems: Medicare hasn’t kept up with the health needs of Australians. </p>
<p>Medicare was established in the 1980s. Today, Australians are living longer, often with chronic diseases. Chronic diseases – such as heart disease, diabetes, asthma, and depression – are the leading cause of illness and death. <a href="https://www.aihw.gov.au/reports/australias-health/chronic-conditions-and-multimorbidity">Almost half</a> of Australians have one chronic condition; more than half of Australians over 65 have two or more. </p>
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<img alt="Doctor takes her patient's blood pressure" src="https://images.theconversation.com/files/523717/original/file-20230502-20-lx98hp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/523717/original/file-20230502-20-lx98hp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=397&fit=crop&dpr=1 600w, https://images.theconversation.com/files/523717/original/file-20230502-20-lx98hp.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=397&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/523717/original/file-20230502-20-lx98hp.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=397&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/523717/original/file-20230502-20-lx98hp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=499&fit=crop&dpr=1 754w, https://images.theconversation.com/files/523717/original/file-20230502-20-lx98hp.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=499&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/523717/original/file-20230502-20-lx98hp.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=499&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Almost half of Australians have a chronic health condition.</span>
<span class="attribution"><a class="source" href="https://unsplash.com/photos/QTH2xmoJ_p0">Unsplash/CDC</a></span>
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<p>As Minister Butler noted, Medicare has not kept up and has “started to show its age”. A system designed for quick, one-off consultations with doctors isn’t a good fit for the more complex range of ongoing care and support many patients need today. </p>
<p>To update Medicare, the minister announced three areas of reform. </p>
<h2>1. Modernising digital systems</h2>
<p>With people likely to have multiple health conditions, and to see a range of professionals across the health system, it’s more important than ever for patients and clinicians to have relevant and up-to-date health information. That helps clinicians understand their patients’ needs. It also means patients don’t have to provide the same information again and again, or have duplicated, wasteful tests. </p>
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Read more:
<a href="https://theconversation.com/my-health-record-is-meant-to-empower-patients-but-with-little-useful-information-stored-is-it-worth-saving-199508">My Health Record is meant to empower patients – but with little useful information stored, is it worth saving?</a>
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<p>Australia’s digital systems are outdated, hard to use and ineffective. My Health record, our main digital health tool, is only used by <a href="https://journal.achsm.org.au/index.php/achsm/article/view/311/267">a small minority</a> of specialists, private hospitals and allied health providers. According to Minister Butler, only one in ten specialists use it, and only one in five radiology test results (such as X-rays or MRIs) are uploaded. </p>
<p>Computer systems in practices and hospitals usually can’t talk to each other, and often they aren’t connected to My Health Record.</p>
<p>To start to address this, more than $950 million will be spent on digital health, including keeping the Digital Health Agency running and improving My Health record.</p>
<h2>2. Building bigger teams</h2>
<p>To respond to the growing complexity of people’s health needs, most countries are moving towards “multidisciplinary” teams in general practice. Those teams might include nurses, physiotherapists, pharmacists, psychologies and administrative roles. This approach can improve care and take pressure off GPs. </p>
<p>As with digital systems, Australia is well behind other countries. Our GPs are <a href="https://grattan.edu.au/report/a-new-medicare-strengthening-general-practice/">more likely</a> to work on their own, or with little support. That’s because the way we fund general practice is stuck in the past, mostly restricted to paying GPs for disconnected, one-off consultations. </p>
<p>The <a href="https://www.health.gov.au/our-work/workforce-incentive-program/about">Workforce Incentive Program</a>, which funds general practices to hire a range of different health professionals, will be increased. For small clinics, and in areas with too little care to go around, <a href="https://www.health.gov.au/our-work/phn">Primary Health Networks</a> (regional bodies responsible for improving primary care) will fund and attract allied health professionals and nurses to work in GP clinics. </p>
<p>But the biggest change is a new way of funding care. Our outdated fee-for-service system rewards rushed consultations, is <a href="https://www.health.gov.au/sites/default/files/2023-04/independent-review-of-medicare-integrity-and-compliance_0.pdf">complex and confusing</a> for doctors, and blocks team-based care. For clinics and patients who choose to participate, a new system dubbed My Medicare will change that. </p>
<p>Patients will register with a preferred practice. The practice will then get a budget for treating them, on top of fees for each visit. Getting a patient-centred budget alongside visit fees will give care teams the flexibility to plan and deliver care in new and better ways. </p>
<p>Registering with a clinic will support strong relationships between patients and their care teams. Funding will be focused on that relationship, not on isolated visits, and will reflect the work of the whole care team, not just the GP. </p>
<h2>3. Unlocking workforce skills</h2>
<p>Along with measures to attract nurses to primary care settings, there will be a review of the barriers that stop health professionals using all their skills. </p>
<p>Australia has a thicket of inconsistent regulations and complex funding rules that result in double-handling, high costs, wasted talent and GPs having to do too much. The review is an opportunity to clear many of these barriers away, and make sure that workforce roles reflect the best evidence about how to provide safe, high-quality care.</p>
<p>Pharmacists will also <a href="https://www.health.gov.au/sites/default/files/2023-04/summary-of-strengthening-medicare-policies.pdf">do more</a>, with new funding for free vaccinations and expansions to treatment for people addicted to opioids. And there will be more training places in primary care for nurses, and efforts to attract nurses who have left the profession back into general practice. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/should-pharmacists-be-able-to-prescribe-common-medicines-like-antibiotics-for-utis-we-asked-5-experts-195277">Should pharmacists be able to prescribe common medicines like antibiotics for UTIs? We asked 5 experts</a>
</strong>
</em>
</p>
<hr>
<h2>Evolution not revolution – and a team effort</h2>
<p>The breadth of the proposals is important – there will be little progress without improvements in all those areas. </p>
<p>At the National Press Club, Minister Butler said “remaking Medicare for the 21st century will take persistent evolution, not overnight revolution”. </p>
<p>That incremental approach is important too, including making the most complex reform, My Medicare, voluntary. These changes will be hard, so participating clinicians and patients must be convinced of the benefits, willing to change, and ready for inevitable setbacks. </p>
<figure class="align-center ">
<img alt="Nurse shows a patient a pamphlet" src="https://images.theconversation.com/files/523719/original/file-20230502-18-1rui3z.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/523719/original/file-20230502-18-1rui3z.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/523719/original/file-20230502-18-1rui3z.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/523719/original/file-20230502-18-1rui3z.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/523719/original/file-20230502-18-1rui3z.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/523719/original/file-20230502-18-1rui3z.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/523719/original/file-20230502-18-1rui3z.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 Medicare reform process will be incremental.</span>
<span class="attribution"><a class="source" href="https://unsplash.com/photos/lNkRnZPfiwY">Unsplash/CDC</a></span>
</figcaption>
</figure>
<p>The reforms won’t satisfy everyone, but this might be the biggest opportunity for primary care reform in a generation. </p>
<p>The minister remarked on the “pointy elbows and loud voices” of the various professional groups in health care that provided input through his <a href="https://www.health.gov.au/committees-and-groups/strengthening-medicare-taskforce#publications">Strengthening Medicare Taskforce</a>. This package needs the support of all the workforce groups involved in primary care, and a strong voice for patients. Hopefully they will work together to make sure these reforms succeed.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/heres-why-pharmacists-are-angry-at-script-changes-and-why-the-government-is-making-them-anyway-204028">Here's why pharmacists are angry at script changes – and why the government is making them anyway</a>
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</em>
</p>
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<img src="https://counter.theconversation.com/content/204800/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Peter Breadon's employer, Grattan Institute, has been supported in its work by government, corporates, and philanthropic gifts. A full list of supporting organisations is published at <a href="http://www.grattan.edu.au">www.grattan.edu.au</a>.</span></em></p><p class="fine-print"><em><span>Lachlan Fox's employer, Grattan Institute, has been supported in its work by government, corporates, and philanthropic gifts. A full list of supporting organisations is published at <a href="http://www.grattan.edu.au">www.grattan.edu.au</a>.</span></em></p>The new reforms tackle some of the biggest challenges in general practice: outmoded technology, GPs working with little support, a broken funding model and restrictive regulations.Peter Breadon, Program Director, Health and Aged Care, Grattan InstituteLachlan Fox, Associate, Grattan InstituteLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2040282023-05-01T20:01:20Z2023-05-01T20:01:20ZHere’s why pharmacists are angry at script changes – and why the government is making them anyway<figure><img src="https://images.theconversation.com/files/523557/original/file-20230501-28-rxhhxq.jpg?ixlib=rb-1.1.0&rect=70%2C0%2C6639%2C3370&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/female-pharmacist-protective-mask-on-her-1734593969">Shutterstock</a></span></figcaption></figure><p>Australians will <a href="https://www.health.gov.au/ministers/the-hon-mark-butler-mp/media/minister-for-health-and-aged-care-press-conference-26-april-2023?language=en">soon be able to fill</a> two months’ supply of medicines at their community pharmacy, rather than one, for 325 common medicines. This change is expected to halve the cost of prescriptions for six million Australians.</p>
<p>The Pharmacy Guild of Australia has taken exception to the government’s policy change, <a href="https://www.guild.org.au/news-events/news/2023/8-in-10-australians-reject-federal-budget-proposal-due-to-medicine-shortages">warning</a> it will create medicine shortages and make pharmacies financially worse off.</p>
<p>The president of the guild <a href="https://www.sbs.com.au/news/video/pharmacy-advocate-in-tears-over-prescription-changes/mu92ka0aq">wept</a> at the thought of pharmacies going under because of reduced income from dispensing fees and co-payments. </p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1651443571981971457"}"></div></p>
<p>Mark Butler, the federal minister for health and aged care, was deft in his response, <a href="https://www.health.gov.au/ministers/the-hon-mark-butler-mp/media/minister-for-health-and-aged-care-press-conference-26-april-2023">advising Australians to</a>: </p>
<blockquote>
<p>take advice around medicine supply and medicine shortages from our medicines authorities rather than the pharmacy lobby group.</p>
</blockquote>
<p>This argy-bargy between the government and the guild is not uncommon.</p>
<p>What is uncommon is the public dismissal from a health minister of the guild’s views. This government is using its political capital to push health reform forward and doesn’t seem afraid to ruffle a few feathers.</p>
<h2>What is the Pharmacy Guild of Australia?</h2>
<p>The guild is an <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4605468/">influential peak body</a> registered under the federal Fair Work Act 2009. It acts like a union for community pharmacy (also known as chemists) owners. It provides resources to help pharmacists improve their small businesses, but most of its membership value comes from advocating for community pharmacy owners.</p>
<p>The Pharmaceutical Society of Australia is a separate group which represents all pharmacists, including those who work in hospitals and those who don’t own the pharmacy they work in.</p>
<p>The guild and the Pharmaceutical Society of Australia negotiate five-year agreements with the government on remuneration and funding for supplying Pharmaceutical Benefits Scheme (PBS) medicines in the community and for delivering pharmacy programs to support patients.</p>
<p>Known as <a href="https://theconversation.com/explainer-what-is-the-community-pharmacy-agreement-38789#:%7E:text=Patients%20pay%20a%20contribution%20towards,patient%20contribution%20from%20the%20government.">Community Pharmacy Agreements</a>, the first was signed in 1990, while the most recent seventh Community Pharmacy Agreement was signed in 2020. That agreement is due to expire in 2025, potentially costing A$25 billion over five years. Of this, $16 billion will be paid for by the government and $9 billion will be paid for by patients.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/explainer-what-is-the-community-pharmacy-agreement-38789">Explainer: what is the Community Pharmacy Agreement?</a>
</strong>
</em>
</p>
<hr>
<h2>How does the guild wield its power?</h2>
<p>The guild is nearly 100 years old. It understands health care and how health policy is made. It has a reputation for shaping government health policy envied by many a health care peak body.</p>
<p>It doesn’t have authority over government policy. It asserts its influence through its soft power by shaping community preferences to get patients behind what it wants. This stems from community pharmacy’s reach into every corner of Australia and the inherent trust between a pharmacist and a patient. It undertakes its own research to generate ideas and to criticise government policy when it suits.</p>
<figure class="align-center ">
<img alt="Pharmacist explains a medicine to a mother holding a young child" src="https://images.theconversation.com/files/523560/original/file-20230501-28-swsnio.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/523560/original/file-20230501-28-swsnio.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/523560/original/file-20230501-28-swsnio.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/523560/original/file-20230501-28-swsnio.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/523560/original/file-20230501-28-swsnio.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/523560/original/file-20230501-28-swsnio.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/523560/original/file-20230501-28-swsnio.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">Pharmacies are found in all corners of the country.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/cheerful-pharmacist-chemist-woman-giving-vitamins-211739305">Shutterstock</a></span>
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</figure>
<p>The guild also takes a more direct approach to influencing government policy. The Australian Electoral Commission <a href="https://transparency.aec.gov.au/Donor">reported</a> the guild was the 13th largest political donor in 2021–22, donating $578,000 to political parties across 88 separate donations. This was in an election year, which almost doubled its donations compared to the previous year.</p>
<h2>What policies has the guild influenced?</h2>
<p>The recent extent of the guild’s power is reflected in favourable policy outcomes for community pharmacies, despite these sometimes being unfavourable for taxpayers or patients.</p>
<p>The guild convinced the government to provide community pharmacies and pharmaceutical wholesalers with <a href="https://archive.budget.gov.au/2017-18/bp2/bp2.pdf">an extra</a> $225 million in the 2017–18 budget because prescription volumes were lower than expected within the sixth Community Pharmacy Agreement. This was a simple cash grab by pharmacies from taxpayers.</p>
<p>The guild also won a contentious policy back-flip in 2018 by getting the government to retain the Pharmacy Location Rules, <a href="https://www.guild.org.au/resources/business-conditions-survey">arguing</a> they provide “certainty and stability” for pharmacy small business. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/what-is-the-pharmacy-guild-of-australia-and-why-does-it-wield-so-much-power-127315">What is the Pharmacy Guild of Australia and why does it wield so much power?</a>
</strong>
</em>
</p>
<hr>
<h2>What are the Pharmacy Location Rules?</h2>
<p>The Pharmacy Location Rules are an <a href="https://www1.health.gov.au/internet/main/publishing.nsf/content/DDB409EBB18FCE8FCA257BF0001D3C0C/%24File/Pharmacy-Location-Rules-Applicants-Handbook-October-2018-v1-1.pdf">agreement</a> between the Australian government and the Pharmacy Guild of Australia. They place restrictions on where a new pharmacy can be established or where an existing pharmacy can be relocated. Pharmacies must meet location based criteria to be approved by the Australian Community Pharmacy Authority to receive pharmaceutical benefits. </p>
<p>The Pharmacy Location Rules <a href="https://www1.health.gov.au/internet/main/publishing.nsf/content/DDB409EBB18FCE8FCA257BF0001D3C0C/%24File/Pharmacy-Location-Rules-Applicants-Handbook-October-2018-v1-1.pdf">do not allow</a> new pharmacies to open within 1.5 kilometres or 10 kilometres of an existing pharmacy depending on the location, distance to the nearest pharmacy, and the number of supermarkets and medical practitioners in the area. Unless exempt, they do not allow pharmacies to be relocated from the town in which the approval was originally granted.</p>
<figure class="align-center ">
<img alt="shelf of common medicines" src="https://images.theconversation.com/files/523562/original/file-20230501-26-61xeda.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/523562/original/file-20230501-26-61xeda.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=445&fit=crop&dpr=1 600w, https://images.theconversation.com/files/523562/original/file-20230501-26-61xeda.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=445&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/523562/original/file-20230501-26-61xeda.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=445&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/523562/original/file-20230501-26-61xeda.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=560&fit=crop&dpr=1 754w, https://images.theconversation.com/files/523562/original/file-20230501-26-61xeda.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=560&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/523562/original/file-20230501-26-61xeda.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=560&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">The Pharmacy Location Rules determine where new pharmacy retailers can set up.</span>
<span class="attribution"><a class="source" href="https://unsplash.com/photos/pyuOXgO951U">Unsplash/Franki Chamaki</a></span>
</figcaption>
</figure>
<p>While no research has directly examined the impact, this policy has likely inflated consumer costs due to a restricted competitive pharmacy environment.</p>
<p>The Pharmacy Location Rules were introduced in the <a href="https://www.aph.gov.au/DocumentStore.ashx?id=523bbb1a-7e5f-485d-a8d5-d80b94a2c6d8&subId=561469">first Community Pharmacy Agreement</a> to help larger pharmacies generate efficiencies and profit through scale. The rules sweetened accompanying restrictions on PBS remuneration from the government. They have been included in each subsequent Community Pharmacy Agreement.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/relaxing-pharmacy-ownership-rules-could-result-in-more-chemist-chains-and-poorer-care-122628">Relaxing pharmacy ownership rules could result in more chemist chains and poorer care</a>
</strong>
</em>
</p>
<hr>
<p>The Pharmacy Location Rules were meant to expire in 2015 after the government initiated Competition Policy Review <a href="https://treasury.gov.au/publication/p2015-cpr-final-report">recommended</a> they “should be removed in the long term interests of consumers”. Instead, the guild <a href="https://www.theguardian.com/australia-news/2015/may/27/pharmacy-guild-shelves-protest-plans-after-compromise-deal-with-government">pulled back on a threat</a> made to the government to launch a major campaign on another policy initiative, in exchange for delaying the removal of the location rules for five years. </p>
<p>Upon further lobbying, the Pharmacy Location Rules sunset clause <a href="https://www.pbs.gov.au/general/sixth-cpa-pages/cpsf-files/cpsf-progress-of-commitments-compact-between-the-guild-and-health.docx">was removed</a> after the guild formed a Pharmacy Compact with the government in 2017. </p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1638678308589305856"}"></div></p>
<h2>Pharmacy policies that benefit consumers</h2>
<p>Some government policy change has aligned guild and patient interests.</p>
<p>Community pharmacists are increasingly providing services traditionally delivered by GPs. Pharmacists can now administer flu and COVID vaccines, and state trials allowing pharmacists to dispense oral contraception and antibiotics without a prescription are gaining favour.</p>
<p>This push towards greater scope of practice is embedded in the current and prior Community Pharmacy Agreements. But it threatens GP revenues.</p>
<p>The Australian Medical Association, the peak body for doctors, recently took a swing at the guild. It <a href="https://www.aph.gov.au/DocumentStore.ashx?id=cecc2818-fb71-4e9e-b2df-203e8c7e4e27&subId=736754">outlined ways</a> to improve pharmacy competition in a government submission, which included removing Pharmacy Location Rules and getting pharmacies to compete on medicine prices through discounting. </p>
<h2>What does this all mean for patients?</h2>
<p>The government has assured the guild that the $1.2 billion savings from allowing patients to fill two months’ supply of medicines will be invested directly back into pharmacies.</p>
<p>Savings will be used to <a href="https://www.health.gov.au/sites/default/files/2023-04/summary-of-strengthening-medicare-policies.pdf">further expand</a> the scope of practice for pharmacists, potentially informed by a National Scope of Practice Review to start in 2023.</p>
<p>Despite this assurance, the guild will fight. It has <a href="https://www.guild.org.au/news-events/news/2023/8-in-10-australians-reject-federal-budget-proposal-due-to-medicine-shortages">already canvassed</a> 2,500 “voters” across Australia on the budget proposal. In addition to reduced dispensing fee revenue, having patients with chronic diseases reduce their pharmacy visits by half means the opportunity to sell other products sitting on shelves is also halved.</p>
<p>Substantial health reform is on the horizon, but it won’t be painless. Policy change can upset embedded business models. It can impact livelihoods if providers don’t respond to their new regulatory environment. In the coming whirlwind of power struggles, wouldn’t it be nice if the government and providers worked together to put the patient first?</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/should-pharmacists-be-able-to-prescribe-common-medicines-like-antibiotics-for-utis-we-asked-5-experts-195277">Should pharmacists be able to prescribe common medicines like antibiotics for UTIs? We asked 5 experts</a>
</strong>
</em>
</p>
<hr>
<img src="https://counter.theconversation.com/content/204028/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Henry Cutler 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 Pharmacy Guild head wept at the thought of pharmacies losing income from a change that allows people with chronic diseases to halve their prescription costs. What’s going on?Henry Cutler, Professor and Director, Macquarie University Centre for the Health Economy, Macquarie UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2040292023-04-20T20:02:27Z2023-04-20T20:02:27ZIf you live in a bulk-billing ‘desert’ it’s hard to see a doctor for free. Here’s how to fix this<figure><img src="https://images.theconversation.com/files/521979/original/file-20230419-28-a9e1kl.jpg?ixlib=rb-1.1.0&rect=11%2C104%2C7764%2C5024&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/doctor-examining-sick-patient-face-mask-1718117674">Shutterstock</a></span></figcaption></figure><p>GP fees are hitting more Australians than they did a few years ago. There’s a lot of talk about a crisis in bulk billing, with many people reporting they’re unable to see a doctor without paying an out-of-pocket fee. </p>
<p>But the biggest, most urgent problem is in the communities where most people pay fees, so called bulk-billing “deserts”. These deserts are more likely in poorer areas, so the people who most need bulk billing are missing out.</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1647859792986120193"}"></div></p>
<p>While Medicare funding changes are needed to address this problem, we also need to look at more innovative solutions. One option is for federal and state governments to <a href="https://grattan.edu.au/wp-content/uploads/2022/12/A-new-Medicare-strengthening-general-practice-Grattan-Report.pdf">step in</a> and support or set up clinics that employ doctors, nurses and other health workers. </p>
<h2>Bulk billing is falling, but from a historic high</h2>
<p>The share of patients who <a href="https://www.health.gov.au/resources/publications/medicare-statistics-per-patient-bulk-billing-dashboard-2021-22?language=en">never paid a GP fee fell</a> from 67% in 2020-21 to 64% in 2021-22. But those rates are still high by recent standards. The rate has only fallen back to the level of 2015, and it remains much higher than a decade ago.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/521791/original/file-20230419-26-gvtlwq.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/521791/original/file-20230419-26-gvtlwq.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/521791/original/file-20230419-26-gvtlwq.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=338&fit=crop&dpr=1 600w, https://images.theconversation.com/files/521791/original/file-20230419-26-gvtlwq.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=338&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/521791/original/file-20230419-26-gvtlwq.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=338&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/521791/original/file-20230419-26-gvtlwq.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=424&fit=crop&dpr=1 754w, https://images.theconversation.com/files/521791/original/file-20230419-26-gvtlwq.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=424&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/521791/original/file-20230419-26-gvtlwq.png?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"></a>
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<p>Yes, it’s troubling to see bulk billing falling, especially when fees have risen a lot. Patients who are not bulk billed now pay <a href="https://www.health.gov.au/resources/publications/medicare-annual-statistics-state-and-territory-2009-10-to-2021-22?language=en">on average A$45</a> out of pocket when they see a GP. This is up 20% in real terms over the past decade. </p>
<p>But while the national trend is concerning, it masks a much bigger problem.</p>
<h2>Great disparity</h2>
<p>In some parts of Australia – for example, <a href="https://www.theguardian.com/news/datablog/2023/feb/17/revealed-the-areas-where-australians-are-struggling-to-access-free-gp-care">the electorates</a> of Chiefly, Fowler, and Werriwa in outer-western Sydney – more than nine in ten GP patients are always bulk billed. </p>
<p>But in other parts – for example, the electorates of Canberra, and Franklin and Clark in southern Tasmania – that figure is less than four in ten. </p>
<p>Unlike the overall bulk-billing rate, these vast disparities have persisted for many years: the problem was just as bad a decade ago. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/521790/original/file-20230419-20-41cvqa.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/521790/original/file-20230419-20-41cvqa.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=338&fit=crop&dpr=1 600w, https://images.theconversation.com/files/521790/original/file-20230419-20-41cvqa.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=338&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/521790/original/file-20230419-20-41cvqa.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=338&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/521790/original/file-20230419-20-41cvqa.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=424&fit=crop&dpr=1 754w, https://images.theconversation.com/files/521790/original/file-20230419-20-41cvqa.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=424&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/521790/original/file-20230419-20-41cvqa.png?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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<p>Bulk-billing deserts wouldn’t be such a problem if they were only in the wealthiest parts of Australia, because fees are less likely to stop wealthy people getting the care they need. But there are bulk-billing deserts in many poorer areas. </p>
<p>Compared to all but the wealthiest areas, the bottom fifth of electorates by income have the lowest bulk-billing rates. In 13 of the lowest-income electorates, less than 60% of patients are bulk billed. </p>
<p>Rural areas are worse off too: 60% of patients in rural areas are always bulked billed, compared to almost 69% in metropolitan areas.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/521792/original/file-20230419-241-gvtlwq.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/521792/original/file-20230419-241-gvtlwq.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=338&fit=crop&dpr=1 600w, https://images.theconversation.com/files/521792/original/file-20230419-241-gvtlwq.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=338&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/521792/original/file-20230419-241-gvtlwq.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=338&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/521792/original/file-20230419-241-gvtlwq.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=424&fit=crop&dpr=1 754w, https://images.theconversation.com/files/521792/original/file-20230419-241-gvtlwq.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=424&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/521792/original/file-20230419-241-gvtlwq.png?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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<p>The bulk-billing deserts in poorer parts of Australia represent a serious failure of the system. Nationally, about <a href="https://www.abs.gov.au/statistics/health/health-services/patient-experiences/latest-release">3.5%</a> of people say they skip GP care because of the cost, with higher rates in rural and poorer areas. Those figures will be far higher in bulk-billing deserts, putting many people’s health at risk. </p>
<h2>What the government should do</h2>
<p>There have been <a href="https://www1.racgp.org.au/newsgp/professional/crisis-summit-white-paper-released">calls</a> to pour billions of dollars into increasing the Medicare rebate and bulk billing incentives. </p>
<p>But while the government should make sure payments to GPs keep up with their costs, that won’t fix the problem of bulk-billing deserts. </p>
<p>It might help arrest the decline in bulk billing nationally, and in some areas where bulk billing is low. But the money will mostly flow to high-bulk billing areas – it won’t do much to provide more care where there is far too little. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/general-practices-are-struggling-here-are-5-lessons-from-overseas-to-reform-the-funding-system-188902">General practices are struggling. Here are 5 lessons from overseas to reform the funding system</a>
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</em>
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<p>Bulk billing deserts are an enduring problem that need new solutions. To turn them around, the government must tackle two of the structural problems causing them: one-size-fits-all funding of GPs, and areas that don’t have enough health care to go around. </p>
<p>The government has already <a href="https://www.health.gov.au/sites/default/files/2023-02/strengthening-medicare-taskforce-report_0.pdf">signalled</a> it will develop a new funding model that pays GPs for providing ongoing care, which would improve on the current <a href="https://www.health.gov.au/resources/publications/independent-review-of-medicare-integrity-and-compliance?language=en">outdated and dysfunctional system</a>. That funding should give <a href="https://theconversation.com/general-practices-are-struggling-here-are-5-lessons-from-overseas-to-reform-the-funding-system-188902">higher payments</a> for patients with greater need. </p>
<p>That would boost income for clinics with patients who need free care the most, helping those clinics to avoid charging their patients. It would be a big step in the right direction.</p>
<figure class="align-center ">
<img alt="Clinician checks a patient's blood pressure" src="https://images.theconversation.com/files/521980/original/file-20230420-2867-5s2pdd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/521980/original/file-20230420-2867-5s2pdd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/521980/original/file-20230420-2867-5s2pdd.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/521980/original/file-20230420-2867-5s2pdd.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/521980/original/file-20230420-2867-5s2pdd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/521980/original/file-20230420-2867-5s2pdd.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/521980/original/file-20230420-2867-5s2pdd.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">Funding reform will help clinics avoid overcharging patients.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/male-nurse-measures-blood-pressure-senior-1817431535">Shutterstock</a></span>
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<p>But even then, there would still be areas without enough health-care workers to meet the community’s needs, including many rural areas, resulting in too little care, and <a href="https://onlinelibrary.wiley.com/doi/abs/10.1111/joie.12098">too little bulk billing</a>. Governments must go well beyond the Medicare rebate and other incentives to fix these broken health-care “markets”. </p>
<p>The federal and state governments need to <a href="https://grattan.edu.au/wp-content/uploads/2022/12/A-new-Medicare-strengthening-general-practice-Grattan-Report.pdf">step in</a> to support existing clinics or set up new ones that employ salaried health-care workers. This support needs to be tailored to local needs. It could be employing a GP to work out of a rural hospital if there are no GPs in the area, or setting up a new <a href="https://treasury.gov.au/sites/default/files/2022-03/258735_national_rural_health_alliance.pdf">community-controlled primary care service</a>, or helping an existing clinic hire extra staff. </p>
<p>Rather than ad hoc announcements, there should be secure national funding for this care, targeted at the areas of greatest need – especially the poorest bulk-billing deserts. </p>
<p>This change should be accompanied by many other reforms to attract clinicians to areas where they’re needed most, such as further expanding new <a href="https://www.abc.net.au/news/2023-04-15/gp-s-idea-for-rural-generalist-hub-to-avoid-doctor-burnout/102102204">models</a> of GP <a href="https://www.mlhd.health.nsw.gov.au/getmedia/0d396ca5-0028-4cca-99ac-e573dd90bda8/A4-Brochure-Rural-Generalist-Training-Pathway">employment</a> and <a href="https://www.abc.net.au/news/2023-01-27/australia-first-trial-to-retain-gps-in-rural-areas/101898362">training</a> in rural areas, which give “<a href="https://www.health.gov.au/our-work/national-rural-generalist-pathway">rural generalist</a>” doctors a single employer during their training across a range of different health settings in a region.</p>
<p>There should also be reforms to expand the teams supporting GPs in areas with too little care. This can reduce GP burnout, allow clinics to provide more care, and bring Australia <a href="https://grattan.edu.au/wp-content/uploads/2022/12/A-new-Medicare-strengthening-general-practice-Grattan-Report.pdf">in line</a> with other countries. As well as administrative, allied health, pharmacist and other roles, some teams could include <a href="https://grattan.edu.au/wp-content/uploads/2014/04/196-Access-All-Areas.pdf">physician assistants</a>, who work under the supervision of a doctor and can provide the full range of services a doctor provides.</p>
<p>One test for next month’s federal budget is whether it funds solutions to bulk-billing deserts – an enduring injustice in our health-care system.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/medicare-reform-is-off-to-a-promising-start-now-comes-the-hard-part-197914">Medicare reform is off to a promising start. Now comes the hard part</a>
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</em>
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<img src="https://counter.theconversation.com/content/204029/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Peter Breadon's employer, Grattan Institute, has been supported in its work by government, corporates, and philanthropic gifts. A full list of supporting organisations is published at <a href="http://www.grattan.edu.au">www.grattan.edu.au</a>.</span></em></p><p class="fine-print"><em><span>Lachlan Fox's employer, Grattan Institute, has been supported in its work by government, corporates, and philanthropic gifts. A full list of supporting organisations is published at <a href="http://www.grattan.edu.au">www.grattan.edu.au</a>.</span></em></p>In Australia’s bulk-billing ‘deserts’, it’s incredibly difficult to find a doctor who will bulk bill. The government should step in to support or set up clinics so locals have access to health care.Peter Breadon, Program Director, Health and Aged Care, Grattan InstituteLachlan Fox, Associate, Grattan InstituteLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1952572023-02-22T15:31:47Z2023-02-22T15:31:47ZOver 90% of Rwandans have health insurance – the health minister tells an expert what went right<figure><img src="https://images.theconversation.com/files/498920/original/file-20221205-16-bcm2cc.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Xinhua/Cyril Ndegeya via Getty Images</span></span></figcaption></figure><p><em>In 2015 the United Nations General Assembly <a href="https://www.who.int/news-room/fact-sheets/detail/universal-health-coverage-(uhc)">adopted</a> universal health coverage as one of the sustainable development goals. The aim of universal health coverage is to ensure that every person and community, irrespective of their circumstances, has access to the health services they need, at the time and place they need it, without the risk of financial devastation. Many countries have committed to the concept, which has resulted in numerous health reforms. The World Health Organization <a href="https://apps.who.int/iris/bitstream/handle/10665/361229/9789290234760-eng.pdf?sequence=1&isAllowed=y">recognises</a> Rwanda as one of the countries that are performing well on the goal of universal health coverage. The <a href="https://southafrica.cochrane.org/">Cochrane Centre</a> summarises and disseminates information on what works and what doesn’t in health care. Professor Charles Shey Wiysonge, director of Cochrane South Africa and senior director at the South African Medical Research Council, spoke to Rwanda’s health minister, Dr Sabin Nsanzimana, about the road map for universal health coverage in the country.</em> </p>
<hr>
<p><strong>Charles Wiysonge:</strong> What does universal health coverage look like in Rwanda? </p>
<p><strong>Sabin Nsanzimana:</strong> In the last decade, calls for increased efforts to achieve universal health coverage have grown. Many countries have committed to universal health coverage – particularly in Africa. This has resulted in numerous health reforms. </p>
<p>Rwanda’s President Paul Kagame was <a href="https://au.int/en/pressreleases/20190209/africas-leaders-gather-launch-new-health-financing-initiative-aimed-closing">appointed</a> by other African heads of state as the leader on domestic health financing in the AU Assembly Declaration in February 2019. The aim of the declaration was to increase investment in health and have member states spend efficiently and effectively to achieve better health outcomes.</p>
<p>In the last couple of decades Rwanda has improved the health and well-being of all its people. This was done through a combination of evidence-based and people-centred strategies and interventions. The country has been able to make the following substantial progress:</p>
<ul>
<li><p>On the supply side, the country has built a healthcare delivery system on primary healthcare. Individuals and communities are at the centre of our actions. The increased number of health facilities <a href="https://www.statistics.gov.rw/publication/1767">(from 1,036 in 2013 to 1,457 in 2020)</a> has improved the geographical accessibility of care. It’s also contributed to the reduction of the average time used by a Rwandan citizen to reach a health facility. The average <a href="https://www.who.int/news-room/feature-stories/detail/rwanda-s-primary-health-care-strategy-improves-access-to-essential-and-life-saving-health-services">time used to reach</a> the nearest health facility has fallen from 95.1 minutes in 2010 to 49.9 minutes in the past 10 years.</p></li>
<li><p>On the demand side, the risk pooling has been greatly improved as a result of the extension of <a href="https://www.who.int/news-room/fact-sheets/detail/community-based-health-insurance-2020#:%7E:text=CBHI%20is%20a%20form%20of,setup%20and%20in%20its%20management.">Community-Based Health Insurance schemes</a>. These give the majority of the population access to healthcare services, and improve access to quality services. Insurance has also reduced out-of-pocket expenditures (which are 4% as a share of total health expenditure) in particular for the poor and most vulnerable people. Community-based health insurance covers <a href="https://www.rssb.rw/community-based-health-insurance-scheme-receives-financial-boost-from-ahf">over 85%</a> of the population. The percentage of the population with some kind of <a href="https://dhsprogram.com/pubs/pdf/FR370/FR370.pdf#page=74">health insurance</a> has increased from 43.3% in 2005 to 90.5% in 2020. This has helped to protect households against financial risks associated with sickness.</p></li>
<li><p>The government spending on health (15.6% as of the 2019/2020 financial year) has surpassed the <a href="https://au.int/sites/default/files/pages/32894-file-2001-abuja-declaration.pdf#page=6">15%</a> required under the 2001 Abuja Declaration. This shows the country’s high commitment to the development of health sector financing. </p></li>
</ul>
<p><strong>Charles Wiysonge:</strong> Where are the gaps and why do they exist?</p>
<p><strong>Sabin Nsanzimana:</strong> Progress towards universal health coverage is a continuous process. It responds to shifts in demographic, epidemiological and technological trends as well as people’s socio-economic status and expectations. If Rwanda is to meet the goal of achieving universal health coverage by 2030, we need to be far more ambitious to leave no one behind.</p>
<p>Additional health financing reforms and actions to maintain achieved gains and improve further health outcomes are needed. The fact that the country has achieved close to universal population coverage is in itself a great achievement. But there are still some people who are uninsured. We need to identify policy options to expand coverage to the hard-to-reach population in the informal sector. Health insurance has positively affected the use of services and equity. But further improvements are needed. We must extend the service coverage based on the need and reduce cost-sharing, especially for secondary and tertiary care.</p>
<p>Sustainability of health financing is also a critical issue. It requires finding innovative ways to mobilise domestic resources, adopting better resource pooling mechanisms and an effective strategic purchasing mechanism. These must ensure equity and efficient use of available resource and value for money.</p>
<p><strong>Charles Wiysonge:</strong> What else is needed?</p>
<p><strong>Sabin Nsanzimana:</strong> To move further and deeper towards universal health coverage calls for evidence-based policy reforms that would provide direction for a long-term model for service delivery (focusing on the primary healthcare level) and health financing in Rwanda. This will require adequate awareness among policy decision makers, and increased capacity in those areas and shared understanding of universal health coverage to support the necessary reforms.</p>
<p><strong>Charles Wiysonge:</strong> What can other countries on the continent learn from Rwanda’s experience?</p>
<p><strong>Sabin Nsanzimana:</strong> Strong leadership that sets a clear vision for the future is imperative. Countries need a development model that is inclusive. Such a model must consider gender equality, pro-poor policies, unity and solidarity.</p>
<p>Most important are robust institutions and legal frameworks driven by good governance, with:</p>
<ul>
<li><p>accountability, citizen participation, decentralisation </p></li>
<li><p>results orientation – performance contracts</p></li>
<li><p>investment in human capital – mainly capacity building.</p></li>
</ul><img src="https://counter.theconversation.com/content/195257/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>Rwanda has built a healthcare delivery system on primary healthcare with individuals and communities at the centre.Charles Shey Wiysonge, Director, Cochrane South Africa, South African Medical Research CouncilLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1954792022-12-13T13:27:56Z2022-12-13T13:27:56ZHypertension, diabetes, stroke: they kill more people than infectious diseases and should get a Global Fund<figure><img src="https://images.theconversation.com/files/499986/original/file-20221209-19531-9yfpxs.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">shutterstock</span> </figcaption></figure><p>Noncommunicable diseases such as diabetes, hypertension and cardiovascular conditions account for <a href="https://www.who.int/news-room/fact-sheets/detail/noncommunicable-diseases">41 million deaths</a> each year. That’s more than 70% of all deaths globally. Most of these deaths (77%) are in low-income and middle-income countries – including those in Africa. </p>
<p>These conditions are currently <a href="https://www.researchgate.net/publication/356360474_Tanzania_Non-communicable_Diseases_and_Injuries_Poverty_Commission_Findings_and_Recommendations">more prevalent</a> than infectious diseases. Sixty-seven percent occur before the age of 40. Besides being the leading causes of death worldwide, noncommunicable diseases carry a <a href="https://apps.who.int/iris/handle/10665/274512">huge cost</a> to individuals. These also undermine workforce productivity and threaten economic prosperity.</p>
<p>Healthcare provision in much of Africa still relies on <a href="https://www.brookings.edu/blog/future-development/2019/03/01/closing-africas-health-financing-gap/">external donors</a>. There’s insufficient funding to help low-income and middle-income countries control noncommunicable diseases. Most <a href="https://jamanetwork.com/journals/jama/fullarticle/2320320">development assistance for health funding</a> provided by international donors is allocated for infectious diseases and maternal and child health. In <a href="https://vizhub.healthdata.org/fgh/">2019</a>, funding for HIV amounted to US$9.5 billion. The amount allocated to noncommunicable diseases was US$0.7 billion. </p>
<p>Evidence suggests that addressing the noncommunicable disease pandemic can also mitigate other challenges like HIV, tuberculosis (TB), maternal and child health, and universal health coverage. </p>
<p>The <a href="https://www.theglobalfund.org/en/">Global Fund</a> to Fight AIDS, TB and Malaria is an international partnership. The fund invests US$4 billion a year to fight these three diseases. </p>
<p>I believe it’s now time to think of establishing a Global Fund for noncommunicable diseases, or expand the mandate of Global Fund beyond AIDS, TB and malaria. The epidemics of these conditions overlap. For example, <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8872228/#:%7E:text=The%20most%20prevalent%20HIV%20comorbidities,and%20hepatitis%20C%20%5B14%5D.">research</a> has shown that <a href="https://jamanetwork.com/journals/jama/article-abstract/2757599">comorbidities</a> such as diabetes and cancers are common in people living with HIV. </p>
<h2>Broadening healthcare provision</h2>
<p>Disease specific programmes have <a href="https://academic.oup.com/heapol/article/33/3/381/4812662">limitations</a>. As public health practitioners we should learn from our mistakes. We must build integrated programmes and health systems that address the interlinkages and co-morbidities. One example would be to include diabetes screening in TB treatment programmes. </p>
<p>In addition to integration, noncommunicable diseases require increasing investments. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/499973/original/file-20221209-22427-6zj374.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/499973/original/file-20221209-22427-6zj374.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/499973/original/file-20221209-22427-6zj374.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=280&fit=crop&dpr=1 600w, https://images.theconversation.com/files/499973/original/file-20221209-22427-6zj374.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=280&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/499973/original/file-20221209-22427-6zj374.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=280&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/499973/original/file-20221209-22427-6zj374.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=352&fit=crop&dpr=1 754w, https://images.theconversation.com/files/499973/original/file-20221209-22427-6zj374.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=352&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/499973/original/file-20221209-22427-6zj374.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=352&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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</figure>
<p>The Global Fund is seeking US$18 billion this year. At the same time <a href="https://www.thelancet.com/ncd-countdown-2030">The Lancet NCD Countdown 2030</a> projects that interventions for noncommunicable diseases need US$18 billion a year. That’s what it would take to meet the UN target of reducing noncommunicable diseases by a third by the year 2030. </p>
<p>I would argue that the case for <a href="https://pubmed.ncbi.nlm.nih.gov/35339227/">investment</a> in noncommunicable diseases has never been stronger. </p>
<h2>A roadmap</h2>
<p>The World Health Assembly recently <a href="https://www.who.int/news-room/feature-stories/detail/world-health-assembly-approves-a-global-implementation-roadmap-to-accelerate-action-on-noncommunicable-diseases-(ncds)">approved</a> the World Health Organization’s roadmap for the prevention and control of noncommunicable diseases covering the period 2023-2030. </p>
<p>The roadmap recommends actions to: </p>
<ul>
<li><p>promote “best-buys” interventions with a high return for every dollar spent, such as smoking cessation programmes </p></li>
<li><p>strengthen health systems </p></li>
<li><p>reduce noncommunicable disease risk factors such as tobacco use and unhealthy diets </p></li>
<li><p>embed noncommunicable diseases within primary healthcare and universal health coverage. </p></li>
</ul>
<p>This roadmap needs to be followed in line with the commitments to reduce air pollution and promote mental health and well-being.</p>
<p>The lessons learned from the COVID-19 pandemic offer opportunities for strengthening emergency preparedness and responses beyond pandemics. Emergency risk management and continuity of essential health services for all hazards – addressing the foundational health system gaps – can improve health security.</p>
<h2>What should be done</h2>
<p>How should Africa respond to the increasing burden of noncommunicable diseases? There needs to be a strong political will and buy-in from governments, with strong multi-stakeholder participation. </p>
<p>The <a href="https://www.who.int/teams/noncommunicable-diseases/on-the-road-to-2025">UN General Assembly</a> decision on HIV and noncommunicable diseases commits governments to identify and address the comorbidities of HIV and other links to pressing global health challenges. These include links to noncommunicable diseases, learning from the perspectives of people living with these conditions and underscoring the importance of focusing on comorbidities. </p>
<p>The WHO’s <a href="https://www.who.int/initiatives/global-noncommunicable-diseases-compact-2020-2030#:%7E:text=The%20Global%20NCD%20Compact%202020,of%20people%20living%20with%20NCDs.">noncommunicable disease compact</a> proposes concrete actions. These actions need to be data-driven and supported by noncommunicable disease-related indicators in health systems performance and access to healthcare metrics. </p>
<p>Monitoring systems need to be more diverse. The systems should capture and monitor progress made through sectors that affect health, such as housing and sanitation. Doing this would strengthen the monitoring of national systems and the capacity to address noncommunicable diseases comprehensively.</p>
<p>Health system strengthening and quality of care will improve significantly with additional resources for noncommunicable diseases through an entity like the Global Fund. </p>
<p><em>This article is part of a media partnership between The Conversation Africa and the 2022 Conference on Public Health in Africa.</em></p><img src="https://counter.theconversation.com/content/195479/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Kaushik Ramaiya is Honorary General Secretary of Tanzania Diabetes Association and we work with Ministry of Health (Tanzania) in implementing National NCD program which has been funded by World Diabetes Foundation (WDF) and Novo Nordisk Foundation. </span></em></p>Addressing the noncommunicable disease pandemic can also mitigate challenges facing people living with HIV and complement efforts against TB.Kaushik Ramaiya, Honorary Professor of Medicine & Global Health , Liverpool School of Tropical MedicineLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1954472022-12-04T19:01:29Z2022-12-04T19:01:29ZHow do you fix general practice? More GPs won’t be enough. Here’s what to do<figure><img src="https://images.theconversation.com/files/498406/original/file-20221201-26-16ycmp.jpg?ixlib=rb-1.1.0&rect=0%2C785%2C4060%2C3774&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.pexels.com/photo/doctor-writing-on-a-notebook-while-talking-on-the-phone-5207088/">Karolina Grabowska/Pexels</a></span></figcaption></figure><p>Australians are getting older, sicker, and harder to treat. This isn’t news to GPs, who say they are <a href="https://www1.racgp.org.au/newsgp/professional/ministers-told-overwhelmed-gps-need-help">overwhelmed with demand</a> and frustrated with a rigid system that <a href="https://www1.racgp.org.au/newsgp/gp-opinion/people-do-not-understand-general-practice-and-that">doesn’t support them</a>. </p>
<p>To improve general practice, the Albanese government has set aside almost a billion dollars and convened a <a href="https://www.health.gov.au/committees-and-groups/strengthening-medicare-taskforce">Strengthening Medicare Taskforce</a> to advise how to spend it. <a href="https://www.racgp.org.au/advocacy/reports-and-submissions/2022-reports-and-submissions/gp-crisis-summit-white-paper">Many people argue</a> recruiting more GPs is the best path forward. </p>
<p>But as a <a href="https://grattan.edu.au/report/a-new-medicare-strengthening-general-practice">new Grattan Institute report shows</a>, Australia has plenty of GPs – although they’re not always in the right areas. What we lack are supporting clinicians to help GPs respond to a growing tide of chronic disease. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/some-gps-just-keep-their-heads-above-water-other-doctors-businesses-are-more-profitable-than-law-firms-192163">Some GPs just keep their heads above water. Other doctors' businesses are more profitable than law firms</a>
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</em>
</p>
<hr>
<h2>General practice is becoming more complex</h2>
<p>One reason many GPs feel overwhelmed is because their patients are getting sicker. More patients have <a href="https://www.sydney.edu.au/content/dam/corporate/documents/faculty-of-medicine-and-health/research/research-collaborations-networks-and-groups/41-2006-07-to-2015-16.pdf">multiple conditions</a> that need to be managed by their GP, and the proportion with more than one chronic condition has been estimated at <a href="https://pubmed.ncbi.nlm.nih.gov/27027989/">nearly half</a>.</p>
<p>Managing these patients is more complex and takes more time, but Medicare does not reward GPs for longer consultations. Average consultation length has been stuck at between 14 and 15 minutes since 2002, despite the increasing complexity of patients’ needs. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/497871/original/file-20221129-22-4qs0rs.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/497871/original/file-20221129-22-4qs0rs.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=393&fit=crop&dpr=1 600w, https://images.theconversation.com/files/497871/original/file-20221129-22-4qs0rs.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=393&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/497871/original/file-20221129-22-4qs0rs.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=393&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/497871/original/file-20221129-22-4qs0rs.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=493&fit=crop&dpr=1 754w, https://images.theconversation.com/files/497871/original/file-20221129-22-4qs0rs.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=493&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/497871/original/file-20221129-22-4qs0rs.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=493&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Patients’ needs are becoming more complex.</span>
<span class="attribution"><span class="source">BEACH survey results, Britt et al. (2010) and Britt et al. (2015)</span>, <span class="license">Author provided</span></span>
</figcaption>
</figure>
<h2>Australia has many GPs</h2>
<p>To help general practices meet this demand, <a href="https://www.racgp.org.au/advocacy/reports-and-submissions/2022-reports-and-submissions/gp-crisis-summit-white-paper">peak bodies have called for</a> more GPs, and to attract them to the specialty through higher pay. </p>
<p>It’s true that many places in Australia, particularly some rural areas, <a href="https://www.sciencedirect.com/science/article/pii/S0277953621003774">don’t have enough GPs</a>. And the pandemic has led to a surge in demand everywhere, with wait times spiking after years of steady decline. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/497840/original/file-20221129-18-z9z333.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/497840/original/file-20221129-18-z9z333.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=393&fit=crop&dpr=1 600w, https://images.theconversation.com/files/497840/original/file-20221129-18-z9z333.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=393&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/497840/original/file-20221129-18-z9z333.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=393&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/497840/original/file-20221129-18-z9z333.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=493&fit=crop&dpr=1 754w, https://images.theconversation.com/files/497840/original/file-20221129-18-z9z333.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=493&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/497840/original/file-20221129-18-z9z333.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=493&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Wait times have spiked.</span>
<span class="attribution"><span class="source">ABS patient experiences survey (2022)</span>, <span class="license">Author provided</span></span>
</figcaption>
</figure>
<p>But at a national level, almost all the indicators suggest GP supply is stronger than ever. As our report shows, Australia has more GPs per person than ever before, more GPs than most wealthy countries, and record numbers of GPs in training. </p>
<h2>GPs need more support</h2>
<p>While the supply of GPs has grown, more GPs alone can’t manage the rising tide of chronic disease, or the growing pressure on many general practices. Instead, we need to make general practice a team sport. </p>
<figure class="align-left ">
<img alt="Nurse looks into the distance" src="https://images.theconversation.com/files/498407/original/file-20221201-12-1tn5v7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/498407/original/file-20221201-12-1tn5v7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=900&fit=crop&dpr=1 600w, https://images.theconversation.com/files/498407/original/file-20221201-12-1tn5v7.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=900&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/498407/original/file-20221201-12-1tn5v7.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=900&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/498407/original/file-20221201-12-1tn5v7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1131&fit=crop&dpr=1 754w, https://images.theconversation.com/files/498407/original/file-20221201-12-1tn5v7.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1131&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/498407/original/file-20221201-12-1tn5v7.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1131&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Nurses don’t get to use all their skills.</span>
<span class="attribution"><a class="source" href="https://unsplash.com/photos/CEFYNiM9xLk">Luke Jones/Unsplash</a></span>
</figcaption>
</figure>
<p>Team-based care is increasingly used in general practice overseas. But compared with similar countries, Australian GPs have little support. </p>
<p>About three-quarters of clinical staff in Australian general practice are GPs, with nurses making up almost all the remaining quarter. And those nurses don’t get to help as much as they want, with three-quarters saying they face barriers to using all their skills. </p>
<p>Other countries have different types of workers that Australia lacks. Germany has about <a href="https://bmcprimcare.biomedcentral.com/articles/10.1186/1471-2296-14-110">400,000 medical assistants</a>, providing administrative and clinical support in general practice, while Australia has only about 100. England has about <a href="https://digital.nhs.uk/data-and-information/publications/statistical/general-and-personal-medical-services/30-september-2022">one supporting clinician for every GP</a>, three times as many as Australia. In the United States, nurse practitioners and physician assistants deliver <a href="https://pubmed.ncbi.nlm.nih.gov/21851446/">about 11%</a> of all medical services outside hospitals. In Australia they would deliver less than 0.1%.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/general-practices-are-struggling-here-are-5-lessons-from-overseas-to-reform-the-funding-system-188902">General practices are struggling. Here are 5 lessons from overseas to reform the funding system</a>
</strong>
</em>
</p>
<hr>
<h2>Team care is good for everyone</h2>
<p>Evidence overwhelmingly confirms these and many other clinicians can share parts of a GP’s load with the same safety and quality of care. Studies suggest well-implemented team care can improve <a href="https://pubmed.ncbi.nlm.nih.gov/22042511/">quality of care</a>, <a href="https://pubmed.ncbi.nlm.nih.gov/22042511/">patient safety</a> and <a href="https://www.tandfonline.com/doi/full/10.3109/13561820.2015.1051616?scroll=top&needAccess=true">health outcomes</a>, as well as reducing demand on hospitals.</p>
<p>It also makes GPs’ jobs more manageable, impactful and satisfying. By sharing simpler care with other team members, GPs can spend more time working with more complex patients. </p>
<p>It also creates time for other types of work: planning, improving care, maintaining oversight of the team’s care, and consulting with other specialists. While a GP’s clinical work will be more complex, they will also have more time to do other vital aspects of their role.</p>
<p>Emerging trials in many states (such as the pharmacist-prescribing trials in <a href="https://www.abc.net.au/news/2022-10-12/queensland-gov-plan-for-controversial-pharmacy-program-revealed/101529066">Queensland</a>, <a href="https://www.theguardian.com/australia-news/2022/nov/13/pharmacists-to-get-prescription-powers-in-nsw-game-changer-trial-that-gps-call-madness">New South Wales</a> and <a href="https://www.aap.com.au/news/andrews-scores-narrow-vic-poll-debate-win/">Victoria</a>) have also made it clear task-sharing is happening – with GPs, or without them. </p>
<p>Unlike these trials, our recommendations focus on bringing new workforces into general practice, not taking care out.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/should-pharmacists-be-able-to-prescribe-common-medicines-like-antibiotics-for-utis-we-asked-5-experts-195277">Should pharmacists be able to prescribe common medicines like antibiotics for UTIs? We asked 5 experts</a>
</strong>
</em>
</p>
<hr>
<h2>What needs to change?</h2>
<p>GPs might think this sounds like a fantasy that would never work for them. That’s because for most clinics, it will only be possible if there are fundamental changes to how the system is run. </p>
<p>The first barrier is funding. General practices <a href="https://doi.org/10.1093/fampra/cmx095">lose revenue</a> if they have anyone other than a GP deliver care. Medicare does not fund practice pharmacists, physiotherapists, practice nurses, nurse practitioners or Indigenous health workers to work to their full skill level. </p>
<p>Other workforces, such as physician assistants, community paramedics and medical assistants, are not funded to provide care at all. </p>
<figure class="align-right ">
<img alt="Medic puts gloves on" src="https://images.theconversation.com/files/498408/original/file-20221201-24-fuusx4.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/498408/original/file-20221201-24-fuusx4.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=900&fit=crop&dpr=1 600w, https://images.theconversation.com/files/498408/original/file-20221201-24-fuusx4.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=900&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/498408/original/file-20221201-24-fuusx4.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=900&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/498408/original/file-20221201-24-fuusx4.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1131&fit=crop&dpr=1 754w, https://images.theconversation.com/files/498408/original/file-20221201-24-fuusx4.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1131&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/498408/original/file-20221201-24-fuusx4.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1131&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Funding is a key barrier to using other health workers’ skills.</span>
<span class="attribution"><a class="source" href="https://unsplash.com/photos/7hjh_X3xsDA">Magdiel Lagos/Unsplash</a></span>
</figcaption>
</figure>
<p>General practices should be able to opt into a new funding model which, as well as paying GPs for each appointment, gives them a budget for ongoing care of each patient. This would enable GPs to expand their team, and give them funding even when another team member is providing care. Most wealthy countries use this kind of funding model. </p>
<p>The second barrier is regulation. An independent commission should advise government on how different roles should be regulated, to make sure workers can safely use all their skills.</p>
<p>Finally, taking away barriers isn’t enough. As <a href="https://www.england.nhs.uk/gp/expanding-our-workforce/">other countries</a> have found, change needs financial support. </p>
<p>The federal government should use Strengthening Medicare funding to roll out 1,000 new nurses, physiotherapists, mental health clinicians, pharmacists and other allied health workers in the highest-need communities, to work in general practices alongside GPs, providing fee-free care. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/the-physio-will-see-you-now-why-health-workers-need-to-broaden-their-roles-to-fix-the-workforce-crisis-188984">The physio will see you now. Why health workers need to broaden their roles to fix the workforce crisis</a>
</strong>
</em>
</p>
<hr>
<p>The shift to team-based general practice won’t be easy. It will require changes in how practices are designed and operate, and enough funding, time and training for teams to work well together. This should be recognised with more funding and sustained expert support. </p>
<p>Although it will be hard, the payoff will be worth it. GPs will be free to choose a model with more support and more sustainable workloads. Government will be able to reduce the biggest gaps in access and outcomes. And patients will have more time with their general practice team, quicker access when they need it, and better care.</p><img src="https://counter.theconversation.com/content/195447/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>A new Grattan report recommends making general practice a team sport, using the skills of other clinicians and health-care workers.Peter Breadon, Program Director, Health and Aged Care, Grattan InstituteDanielle Romanes, Visiting Fellow, Grattan InstituteLachlan Fox, Associate, Grattan InstituteLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1716692021-11-11T05:14:21Z2021-11-11T05:14:21ZPeople who choose not to get vaccinated shouldn’t have to pay for COVID care in hospital<figure><img src="https://images.theconversation.com/files/431422/original/file-20211111-27-1tk1ujl.jpg?ixlib=rb-1.1.0&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/healthcare-worker-protective-equipment-performs-coronavirus-1753344953">Shutterstock</a></span></figcaption></figure><p>When I went out in Melbourne for a coffee with a friend earlier this week, the waiter verified my vaccination status before allowing me to sit down. But for the unvaccinated in Victoria and New South Wales, it’s a case of no clubbing, no coffee catch-ups, no movies. </p>
<p>Many employers have even gone beyond the government-mandated minimum and required all staff to be vaccinated as part of <a href="https://ozsage.org/working_group/business/">ensuring a safe workplace</a>.</p>
<p>These mandates are designed to reduce the number of COVID-19 outbreaks and their consequences as Australia’s “lockdown states” open up. Introducing different rules for the vaccinated and the unvaccinated also gives people an incentive to get vaccinated as soon as possible. </p>
<p>Singapore went a step further this week, announcing people <a href="https://www.moh.gov.sg/news-highlights/details/calibrated-adjustments-in-stabilisation-phase_8Nov20210%E2%80%99">who are unvaccinated by choice</a> will have to pay for their own health care. </p>
<p>This isn’t the right way to encourage vaccination, and shouldn’t be replicated in Australia.</p>
<h2>What if an unvaccinated Singaporean gets COVID?</h2>
<p>Singapore has a complicated system of health insurance which includes “<a href="https://www.moh.gov.sg/cost-financing/healthcare-schemes-subsidies/medisave">medical savings accounts</a>” from which people can pay for their health care and keep the balance for <a href="https://www.cpf.gov.sg/member/account-services/providing-for-your-loved-ones/making-a-cpf-nomination">distribution to their estate when they die</a>.</p>
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<strong>
Read more:
<a href="https://theconversation.com/creating-a-better-health-system-lessons-from-singapore-30607">Creating a better health system: lessons from Singapore</a>
</strong>
</em>
</p>
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<p>Under the new policy, unvaccinated Singaporeans will still get care, but could be substantially out-of-pocket when or if they recover. COVID-related hospital care can be expensive and so could easily wipe out a medical savings account balance. </p>
<p>Singapore’s new policy is implemented with the best intentions – to reduce demand on a stretched health system by reducing the number of avoidable hospital admissions among the unvaccinated. </p>
<h2>Why some are calling for us to follow Singapore’s lead</h2>
<p>Despite high rates of vaccination in Australia (<a href="https://covidbaseau.com/">more than 80% of over-16s are double-dose vaccinated</a>) and COVID cases trending down, hospitals in NSW and Victoria are still under pressure. </p>
<p>And even though the unvaccinated are only a small proportion of the population in those jurisdictions, <a href="https://www.health.vic.gov.au/media-releases/coronavirus-update-for-victoria-10-november-2021">almost everyone</a> with COVID in an intensive care unit bed is unvaccinated.</p>
<p>Former NSW premier <a href="https://www.news.com.au/lifestyle/health/health-problems/you-pay-for-your-wilful-stupidity-bob-carr-calls-for-unvaccinated-to-be-denied-free-healthcare/news-story/4d8cdb8319d20dda21fbc1acf0d7a5e3">Bob Carr endorsed the Singaporean approach</a> and called for Australia to follow suit. </p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1457977588299689987"}"></div></p>
<p>Others have <a href="https://www.crikey.com.au/2021/11/11/vaccine-refuseniks-need-to-pay-for-the-pressure-their-actions-put-on-public-hospitals/">hopped on the bandwagon</a>. I strongly disagree.</p>
<h2>The importance of universal coverage – for everyone</h2>
<p>Australia’s Medicare system provides universal coverage for medical and public hospital care. It’s not a system just for the poor, or just for the well-behaved. It promotes social solidarity. </p>
<p>Widespread vaccination was always going to be the best way out of lockdowns and the path to reopening Australian and state borders. Grattan Institute’s <a href="https://grattan.edu.au/report/race-to-80/">Race to 80</a> report supported vaccine passports and other strategies to encourage vaccination. But <a href="https://www.sciencedirect.com/science/article/pii/S0264410X15003564">how far</a> should these nudges to increase vaccination rates go?</p>
<p>Undermining Medicare’s universality – by excluding the unvaccinated from its financial protection – is a bridge too far. </p>
<figure class="align-center ">
<img alt="Hospital trolly in a dark corridor." src="https://images.theconversation.com/files/431427/original/file-20211111-13-tdkl73.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/431427/original/file-20211111-13-tdkl73.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=340&fit=crop&dpr=1 600w, https://images.theconversation.com/files/431427/original/file-20211111-13-tdkl73.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=340&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/431427/original/file-20211111-13-tdkl73.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=340&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/431427/original/file-20211111-13-tdkl73.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=428&fit=crop&dpr=1 754w, https://images.theconversation.com/files/431427/original/file-20211111-13-tdkl73.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=428&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/431427/original/file-20211111-13-tdkl73.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=428&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Unvaccinated Australians should have access to free hospital care, just like the rest of the population.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/empty-hospital-hallway-611606933">Shutterstock</a></span>
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<p>Sure, I think anti-vaxxers should know better; their vaccination status poses a risk to themselves and all of us.</p>
<p>But the Singaporean policy statement has hidden in it the root of the problem – it is targeted at those who are unvaccinated by choice.</p>
<p>The evidence shows vaccination in Australia – like other aspects of health care – <a href="https://csrm.cass.anu.edu.au/sites/default/files/docs/2021/9/Determinants_of_COVID-19_vaccination_and_views_of_parents_about_vaccination_of_children_in_Australia_-_August_2021_-_For_web.pdf">suffers from a distinct social gradient</a>. Poorer people and those less well educated have lower rates of vaccination. </p>
<p>This may be because their lives are less well organised, and they can’t take time off from precarious employment to get vaccinated. It may be they are more susceptible to misinformation campaigns. </p>
<p>Whatever the case, their “choice” may not be a fully informed and freely made one. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/just-the-facts-or-more-detail-to-battle-vaccine-hesitancy-the-messaging-has-to-be-just-right-155953">Just the facts, or more detail? To battle vaccine hesitancy, the messaging has to be just right</a>
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<h2>Failures in the government’s vaccination program</h2>
<p>Penalising unvaccinated Australians by excluding them from Medicare would be a convenient way of shifting responsibility on to individuals for government failures. </p>
<p>Early on, the federal government did not make vaccination easy to get. And the government has failed to ensure the whole population has all the information it needs to make good vaccination decisions. </p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1409718358505791516"}"></div></p>
<p>If the unvaccinated were barred from Medicare, these government failures would magically become a problem for a small number of individuals, and no longer a political failure.</p>
<h2>If we exclude unvaccinated people, where to next?</h2>
<p>If we exclude the unvaccinated from Medicare’s protection today, <a href="https://academic.oup.com/phe/article/12/2/133/5528519">tomorrow we might exclude the smoker, the day after the drinker</a>, or the person who did not go out jogging, or has not taken up private health insurance.</p>
<p>Hospital emergency department staff regularly have to care for a drink driver and their victim on the same day. They have an ethical obligation to treat everybody equally. Similarly, as frustrating as it might seem, the health system must still be there for the unvaccinated. </p>
<p>The health system needs to be there for everyone, not just people who look like us, nor just for people we like, nor just for people whose choices we endorse.</p>
<p>Nudges to encourage people to get vaccinated are good public policy. But if they undermine the universality of health care, these well-intentioned policies would cause more harm than good.</p>
<p><em>Correction: an earlier version of this article incorrectly said unvaccinated people in the ACT were subject to certain restrictions and ACT hospitals were under pressure.</em></p><img src="https://counter.theconversation.com/content/171669/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>Singapore will start charging people who choose not to be vaccinated for any COVID-related hospital care. While Australia’s hospitals are also under pressure, we shouldn’t follow suit.Stephen Duckett, Director, Health and Aged Care Program, Grattan InstituteLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1320042020-02-18T19:02:04Z2020-02-18T19:02:04ZYoung people dropping private health hurts insurers most, not public hospitals<figure><img src="https://images.theconversation.com/files/315858/original/file-20200218-10995-63wavc.jpg?ixlib=rb-1.1.0&rect=49%2C16%2C5453%2C3646&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/family-budget-finances-young-woman-doing-546537382">Shutterstock</a></span></figcaption></figure><p>Young Australians are abandoning private health insurance in droves. And the overall decline in the percentage of the population with private coverage is continuing.</p>
<p><a href="https://www.apra.gov.au/quarterly-private-health-insurance-statistics">New data</a> for the three months to the end of 2019, released yesterday by the private health insurance regulator, show that compared with the same time a year ago, 44,000 fewer young people (aged 25 to 34) have private health insurance. </p>
<p>The percentage of the population with some form of private hospital insurance is down 0.7 percentage points compared to the December quarter in 2018 and now stands at 44.0%.</p>
<hr>
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<p>The private health insurance industry is in a dire predicament, and people who remain in private health insurance also stand to lose out.</p>
<p>But the industry’s argument a youth exodus will put massive amounts of additional pressure on public hospitals doesn’t stack up. The industry’s self-serving claims are simply designed to bolster its case for yet more government handouts.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/youth-discounts-fail-to-keep-young-people-in-private-health-insurance-121803">Youth discounts fail to keep young people in private health insurance</a>
</strong>
</em>
</p>
<hr>
<h2>Why is the industry worried?</h2>
<p>The proportion of the population with any form of private hospital insurance is <a href="https://www.apra.gov.au/sites/default/files/2020-02/Quarterly%20private%20health%20insurance%20statistics%20December%202019.pdf">now around 44%</a>. </p>
<p>While the number of young people has fallen, there are 60,000 more people 70 and older than a year ago. The average age of a person with private health insurance continues to creep upwards.</p>
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<p><iframe id="ILORH" class="tc-infographic-datawrapper" src="https://datawrapper.dwcdn.net/ILORH/1/" height="400px" width="100%" style="border: none" frameborder="0"></iframe></p>
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<p>Changes in the composition of the insured population affects different stakeholders – such as the insured, the insurers and the public hospital system – differently.</p>
<p>The more young people drop out, the more the “risk pool” of the insured population worsens, because young people use health care less than older people. </p>
<p>This causes the price of insurance to go up for everyone, which leads to still more young people dropping out. This creates a death spiral for the industry. </p>
<p>Insurers lose out because fewer people are paying insurance premiums. </p>
<p>And those who remain in private insurance lose out because they have to pay higher premiums.</p>
<h2>Little impact on the public hospital system</h2>
<p>A critical issue is what happens to demand on the public system as the proportion of people who are privately insured declines. </p>
<p>The people who are most likely to drop out are younger people and people who don’t expect to use hospitals much. So logically, this is not likely to have much impact on demand for public care.</p>
<p>Private health insurance is now differentiated into Gold, Silver, Bronze, and Basic products, with “+” designations on the last three of these. Typically debates about private health insurance only focus on the number of people insured not the level of cover they have. </p>
<hr>
<p>
<em>
<strong>
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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</em>
</p>
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<p><a href="https://www.apra.gov.au/quarterly-private-health-insurance-statistics">About 41% of those insured</a> have coverage with “no exclusions”, the equivalent of Gold.</p>
<p>This means less than 20% of the total population has insurance coverage for all conditions. So many people with private health insurance already rely on the public system for those procedures not covered in their insurance package.</p>
<p>Maternity care, for example, is usually only covered at the <a href="https://www1.health.gov.au/internet/main/publishing.nsf/Content/89DCC17F86C24B4ACA2581BA007A2DC7/$File/20181010%20-%20GSBB%20fact%20sheet%20w%20tiers%20table.pdf">Gold tier</a>. Presumably, people with Silver, Bronze, or Basic products were always going to have their baby in a public hospital. So a reduction in the number of people with those products will have no impact on demand for maternity care in public hospitals. </p>
<p>Joint replacements, such as hips and knees, are also normally covered only in Gold products, so the same arguments apply.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/315860/original/file-20200218-10985-zm2zlh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/315860/original/file-20200218-10985-zm2zlh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=340&fit=crop&dpr=1 600w, https://images.theconversation.com/files/315860/original/file-20200218-10985-zm2zlh.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=340&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/315860/original/file-20200218-10985-zm2zlh.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=340&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/315860/original/file-20200218-10985-zm2zlh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=428&fit=crop&dpr=1 754w, https://images.theconversation.com/files/315860/original/file-20200218-10985-zm2zlh.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=428&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/315860/original/file-20200218-10985-zm2zlh.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=428&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">People with lower levels of private health insurance already use the public system.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/empty-hospital-hallway-611606933">Shutterstock</a></span>
</figcaption>
</figure>
<p>There has been extensive research trying to predict the impact of a decline in private insurance on public hospitals. Researchers have found consumers are relatively slow to respond to changes in the price of insurance. Private health insurance is therefore said to be “sticky”. </p>
<p>Once insured, people, especially older people, tend to stay insured, and respond to premium increases by downgrading their cover, either in terms of what they are covered for (dropping from Gold to Silver, for example), or taking on a higher excess they have to pay if they go to hospital. But a higher excess is unlikely to make them choose a public hospital.</p>
<p>The big changes in terms of dropping out are happening in the group which is new to private health insurance – the young – who have not established a history with insurance. </p>
<p>But young people use health care infrequently, meaning only a small number of hospital admissions would be expected to move from the private to the public system.</p>
<h2>A slow death</h2>
<p><a href="https://grattan.edu.au/report/saving-private-health-2/">Our own modelling</a> at the Grattan Institute suggests the death spiral is real, but is slow. People over 70 will probably still be insured at much the same rate they are now over the next ten years, but people under 70 will drop out, with people under 55 dropping out more rapidly.</p>
<p>Young people receive a bad deal from private health insurance. The premium they pay – which is essentially the same as the premium everyone else pays under Australia’s system of “community rating” – is much greater than the costs of their expected use of health care. </p>
<p>The gap between what they pay and expected benefit is getting worse. That’s why they are leaving in droves. </p>
<p>But this decline is a bigger problem for the private insurers than it will be for the public health system.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/how-do-you-stop-the-youth-exodus-from-private-health-insurance-cut-premiums-for-under-55s-128101">How do you stop the youth exodus from private health insurance? Cut premiums for under-55s</a>
</strong>
</em>
</p>
<hr>
<img src="https://counter.theconversation.com/content/132004/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. Medibank Private is an Affiliate partner of Grattan Institute. Stephen Duckett has private health insurance.</span></em></p>New private health insurance data show young people are continuing to drop their cover. But the industry’s argument a youth exodus will put pressure on public hospitals isn’t necessarily right.Stephen Duckett, Director, Health Program, Grattan InstituteLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1315652020-02-17T18:54:06Z2020-02-17T18:54:06ZHome-owning older Australians should pay more for residential aged care<figure><img src="https://images.theconversation.com/files/315618/original/file-20200217-11011-1fqc6vt.jpg?ixlib=rb-1.1.0&rect=10%2C524%2C7135%2C4242&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/old-people-geriatric-hospice-young-attractive-405715657">Shutterstock</a></span></figcaption></figure><p>Heavily subsidised aged care services used to be seen as a right and entitlement for all older Australians. But as aged care demand grows and costs rise, it’s becoming increasingly clear the current system isn’t sustainable. </p>
<p>The family home has always been a central part of the debate over how much older Australians should contribute to their aged care services. But it has largely been protected from means tests. </p>
<p>It’s time for Australians who own their own home to contribute more to the cost of their aged care – and there are fair and equitable ways to go about this. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/nearly-2-out-of-3-nursing-homes-are-understaffed-these-10-charts-explain-why-aged-care-is-in-crisis-114182">Nearly 2 out of 3 nursing homes are understaffed. These 10 charts explain why aged care is in crisis</a>
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</em>
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<hr>
<h2>How does the system currently work?</h2>
<p>Currently, <a href="https://www.health.gov.au/sites/default/files/documents/2019/11/seventh-report-on-the-funding-and-financing-of-the-aged-care-industry-july-2019.pdf">taxpayers pay the majority</a> of the cost of subsidised aged care services. </p>
<p>In 2017-18, the total cost was A$21.4 billion; the Australian government paid A$16.6 billion, or 77% of that total. </p>
<p>Older people pay less than 10% of the cost of home support and home care. </p>
<p>For residential care, they still only pay around a quarter of the cost (27%). <a href="https://www.myagedcare.gov.au/aged-care-home-costs-and-fees">Most of their payment</a> is for meals, cleaning, laundry, and so on – things they would have done or paid for when living at home. </p>
<h2>What aged care services are means tested?</h2>
<p>There are different consumer contribution arrangements for the three main aged care programs: <a href="https://www.myagedcare.gov.au/commonwealth-home-support-programme-costs">home support</a>, <a href="https://www.myagedcare.gov.au/help-at-home/home-care-packages">home care packages</a> and residential aged care homes. </p>
<p>Only one – residential care – takes into account the value of a person’s home. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/315622/original/file-20200217-10976-qeitw8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/315622/original/file-20200217-10976-qeitw8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=387&fit=crop&dpr=1 600w, https://images.theconversation.com/files/315622/original/file-20200217-10976-qeitw8.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=387&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/315622/original/file-20200217-10976-qeitw8.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=387&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/315622/original/file-20200217-10976-qeitw8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=486&fit=crop&dpr=1 754w, https://images.theconversation.com/files/315622/original/file-20200217-10976-qeitw8.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=486&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/315622/original/file-20200217-10976-qeitw8.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=486&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">Home support and home care packages don’t take into account the value of a person’s home.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/senior-woman-wheelchair-alone-room-782087950">Shutterstock</a></span>
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</figure>
<p>The home is <a href="https://www.myagedcare.gov.au/income-and-assets-assessment-aged-care-homes">not counted in the assets test</a> if a partner or dependent children live there, or (with conditions) a carer or close relative lives there. </p>
<p>Further, the value of the home used for the assets test is <a href="https://www.myagedcare.gov.au/income-and-assets-assessment-aged-care-homes">limited to only A$169,079.20</a>. This may be the total value of the home for those living in poorer areas or rural communities. But it represents only a tenth of the value or less for wealthy home-owners, so it fails to take into account a large proportion of their wealth.</p>
<h2>Why the current system isn’t working</h2>
<p>The current system isn’t sustainable. The <a href="https://www.health.gov.au/sites/default/files/health-portfolio-budget-statements-2018-19.pdf">federal government’s budget outlook shows</a> taxpayer expenditure on aged care services will grow rapidly from A$16.8 billion in 2017-18 to A$24 billion by 2022-23 and will continue growing thereafter. </p>
<p>Without change, these aged care subsidies will become an increasingly larger part of Australia’s total economy, growing from around 1% of GDP now to a <a href="https://treasury.gov.au/publication/2015-igr">projected</a> 1.7% of GDP by 2054-55. As such, more of the economy’s production will be devoted to aged care at the expense of other goods and services. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/dont-wait-for-a-crisis-start-planning-your-aged-care-now-113572">Don't wait for a crisis – start planning your aged care now</a>
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<hr>
<p>The family home’s special treatment isn’t even supported by the not-for-profit sector.</p>
<p>The <a href="https://www.cota.org.au/wp-content/uploads/2020/02/RC-System-Design-Consultation-COTA-Submission-Final-24-01-2020.pdf">Council on the Ageing</a> (COTA) recently told the <a href="https://agedcare.royalcommission.gov.au/Pages/default.aspx">Royal Commission into Aged Care Quality and Safety</a> that the current levels of taxpayer subsidies are likely to become unsustainable into the future. </p>
<p>COTA said consumer contributions should be more equitable and have regard to their total wealth, including their “real property” – read “the family home”. </p>
<p><a href="https://www.cha.org.au/images/agedcare/2019/Catholic_Health_Australia_-_Pre-Budget_Submission_2020-21.pdf">Catholic Health Australia</a>, in a submission to the federal government, similarly said it would publicly support including the full value of a person’s former home in the residential care assets test. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/315624/original/file-20200217-10976-1mw7yux.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/315624/original/file-20200217-10976-1mw7yux.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/315624/original/file-20200217-10976-1mw7yux.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/315624/original/file-20200217-10976-1mw7yux.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/315624/original/file-20200217-10976-1mw7yux.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/315624/original/file-20200217-10976-1mw7yux.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/315624/original/file-20200217-10976-1mw7yux.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">The value of the home used for the residential aged care assets test is limited to A$169,079.20.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/senior-woman-sitting-alone-on-chair-457918912">Shutterstock</a></span>
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</figure>
<h2>So what should we do?</h2>
<p>To overcome the current inequities and improve the sustainability of the system, we need to broaden the assessment of an older person’s capacity to pay, by taking greater account of their wealth. </p>
<p>The first step should be to raise the cap on the value of the home in the current residential care assets tests, potentially to the full value of the home.</p>
<p>An assets test could also be included for consumer contributions to home care packages.</p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/so-youre-thinking-of-going-into-a-nursing-home-heres-what-youll-have-to-pay-for-114295">So you're thinking of going into a nursing home? Here's what you'll have to pay for</a>
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<p>A second issue is for an older person to draw more readily on their wealth to pay for goods and services, including aged care services, without having to sell their home during their lifetime. </p>
<p>One way forward is greater use of the <a href="https://www.servicesaustralia.gov.au/individuals/services/centrelink/pension-loans-scheme">Pension Loans Scheme</a>, which enables older Australians to receive a voluntary non-taxable fortnightly loan from the government using their home as security.</p>
<p>Given the imperative for greater quality and safety in aged care, and the rising use and cost of these services, the government should publicly explore these options and open up the modelling to community debate. Budget sustainability and the equitable treatment of all older Australians demand nothing less.</p><img src="https://counter.theconversation.com/content/131565/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Michael Woods undertakes policy research for the Australian government, is on the board of the Australian Digital Health Agency and is a member of the Aged Care Financing Authority.</span></em></p>The family home has largely been protected from mean tests to determine how much older people should pay for their aged care. It’s time this changed.Michael Woods, Professor of Health Economics, University of Technology SydneyLicensed 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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<p>
<em>
<strong>
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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<p>
<em>
<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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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/do-you-really-need-private-health-insurance-heres-what-you-need-to-know-before-deciding-93661">Do you really need private health insurance? Here's what you need to know before deciding</a>
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<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/1181792019-06-05T04:03:09Z2019-06-05T04:03:09ZIt’s perfectly legal for doctors to charge huge amounts for surgery, but should it be allowed?<figure><img src="https://images.theconversation.com/files/277995/original/file-20190604-69087-6q2xjq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Desperate families are increasingly turning to crowdfunding campaigns to raise tens of thousands of dollars for surgery and other medical expenses.</span> <span class="attribution"><span class="source">From shutterstock.com</span></span></figcaption></figure><p>Australia’s Chief Medical Officer Brendan Murphy <a href="https://www.abc.net.au/radio/programs/pm/are-medical-specialists-fees-too-high/11178754">will investigate how to better protect patients</a> from doctors charging “really unjustifiable, excessive fees” of up to A$10,000 or more for medical procedures.</p>
<p>Murphy said it was potentially unethical for doctors to charge such high out-of-pocket fees that left families in severe financial pain, and that contrary to some patients’ hopes, paying more didn’t equate to better outcomes. </p>
<p>The call comes as desperate families increasingly turn to crowdfunding, remortgaging their homes and eating into their superannuation to raise tens of thousands of dollars for <a href="https://www.gofundme.com/mvc.php?route=category&term=surgery%20australia&country=AU">surgeries and other medical expenses</a>.</p>
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<em>
<strong>
Read more:
<a href="https://theconversation.com/we-need-more-than-a-website-to-stop-australians-paying-exorbitant-out-of-pocket-health-costs-108740">We need more than a website to stop Australians paying exorbitant out-of-pocket health costs</a>
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<p>It is perfectly legal for a doctor working in private practice to charge what they believe is fair and reasonable. It’s a private market, so buyers beware. </p>
<p>But that doesn’t mean it’s right, or that it should be allowed to continue. </p>
<h2>Not everything is available in the public system</h2>
<p>Some patients’ out-of-pocket costs are from the gap between what their private health insurance and/or Medicare will pay for a procedure or treatment. </p>
<p>But some treatments aren’t funded by Medicare or offered in public hospitals because their safety, efficacy and value for money have not yet been demonstrated. </p>
<p>Medical technologies, devices and surgical techniques need to be rigorously tested in clinical trials to demonstrate safety and clinical effectiveness. They will only be widely adopted when they have a <a href="http://www.msac.gov.au/internet/msac/publishing.nsf/Content/about-msac">strong evidence base</a>. </p>
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<img alt="" src="https://images.theconversation.com/files/277996/original/file-20190604-69095-n4wl77.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/277996/original/file-20190604-69095-n4wl77.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/277996/original/file-20190604-69095-n4wl77.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/277996/original/file-20190604-69095-n4wl77.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/277996/original/file-20190604-69095-n4wl77.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/277996/original/file-20190604-69095-n4wl77.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/277996/original/file-20190604-69095-n4wl77.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">Out-of-pocket costs can be particularly high for patients with cancer.</span>
<span class="attribution"><span class="source">From shutterstock.com</span></span>
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<p>When the government pays for a health service, value for money is also considered. For really expensive services and medicines that have the potential to greatly benefit patients, the government will try to negotiate prices down, to reduce the impact on the health budget. </p>
<p>While a lack of evidence of a benefit does not necessarily mean the procedure does not benefit patients, the outcomes need to be reviewed and demonstrated to justify its ongoing use. </p>
<p>Sometimes new technologies are adopted prematurely based on weak evidence and strong marketing which can lead to poor investment decisions. This was the case with robotic surgery for prostate cancer, offered early in private practice in Australia, only to find later it was no better than <a href="https://www.ncbi.nlm.nih.gov/pubmed/28701134">traditional surgery</a>. </p>
<h2>If a patient chooses to spend money on a high-risk surgery, is it really anyone’s business?</h2>
<p>Sometimes patients will choose to undergo high-risk surgery, not covered under the public system, and are willing to pay out of their own pocket, or raise the funds through crowdsourcing or remortgaging their home. </p>
<p>Some will argue the value is whatever the patient is <a href="https://www.ncbi.nlm.nih.gov/pubmed/?term=Garrison+LP%2C++2018%3B21(2)%3A124-130.">willing to pay for it</a> and it’s up to the patient’s own risk-benefit preferences. </p>
<p>There are some major problems with this. Patients often make health decisions while distressed, ill and emotional. They may not be able to determine the best course of action or have all the information at hand. They must trust the doctor and his or her superior knowledge and experience. </p>
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<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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<p>Health economists call this “<a href="https://www.aushsi.org.au/market-failure-and-information-problems-in-healthcare/">asymmetric information</a>”. The doctor has extensive years of training, expertise and qualifications. The patient has Dr Google. </p>
<p>A key reason governments intervene in health care systems is to avoid market failure arising from unequal information and the profiteering of providers. </p>
<h2>Our ‘fee-for-service’ system is failing</h2>
<p>In the private system, doctors are paid a fee for each service they provide. This creates an incentive for doctors to provide more services: the more services they provide, the more they get paid. </p>
<p>But the high volumes of testing, consultations and fragmented services we’re currently seeing aren’t translating to a better quality of care. As such, economists are calling for major reforms of our fee-for-service private health system and the way that doctors are paid. </p>
<p>This could involve <a href="https://theconversation.com/more-visits-to-the-doctor-doesnt-mean-better-care-its-time-for-a-medicare-shake-up-110884">paying doctors for caring for a patient’s medical condition</a> over a set period, rather than each time they see the patient, or charging private patients a “<a href="https://www.abc.net.au/radio/programs/pm/are-medical-specialists-fees-too-high/11178754">bundled fee</a>” for all the scans, appointments and other costs associated with something like a hip replacement. </p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/more-visits-to-the-doctor-doesnt-mean-better-care-its-time-for-a-medicare-shake-up-110884">More visits to the doctor doesn't mean better care – it's time for a Medicare shake-up</a>
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<p><a href="https://www.bcna.org.au/about-us/advocacy/research-reports/the-financial-impact-of-breast-cancer/">Out-of-pocket</a> costs are very high for some Australians with cancer. A quarter of Queenslanders diagnosed with cancer will pay provider fees of more than A$20,000 in the first two years after <a href="https://www.ncbi.nlm.nih.gov/pubmed/30463662">diagnosis</a>. </p>
<p>While what constitutes “value” will be in the eye of the beholder, a well-functioning and sustainable health system is one that puts patients’ interests above all others and holds health providers accountable. </p>
<p>Australia’s universal health care system is one of the best in the world and we need to work hard to preserve it. Surgeries costing tens of thousands of dollars will continue unless the government regulates private medical practice or reforms the way doctors are remunerated. </p>
<p>It’s time to cap what physicians can charge for services and provide incentives for specialists to bulk-bill their patients. </p>
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<em>
<strong>
Read more:
<a href="https://theconversation.com/why-do-specialists-get-paid-so-much-and-does-something-need-to-be-done-about-it-74066">Why do specialists get paid so much and does something need to be done about it?</a>
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<img src="https://counter.theconversation.com/content/118179/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Louisa Gordon receives funding from the National Health and Medical Research Council. </span></em></p>It is perfectly legal for a doctor working in private practice to charge what they believe is fair and reasonable. But that doesn’t mean it’s OK to charge tens of thousands of dollars for a procedure.Louisa Gordon, Associate Professor - Health Economics, QIMR Berghofer Medical Research InstituteLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1154472019-04-15T03:20:10Z2019-04-15T03:20:10ZAs Mediscare 2.0 takes centre stage, here’s what you need to know about hospital ‘cuts’ and cancer funding<p>Health is proving a bone of contention in the 2019 election campaign. Labor has positioned health as a key point of difference, and the Coalition is arguing that Labor’s promises are untrue in one case and underfunded in another. </p>
<p>This cheat sheet will help you sort fact from fiction in two key health policy areas: public hospital funding and cancer care. </p>
<h2>Public hospitals</h2>
<p>In his <a href="https://parlinfo.aph.gov.au/parlInfo/download/chamber/hansardr/84457b57-5639-432a-b4df-68b704cb3563/toc_pdf/House%20of%20Representatives_2019_04_04_7041.pdf;fileType=application%2Fpdf">budget reply</a>, Opposition Leader Bill Shorten promised that Labor would restore every dollar the government had “cut” from public hospital funding. </p>
<p>The government counter-claimed that hospital funding has increased. So who is right?</p>
<p>The short answer is both. </p>
<p>In 2011, the then Labor government negotiated a <a href="http://www.federalfinancialrelations.gov.au/content/npa/health/_archive/national-agreement.pdf">funding agreement with the states</a> for the Commonwealth to share 45% of the growth in the cost of public hospital care, funded at the “national efficient price”. This price is based on the average cost of the procedure, test or treatment.</p>
<p>The funding share was to increase to 50% of growth from July 1, 2017.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/public-hospital-blame-game-heres-how-we-got-into-this-funding-mess-89498">Public hospital blame game – here's how we got into this funding mess</a>
</strong>
</em>
</p>
<hr>
<p>At the 2013 election, the then Liberal opposition agreed to match that promise and, indeed, <a href="https://grattan.edu.au/news/another-day-another-hospital-funding-dispute-how-to-make-sense-of-todays-coag-talks/">claimed</a> they were the only ones who could be trusted to keep the promise:</p>
<blockquote>
<p>A Coalition government will support the transition to the Commonwealth providing 50% growth funding of the efficient price are hospital services as proposed. But only the Coalition has the economic record to be able to deliver.</p>
</blockquote>
<p>However, in the 2014 budget the Coalition scrapped its promise. The <a href="https://www.budget.gov.au/2014-15/content/bp2/html/bp2_expense-14.htm">2014 budget papers list the savings</a> that were made by the decision. It was a clear and documented cut that the Coalition was proud to claim at the time.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/269215/original/file-20190415-76859-10oqyoi.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/269215/original/file-20190415-76859-10oqyoi.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=460&fit=crop&dpr=1 600w, https://images.theconversation.com/files/269215/original/file-20190415-76859-10oqyoi.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=460&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/269215/original/file-20190415-76859-10oqyoi.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=460&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/269215/original/file-20190415-76859-10oqyoi.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=578&fit=crop&dpr=1 754w, https://images.theconversation.com/files/269215/original/file-20190415-76859-10oqyoi.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=578&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/269215/original/file-20190415-76859-10oqyoi.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=578&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">The green line represents the Gillard hospital funding agreement; the blue line is the revised projection from the 2014 budget.</span>
<span class="attribution"><a class="source" href="https://budget.gov.au/2014-15/content/overview/download/Budget_Overview.pdf">Budget 2014-15</a></span>
</figcaption>
</figure>
<p>Since then, the Turnbull government has backtracked on the 2014 cuts to health but only to restore sharing to 45% of the costs of growth. </p>
<p>Labor has estimated the impact of the gap between 45% and 50% on every public hospital in the country, and spruiks the difference at every opportunity.</p>
<p>Hospital costs increase faster than inflation because of growth and ageing population, the introduction of new technologies, and new approaches to treatment. </p>
<p>As a result, the Commonwealth’s existing 45% sharing policy drives increased spending, and so Commonwealth spending is now at record levels, albeit not at the even higher levels that Labor had promised.</p>
<p>Labor’s promise is, appropriately, phrased as an additional quantum of money to the states, sufficient to restore the 50% share in the cost of growth. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/269225/original/file-20190415-76831-1vs72jo.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/269225/original/file-20190415-76831-1vs72jo.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=401&fit=crop&dpr=1 600w, https://images.theconversation.com/files/269225/original/file-20190415-76831-1vs72jo.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=401&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/269225/original/file-20190415-76831-1vs72jo.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=401&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/269225/original/file-20190415-76831-1vs72jo.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/269225/original/file-20190415-76831-1vs72jo.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/269225/original/file-20190415-76831-1vs72jo.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 public hospital funding gap comes down to how much of the growth in hospital funding each party has committed to.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/665449870?src=CRCnZ-2UKKWBIUb0mQBTmg-1-13&size=huge_jpg">Shutterstock</a></span>
</figcaption>
</figure>
<p>The details of how this funding should be operationalised to the states should be left to detailed negotiations after the election as it is not good practice for all the details of your negotiating position to be aired in the heat of a campaign.</p>
<p>So Labor is right to say hospital funding is lower than it would have been if the 50% growth share commitment had been maintained. But the Coalition is right to say the Commonwealth is spending more on hospital care than when it came to office.</p>
<h2>Cancer care</h2>
<p>The second major element of the Labor campaign was a high-profile A$2.3 billion package to address high out-of-pocket costs for Australians with cancer. The package has three key components:</p>
<ul>
<li>additional public hospital outpatient funding to reduce waiting times</li>
<li>a new bulk-billing item for consultations</li>
<li>more funding for MRI machines for cancer diagnosis.</li>
</ul>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/labors-cancer-package-would-cut-the-cost-of-care-but-beware-of-unintended-side-effects-114979">Labor's cancer package would cut the cost of care, but beware of unintended side effects</a>
</strong>
</em>
</p>
<hr>
<p>Labor did <em>not</em> promise to eliminate out-of-pocket costs for cancer, not even for consultations. It claimed bulk-billing would increase from 40% to 80% of consultations. </p>
<p>This promise has led to another showdown between Labor and the Coalition. <a href="https://www.abc.net.au/radionational/programs/breakfast/cancer-care-providers-wont-accept-labors-medicare-promise/11002660">Health Minister Greg Hunt claims</a> to have found a A$6 billion black hole in Labor’s cancer policy. </p>
<p>The Coalition has <a href="https://grattan.edu.au/wp-content/uploads/2019/04/List-of-Cancer-Items-for-MBS-1.pdf">produced a list of 421 Medicare items</a> used for cancer treatment - including treatment in private hospitals - and noted Labor has not allocated funds to cover the fees specialists charge for these items. </p>
<p>But Labor rightly claims the 421-item list is not what it promised. Labor’s promise was about increasing the rate of bulk-billing for consultations and is based on a new item which is only available if the specialist bulk-bills.</p>
<p>Expect more claims and counter-claims in the weeks ahead.</p><img src="https://counter.theconversation.com/content/115447/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Stephen Duckett works at Grattan Institute which 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>Health has taken centre stage of the election campaign. Here’s what you need to know to make sense of the claims (and counter claims) of the major parties so far.Stephen Duckett, Director, Health Program, Grattan InstituteLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1137342019-04-09T07:12:17Z2019-04-09T07:12:17ZThe Coalition’s report card on health includes some passes and quite a few fails<figure><img src="https://images.theconversation.com/files/268254/original/file-20190408-2918-1yduncg.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The Coalition's record on health is patchy, at best. Meanwhile, Labor is already campaigning hard on Medicare. </span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/hospital-ward-beds-medical-equipment-102915128">Shutterstock </a></span></figcaption></figure><p><em>This article is part of a <a href="https://theconversation.com/au/topics/coalition-record-2019-69102">series</a> examining the Coalition government’s record on key issues while in power and what Labor is promising if it wins the 2019 federal election.</em></p>
<hr>
<p>The Turnbull/Morrison government has a mixed record, at best, on health. </p>
<p>The 2019 budget cash splash includes more promises on health but these will not come into effect until after the election. So they are just promises, not actions that have changed the health system.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/budget-2019-boosts-aged-care-and-mental-health-and-modernises-medicare-health-experts-respond-114194">Budget 2019 boosts aged care and mental health, and modernises Medicare: health experts respond</a>
</strong>
</em>
</p>
<hr>
<p>In 2016-17, the Commonwealth government spent <a href="https://www.aihw.gov.au/reports/hwe/073-1/health-expenditure-australia-2016-17/contents/table-of-contents">A$74.5 billion on health care</a>, mostly on:</p>
<ul>
<li>grants to the states for public hospitals (29% of total spending)</li>
<li>medical specialists and diagnostic tests (18%)</li>
<li>general practice (14%)</li>
<li>the Pharmaceutical Benefits Scheme (14%)</li>
<li>support for private health insurance (8%).</li>
</ul>
<p>Here’s the report card on the Coalition’s performance since the 2016 election.</p>
<h2>1. Grants to the states for public hospitals</h2>
<p>Public hospital funding has been a failure for this government. </p>
<p>The Coalition’s <a href="https://www.abc.net.au/news/2013-05-10/federal-election-policy-health/4657630">2013 election promise to keep the Labor policy on hospital funding growth</a> was not repeated at the 2016 election. The Commonwealth now funds only 45% of the costs of growth, not 50% as previously promised.</p>
<p>This funding gap – Labor calls it a cut – left the government exposed during last year’s by-elections to <a href="https://www.theaustralian.com.au/nation/politics/longman-byelection-hospital-a-pawn-in-seat-war/news-story/86b32e770c203c8c9549cca4d81510d2">charges that it was short-changing local hospitals</a>. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/public-hospital-blame-game-heres-how-we-got-into-this-funding-mess-89498">Public hospital blame game – here's how we got into this funding mess</a>
</strong>
</em>
</p>
<hr>
<p>The claim appeared to gain traction with voters, so we should expect to see a re-run of this tactic in this election. This started with Bill Shorten highlighting the issue in his <a href="https://parlinfo.aph.gov.au/parlInfo/search/display/display.w3p;db=CHAMBER;id=chamber%2Fhansardr%2F84457b57-5639-432a-b4df-68b704cb3563%2F0288;query=Id%3A%22chamber%2Fhansardr%2F84457b57-5639-432a-b4df-68b704cb3563%2F0032%22">budget reply speech</a>, promising to “put back every single dollar that the Liberals have cut from public schools and public hospitals”.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/268247/original/file-20190408-2924-51u30.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/268247/original/file-20190408-2924-51u30.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=399&fit=crop&dpr=1 600w, https://images.theconversation.com/files/268247/original/file-20190408-2924-51u30.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=399&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/268247/original/file-20190408-2924-51u30.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=399&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/268247/original/file-20190408-2924-51u30.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=502&fit=crop&dpr=1 754w, https://images.theconversation.com/files/268247/original/file-20190408-2924-51u30.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=502&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/268247/original/file-20190408-2924-51u30.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=502&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">The Coalition now funds only 45% of hospital funding growth, down from 50%.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/245905492?size=huge_jpg">hxdbzxy/Shutterstock</a></span>
</figcaption>
</figure>
<p>Despite bribes and threats, the federal government has failed to negotiate hospital funding agreements with Victoria and Queensland, together covering <a href="https://www.abs.gov.au/ausstats/abs@.nsf/0/D56C4A3E41586764CA2581A70015893E?Opendocument">46% of the population</a>. As a result, those states are at risk of being left in a funding limbo when the current arrangements expire on June 30, 2020.</p>
<h2>2. Specialist medical services and diagnostics</h2>
<p>A key challenge for policy on specialist medical services is out-of-pocket costs. <a href="http://www.health.gov.au/internet/main/publishing.nsf/Content/Quarterly-Medicare-Statistics">General practitioner bulk-billing rates are good</a>, but patients are angry about the <a href="https://chf.org.au/publications/out-pocket-pain">out-of-pocket costs they face when they go to a specialist</a>. </p>
<p>The government response has been <a href="http://www.health.gov.au/internet/main/publishing.nsf/Content/min-advisory-comm-out-of-pocket">a committee</a>, a <a href="http://www.health.gov.au/internet/main/publishing.nsf/Content/3A14048A458101B0CA258231007767FB/$File/Report%20-%20Ministerial%20Advisory%20Committee%20on%20Out-of-Pocket%20Costs.pdf">report</a>, and a promise of transparency or, more accurately, a <a href="http://www.health.gov.au/internet/ministers/publishing.nsf/Content/health-mediarel-yr2019-hunt035.htm">promise to encourage voluntary fee transparency</a>. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/we-need-more-than-a-website-to-stop-australians-paying-exorbitant-out-of-pocket-health-costs-108740">We need more than a website to stop Australians paying exorbitant out-of-pocket health costs</a>
</strong>
</em>
</p>
<hr>
<p>Increased transparency is all well and good, but it puts the burden of reducing out-of-pocket costs on consumers, who generally do not have enough information to make informed choices. The complication rates of different specialists, and other measures of quality, are not yet routinely available to <a href="https://grattan.edu.au/report/all-complications-should-count-using-our-data-to-make-hospitals-safer/">patients</a>, or even GPs. </p>
<p>This area should be marked as a policy fail.</p>
<p>Promises about diagnostic testing before the 2016 election were of two kinds: <a href="https://grattan.edu.au/wp-content/uploads/2019/04/Coalition-plan-for-access-to-affordable-diagnostic-imaging-for-all-Australians-_-Liberal-Party-of-Australia.pdf">more reviews</a> and more <a href="https://www.youtube.com/watch?v=arCITMfxvEc">machines that go ping</a>, the latter dropped into <a href="https://grattan.edu.au/wp-content/uploads/2019/04/PET-Scanner-for-the-Northern-Territory-_-Liberal-Party-of-Australia.pdf">marginal electorates</a> as part of the cargo cult which appears endemic during election campaigns. </p>
<p>Left unaddressed is the need to <a href="https://grattan.edu.au/report/blood-money-paying-for-pathology-services/">reform the pathology market</a> to recognise that pathology provision (such as blood and tissue tests) is a big business and needs to be treated as such, by procuring via tenders rather than fee-for-service.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/268249/original/file-20190408-2912-1v37u5d.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/268249/original/file-20190408-2912-1v37u5d.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=401&fit=crop&dpr=1 600w, https://images.theconversation.com/files/268249/original/file-20190408-2912-1v37u5d.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=401&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/268249/original/file-20190408-2912-1v37u5d.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=401&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/268249/original/file-20190408-2912-1v37u5d.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/268249/original/file-20190408-2912-1v37u5d.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/268249/original/file-20190408-2912-1v37u5d.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">Blood testing is big business.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/556394323?src=YyMFtMJUoJy-6i72m0aOog-1-26&size=huge_jpg">Romanets/Shutterstock</a></span>
</figcaption>
</figure>
<p>The government has also failed to end the <a href="https://theconversation.com/getting-doctors-to-reduce-diagnostic-testing-is-hard-but-we-should-keep-trying-42312">over-use of diagnostic tests</a>. This could have been done by reducing payments for tests which have been shown to add little value and <a href="http://www.choosingwisely.org.au/home">encouraging more evidence-based diagnosis</a>. Another fail.</p>
<p>A third key area of specialist provision, mental health, is a mess. Before the 2016 election, the Coalition promised to “<a href="https://grattan.edu.au/wp-content/uploads/2019/04/The-Coalition%E2%80%99s-plan-to-strengthen-mental-health-care-across-Australia-_-Liberal-Party-of-Australia.pdf">strengthen mental health services</a>”. </p>
<p>The latest <a href="https://en.wikipedia.org/wiki/Candide">Panglossian</a> national <a href="https://www.mentalhealthcommission.gov.au/media/245211/Monitoring%20Mental%20Health%20and%20Suicide%20Prevention%20Reform%20National%20Report%202018.pdf">status report on mental health</a> gives no hint of the underlying <a href="https://acem.org.au/getmedia/60763b10-1bf5-4fbc-a7e2-9fd58620d2cf/ACEM_report_41018">problems of poor access</a>, <a href="https://www.abc.net.au/triplej/programs/hack/medicare-subsidised-mental-health-program-has-fundamental-faili/10955008">misdirected funding</a>, <a href="https://www.mja.com.au/journal/2019/210/7/runaway-giant-ten-years-better-access-program">lack of teamwork</a>, and <a href="https://www.creativespirits.info/aboriginalculture/people/aboriginal-suicide-rates#toc2">appalling rates of suicide in Indigenous communities</a>. Yet another fail.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/why-are-we-losing-so-many-indigenous-children-to-suicide-114284">Why are we losing so many Indigenous children to suicide?</a>
</strong>
</em>
</p>
<hr>
<h2>3. General practice and primary care</h2>
<p>The much-vaunted Turnbull-era <a href="https://www.aph.gov.au/About_Parliament/Parliamentary_Departments/Parliamentary_Library/FlagPost/2018/May/Health_care_homes">Primary Health Care Homes Trial</a> – once the vanguard of a <a href="https://grattan.edu.au/wp-content/uploads/2019/04/Budget-puts-patient-outcomes-at-centre-of-health-reform-_-Liberal-Party-of-Australia.pdf">primary care revolution</a> and core to the government’s policy announcement’s before the 2016 election – has <a href="https://www.sbs.com.au/news/health-care-homes-trial-falling-short">disappeared from the radar</a>. </p>
<p>In its place, announced in this year’s budget, is a <a href="https://www.greghunt.com.au/record-investment-advances-long-term-national-health-plan/">new capitation-type payment for general practitioners</a>. </p>
<p>Although the details are still to be fleshed out, this will probably allow general practitioners to introduce remote consultations – such as advice by email <a href="https://bmchealthservres.biomedcentral.com/articles/10.1186/s12913-016-1484-5">for those who want it</a> – and have practice staff reach out to people with chronic illness to track how they are going to reduce future problems.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/more-visits-to-the-doctor-doesnt-mean-better-care-its-time-for-a-medicare-shake-up-110884">More visits to the doctor doesn't mean better care – it's time for a Medicare shake-up</a>
</strong>
</em>
</p>
<hr>
<p>This is a good move, and reflects recommendations from a <a href="http://www.health.gov.au/internet/main/publishing.nsf/Content/mbs-review-2018-taskforce-reports-cp/$File/General-Practice-and-Primary-Care-Clinical-Committee-Phase-2-Report.pdf">review of general practice items</a> as part of the broader Medicare Benefits Schedule Review.</p>
<p>Other important recommendations from the general practice review seem to be languishing, and there is no sense that <a href="https://grattan.edu.au/report/building-better-foundations/">overdue primary care reforms</a> are being tackled in a serious and systematic way.</p>
<p>Overall, however, the government has been moving in the right direction in this area, albeit slowly and with false starts. A solid pass.</p>
<h2>4. Pharmaceutical benefits</h2>
<p>Before the 2016 election, federal health minister Greg Hunt <a href="https://medicinesaustralia.com.au/policy/strategic-agreement/">signed agreements</a> promising to talk to and work with all components of the pharmaceutical supply chain. </p>
<p>This has been a success story. New drugs are now listed in line with recommendations from the Pharmaceutical Benefits Advisory Committee, ending the delays and political interference of yesteryear. </p>
<p>Labor has <a href="https://parlinfo.aph.gov.au/parlInfo/search/display/display.w3p;db=CHAMBER;id=chamber%2Fhansardr%2F84457b57-5639-432a-b4df-68b704cb3563%2F0288;query=Id%3A%22chamber%2Fhansardr%2F84457b57-5639-432a-b4df-68b704cb3563%2F0032%22">promised to do the same</a>.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/268251/original/file-20190408-2924-19kxjfj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/268251/original/file-20190408-2924-19kxjfj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/268251/original/file-20190408-2924-19kxjfj.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/268251/original/file-20190408-2924-19kxjfj.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/268251/original/file-20190408-2924-19kxjfj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/268251/original/file-20190408-2924-19kxjfj.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/268251/original/file-20190408-2924-19kxjfj.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">Policy pass: drugs are now being listed without delay.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/1281072733?size=huge_jpg">iviewfinder/Shutterstock</a></span>
</figcaption>
</figure>
<p>Pharmaceutical prices have come down, so the prices paid by Pharmaceutical Benefits Scheme (PBS) for drugs are now closer to international best practice. But <a href="https://grattan.edu.au/news/pharmacists-should-have-a-bigger-role-submission-to-senate-select-committee-on-red-tape/">anti-competitive restrictions</a> on pharmacy location remain, to the benefit of <a href="http://johnmenadue.com/john-menadue-the-australian-pharmacy-guild-continues-to-dud-taxpayers-and-patients/">pharmacy owners</a>. </p>
<p>Nevertheless, a strong pass.</p>
<h2>5. The private market</h2>
<p>The private health market is supposed to be an area of strength for a Coalition government. On April 1 this year, this government <a href="https://beta.health.gov.au/health-topics/private-health-insurance/private-health-insurance-reforms">introduced changes to private health insurance</a>: </p>
<ul>
<li>standardising product definitions</li>
<li>allowing deductions to encourage young people to take out insurance</li>
<li>removing many natural therapies (for which there is no evidence that they work) from the subsidised extras packages. </li>
</ul>
<hr>
<p>
<em>
<strong>
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>
</strong>
</em>
</p>
<hr>
<p>These changes are <a href="https://theconversation.com/changes-to-lure-young-people-into-private-health-insurance-wont-slow-increase-in-premiums-85663">unlikely to have much impact on private health insurance coverage</a>, which has been declining in recent years.</p>
<p>Overall, no harm has been done, but unfortunately most of the fundamental problems of the private markets have not been confronted. Borderline achievement.</p>
<h2>6. Everything else</h2>
<p>Barely a week goes by when Hunt is not announcing yet another funding initiative. He has two big slush funds from which to dispense goodies: the <a href="https://beta.health.gov.au/initiatives-and-programs/medical-research-future-fund">Medical Research Future Fund</a> and the <a href="https://www.liberal.org.au/latest-news/2018/12/12/125-billion-improve-health-and-care-australian-patients">Community Health and Hospitals Fund</a>. </p>
<p>The criteria for distributing money from these funds is opaque; it is difficult to discern any strategic vision informing the way the largesse is being spread.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/268252/original/file-20190408-2931-c907td.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/268252/original/file-20190408-2931-c907td.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/268252/original/file-20190408-2931-c907td.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/268252/original/file-20190408-2931-c907td.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/268252/original/file-20190408-2931-c907td.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/268252/original/file-20190408-2931-c907td.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/268252/original/file-20190408-2931-c907td.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">Health minister Greg Hunt makes frequent health funding announcements.</span>
<span class="attribution"><a class="source" href="https://photos.aap.com.au">AAP/Penny Stephens</a></span>
</figcaption>
</figure>
<p>There was a veritable cornucopia of policies announced before the last election, from <a href="https://grattan.edu.au/wp-content/uploads/2019/04/The-Coalition%E2%80%99s-Plan-for-Continuous-Glucose-Monitoring-_-Liberal-Party-of-Australia.pdf">glucose monitoring</a> to treatment of <a href="https://grattan.edu.au/wp-content/uploads/2019/04/Coalition-plan-to-fight-rare-teen-cancer-_-Liberal-Party-of-Australia.pdf">rare teen cancers</a>. </p>
<p>All were worthy, and most were designed to placate vocal sectoral interests. Most have been implemented, but few will change the fundamentals of the health system or improve integration of the system’s many disparate elements. </p>
<p>Scattered like <a href="https://www.themandarin.com.au/55708-terry-moran-5-big-challenges-facing-public-administration-australia/">programmatic confetti</a>, each of these funding dollops will yield a minor benefit, but together they will lead to more funding silos, less policy integration, and more confusion about the roles of the Commonwealth government and the states. </p>
<p>What’s more, they will give more heart to vested interests, and undermine rational national health policy.</p>
<h2>What Labor has promised so far?</h2>
<p>Health is an area of comparative advantage for Labor – voters tend to <a href="https://www.essentialvision.com.au/trust-in-parties">trust Labor more than the Coalition on Medicare</a>. </p>
<p>Not surprisingly, Labor capitalises on that, and opposition leader Bill Shorten made health policy a key element of his <a href="https://parlinfo.aph.gov.au/parlInfo/search/display/display.w3p;db=CHAMBER;id=chamber%2Fhansardr%2F84457b57-5639-432a-b4df-68b704cb3563%2F0288;query=Id%3A%22chamber%2Fhansardr%2F84457b57-5639-432a-b4df-68b704cb3563%2F0032%22">budget reply speech</a>. </p>
<p>Last month Labor <a href="https://www.catherineking.com.au/2019/03/25/labor-will-end-morrisons-medicare-freeze-in-first-50-days/">promised to lift the freeze on Medicare rebates for general practice consultations</a>, a promise <a href="https://www.afr.com/news/economy/federal-budget-2019-medicare-freeze-end-just-what-the-doctor-ordered-20190402-1o24rc">matched by the Coalition in the Budget</a>. </p>
<p>Labor has also set out a longer-term vision for reform of the health system, including a proposal for an ongoing “<a href="https://www.catherineking.com.au/2019/02/13/speech-to-the-national-press-club-labors-vision-for-health-care/">reform commission</a>”.</p>
<p>The centrepiece and most expensive was a <a href="https://parlinfo.aph.gov.au/parlInfo/search/display/display.w3p;db=CHAMBER;id=chamber%2Fhansardr%2F84457b57-5639-432a-b4df-68b704cb3563%2F0288;query=Id%3A%22chamber%2Fhansardr%2F84457b57-5639-432a-b4df-68b704cb3563%2F0032%22">massive “cancer plan” commitment</a> to address out-of-pocket costs for people with cancer. This includes expanded Medicare rebates for MRI scans for cancer patients, a new rebate for bulk-billed visits to oncologists, and a guarantee that all new drugs recommended for listing on the PBS will be listed.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/labors-cancer-package-would-cut-the-cost-of-care-but-beware-of-unintended-side-effects-114979">Labor's cancer package would cut the cost of care, but beware of unintended side effects</a>
</strong>
</em>
</p>
<hr>
<img src="https://counter.theconversation.com/content/113734/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Stephen Duckett works at Grattan Institute which 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>Here’s how the Turnbull/Morrison government performed on hospitals, primary care, pharmaceuticals and private health insurance.Stephen Duckett, Director, Health Program, Grattan InstituteLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1149792019-04-08T07:15:46Z2019-04-08T07:15:46ZLabor’s cancer package would cut the cost of care, but beware of unintended side effects<figure><img src="https://images.theconversation.com/files/267998/original/file-20190408-2909-1dbbi9k.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The median out-of-pocket expenses for breast cancer treatment is A$4,192.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/222626152?src=HEkgVN4y0KirD_GvJ69_vg-1-15&size=huge_jpg">ESB Professional/Shutterstock</a></span></figcaption></figure><p>Labor’s big-ticket election promise is a A$2.3 billion package to provide free medical scans and specialist consultations for cancer patients, plus automatic listing of new cancer therapies on the Pharmaceutical Benefits Scheme (PBS) once they’re recommended by the nation’s expert advisory panel. </p>
<p>One in two Australians will be diagnosed with cancer by the age of 85, and <a href="https://www.cancer.org.au/about-cancer/what-is-cancer/facts-and-figures.html">around 145,000 new diagnoses</a> are made each year. So most of us have a close relative or friend who will be affected by the policy. </p>
<p>But there are some important policy considerations a Shorten government would need to plan for to ensure the package provides optimal care, improves patient outcomes, and does actually reduce out-of-pocket costs. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/shorten-promises-2-3-billion-package-to-relieve-costs-for-cancer-patients-114926">Shorten promises $2.3 billion package to relieve costs for cancer patients</a>
</strong>
</em>
</p>
<hr>
<h2>What’s the problem with cancer care?</h2>
<p>New therapies for cancer are rapidly evolving, and are often extremely expensive. Seeking treatment involves navigating a complex array of public and private providers across multiple health care sectors, often leaving patients with high out-of-pocket costs.</p>
<p>These costs are highly dependent on which providers the patients choose (and the fees they charge), the level of private insurance cover, and the volume of services used. </p>
<p>A <a href="https://www.mja.com.au/journal/2018/208/11/out-pocket-medical-expenses-queenslanders-major-cancer">recent Queensland study</a> found the median out-of-pocket expenses for a breast cancer patient, for example, was A$4,192. </p>
<p>It’s possible but very time-consuming for patients to “shop around” to reduce costs. But this is an unreasonable burden to place on patients.</p>
<p>The Labor proposal provides an opportunity to develop a comprehensive cancer control program that encompasses prevention, early diagnosis, treatment and follow-up – at a reasonable cost.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/cutting-cancer-costs-is-a-worthy-policy-but-we-need-to-try-to-prevent-it-too-114976">Cutting cancer costs is a worthy policy, but we need to try to prevent it too</a>
</strong>
</em>
</p>
<hr>
<h2>Better care for cancer patients</h2>
<p>Cancer treatment is well researched; there are clear <a href="https://www.clinicalguidelines.gov.au/portal/2587/clinical-practice-guidelines-prevention-early-detection-and-management-colorectal-cancer">evidence-based guidelines</a> that establish clinical pathways for the best treatment. </p>
<p>Nevertheless, there is <a href="https://www2.health.vic.gov.au/about/publications/researchandreports/optimal-cancer-pathways-data-project-interim-report-may-2017">substantial variation in treatments</a> given to cancer patients. This difference cannot always be explained by their clinical conditions, and sometimes the care is not evidence-based.</p>
<p>It’s important that the proposed reforms do not just fund more care, but support more of the <em>best</em> care. </p>
<p>The approach that has <a href="http://www.oecd.org/publications/better-ways-to-pay-for-health-care-9789264258211-en.htm">shown promise</a> in other countries is known as “bundled payments”. </p>
<p>Under bundled payments, a series of health care services – that can span over time and across multiple health care sectors and providers – are bundled together for funding purposes. This gives providers or institutions greater flexibility in how they spend money delivering care to the patient. </p>
<p>There is a danger that bundling can provide incentives to skimp on care, because the provider receives the same amount of funding no matter how much care is provided. But this can be addressed by monitoring the quality of care and the patients’ outcomes. </p>
<h2>Ensuring the financial benefits flow to patients</h2>
<p>Australian governments have made several attempts to provide better safety nets that cushion patients from extra charges. </p>
<p>Study after study <a href="https://www.sciencedirect.com/science/article/pii/S0167268119300794">shows</a> that, in these circumstances, providers are likely to raise their fees. So while patients get some financial benefit, the doctors benefit also.</p>
<p>Under current Medicare rules, the Australian government does not and cannot determine doctors’ fees. It can only determine the amount of the Medicare benefit. </p>
<p>In general practice, most consultations are bulk-billed implying that the fee the doctor charges is equivalent to the Medicare benefit. </p>
<p>Only 31% of specialist consultations are bulk-billed, leaving more patients with an out-of-pocket payment.</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>
</strong>
</em>
</p>
<hr>
<p>What can government do to encourage cancer care providers to bulk-bill? </p>
<p>Labor has announced they will add a <a href="https://www.afr.com/news/politics/national/doctors-forced-to-bulk-bill-to-get-labor-s-medicare-cancer-rebate-20190405-p51b33">bulk-billing incentive payment</a>, as occurs in primary care. Specialists will receive an additional payment if they bulk-bill a cancer-related service. </p>
<p>This will not guarantee that every patient will not incur any out-of-pocket costs – although it should increase the likelihood that they will. Indeed, the Labor target is that 80% of patients will be bulk-billed. </p>
<p>However, <a href="https://www.ncbi.nlm.nih.gov/pubmed/27385166">previous research</a> has shown that while the GP bulk-billing incentive led to a reduction in costs for those eligible (concession card holders), it also increased costs for those not eligible.</p>
<p>Careful monitoring is required to ensure the volume of services – and their fees for non-cancer patients – do not go up. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/268009/original/file-20190408-2918-19svy5j.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/268009/original/file-20190408-2918-19svy5j.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=399&fit=crop&dpr=1 600w, https://images.theconversation.com/files/268009/original/file-20190408-2918-19svy5j.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=399&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/268009/original/file-20190408-2918-19svy5j.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=399&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/268009/original/file-20190408-2918-19svy5j.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=502&fit=crop&dpr=1 754w, https://images.theconversation.com/files/268009/original/file-20190408-2918-19svy5j.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=502&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/268009/original/file-20190408-2918-19svy5j.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=502&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Not all cancer care is based on the best available evidence.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/529109200?src=HEkgVN4y0KirD_GvJ69_vg-1-1&size=huge_jpg">Napocska/Shutterstock</a></span>
</figcaption>
</figure>
<p>A further unprecedented complication is that for some services, it will be necessary to differentiate Medicare payments on the basis of the patient’s cancer status. </p>
<p>To guarantee patients face no out-of-pocket costs would require more radical reform. Again, the bundled payment system could be a vehicle for such reforms whereby payments are conditional on all the patient’s service providers agreeing to deliver care with no additional fee to the patient. </p>
<p>Depending on whether a patient is privately insured, the bundled payment could be financed by private health funds and Medicare. </p>
<p>Of course, it’s <a href="https://www.ncbi.nlm.nih.gov/pubmed/27385166">not yet clear</a> that bundled payment schemes <a href="https://www.gynecologiconcology-online.net/article/S0090-8258(18)30574-2/abstract">can be directly applied</a> to the <a href="https://www.ncbi.nlm.nih.gov/pubmed/30141837">Australian setting</a>. </p>
<p>The Labor cancer package requires careful and rigorous research effort to inform and guide the policy development.</p>
<h2>A new vision for Medicare</h2>
<p>Medicare is now 35 years old. It was built on fee-for-service payment, and focused on short, acute episodes of illness. </p>
<p>Now it’s time to move to new funding mechanisms that provide better care for complex, ongoing conditions, at a cost patients and the country can be sure represent efficient use of resources. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/more-visits-to-the-doctor-doesnt-mean-better-care-its-time-for-a-medicare-shake-up-110884">More visits to the doctor doesn't mean better care – it's time for a Medicare shake-up</a>
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</em>
</p>
<hr>
<p>Cancer is a good place to start and it could indeed be the most significant reform of <a href="https://jamanetwork.com/journals/jama/article-abstract/2478320">Medicare so far</a>. </p>
<p>Imagine a health system where every Australian was assured of optimal care, no matter what their illness or economic circumstances. That is a health system worth paying taxes for.</p><img src="https://counter.theconversation.com/content/114979/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Kees Van Gool receives funding from the ARC </span></em></p><p class="fine-print"><em><span>Jane Hall receives funding from ARC and NHMRC.</span></em></p>It’s important that the proposed reforms do not just fund more care, but support more of the best care.Kees Van Gool, Health economist, University of Technology SydneyJane Hall, Professor of Health Economics and Director, Centre for Health Economics Research and Evaluation, University of Technology SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1141692019-03-26T01:14:50Z2019-03-26T01:14:50ZWhat is the Medicare rebate freeze and what does it mean for you?<p>On the weekend, <a href="https://twitter.com/billshortenmp/status/1109913552620388352">Opposition Leader Bill Shorten said</a> he would end the Medicare freeze in his first 50 days as prime minister if Labor won the election.</p>
<blockquote>
<p>Every day Morrison’s Medicare freeze stays in place is another day that families are paying higher out-of-pocket costs to visit the doctor. If I’m elected prime minister, I won’t waste any time stopping Morrison’s cuts to Medicare. </p>
</blockquote>
<p>Health issues always feature strongly in election debates, but what is the Medicare rebate freeze and how does it affect what you pay when you see a GP?</p>
<h2>How Medicare works</h2>
<p>Medicare is our public health insurance system and funds a range of services such as GP visits, blood tests, X-rays and consultations with other medical specialists.</p>
<p><a href="http://www.mbsonline.gov.au/internet/mbsonline/publishing.nsf/Content/Home">The Medicare Benefits Schedule</a> (MBS) lists the services the Australian government will provide a Medicare rebate for. Medicare rebates don’t cover the full cost of medical services and are typically paid as a percentage of the Medicare schedule fee.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/explainer-what-is-medicare-and-how-does-it-work-22523">Explainer: what is Medicare and how does it work?</a>
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</em>
</p>
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<p>GPs who bulk bill agree to charge the Medicare schedule fee and are directly reimbursed by government.</p>
<p>Those who don’t bulk bill are free to set their own prices for services. Patients pay for their treatment and receive a rebate from Medicare. </p>
<p>There is often a gap between what patients pay for services and the amount that Medicare reimburses (A$37 for a GP consultation, for example). This gap is known as an out-of-pocket expense, as the patient is required to make up the difference out of his or her own pocket.</p>
<p>Under an indexing process, the Medicare Benefits Schedule fees are raised according to the Department of Finance’s <a href="http://www.healthandlife.com.au/wp-content/uploads/2015/10/Out-in-the-cold_-MBS-freeze-hits-today.pdf">Wage Cost Index</a>, a combination of indices relating to wage levels and the <a href="http://www.treasury.nt.gov.au/Economy/EconomicBriefs/Pages/ConsumerPriceIndex.aspx">Consumer Price Index</a>.</p>
<p>Organisations such as the Australian Medical Association (AMA) have long argued this process is inadequate and Medicare schedule fees have not kept up with “<a href="https://ama.com.au/system/tdf/documents/Guide%20for%20Patients%20on%20How%20the%20Health%20Care%20System%20Funds%20Medical%20Care_7.pdf?file=1&type=node&id=40914">real</a>” increases in costs to medical practitioners of delivering services. </p>
<p>The rebate freeze compounds this financial challenge by continuing to keep prices at what the AMA and others argue are “<a href="https://ama.com.au/system/tdf/documents/Guide%20for%20Patients%20on%20How%20the%20Health%20Care%20System%20Funds%20Medical%20Care_7.pdf?file=1&type=node&id=40914">unsustainable levels</a>”.</p>
<h2>How did the freeze begin?</h2>
<p>Although the Coalition is largely associated with this issue, Labor first introduced the Medicare rebate freeze. The freeze was introduced as a “temporary” measure in 2013, as part of a A$664 million budget savings plan. </p>
<p>The AMA, the Coalition and others <a href="http://www.abc.net.au/news/2013-10-16/medicare-rebate-freeze-row-as-patients-face-increasing-costs/5026996">loudly criticised</a> the then government for the freeze. </p>
<p>However, on being elected to office in 2014, the Coalition froze the rebate after the failure of a number of proposed health policies. The rebate was frozen initially for four years, starting in July 2014, and extended in the <a href="https://theconversation.com/federal-budget-2016-health-experts-react-58638">2016 federal budget to 2020</a>.</p>
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Read more:
<a href="https://theconversation.com/rebate-freeze-will-set-gps-back-11-per-general-patient-consultation-but-theyre-likely-to-charge-them-more-59080">Rebate freeze will set GPs back $11 per general patient consultation, but they’re likely to charge them more</a>
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<p>Although the freeze was to be in place across the board until 2020, since 2017 there has been a <a href="https://theconversation.com/budget-2017-sees-medicare-rebate-freeze-slowly-lifted-and-more-funding-for-the-ndis-experts-respond-77315">phased lifting of the freeze</a> for GP <a href="http://www.mbsonline.gov.au/internet/mbsonline/publishing.nsf/Content/Factsheet-MedicareIndexationSchedule">bulk-billing incentive payments</a> (July 2017), standard GP consultations and other specialist consultations (July 2018), medical procedures (due July 2019) and targeted diagnostic imaging services (from July 2020). </p>
<h2>What impact has the freeze had?</h2>
<p>The freeze means those medical professionals who have not seen it lifted are reimbursed the same for delivering health services today as they were in 2014.</p>
<p>Professionals are paying more for their practices, staff, medical products, utilities and just about anything else that goes into running a medical service. But the amount paid remains static. </p>
<p>Those who have had indexing return to their services have seen only a limited rise in their value – A$0.55 for a GP consultation, for example. </p>
<p>In the run-up to the 2016 federal election, Labor <a href="https://www.abc.net.au/news/2016-05-19/labor-to-unveil-%2412b-medicare-rebate-freeze-rollback/7426958">made a similar promise</a> and told voters they needed to “save Medicare” from the government’s plans to privatise the system. </p>
<p>This tactic was dubbed the “Mediscare” campaign. Some saw it as being highly effective in <a href="https://www.news.com.au/national/federal-election/mediscare-returns-labor-revives-governments-2016-election-nightmare/news-story/24634880a05dee658706ab5b5922d514">driving a swing</a> towards Labor in the last election. </p>
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Read more:
<a href="https://theconversation.com/labors-mediscare-campaign-capitalised-on-coalition-history-of-hostility-towards-medicare-61976">Labor's 'Mediscare' campaign capitalised on Coalition history of hostility towards Medicare</a>
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<p>Last month the shadow health minister, Catherine King, <a href="https://www.catherineking.com.au/2019/02/13/speech-to-the-national-press-club-labors-vision-for-health-care/">blamed the Coalition</a> for the freeze and argued this had driven up out-of-pocket costs for both GP and specialist visits, leading to more than 1 million people delaying or avoiding medical care.</p>
<p>There are a number of reports of GP practices and specialist services halting bulk-billing and patients having to pay higher out-of-pocket costs. </p>
<p>Yet the <a href="http://www.health.gov.au/internet/main/publishing.nsf/Content/Quarterly-Medicare-Statistics">data on bulk-billing</a> show bulk-billing rates have not fallen. In fact, the latest data show bulk-billing at an all-time high at 86.1%. </p>
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Read more:
<a href="https://theconversation.com/factcheck-are-bulk-billing-rates-falling-or-at-record-levels-72278">FactCheck: are bulk-billing rates falling, or at record levels?</a>
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<p>Some commentators argue these figures <a href="https://www.amansw.com.au/a-slap-in-the-face/">are misleading</a> as they are calculated on services and not patients and so may be an indication of the increasing number of health services that use the MBS.</p>
<p>GP groups <a href="https://www1.racgp.org.au/newsgp/professional/medicare-freeze-continues-to-thaw-%E2%80%93-but-not-fast-e">have welcomed</a> the lifting of the Medicare freeze, but argue the indexation rates still fail to reflect the genuine value of general practice. </p>
<p>For those in areas such as diagnostic testing, the freeze is argued to have a profound impact. The Australian Sonographers Association argues that for ultrasound alone the average out-of-pocket cost for patients <a href="http://www.medianet.com.au/releases/132521/">has increased by 117%</a>.</p>
<p><a href="https://theconversation.com/money-given-to-gps-from-ending-the-medicare-rebate-freeze-should-target-reform-76778">Many experts</a> argue that just giving a little more funding to GP services will not improve the quality of the Australian health care system and far more fundamental issues need attention if we are to see significant reform.</p><img src="https://counter.theconversation.com/content/114169/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Helen Dickinson receives funding from the ARC and NHMRC and is a member of North Western Melbourne Primary Health Network's community advisory council. </span></em></p>While the freeze has been blamed for rising out-of-pocket costs for consumers, bulk billing rates haven’t fallen.Helen Dickinson, Professor, Public Service Research, UNSW SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1108842019-03-01T02:31:15Z2019-03-01T02:31:15ZMore visits to the doctor doesn’t mean better care – it’s time for a Medicare shake-up<figure><img src="https://images.theconversation.com/files/258951/original/file-20190214-1726-18vyxyz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The number of Medicare claims Australians make in a year doubled between 1984 and 2018.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/778331905?src=sw1NMvwQMz9pEMmrD13NSg-1-99&size=huge_jpg">By Sopotnick</a></span></figcaption></figure><p><em>This is part of a major series called Advancing Australia, in which leading academics examine the key issues facing Australia in the lead-up to the 2019 federal election and beyond. Read the other pieces in the series <a href="https://theconversation.com/au/topics/advancing-australia-66135">here</a>.</em></p>
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<p>Over the last 35 years, Medicare has given Australians access to high-quality health care at a reasonable cost. But, despite our justifiable pride in Medicare, it’s time to reconsider the way we pay for health care. </p>
<p>Australia’s Medicare system is a <a href="http://www.health.gov.au/internet/main/publishing.nsf/Content/Annual-Medicare-Statistics">A$20 billion-a-year program</a>. It subsidises most of our out-of-hospital doctor consultations, blood tests, X-rays and scans, physio appointments, eye tests and many other health services. It’s based on a long list of items and each time an item is provided, Medicare pays a benefit.</p>
<p>But paying doctors and other health providers a set fee for each service they deliver is not delivering optimal value for the health dollar. There are two reasons for this. </p>
<p>First, it encourages a higher volume of services, but not necessarily better-value services. </p>
<p>Second, it constrains doctors into delivering the care based on the items in the schedule, which often don’t meet the needs of complex patients.</p>
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Read more:
<a href="https://theconversation.com/explainer-what-is-medicare-and-how-does-it-work-22523">Explainer: what is Medicare and how does it work?</a>
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<p>One promising alternative is “bundled payments”. Rather than paying doctors a “fee for service”, they would be paid a prospective lump sum to care for the patient’s medical problem, over a specified period.</p>
<p>The lump sum would be a pooled payment for all services provided to treat the condition. The provider’s role would be to coordinate the patient’s care across different parts of the health system and work with a range of health professionals to deliver high-quality care. </p>
<p>This would give doctors greater flexibility to manage the care patients need. At the same time, doctors would be held accountable via measurements of the quality of their care. </p>
<p>Importantly, this would give patients greater access to a broader range of services and make it easier to navigate our complicated health system.</p>
<h2>Why health costs are rising</h2>
<p>Between 1984 and 2018, Australian government spending on services outside of hospitals has increased from <a href="http://www.health.gov.au/internet/main/publishing.nsf/Content/Annual-Medicare-Statistics">A$426</a> to <a href="https://www.abs.gov.au/AUSSTATS/abs@.nsf/DetailsPage/6401.0Dec%202018?OpenDocument#Time">A$818</a> per person, after adjusting for inflation. </p>
<p>This increase is almost entirely due to service volume. Back in 1984, the average Australian made 7.25 out-of-hospital Medicare claims a year. By 2018, this had escalated to 15.34; a doubling in the average number of claims.</p>
<p>The biggest growth has been in the number of pathology claims for blood and tissue tests (1.4 in 1984 to 5.2 in 2018), followed by GP consultations (4.2 compared to 6.3) and diagnostic imaging, including X-rays and other types of scans (0.3 versus 1.0).</p>
<p>This is not just the result of population ageing. At every age, we are making more Medicare claims. In 1985, people aged between 75 and 84 made 16.1 Medicare claims per year. In 2018, this number had grown to 44.6 claims per person per year.</p>
<p>Medicare prices have been very steady. For GP consultations, for example, the benefit paid per service has increased by 72% over the 35-year period, and mostly as a <a href="https://www.ncbi.nlm.nih.gov/pubmed/27385166">direct result</a> of policy initiatives such as the Strengthening Medicare reforms introduced in 2004-05.</p>
<p>In fact, since 2005, the benefit per service has declined by 6% in real terms. This is a result, in part, of the Medicare freeze imposed by government between 2012 and 2018. </p>
<p>So price control is only one part of constraining expenditure growth. The other is the volume of services. </p>
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Read more:
<a href="https://theconversation.com/factcheck-has-medicare-spending-more-than-doubled-in-the-last-decade-38374">FactCheck: has Medicare spending more than doubled in the last decade?</a>
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<p>The medical care market has undergone considerable corporatisation. Corporate entities <a href="https://fbe.unimelb.edu.au/newsroom/anz-melbourne-institute-general-practice-trends-released">now own around 10% to 15%</a> of all GP practices in Australia. </p>
<p>Corporate entities can own and run primary care practices as well as pathology laboratories, diagnostic imaging services and even pharmacies. This creates more incentive to refer patients to their own businesses for blood tests and imaging to increase the volume of claims, and therefore increase profits.</p>
<h2>Greater spending doesn’t mean better care</h2>
<p>The second critique of Medicare is that current funding arrangements create disincentives for delivering optimum care over a longer period, particularly for complex patients who require multiple services from multiple providers. They might have cancer, for instance, or multiple chronic diseases such as heart disease and diabetes or dementia.</p>
<p>Currently, Medicare makes a payment for every claim made within what we call an “episode of care” – a set of services to treat a condition, or a procedure. Each provider in that episode has an incentive to increase their own volume of care, but there are virtually no incentives to coordinate or deliver an optimum pathway of care for the patient. </p>
<p>Further, there are too few opportunities and rewards in this system to give doctors flexibility to offer different types of care for patients. This includes care provided by nurses, physiotherapists or dietitians; email or telephone consultations; patient education; and coordination services.</p>
<h2>Instead, pay doctors a lump sum</h2>
<p>The main feature of a good payment system is that it creates the right incentives for providers and patients to use health care resources effectively, efficiently and equitably. </p>
<p>Bundling payment involves working out the best care pathways for each condition. Cancer, for example, is a complex disease that requires ongoing care from primary, specialist and hospital services. </p>
<p>Under a bundled payment, the patient’s GP clinic would be paid a lump sum to ensure the patient receives all the services they need. This includes consultations, health checks, blood tests, physiotherapy, dietetics, patient education, and so on. The GP would have more control over how each of those services is delivered. </p>
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<img alt="" src="https://images.theconversation.com/files/261359/original/file-20190228-150708-1lwut3c.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/261359/original/file-20190228-150708-1lwut3c.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/261359/original/file-20190228-150708-1lwut3c.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/261359/original/file-20190228-150708-1lwut3c.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/261359/original/file-20190228-150708-1lwut3c.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/261359/original/file-20190228-150708-1lwut3c.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/261359/original/file-20190228-150708-1lwut3c.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">Sometimes will be best cared for by a physiotherapist.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/physiotherapist-working-patient-clinic-closeup-563063209">Africa Studio/Shutterstock</a></span>
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<p>If viable, the GP could bring some of these services into their practice, or they could subcontract them to other organisations. </p>
<p>The practice would be held accountable for providing high-quality care through various performance measures. These could range from patient satisfaction measures to objective measures such as timeliness of care or fewer avoidable complications. Payments could, in part, be made conditional on meeting performance targets.</p>
<p>Ultimately, because we are giving the provider more say over how care is delivered, the model of care can be more easily adapted to the needs of the patient. </p>
<h2>Health reform must be based on evidence</h2>
<p>In the small number of countries where bundled payments have been piloted, they are <a href="http://www.oecd.org/publications/better-ways-to-pay-for-health-care-9789264258211-en.htm">associated with</a> improved quality, financial savings and increased patient satisfaction. </p>
<p>A <a href="https://www.nuffieldtrust.org.uk/files/2017-01/2014-nhs-payment-research-report-web-final.pdf">bundled payment for hip-fracture patients in England</a>, for example, resulted in more patients receiving surgery within 48 hours after admission and lower death rates. </p>
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Read more:
<a href="https://theconversation.com/creating-a-better-health-system-lessons-from-england-30144">Creating a better health system: lessons from England</a>
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<p>Although these studies show promise, the evidence base is still in its infancy. </p>
<p>Successful reform in this area will require careful design of the bundles, the payment levels and patient selection process, as well as how best to monitor quality care. In particular it requires robust evidence to determine:</p>
<ul>
<li>what constitutes an optimal bundle of care for a particular condition</li>
<li>the cost of delivering those services</li>
<li>how the payment should be adjusted for the specific characteristics of a patient</li>
<li>the role performance targets may play in motivating health providers to deliver high-quality care.</li>
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Read more:
<a href="https://theconversation.com/is-it-time-to-ditch-the-private-health-insurance-rebate-its-a-question-labor-cant-ignore-111171">Is it time to ditch the private health insurance rebate? It's a question Labor can't ignore</a>
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<img src="https://counter.theconversation.com/content/110884/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jane Hall receives funding from ARC and NHMRC</span></em></p><p class="fine-print"><em><span>Kees Van Gool receives funding from Australian Research Council. </span></em></p>Paying doctors a fee for each service they provide isn’t delivering optimal value for the health dollar. Instead, we should pay doctors a lump sum to care for a patient’s medical problem over time.Jane Hall, Professor of Health Economics and Director, Centre for Health Economics Research and Evaluation, University of Technology SydneyKees Van Gool, Health economist, University of Technology SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1087472018-12-13T19:12:40Z2018-12-13T19:12:40ZMorrison’s health handout is bad policy (but might be good politics)<figure><img src="https://images.theconversation.com/files/250390/original/file-20181213-110249-1y7kc3t.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The funding proposal is no fix for Australia's health system but it could take some political pressure off the Coalition in the lead up to the 2019 federal election.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/empty-bed-on-hospital-ward-247358674?src=6H6yrdkPEeBQ7-aCp5OlIQ-1-2">OnE studio/Shutterstock</a></span></figcaption></figure><p>The A$1.25 billion <a href="https://www.pm.gov.au/media/improving-health-and-care-australian-patients">Community Health and Hospitals Program</a> Prime Minister Scott Morrison announced this week should be awarded a big policy fail. </p>
<p>The move sets back Commonwealth-state relations by decades – and it’s unclear exactly how much money will actually be provided. </p>
<p>Rather than being based on any coherent policy direction, it appears designed to shore up support in marginal electorates.</p>
<h2>Bad for Commonwealth-state relations</h2>
<p>One of the complicating factors in providing health care to Australians is the fact that the Commonwealth and states each have leadership roles in different parts of the system: the Commonwealth for primary care; and the states for public hospitals. </p>
<p>Health professionals yearn for the Holy Grail of a single level of government being responsible for all aspects of a patient’s care. That quest has proved illusory. But recent policy direction has at least sought to clarify the roles of the two levels of government.</p>
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Read more:
<a href="https://theconversation.com/public-hospital-blame-game-heres-how-we-got-into-this-funding-mess-89498">Public hospital blame game – here's how we got into this funding mess</a>
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<p>For the past five years, the states have been acknowledged as the “system managers” of the public hospital system. A rational, formula-driven funding framework has been created. </p>
<p>Under this framework, the Commonwealth shares the cost of growth in public hospital activity with the states. This exposes the Commonwealth directly to growing costs of technology-driven needs and giving it an incentive to work with the states to meet needs in the most efficient way.</p>
<p>This framework means there is one level of government to whom all public hospitals are accountable: the state. And it means voters can hold their state government accountable for hospital planning and management.</p>
<p>The new Morrison proposal tramples all over this policy rationality in the interests of electoral expediency. It replaces state-based planning with submission-based funding, which will enable a politician with a whiteboard in Canberra to override state priorities in favour of projects which have the greatest electoral appeal in targeted marginal seats. </p>
<p>It makes accountability for the overall system more confusing, and it assumes Canberra knows best.</p>
<p>It is a federalism fail.</p>
<h2>An opaque policy</h2>
<p>Labor ran a devastating campaign in the July federal by-elections, especially in the Queensland seat of Longman, which involved calculating and publicising precisely how much worse off the local hospital was under the Liberal health policy – where the Commonwealth funds 45% of hospital growth – compared with Labor’s 50% sharing policy. </p>
<p>In the Longman case, Labor asserted there was a <a href="http://www.billshorten.com.au/address_to_the_longman_labor_campaign_launch_caboolture_sunday_22_july_2018">A$2.9 million cut to Caboolture Hospital</a> based on the decisions taken in the 2014 Abbott/Hockey “<a href="https://theconversation.com/federal-budget-2014-the-road-to-a-lean-mean-government-26665">slash and burn</a>” budget.</p>
<p>Scott Morrison’s new cash splash is no doubt designed to overcome this political weakness for the Coalition. </p>
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Read more:
<a href="https://theconversation.com/why-scare-campaigns-like-mediscare-work-even-if-voters-hate-them-62279">Why scare campaigns like 'Mediscare' work – even if voters hate them</a>
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<p>However, unlike Labor’s funding, which is ongoing, it’s unclear whether the extra largess the Coalition is offering will continue beyond the budget “forward estimates” (that is, the next four years). It’s unclear how much will be devoured from existing Commonwealth funding agreements, such as <a href="http://www.federalfinancialrelations.gov.au/content/npa/health/national-partnership/Adult_Public_Dental_Services_NP_2017-4.pdf">the dental agreement</a>, which are coming to an end.</p>
<p>The Commonwealth has responsibility for most aspects of policy to address social determinants of health, particularly employment and income policies. Rational health policy would recognise the importance of considering these issues and balancing the health benefits of, for example, <a href="https://onlinelibrary.wiley.com/doi/abs/10.1002/ajs4.30">lifting the Newstart allowance</a>, against funding for specific health initiatives. There is no hint this has happened with this announcement.</p>
<p>New handouts under the Morrison package will be portrayed as being for specific areas of “high political need”. But the reality is funding will eventually be swept into the <a href="https://www.cgc.gov.au/about-us/fiscal-equalisation">Grants Commission allocation process</a> and redirected according to the Grants Commission formula. </p>
<p>This may restore some rationality into the health handout, albeit with a lag of a few years. But the actual level of funding to be allocated to specific areas will be shrouded in Grants Commission opacity. Insiders will be able to follow the money, but voters will be kept in dismal ignorance about how much they will benefit in the long-term – after the gloss of a local funding handout has worn off.</p>
<p>This policy is a transparency fail.</p>
<h2>Politics versus policy</h2>
<p>The Community Health and Hospitals Program lists four feel-good, worthy funding targets:</p>
<ul>
<li>specialist hospital services such as cancer treatment, rural health and hospital infrastructure</li>
<li>drug and alcohol treatment</li>
<li>preventive health, primary care and chronic disease management, and </li>
<li>mental health.</li>
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Read more:
<a href="https://theconversation.com/morrison-government-promises-1-25-billion-for-health-care-108607">Morrison government promises $1.25 billion for health care</a>
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<p>Everyone has a potential place in this funding Nirvana. Lobby your local MP, and your local hospital or community health program might be the lucky health policy lottery winner!</p>
<p>Provided voters don’t see this as a cynical political exercise – and that is a big risk in an electorate which already <a href="https://grattan.edu.au/report/a-crisis-of-trust/">ranks politicians low on the trustworthiness scale</a> – then the new policy could be smart politics. We won’t know until the votes in next year’s federal election are counted.</p>
<p>In the meantime, given the <a href="https://www.theage.com.au/politics/victoria/wipeout-for-the-liberals-as-andrews-surges-to-victory-on-huge-red-wave-20181124-p50i53.html">drubbing the Liberals received in last month’s Victorian state election</a>, the biggest challenge for the Morrison Government might be deciding which electorates are now marginal and worth shoring up.</p><img src="https://counter.theconversation.com/content/108747/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>The A$1.25 billion health funding boost isn’t based on any coherent policy direction. It’s designed to shore up support in marginal electorates.Stephen Duckett, Director, Health Program, Grattan InstituteLicensed 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>
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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>
</strong>
</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>
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</em>
</p>
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<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>
<figure class="align-center ">
<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">
<figcaption>
<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>
</figcaption>
</figure>
<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>
</blockquote>
<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>
<hr>
<p>
<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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</em>
</p>
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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/990282018-06-28T14:04:52Z2018-06-28T14:04:52ZSouth Africa’s universal health care plan falls short of fixing an ailing system<figure><img src="https://images.theconversation.com/files/225142/original/file-20180627-112604-12nm7oq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A patient collects her medication at a clinic in Khayelitsha, South Africa.</span> <span class="attribution"><span class="source">MSF/Sydelle WIllow Smith</span></span></figcaption></figure><p>South Africa’s Health Minister Aaron Motsoaledi has finally gazetted the bill detailing an ambitious plan to roll out universal health care in the country through a <a href="https://www.gov.za/sites/default/files/41725_gon635s.pdf">National Health Insurance</a>. </p>
<p>The bill responds to a global campaign spearheaded by the <a href="http://www.who.int/universal_health_coverage/en/">World Health Organisation</a> and linked to the <a href="http://indicators.report/targets/3-8/">UN’s sustainable development goals</a> to make sure that no-one is left behind in accessing quality health care. </p>
<p>There’s no dispute that South Africa’s health care system needs major reforms. There are considerable inequities in health care between <a href="https://theconversation.com/a-human-step-to-equal-health-care-in-south-africas-rural-hospitals-41648">urban and rural areas</a>; between public and private <a href="https://scholarworks.wmich.edu/cgi/viewcontent.cgi?article=3752&context=honors_theses">health sectors</a> and between primary health care and hospital care. And the country has a complex disease burden with heavy caseloads of <a href="https://theconversation.com/scientists-are-combining-forces-to-tackle-the-deadly-duo-of-tb-and-hiv-62378">HIV, TB</a> and <a href="https://theconversation.com/south-africas-sugar-tax-a-bold-move-and-the-right-thing-to-do-72010">non-communicable diseases</a>. </p>
<p>South Africa has poor health outcomes compared to other middle-income countries such as Brazil with similar health spending as a percentage of GDP. It spends more than R300 billion – or around 8.5% of its gross domestic product – on health care. But half is spent in the private sector catering for people who are well off while the remaining 84% of the population, which carries a far greater burden of disease, depends on the under-resourced public sector. </p>
<p>The health system performs poorly due to a combination of factors including the poor management of public sector hospitals, health professional shortages (particularly in rural areas), low productivity levels among staff, escalating private health care costs and poor quality of care. </p>
<p>But in its current form the proposed legislation won’t be a silver bullet. There are still too many inconsistencies and unanswered questions for it to be the final roadmap to universal health care in the country. </p>
<p>For example, the bill focuses on curative services, missing an opportunity to take a public health approach that focuses on disease prevention, health promotion and health protection. In addition, it doesn’t address the relationship between the public and private health sectors which is seen as a major impediment to fundamental change. </p>
<h2>How it will work</h2>
<p>The bill is informed by a vision of ensuring equitable access to quality health services, regardless of a person’s ability to pay or whether they live in an urban or rural area. The proposed insurance fund envisages the consolidation of public and private revenue into one funding pool. </p>
<p>The idea is to enable a more equitable system through, for example, cross-subsidisation and ensuring that essential services are made available. </p>
<p>All people will have to register as users of the fund at an accredited health care establishment or facility (whether public or private). And the fund will decide on the health benefits that the facilities will have to provide. This will depend on what resources the facility has. People will be able to pay for complementary health service benefits not covered by the fund. </p>
<p>To be paid, health care providers, such as general practitioners and hospitals, will have to register with the fund. They will have to claim for each patient that they treat and will have to keep a record of diagnosis, treatment and length of stay.</p>
<h2>Governance</h2>
<p>The structure that’s been proposed for the fund is raising concerns on two fronts: it appears unnecessarily cumbersome and there’s a lack of clarity on lines of command.</p>
<p>The bill makes provision for the fund to establish an independent board that will report to South Africa’s Parliament. But it makes no mention of how the board will engage with the health minister (political custodian) and public servants in the health department. Nor does it explain how the performance of the fund will be evaluated. </p>
<p>The bill also introduces two additional management layers: district health management offices and contracting units for primary health care. These units will provide primary health care services in specific areas. It includes a district hospital, clinics and community health centres as well as ward-based outreach teams and private primary care service providers. They will be contracted by the fund. </p>
<p>National, provincial, and municipal health departments will still exist. </p>
<p>But the bill fails to explain the relationship between the district health management offices and the contracting units and how they will engage with the national, provincial and municipal health departments. </p>
<p>Given that there are ten health departments operating in South Africa – a national department and one in each of the country’s nine provinces – these additional offices and units could result in a more cumbersome bureaucracy. This could lead to more inefficiency and greater opportunity for corruption. </p>
<p>The new structure will also change the responsibilities of provincial health departments. Some of the proposals don’t make sense such as the idea that municipalities should take control of managing communicable diseases. Ideally this should be a national function, given the serious threat that is posed by some infectious diseases. </p>
<h2>Many questions</h2>
<p>Other parts of the bill are also unclear. These range from financing to how complaints will be managed.</p>
<p><strong>Health financing and management:</strong> The bill doesn’t explain what the tax implications of the national health insurance will be for citizens. It also doesn’t set out the mechanisms that will be put in place to strengthen financial planning and monitoring systems, particularly in the public health sector. These are very important given current <a href="https://www.news24.com/Archives/City-Press/R12bn-unaccounted-for-in-Gauteng-health-department-20150429">chronic overspending</a>, inadequate financial management and corruption and lack of accountability in many <a href="https://www.thesouthafrican.com/public-health-fail-report-reveals-that-sas-health-facilities-are-in-crisis/">provincial health departments</a>.</p>
<p><strong>Service provision:</strong> The bill says everyone is entitled to a comprehensive package of services at all levels of health care. But it doesn’t spell out what these packages will include. Given budgetary constraints, it’s obvious that there will inevitably have to be trade-offs and difficult choices. </p>
<p><strong>The health workforce:</strong> South Africa doesn’t have a comprehensive health workforce strategy with detailed norms and standards. This remains the Achilles heel of health sector reform in the country. The lack of detail remains a serious omission in the bill. </p>
<p><strong>Complaints mechanisms:</strong> The bill introduces a new separate complaints directorate – the investigating unit. But it’s unclear whether this will be the first level of complaints or whether it’s a duplication of the complaints directorate in the existing Office of Health Standards Compliance. There also isn’t clarity about where the Health Ombud fits in. </p>
<p>Ensuring that South Africa has a quality affordable health care system is critical. And the bill presents an important opportunity to think systematically about what needs to be done to fix the current health system. But there is still a long way to go.</p><img src="https://counter.theconversation.com/content/99028/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Laetitia Rispel receives funding from the National Research Foundation. </span></em></p>The bill to provide universal health care in South Africa is not the silver bullet for the challenges in the health sector.Laetitia Rispel, Professor of Public Health and DST/NRF Research Chair., University of the WitwatersrandLicensed as Creative Commons – attribution, no derivatives.