tag:theconversation.com,2011:/uk/topics/health-care-2204/articlesHealth care – The Conversation2024-03-13T12:45:24Ztag:theconversation.com,2011:article/2222472024-03-13T12:45:24Z2024-03-13T12:45:24ZBuyouts can bring relief from medical debt, but they’re far from a cure<figure><img src="https://images.theconversation.com/files/577693/original/file-20240223-20-aiwmsy.jpg?ixlib=rb-1.1.0&rect=0%2C15%2C5145%2C3462&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Medical debt can have devastating consequences.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/stethscope-on-pile-of-us-banknotes-royalty-free-image/153349316">PhotoAlto/Odilon Dimier via Getty Images</a></span></figcaption></figure><p><a href="https://www.kff.org/health-costs/press-release/1-in-10-adults-owe-medical-debt-with-millions-owing-more-than-10000/#:%7E:text=Americans%20Likely%20Owe%20Hundreds%20of,who%20owe%20more%20than%20%2410%2C000.">One in 10 Americans</a> carry medical debt, while <a href="https://www.commonwealthfund.org/publications/issue-briefs/2022/sep/state-us-health-insurance-2022-biennial-survey">2 in 5</a> are underinsured and at risk of not being able to pay their medical bills.</p>
<p><a href="https://doi.org/10.1001/jamanetworkopen.2022.31898">This burden</a> <a href="https://www.commonwealthfund.org/publications/podcast/2023/oct/how-medical-debt-makes-people-sicker-what-we-can-do-about-it">crushes millions</a> <a href="https://doi.org/10.1377/hlthaff.2023.00604">of families</a> under mounting bills and contributes to the <a href="http://doi.org/10.1001/jamanetworkopen.2022.31898">widening gap</a> between rich and poor. </p>
<p>Some relief has come with a wave of debt buyouts by <a href="https://fortune.com/2023/03/10/local-communities-are-buying-medical-debt-for-pennies-on-the-dollar-and-freeing-american-families-from-the-threat-of-bankruptcy/">county and city governments</a>, <a href="https://apnews.com/article/business-georgia-nonprofits-2a5c3afc4a646d489242bd99eb6652fc">charities</a> and even <a href="https://www.wmdt.com/2024/01/chick-fil-a-pays-medical-debt-on-delmarva/">fast-food restaurants</a> that pay pennies on the dollar to clear enormous balances. But as a <a href="https://scholar.google.com/citations?user=cGZVMkoAAAAJ&hl=en">health policy and economics researcher</a> who studies out-of-pocket medical expenses, I think these buyouts are only a partial solution.</p>
<h2>A quick fix that works</h2>
<p>Over the past 10 years, the nonprofit <a href="https://ripmedicaldebt.org/">RIP Medical Debt</a> has emerged as the leader in making buyouts happen, using <a href="https://www.cnn.com/2020/03/01/us/medical-debt-campaigns-give-back-trnd/index.html">crowdfunding campaigns</a>, <a href="https://www.theguardian.com/us-news/2016/jun/06/john-oliver-medical-debt-forgiveness-last-week-tonight">celebrity engagement</a>, and partnerships in the private and public sectors. It connects charitable buyers with hospitals and debt collection companies to arrange the sale and erasure of large bundles of debt. </p>
<p>The buyouts focus on low-income households and those with extreme debt burdens. You can’t sign up to have debt wiped away; you just get notified if you’re one of the lucky ones included in a bundle that’s bought off. In 2020, the U.S. Department of Health and Human Services <a href="https://revcycleintelligence.com/news/hospitals-can-sell-patient-bad-debt-to-charitable-orgs-oig-says">reviewed this strategy</a> and determined it didn’t violate anti-kickback statutes, which reassured hospitals and collectors that they wouldn’t get in legal trouble partnering with RIP Medical Debt. </p>
<p>Buying a bundle of debt saddling low-income families can be a bargain. Hospitals and collection agencies are typically <a href="https://www.wbur.org/onpoint/2023/09/21/buy-and-sell-medical-debt-health-care">willing to sell</a> the debt for <a href="https://www.theatlantic.com/health/archive/2019/08/medical-bill-debt-collection/596914/">steep discounts</a>, even <a href="https://fortune.com/2023/03/10/local-communities-are-buying-medical-debt-for-pennies-on-the-dollar-and-freeing-american-families-from-the-threat-of-bankruptcy/">pennies on the dollar</a>. That’s a great return on investment for philanthropists looking to make a big social impact.</p>
<p>And it’s not just charities pitching in. <a href="https://www.npr.org/sections/health-shots/2024/01/23/1225014618/nyc-joins-a-growing-wave-of-local-governments-erasing-residents-medical-debt">Local governments</a> across the country, from <a href="https://arpa.cookcountyil.gov/medical-debt-relief-initiative">Cook County, Illinois</a>, to <a href="https://www.axios.com/local/new-orleans/2023/05/23/new-orleans-medical-debt-forgiveness">New Orleans</a>, have been directing <a href="https://apnews.com/article/health-care-costs-boston-toledo-e423c64c1322bc8e4254b7a70b1da50c">sizable public funds</a> toward this cause. <a href="https://www.nytimes.com/2024/01/22/nyregion/medical-debt-forgiveness.html">New York City</a> recently announced plans to buy off the medical debt for half a million residents, at a cost of US$18 million. That would be the largest public buyout on record, although Los Angeles County may trump New York if it <a href="https://www.latimes.com/california/story/2023-10-04/la-county-buy-forgive-medical-debt-how-work">carries out its proposal</a> <a href="https://www.cbsnews.com/losangeles/news/la-county-considering-plan-to-erase-medical-debt-for-residents/">to spend</a> $24 million to help 810,000 residents erase their debt.</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/2wSarEVgjM0?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">HBO’s John Oliver has collaborated with RIP Medical Debt.</span></figcaption>
</figure>
<p>Nationally, RIP Medical Debt has helped clear more than <a href="https://ripmedicaldebt.org/about/">$10 billion</a> in debt over the past decade. That’s a huge number, but a small fraction of the estimated <a href="https://www.kff.org/health-costs/issue-brief/the-burden-of-medical-debt-in-the-united-states/">$220 billion</a> in medical debt out there. Ultimately, prevention would be better than cure.</p>
<h2>Preventing medical debt is trickier</h2>
<p>Medical debt has been a persistent <a href="https://files.consumerfinance.gov/f/documents/cfpb_medical-debt-burden-in-the-united-states_report_2022-03.pdf">problem over the past decade</a> even after the reforms of the 2010 Affordable Care Act <a href="http://doi.org/10.1056/NEJMsr1406753">increased</a> <a href="http://doi.org/doi:10.1001/jama.307.9.913">insurance</a> <a href="http://doi.org/doi:10.1001/jama.2015.8421">coverage</a> and <a href="https://doi.org/10.1353/hpu.2020.0031">made a dent</a> in debt, especially in states that <a href="http://doi.org/10.3386/w22170">expanded</a> <a href="http://doi.org/10.1001/jama.2021.8694/">Medicaid</a>. A recent <a href="https://www.commonwealthfund.org/publications/issue-briefs/2022/sep/state-us-health-insurance-2022-biennial-survey">national survey by the Commonwealth Fund</a> found that 43% of Americans lacked adequate insurance in 2022, which puts them at risk of taking on medical debt. </p>
<p>Unfortunately, it’s incredibly difficult to close coverage gaps in the patchwork American insurance system, which ties eligibility to employment, income, age, family size and location – all things that can change over time. But even in the absence of a total overhaul, there are several policy proposals that could keep the medical debt problem from getting worse.</p>
<p><a href="https://www.urban.org/sites/default/files/2022-06/Which%20County%20Characteristics%20Predict%20Medical%20Debt.pdf">Medicaid expansion</a> has been shown to reduce uninsurance, underinsurance and medical debt. Unfortunately, insurance gaps are likely to get worse in the coming year, as states <a href="https://www.kff.org/medicaid/issue-brief/10-things-to-know-about-the-unwinding-of-the-medicaid-continuous-enrollment-provision/">unwind their pandemic-era Medicaid rules</a>, leaving millions without coverage. Bolstering Medicaid access in the <a href="https://www.kff.org/medicaid/issue-brief/status-of-state-medicaid-expansion-decisions-interactive-map/">10 states</a> that haven’t yet expanded the program could go a long way.</p>
<p>Once patients have a medical bill in hand that they can’t afford, it can be tricky to navigate financial aid and payment options. Some states, like <a href="https://medicaldebtpolicyscorecard.org/state/MD">Maryland</a> and <a href="https://medicaldebtpolicyscorecard.org/state/CA">California</a>, are <a href="https://doi.org/10.1001/jama.2021.23061">ahead of the curve</a> <a href="https://medicaldebtpolicyscorecard.org/">with policies</a> that make it easier for patients to access aid and that rein in the use of liens, lawsuits and other aggressive collections tactics. More states could follow suit.</p>
<p>Another major factor driving underinsurance is <a href="https://www.npr.org/sections/health-shots/2022/06/16/1104679219/medical-bills-debt-investigation#:%7E:text=For%20many%20Americans%2C%20the%20combination,slightly%20lower%20than%20the%20uninsured.">rising out-of-pocket costs</a> – like high deductibles – for those with private insurance. This is especially a concern for <a href="https://www.chiamass.gov/assets/docs/r/pubs/2020/High-Deductable-Health-Plans-CHIA-Research-Brief.pdf">low-wage</a> <a href="https://www.ajmc.com/view/financial-burden-of-healthcare-utilization-in-consumer-directed-health-plans">workers</a> who live paycheck to paycheck. More than half of large employers believe their employees <a href="https://www.kff.org/report-section/ehbs-2023-summary-of-findings/#:%7E:text=As%20noted%20above%2C%2025%25%20of,a%20moderate%20level%20of%20concern">have concerns</a> about their ability to afford medical care.</p>
<p>Lowering deductibles and out-of-pocket maximums could protect patients from accumulating debt, since it would lower the total amount they could incur in a given time period. But if the current system otherwise stayed the same, then premiums would have to rise to offset the reduction in out-of-pocket payments. Higher premiums would transfer costs across everyone in the insurance pool and make enrolling in insurance unreachable for some – which doesn’t solve the underinsurance problem.</p>
<p>Reducing out-of-pocket liability without inflating premiums would only be possible if the overall cost of health care drops. Fortunately, there’s room to reduce waste. Americans <a href="https://www.pgpf.org/blog/2023/07/why-are-americans-paying-more-for-healthcare">spend more on health care</a> than people in other wealthy countries do, and arguably get less for their money. <a href="http://doi.org/doi:10.1001/jama.2019.13978">More than a quarter</a> of health spending is on <a href="https://www.brookings.edu/articles/reducing-administrative-costs-in-u-s-health-care/#:%7E:text=Cutler%20proposes%20several%20reforms%20to,in%20the%20health%2Dcare%20system.">administrative</a> <a href="http://doi.org/10.1111/1475-6773.13649">costs</a>, and the <a href="https://doi.org/10.1377/hlthaff.2018.05144">high prices</a> Americans pay don’t necessarily translate into <a href="https://www.doi.org/10.1001/jama.2019.13978">high-value care</a>. That’s why some states like <a href="https://www.milbank.org/publications/the-massachusetts-health-care-cost-growth-benchmark-and-accountability-mechanisms-stakeholder-perspectives/">Massachusetts</a> and <a href="https://hcai.ca.gov/get-the-facts-about-the-office-of-health-care-affordability/">California</a> are experimenting with <a href="https://www.chcf.org/wp-content/uploads/2022/04/HealthCareCostCommissionstatesAddressCostGrowth.pdf">cost growth limits</a>.</p>
<h2>Momentum toward policy change</h2>
<p>The growing number of city and county governments buying off medical debt signals that local leaders view medical debt as a problem worth solving. Congress has passed substantial <a href="https://www.cms.gov/priorities/key-initiatives/hospital-price-transparency">price transparency laws</a> and prohibited <a href="https://www.cms.gov/nosurprises">surprise medical billing</a> in recent years. The Consumer Financial Protection Bureau is <a href="https://www.consumerfinance.gov/about-us/newsroom/cfpb-kicks-off-rulemaking-to-remove-medical-bills-from-credit-reports/">exploring rule changes</a> for medical debt collections and reporting, and national credit bureaus have <a href="https://www.urban.org/urban-wire/medical-debt-was-erased-credit-records-most-consumers-potentially-improving-many">voluntarily removed</a> some medical debt from credit reports to limit its impact on people’s approval for loans, leases and jobs. </p>
<p>These recent actions show that leaders at all levels of government want to end medical debt. I think that’s a good sign. After all, recognizing a problem is the first step toward meaningful change.</p><img src="https://counter.theconversation.com/content/222247/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Erin Duffy receives funding from Arnold Ventures. </span></em></p>Local governments are increasingly buying – and forgiving – their residents’ medical debt.Erin Duffy, Research Scientist, University of Southern CaliforniaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2228582024-03-08T13:38:33Z2024-03-08T13:38:33ZAsthma meds have become shockingly unaffordable − but relief may be on the way<figure><img src="https://images.theconversation.com/files/579691/original/file-20240304-18-r33cu5.jpg?ixlib=rb-1.1.0&rect=25%2C51%2C8538%2C5469&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Its price will take your breath away.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/man-using-blue-asthma-inhaler-medication-royalty-free-image/1179346207?">Brian Jackson/Getty Images</a></span></figcaption></figure><p>The <a href="https://www.businessinsider.com/cost-asthma-medication-doubled-unjust-2023-7">price of asthma medication has soared</a> in the U.S. over the past decade and a half. </p>
<p>The jump – in some cases from around <a href="https://doi.org/10.1001/jamainternmed.2015.1665">a little over US$10</a> <a href="https://www.singlecare.com/blog/albuterol-sulfate-hfa-proventil-hfa-without-insurance/">to almost $100</a> for an inhaler – has meant that patients in need of asthma-related products <a href="https://www.businessinsider.com/cost-asthma-medication-doubled-unjust-2023-7">often struggle</a> to buy them. Others simply <a href="https://asthma.net/living/cannot-afford-inhalers">can’t afford</a> them. </p>
<p>To make matters worse, asthma <a href="https://www.fda.gov/drugs/buying-using-medicine-safely/generic-drugs">disproportionately affects</a> lower-income patients. Black, Hispanic and Indigenous communities have the <a href="https://aafa.org/asthma-allergy-research/our-research/asthma-disparities-burden-on-minorities/">highest asthma rates</a>. They also shoulder <a href="https://aafa.org/asthma-allergy-research/our-research/asthma-disparities-burden-on-minorities/">the heaviest burden</a> of asthma-related deaths and hospitalizations. Climate change will likely <a href="https://www.hsph.harvard.edu/c-change/subtopics/climate-change-and-asthma/">worsen asthma rates</a> and, consequently, these disparities.</p>
<p>I’m a health law professor at <a href="https://www1.villanova.edu/university/law/faculty-scholarship/faculty-directory/profiles/AnaSantosRutschman.html">Villanova University</a>, <a href="https://papers.ssrn.com/sol3/cf_dev/AbsByAuth.cfm?per_id=2667484">where I study</a> whether patients can get the medicines they need. And I’ve been watching this affordability crisis closely.</p>
<p>In many ways, it shows what happens when law and policy decisions aren’t aligned with public health needs. The good news, however, is that there finally seems to be some political will to rein in the price of asthma meds.</p>
<h2>Why inhaler prices are skyrocketing</h2>
<p>In 2008, the U.S. Food and Drug Administration <a href="https://www.fda.gov/drugs/frequently-asked-questions-popular-topics/transition-cfc-propelled-albuterol-inhalers-hfa-propelled-albuterol-inhalers-questions-and-answers">banned inhalers</a> that use chlorofluorocarbons, or CFCs – which were once widely used as propellants – because they can damage the ozone layer. The FDA was following a timeline set by an environmental treaty, the <a href="https://www.unep.org/ozonaction/who-we-are/about-montreal-protocol">Montreal Protocol</a>, which the U.S. ratified in the late 1980s. </p>
<p>From 2009 onward, CFC inhalers were phased out and replaced with hydrofluoroalkane, or HFA, ones, which are more environmentally friendly. They’re also a lot pricier. For patients with insurance, the average out-of-pocket cost of an inhaler rose from $13.60 per prescription in 2004 to $25 immediately after the 2008 ban, <a href="https://doi.org/10.1001/jamainternmed.2015.1665">a 2015 study found</a>.</p>
<p>Today, the <a href="https://www.singlecare.com/blog/albuterol-sulfate-hfa-proventil-hfa-without-insurance/">average retail price</a> of an albuterol inhaler is $98. Unlike CFC inhalers, which have <a href="https://www.fda.gov/drugs/buying-using-medicine-safely/generic-drugs">generic versions</a>, HFA inhalers are <a href="https://www.scientificamerican.com/article/unlikely-victims-of-banning-cfcs/">covered by patents</a>. While <a href="http://doi.org/10.1089/jamp.2016.1297">the drug itself</a> hasn’t changed, the switch to a different device allowed companies to increase their prices.</p>
<p>In 2020, the FDA finally approved the <a href="https://www.fda.gov/news-events/press-announcements/fda-approves-first-generic-commonly-used-albuterol-inhaler-treat-and-prevent-bronchospasm">first generic version</a> of an albuterol inhaler. But generic competition still isn’t robust enough to lower prices meaningfully.</p>
<p>Patients with good insurance <a href="https://allergyasthmanetwork.org/advocacy-updates/united-healthcare-albuterol-epinephrine-cost/">may pay very little</a> or even nothing. But uninsured patients face steep market prices, and as of 2023, there were <a href="https://aspe.hhs.gov/sites/default/files/documents/e06a66dfc6f62afc8bb809038dfaebe4/Uninsured-Record-Low-Q12023.pdf">over 25 million</a> uninsured Americans. <a href="https://www.cdc.gov/asthma/asthma_stats/insurance_coverage.htm">Even insured patients may have trouble</a> affording their asthma meds, the CDC has found. </p>
<p>The same asthma medication for which U.S. patients pay top dollar is available elsewhere at much cheaper prices. Consider the following case for inhalers. The pharmaceutical company Teva sells <a href="https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=ccd3aaec-4892-40d0-ad60-3e570178fbe1">QVAR RediHaler</a>, a corticosteroid inhaler, <a href="https://doi.org/10.1016/S2213-2600(24)00012-2">for $286</a> in the U.S.</p>
<p>In Germany, Teva sells that same inhaler for $9.</p>
<h2>Seeking meds from Mexico and Canada</h2>
<p>Some U.S. patients have traveled abroad to obtain cheaper asthma medication. After the 2008 ban on CFCs, it became common for patients to <a href="https://doi.org/10.1177/8755122515595052">visit border towns in Mexico</a> to purchase albuterol inhalers. They were sold for <a href="https://doi.org/10.1177/8755122515595052">as little as $3 to $5</a>. </p>
<p>A study of inhalers available to U.S. patients in Nogales, Mexico – about an hour south of Tucson, Arizona – found that Mexican products were <a href="http://doi.org/10.1177/8755122515595052">generally comparable to U.S. inhalers</a>. But researchers found some differences in performance, suggesting that American patients who use them could be getting a slightly different dose than their usual.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/580250/original/file-20240306-24-xrc96u.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Asthma medication is seen on the shelves of a Mexican pharmacy." src="https://images.theconversation.com/files/580250/original/file-20240306-24-xrc96u.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/580250/original/file-20240306-24-xrc96u.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/580250/original/file-20240306-24-xrc96u.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/580250/original/file-20240306-24-xrc96u.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/580250/original/file-20240306-24-xrc96u.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/580250/original/file-20240306-24-xrc96u.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/580250/original/file-20240306-24-xrc96u.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Asthma meds are considerably more affordable south of the border.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/the-interior-of-farmacia-san-pablo-news-photo/1041982048">Jeffrey Greenberg/Universal Images Group via Getty Images</a></span>
</figcaption>
</figure>
<p>There have also been reports of Americans turning to Canadian pharmacies to purchase asthma inhalers at much cheaper prices. In one case, a U.S. pharmacy would have charged $857 for a three-month supply. A patient obtained it for <a href="https://www.seattletimes.com/life/wellness/canadian-pharmacy-provided-inhaler-at-a-fraction-of-us-cost/">$134 from a pharmacy in Canada</a>.</p>
<h2>One potential fix: Importing cheaper meds</h2>
<p>U.S. law has long <a href="https://www.fda.gov/about-fda/center-drug-evaluation-and-research-cder/frequently-asked-questions-about-drugs">prohibited</a> personal importation of pharmaceutical drugs. However, a recent development could <a href="https://www.reuters.com/business/healthcare-pharmaceuticals/us-fda-allow-florida-import-cheaper-drugs-canada-2024-01-05">pave the way for states</a> to import cheaper asthma drugs.</p>
<p>In January 2024, the <a href="https://www.reuters.com/business/healthcare-pharmaceuticals/us-fda-allow-florida-import-cheaper-drugs-canada-2024-01-05/">FDA authorized</a> the importation of certain prescription drugs from Canada for the first time. <a href="https://www.kff.org/policy-watch/what-to-know-about-the-fdas-recent-decision-to-allow-florida-to-import-prescription-drugs-from-canada/">For now</a>, this authorization is limited to Florida, and it covers only drugs for HIV/AIDS, prostate cancer and certain mental health conditions.</p>
<p>Should it prove successful, the program could serve as a blueprint for other states.</p>
<h2>Another possible solution: Price-capping</h2>
<p>Policymakers could also try borrowing a page from the insulin playbook. Insulin prices <a href="https://doi.org/10.1001/jamanetworkopen.2023.18074">climbed for almost two decades</a> before Congress acted, capping the cost of insulin for Medicare patients. The 2022 <a href="https://www.congress.gov/bill/117th-congress/house-bill/5376/text">Inflation Reduction Act</a> established an out-of-pocket ceiling of $35 per month for prescription-covered insulin products. </p>
<p>If this cap had been in effect two years earlier, it would have saved 1.5 million Medicare patients about $500 annually, <a href="https://www.hhs.gov/about/news/2023/08/16/first-anniversary-inflation-reduction-act-millions-medicare-enrollees-savings-health-care-costs.html">a recent study estimated</a>. It also would have saved Medicare <a href="https://www.hhs.gov/about/news/2023/08/16/first-anniversary-inflation-reduction-act-millions-medicare-enrollees-savings-health-care-costs.html">$761 million</a>.</p>
<p>A similar approach could be taken for asthma meds.</p>
<p>Congress could create an asthma-specific rule similar to the insulin case. Or it could place provisions for asthma-med prices into a larger piece of legislation.</p>
<p>While this approach depends on the political environment, there are signs the government is becoming more willing to act. In January 2024, the U.S. Department of Health and Human Services <a href="https://www.hhs.gov/about/news/2024/01/29/readout-hhs-officials-meeting-private-sector-patient-advocacy-leaders-improve-national-access-important-asthma-medications.html">hosted a meeting</a> to discuss the problem with manufacturers and other stakeholders.</p>
<p>It’s a start. And – together with other measures – it brings some hope that asthma meds might soon become more affordable to those in need.</p><img src="https://counter.theconversation.com/content/222858/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Ana Santos Rutschman does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>An inhaler that costs nearly $300 in the US goes for just $9 in Germany. What gives?Ana Santos Rutschman, Professor of Law, Villanova School of LawLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2250662024-03-06T17:58:43Z2024-03-06T17:58:43ZCanadians need to know how much money Big Pharma gives health-care providers, but this information is far too difficult to find<figure><img src="https://images.theconversation.com/files/579973/original/file-20240305-18-ban0k5.jpg?ixlib=rb-1.1.0&rect=310%2C120%2C5216%2C3449&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Patients need to know that treatments are recommended based on patient need, not pharma company interests. That's why it's important to know how much Big Pharma is paying to health-care providers and organizations.</span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><p>Drug companies often give payments to physicians, other health-care workers and health-care organizations for things like consulting fees, sitting on advisory boards, speaking at sponsored events or funding research, as well as meals and travel expenses. However, in Canada, it’s difficult to know how much was paid to whom.</p>
<p>Prominent on the website of <a href="https://innovativemedicines.ca/about/ethics/">Innovative Medicines Canada</a> (IMC) — the organization that represents the research-based drug companies operating in Canada — is the statement:</p>
<blockquote>
<p>“As part of our commitment to high ethical standards and enhancing trust, Innovative Medicines Canada has developed a Voluntary Framework on Disclosure of Payments made to health-care professionals and organizations.” </p>
</blockquote>
<p>Based on that commitment, starting in 2016, <a href="https://doi.org/10.12927%2Fhcpol.2022.26729">10 companies</a> — fewer than one-quarter of IMC’s members — have been reporting how much in total they gave to doctors and organizations.</p>
<p>In order to maintain faith in the integrity of treatments that doctors and other health-care providers and organizations offer their patients, it’s vital that the public knows that the choice of therapy is based on the patient’s best interest and not on the interest of the company that makes the drug.</p>
<h2>Lack of transparency</h2>
<p>When the disclosures began, the president of IMC said the <a href="https://www.theglobeandmail.com/news/national/canadian-drug-makers-assailed-for-lack-of-transparency-over-payments/article35392284/">revelations were only the first step in increased transparency</a>, and that more companies were expected to disclose payments in the coming years. However, since that time, there has not been an increase in the amount of information disclosed nor in the number of companies participating.</p>
<figure class="align-center ">
<img alt="A person in a business suit shaking hands with someone in a white coat who is holding a box" src="https://images.theconversation.com/files/579970/original/file-20240305-20-ioc67p.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/579970/original/file-20240305-20-ioc67p.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/579970/original/file-20240305-20-ioc67p.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/579970/original/file-20240305-20-ioc67p.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/579970/original/file-20240305-20-ioc67p.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/579970/original/file-20240305-20-ioc67p.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/579970/original/file-20240305-20-ioc67p.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">Canada’s disclosure guidelines don’t require pharma companies to disclose which doctors and organizations have received payments, or what they have done to earn the money.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<p>In fact, two companies have stopped disclosing information altogether so now only eight companies out of the 48 that belong to IMC make even these minimum disclosures. Another company has not disclosed payments since 2021. The IMC website still lists 10 participating companies. </p>
<p>The disclosures are not centrally collected by IMC; anyone interested has to hunt around on the individual companies’ websites to find the reports. Of course, there are no penalties for failing to disclose because it’s voluntary.</p>
<p>What do we know from the information that has been disclosed? Over seven years (2016-2022) the 10 disclosing companies gave over $236 million to doctors and almost $213 million to organizations. </p>
<p>Which doctors and organizations have received these payments, what have they done to earn the money? We don’t know, because the disclosures don’t name names or give the specific purpose of the payments. And since names are withheld, the amounts given to individual doctors or organizations are also not available.</p>
<h2>Transparency in other countries</h2>
<p>In asking for the disclosure of so little information, IMC is unique among pharmaceutical industry associations in high-income countries. Disclosure systems in Australia, most European countries, <a href="https://doi.org/10.1186/s12992-022-00902-9">Japan</a>, <a href="https://www.medicinesnz.co.nz/our-industry/transparency-guidelines">New Zealand</a> and the United Kingdom are run by their respective industry associations. In some cases, they are still voluntary and there are also weaknesses in what they reveal — for example individual doctors can opt out of being named.</p>
<p>But they all also require that companies provide far more information than IMC does. The <a href="https://www.efpia.eu/media/413643/efpia_about_disclosure_code_updated-july-2019.pdf">European Federation of Pharmaceutical Industries and Associations</a> requires all member companies to disclose the names of professionals and organizations that have received payments or other transfers of value from them. They have to disclose the total amounts of value transferred by type of activity such as grants, consultancy fees, travel payments and registration fees to attend a medical education congress.</p>
<figure class="align-center ">
<img alt="A person in a white coat out of focus in the background with a prescription bottle in the foreground" src="https://images.theconversation.com/files/579972/original/file-20240305-30-aon8rd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/579972/original/file-20240305-30-aon8rd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/579972/original/file-20240305-30-aon8rd.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/579972/original/file-20240305-30-aon8rd.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/579972/original/file-20240305-30-aon8rd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/579972/original/file-20240305-30-aon8rd.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/579972/original/file-20240305-30-aon8rd.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Research has shown that even a $20 meal is enough to influence prescribing behaviour.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<p>These disclosures can tell us a lot about how companies and health-care professionals interact. In the <a href="https://doi.org/10.1136/bmjopen-2017-016701">four years up to September 2015</a>, 42 Australia-based companies sponsored 116,845 events for health professionals, on average 608 per week with 30 attendees per event. The median cost per event was $263 and over 90 per cent included food and beverages.</p>
<p><a href="https://haiweb.org/wp-content/uploads/2017/03/Sunshine-Act.pdf">France, Denmark, Greece, Romania, Latvia, Italy</a>, <a href="https://www.policymed.com/2017/08/sunshine-act-takes-effect-in-south-korea.html">South Korea</a> and especially the United States with its <a href="https://doi.org/10.1056/NEJMp1305090">Physician Payments Sunshine Act</a> go even further and have legislation making reporting a legal requirement. </p>
<p>The U.S. Sunshine Act mandates that pharmaceutical and medical device companies report gifts or any other transfer of value of US$10 or greater to physicians and teaching hospitals. The types of payments that need to be reported include consulting fees, honoraria, gifts, entertainment, food and beverages, travel and lodging, education, research, charitable contributions, royalties or licenses, ownership or investment interests, speakers’ fees and grants. </p>
<p>All of this information is publicly available in the <a href="https://doi.org/10.1007/s11606-021-06657-0">Open Payments database</a> maintained by the Centers for Medicare and Medicaid Services.</p>
<p>A key feature of the Open Payments database is the requirement for companies to name the product(s) that their payments are tied to. This feature has allowed researchers to examine links between doctors’ payments and prescribing. As a result, we know that a $20 meal — not much more than the price of a Quarter Pounder, fries and a Coke at McDonalds — is <a href="https://doi.org/10.1001/jamainternmed.2016.2765">enough to increase prescribing</a> of the drug(s) made by the company providing the meal.</p>
<p>Ontario was poised to go even further than the Sunshine Act. Before the 2019 election, the government was finalizing regulations for <a href="https://www.ontario.ca/laws/statute/s17025">Bill 160</a>, which would have required that all drug and device manufacturers that provided a “transfer of value” to individual health-care practitioners and health-care organizations, including patient groups, report those transfers to a public registry. The <a href="https://doi.org/10.1503/cmaj.109-5718">election of a Progressive Conservative government</a> killed that initiative.</p>
<p>Canadians deserve more transparency about pharma companies’ payments to health-care providers. Multiple studies, including <a href="https://doi.org/10.1371/journal.pmed.1000352">one that I participated in</a>, have looked at what happens when doctors take payments from drug companies. Their prescribing almost never improves. It either stays the same or, more worrisome, it gets worse. Canadians need to know what Big Pharma is paying to whom, since these payments may not be to the benefit of patients.</p><img src="https://counter.theconversation.com/content/225066/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Between 2020-2024, Joel Lexchin received payments for writing a brief on the role of promotion in generating prescriptions for a legal firm, for being on a panel about pharmacare and for co-writing an article for a peer-reviewed medical journal. He is a member of the Board of Canadian Doctors for Medicare. He receives royalties from University of Toronto Press and James Lorimer & Co. Ltd. for books he has written. He is participating in research funded by the Canadian Institutes of Health Research.</span></em></p>Canada has a lack of transparency about Big Pharma’s payments to health-care providers and organizations. Disclosure is voluntary, and there’s no central data on even the few companies that do report.Joel Lexchin, Professor Emeritus of Health Policy and Management, York University, CanadaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2220592024-02-25T14:18:51Z2024-02-25T14:18:51ZHealth-care AI: The potential and pitfalls of diagnosis by app<figure><img src="https://images.theconversation.com/files/577606/original/file-20240223-24-vcg7d2.jpg?ixlib=rb-1.1.0&rect=1951%2C0%2C3458%2C2313&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">As apps are direct-to-consumer health technologies, they represent a new folk medicine. Users adopt these technologies based on trust rather than understanding how they operate.
</span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><p>If <a href="https://www.who.int/about/accountability/governance/constitution">health is a fundamental human right</a>, health-care delivery must be <a href="https://nap.edu/25152">improved globally to achieve universal access</a>. However, the limited number of practitioners creates a barrier for all health-care systems.</p>
<p>Approaches to health-care delivery driven by artificial intelligence (AI) are poised to fill this gap. Whether in urban hospitals or in <a href="https://www.cbc.ca/news/canada/prince-edward-island/pei-artificial-intelligence-1.6994961">rural and remote homes</a>, AI has the reach that health-care professionals cannot hope to achieve. People seeking health information can obtain it quickly and conveniently. For health care to be effective, <a href="https://doi.org/10.2196/18599">patient safety</a> must remain a priority. </p>
<p>The news is filled with examples of novel applications of AI. Riding the wave of recent interest in conversational agents, Google researchers have developed an experimental <a href="https://blog.research.google/2024/01/amie-research-ai-system-for-diagnostic_12.html">diagnostic AI, Articulate Medical Intelligence Explorer (AMIE)</a>. People seeking health information provide their symptoms through a text-chat interface and AMIE begins to ask questions and provide recommendations as a human clinician might. The researchers claim that, when compared against clinicians, <a href="https://arxiv.org/abs/2312.00164">AMIE outperformed clinicians in both diagnostic accuracy and performance</a>.</p>
<figure class="align-center ">
<img alt="Text bubbles in chat." src="https://images.theconversation.com/files/574774/original/file-20240211-30-7rkqni.gif?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/574774/original/file-20240211-30-7rkqni.gif?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=533&fit=crop&dpr=1 600w, https://images.theconversation.com/files/574774/original/file-20240211-30-7rkqni.gif?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=533&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/574774/original/file-20240211-30-7rkqni.gif?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=533&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/574774/original/file-20240211-30-7rkqni.gif?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=670&fit=crop&dpr=1 754w, https://images.theconversation.com/files/574774/original/file-20240211-30-7rkqni.gif?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=670&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/574774/original/file-20240211-30-7rkqni.gif?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=670&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">AMIE dialogue.</span>
<span class="attribution"><a class="source" href="https://blog.research.google/2024/01/amie-research-ai-system-for-diagnostic_12.html">(Google)</a></span>
</figcaption>
</figure>
<p>The potential of large language models (LLMs) like AMIE are clear. By being trained on a large database of text, LLM can generate text, identify the underlying meaning, and respond in a human-like manner. Provided patients have access to the internet, health advice could be tailored to the patient, provided quickly and easily, and allowing for triage of cases that are best handled by human health-care professionals.</p>
<p>But these tools are still in the experimental stages and have limitations. <a href="https://blog.research.google/2024/01/amie-research-ai-system-for-diagnostic_12.html">AMIE researchers</a> say further study is needed to “envision a future in which conversational, empathic and diagnostic AI systems might become safe, helpful and accessible.”</p>
<p>Precautions must be taken. Health-care delivery is a complicated task. Left unregulated — professionally or internationally — it presents challenges to quality of care, privacy and security.</p>
<h2>Medical decision-making</h2>
<p>Medical decision-making is among the most complicated and consequential of any activities. It might seem unlikely that an AI could work as effectively as a human clinician, however, <a href="https://doi.org/10.1037/1040-3590.12.1.19">decades of research</a> suggest that <a href="https://doi.org/10.1177/0011000005285875">algorithmic approaches to decision-making can be equal, or superior to, clinical intuition</a>.</p>
<p>Pattern recognition represents the core of medical expertise. Like other forms of <a href="https://doi.org/10.1111/j.1365-2923.2007.02946.x">expertise</a>, medical experts require <a href="https://doi.org/10.5489%2Fcuaj.3267">extensive training</a> to learn the diagnostic patterns, provide treatment recommendations and deliver care. Through effective instruction, <a href="https://doi.org/10.1037/a0016272">learners</a> <a href="https://doi.org/10.1016/j.humpath.2006.08.024">narrow the focus of their attention to diagnostic features, while ignoring non-diagnostic features</a>. </p>
<p>Yet, effective health-care delivery requires <a href="https://doi.org/10.3109/0142159X.2010.501190">more than just the ability to recognize patterns</a>. Health-care professionals must be capable of communicating this information to their patients. Beyond the difficulties of translating technical knowledge to patients with varying levels of <a href="https://doi.org/10.1111/j.1525-1497.2005.40245.x">health literacy</a>, health information is often emotionally charged, leading to <a href="https://doi.org/10.1136/archdischild-2021-323451">communication traps</a> where doctors and patients withhold information. By developing <a href="https://doi.org/10.1016/j.cpr.2008.04.002">a strong relationship with their patients</a>, health-care professionals can bridge these gaps.</p>
<p>The conversational features of LLMs, like <a href="https://chat.openai.com/auth/login">ChatGPT</a>, have generated considerable public interest. While claims that ChatGPT has “<a href="https://doi.org/10.1038/d41586-023-02361-7">broken the Turing Test</a>” are overstated, their human-like responses make LLM more engaging than previous <a href="https://doi.org/10.1016/j.chb.2016.01.004">chatbots</a>. Future LLMs like AMIE might prove to fill gaps in health-care delivery, however, they must be adopted with caution.</p>
<h2>Promise of accurate, explainable AI in health-care</h2>
<figure class="align-center ">
<img alt="A smartphone with a stethoscope and an image of a white coat on the screen" src="https://images.theconversation.com/files/577607/original/file-20240223-20-fl3i6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/577607/original/file-20240223-20-fl3i6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=333&fit=crop&dpr=1 600w, https://images.theconversation.com/files/577607/original/file-20240223-20-fl3i6.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=333&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/577607/original/file-20240223-20-fl3i6.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=333&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/577607/original/file-20240223-20-fl3i6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=418&fit=crop&dpr=1 754w, https://images.theconversation.com/files/577607/original/file-20240223-20-fl3i6.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=418&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/577607/original/file-20240223-20-fl3i6.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=418&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Effective health-care delivery requires more than just the ability to recognize patterns. Health-care professionals must be capable of communicating this information to their patients.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<p>AMIE is not Google’s first health-care technology. In 2008, <a href="https://www.google.com/publicdata/explore?ds=z3bsqef7ki44ac_">Google Flu Trends (GFT)</a> was used to estimate the prevalence of influenza within a population by using aggregated search terms. They assumed that users’ search behaviour should be related to the prevalence of the flu, with the search trends of the past predicting future cases.</p>
<p>GFT’s early predictions were <a href="https://doi.org/10.1038/nature07634">quite promising</a>. <a href="https://doi.org/10.1126/science.1248506">Until they failed</a>, with old data being identified as the source of bias. <a href="https://doi.org/10.1371/journal.pcbi.1007258">Later efforts to retrain the model with updated search trends again proved successful</a>. </p>
<p><a href="https://www.ibm.com/watson">IBM’s Watson</a> provides another cautionary tale. IBM invested considerable capital in developing Watson and implemented over 50 health-care projects. Watson’s potential <a href="https://doi.org/10.1109/MSPEC.2019.8678513">failed to materialize</a>, with the underlying technologies quietly being sold off. Not only did the system fail to engender trust, that distrust was well deserved as it produced <a href="https://www.statnews.com/2018/07/25/ibm-watson-recommended-unsafe-incorrect-treatments/">“unsafe and incorrect” treatment recommendations</a>.</p>
<p>AIs developed to diagnose, triage and predict the progression of COVID-19 provide the best example of the readiness of AIs in health care to handle public health challenges. Broad reviews of these efforts cast doubt on the outcomes. <a href="https://doi.org/10.1136/bmj.m1328">The validity and accuracy of the models and their predictions were generally lacking</a>. This was largely attributed to <a href="https://cdei.blog.gov.uk/2021/03/08/reflecting-on-the-use-of-ai-and-data-driven-technology-in-the-pandemic/">the quality of data</a>.</p>
<p>One of the lessons that can be gleaned from the use of AI during COVID is that there is no shortage of researchers and algorithms, however, there is a dire need for <em>human</em> quality control. This has led to calls for <a href="https://doi.org/10.1109/TTS.2023.3257627">human-centred design</a>. </p>
<p>This is also true of expert reviews of the technologies themselves. Like <a href="https://arxiv.org/abs/2312.00164">Google’s AMIE</a>, many publications that assess these technologies are released as pre-prints before or during the peer review process. There can also be extensive <a href="https://doi.org/10.1002/asi.23044">lags between a pre-print and its eventual publication</a>. Rather than quality, research has demonstrated that <a href="https://doi.org/10.1371%2Fjournal.pone.0047523">the number of mentions on social media is a greater predictor of a publication’s download rate</a>.</p>
<p>Without ensuring <a href="https://www.routledge.com/Ethical-Artificial-Intelligence-from-Popular-to-Cognitive-Science-Trust/Schoenherr/p/book/9780367697983">the validity of the methods for training and implementation</a>, health technologies might be adopted without any formal means of quality control. </p>
<h2>Technology as folk medicine</h2>
<p>The problem of AI in health-care is made clear when we acknowledge that many health ecosystems can exist in parallel. <a href="https://doi.org/10.1002/9781444395303.ch20">Medical pluralism</a> is observed when two or more <em>systems</em> are available to health consumers. This typically takes the form of <a href="https://www.who.int/health-topics/traditional-complementary-and-integrative-medicine#tab=tab_1">traditional medicine</a> and a western biomedical approach.</p>
<p>As apps are direct-to-consumer health technologies, they represent a <a href="https://doi.org/10.1109/MTS.2022.3197273">new folk medicine</a>. Users adopt these technologies based on <a href="https://doi.org/10.1145/3428361.3428362">trust rather than understanding how they operate</a>. In the absence of medical knowledge and technical understanding of an AIs operations, <a href="https://doi.org/10.2196/11254">users are left to look for cues about a technology’s effectiveness</a>. <a href="https://doi.org/10.1109/MTS.2022.3197273">App store ratings and endorsements</a> can replace the expert review of health-care professionals. </p>
<p>Users might prefer to use AI-enabled technologies rather than humans in cases where their health concerns are associated with <a href="https://doi.org/10.1016/j.jad.2024.01.168">stigma</a> or <a href="https://doi.org/10.1007/978-3-030-91684-8_7">chronic emotional distress</a>. However, the accuracy of these systems might lag due to failures to update data. </p>
<p>The provision of user data also creates challenges. Much like <a href="https://doi.org/10.1186/s12910-016-0101-9">23andMe</a>, if users disclose personal information, it might leave clues to others in their social networks. </p>
<p>If left unregulated, these technologies pose challenges for the quality of care. Professional and national regulations are required to ensure these technologies truly benefit the public.</p><img src="https://counter.theconversation.com/content/222059/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jordan Richard Schoenherr has received funding from the Ottawa Hospital Research Institute for his research in medical education and decision-making.</span></em></p>Future AI large language models like Google’s AMIE might prove to fill gaps in health-care delivery, however, they must be adopted with caution.Jordan Richard Schoenherr, Assistant Professor, Psychology, Concordia UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2214942024-02-04T13:33:47Z2024-02-04T13:33:47ZHow better and cheaper software could save millions of dollars while improving Canada’s health-care system<figure><img src="https://images.theconversation.com/files/570446/original/file-20240120-27145-3rmndw.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C5613%2C3681&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A Canada-wide health information technology system based on open-source software could save billions for the health-care system.</span> <span class="attribution"><a class="source" href="https://www.pexels.com/photo/nurse-labeling-test-tubes-6285380/">(Gustavo Fring/Pexels)</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span></figcaption></figure><p>Billions of Canadian tax dollars have been funnelled to private companies <a href="https://doi.org/10.13162/hro-ors.v2i3.1179">to develop proprietary medical software</a>. More tax dollars were then paid to the same companies to use the software to run our medical system. </p>
<p>This might not have seemed like a big deal at a time when Canadians could easily get a doctor and our medical system <a href="https://nationalpost.com/news/canada-doctor-ratios-what-happened">had one of the best doctor-patient ratios in the world</a>. </p>
<p>Fast forward to today, when <a href="https://globalnews.ca/news/9901922/canadians-family-doctor-shortage-cma-survey/">one-fifth of Canadians cannot find a doctor and more than half “battle” for appointments</a>. You can now easily spend an <a href="https://globalnews.ca/news/10218446/canada-emergency-rooms-overwhelmed-cma/">entire day waiting when you visit the emergency room</a>. Wait time for surgeries and diagnostic tests such as MRIs are much longer now, and <a href="https://toronto.citynews.ca/2023/12/09/canadians-die-waiting-surgery-report/">over 17,000 Canadians died waiting</a> for health care in 2023. </p>
<p>The once-great Canadian health-care system is being <a href="https://globalnews.ca/news/10218446/canada-emergency-rooms-overwhelmed-cma/">pushed to its limits</a>, and as a result, is “<a href="https://www.cfpc.ca/en/canada-s-health-care-system-on-verge-of-collapse-family-doctors-warn">failing</a>.” Add Canada’s <a href="https://www.bbc.com/news/world-us-canada-65047436">recent population growth</a> into the equation, and you have an under-resourced system that is stretched too thin.</p>
<p>The health system might be better prepared for these challenges if literally billions of dollars had not been squandered on proprietary software development. A <a href="https://doi.org/10.1007/s10916-023-01949-w">new study</a> I wrote with my colleague Jack Peplinski at Western University shows how embracing open-source development saves millions and could help rescue Canada’s broken health-care system.</p>
<h2>Undoing waste</h2>
<figure class="align-center ">
<img alt="A woman in a white coat and stethoscope with an iPad" src="https://images.theconversation.com/files/572988/original/file-20240202-25-7vmjxi.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/572988/original/file-20240202-25-7vmjxi.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=338&fit=crop&dpr=1 600w, https://images.theconversation.com/files/572988/original/file-20240202-25-7vmjxi.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=338&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/572988/original/file-20240202-25-7vmjxi.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=338&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/572988/original/file-20240202-25-7vmjxi.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=424&fit=crop&dpr=1 754w, https://images.theconversation.com/files/572988/original/file-20240202-25-7vmjxi.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=424&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/572988/original/file-20240202-25-7vmjxi.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=424&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">On top of the cost of development, with proprietary software, each doctor’s office as well as each hospital has to pay for its own electronic health record licence.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<p>Although the Canadian federal government has invested <a href="https://doi.org/10.13162/hro-ors.v2i3.1179">over $2.1 billion developing health information technology (HIT)</a>, all 10 provinces still have their own separate HIT systems. Besides being an obvious source of redundancy and waste, these systems: </p>
<ul>
<li>do not work together, </li>
<li>are expensive and </li>
<li>are inconsistent. </li>
</ul>
<p>After first reviewing how these systems operate, <a href="https://doi.org/10.1007/s10916-023-01949-w">we analyzed</a> the economic costs and savings of integrating some of the functions of the software. We chose something easy and straightforward that all the provinces needed and settled on the common billing, lab results and diagnostic imaging (BLD) functions of these separate systems. </p>
<p>Then we proposed using a free and open-source software system called HermesAPI to provide BLD for Canada. Our results provide a glimmer of hope for our struggling health-care system.</p>
<h2>Proprietary software vs. open source</h2>
<p>To understand how money is best spent on software development, you have to understand a little bit about licensing. </p>
<p>The HIT software that has been bleeding Canada dry is proprietary. No one other than the company that made it knows how it works, and each province pays these companies a licence fee to use their software even if they originally paid to develop it. No one can share the software either (for example, Ontario cannot legally share the software it helped fund with Alberta or vice versa). </p>
<p>That means each province must fund companies that pay employees to maintain nearly identical software, 10 times over. Each doctor’s office and each hospital has to pay for its own electronic health record licence. </p>
<p>Worse yet, the Canada Health Act states that health care should be portable, <a href="https://doi.org/10.1503/cmaj.181647">but because these HIT systems are separate, it is not</a>. <a href="https://www.cbc.ca/news/canada/toronto/ehealth-scandal-a-1b-waste-auditor-1.808640">The Auditor General of Ontario’s 2009 report on electronic health records (EHRs) found more than a billion dollars of waste</a>. </p>
<p>Another approach that immediately eliminates that waste is called <a href="https://itsfoss.com/what-is-foss/">free and open source software</a> (FOSS). FOSS is available in source code (open source) form, and can be used, studied, copied, modified and redistributed with restrictions that only ensure that further recipients have the same rights as those under which it was obtained. </p>
<p>That last bit is the core viral idea of open source development: if anyone makes an improvement in the software, they must share it back with the community. This is how FOSS evolves and the rapid churn in <a href="https://doi.org/10.1109/MRA.2016.2646748">innovation</a> in a <a href="https://www.appropedia.org/Create,_Share,_and_Save_Money_Using_Open-Source_Projects">wide array of areas</a> is the result.</p>
<p>Not surprisingly, industry loves open source. Ninety per cent <a href="https://fortune.com/2013/05/06/how-linux-conquered-the-fortune-500/">of the Fortune Global 500 use open-source development</a>. In fact, today, open source software is the dominant way to develop software in industry because it tends to be <a href="https://www.doi.org/10.1257/0895330054048678">technically superior</a> and <a href="https://doi.org/10.1109/52.951496">more secure</a>. </p>
<p>The evidence for this is that FOSS is in <a href="https://www.zdnet.com/article/supercomputers-all-linux-all-the-time/">100 per cent of the world’s supercomputers</a>, <a href="https://www.rackspace.com/en-gb/blog/realising-the-value-of-cloud-computing-with-linux">90 per cent of cloud servers</a>, <a href="https://www.idc.com/promo/smartphone-market-share">82 per cent of smartphones</a> and <a href="https://spectrum.ieee.org/open-source-ai">most artificial intelligence</a>. </p>
<p>Every internet company you use, from Facebook to Amazon to Wikipedia, is built on a stack of open source software.</p>
<h2>A better way to develop medical software</h2>
<p>Currently, eight provincial governments representing over 95 per cent of Canada’s population allow private companies to create their own electronic medical records (EMR) system and integrate with provincial BLD systems.</p>
<p>Our study found the cost to develop and maintain HermesAPI would be about $610,000, but would prevent $120,000 per software development company per province in development costs, for a savings of $6.4 million. This approach would lower barriers to entry for the HIT industry to increase competition, improve the quality of HIT products and ultimately patient care.</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/L1yGlEGfH4g?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">Jack Peplinski, software engineering and business administration student at Western University and co-author of a study on the potential impact of open-source health software, describes HermesAPI.</span></figcaption>
</figure>
<p>The real secret of open source software is that it encourages competition in capitalism. FOSS prevents vendor lock-in and monopolistic companies, both of which are common with our current proprietary software model. For example, <a href="https://doi.org/10.1503/cmaj.109-5765">90 per cent of EMRs in Canada</a> are the products of just three United States-based companies.</p>
<p>Our study looked just at BLD, but there are many other such opportunities in our health-care system. The open-source approach is one option towards building a more interoperable, less expensive and more consistent HIT system for Canada. </p>
<p>Yes, this means we will be sending less money to prop-up American software companies, but the return on investment of open source is likely to be very high. Fifteen years ago, Ontario’s Auditor General found that by implementing a unified medical records system, we could save at <a href="https://www.cbc.ca/news/canada/toronto/ehealth-scandal-a-1b-waste-auditor-1.808640">least $6 billion</a>. It is far more than that now. </p>
<p>This time, we could do it right and instead of subsidizing proprietary U.S. companies, we can ensure every Canadian dollar invested in software is open source so we can save our loonies for doctors, nurses and hospital beds to keep up with our burgeoning population.</p><img src="https://counter.theconversation.com/content/221494/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Joshua M. Pearce has received funding for research from the Natural Sciences and Engineering Research Council of Canada, the Canada Foundation for Innovation, Mitacs, the U.S. Department of Energy (DOE) and the Advanced Research Projects Agency-Energy (ARPA-E), U.S. Department of Defense, The Defense Advanced Research Projects Agency (DARPA), and the National Science Foundation (NSF). In addition, his past and present consulting work and research is funded by the United Nations, the National Academies of Science, Engineering and Medicine, many non-profits and for-profit companies. He has no direct conflicts of interests.</span></em></p>Canada has spent billions on health-care software that does not even communicate province to province. Free and open-source software would be a technically superior and far less expensive option.Joshua M. Pearce, John M. Thompson Chair in Information Technology and Innovation and Professor, Western UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2172642024-01-28T19:05:20Z2024-01-28T19:05:20ZMedicare turns 40: since 1984 our health needs have changed but the system hasn’t. 3 reforms to update it<figure><img src="https://images.theconversation.com/files/571353/original/file-20240125-29-9x8icz.jpg?ixlib=rb-1.1.0&rect=0%2C57%2C7719%2C4513&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://unsplash.com/photos/selective-focus-photography-of-assorted-color-balloons-Hli3R6LKibo">Ali Goldstein/Unsplash</a></span></figcaption></figure><p>Forty years ago, Medicare as we know it today was born. It was the reincarnation of the Whitlam government’s Medibank, introduced in 1975 but <a href="https://www.sciencedirect.com/science/article/abs/pii/0277953684902661">dismantled</a> in stages by the Fraser Liberal government. </p>
<p>Medibank was developed in the 1960s by health economists <a href="https://grattan.edu.au/news/remebering-richard-scotton-co-founder-of-medicare/">Dick Scotton</a> and <a href="https://openresearch-repository.anu.edu.au/bitstream/1885/159512/1/Daring_to_Dream.pdf">John Deeble</a>, when disease prevalence was different and the politics of reform were diabolical. </p>
<p>But the nation has changed since 1984, and so have our health needs. Medicare is now struggling to ensure the access to health care for millions of Australians we were once promised. </p>
<p>Let’s look at how we got here – and three radical changes we need to keep the Medicare promise into the future: making it cheaper to see a GP; paying less for blood and imaging tests; and covering dental care. </p>
<hr>
<p>
<em>
<strong>
Read more:
<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">If you live in a bulk-billing ‘desert’ it's hard to see a doctor for free. Here's how to fix this</a>
</strong>
</em>
</p>
<hr>
<h2>Free hospital care, but you might pay to see a GP</h2>
<p>One of my first jobs in the health system, in the days before Medicare and Medibank, was acting in charge of revenue collection for three public hospitals. A small subset of people could get free, albeit stigmatised, care. </p>
<p>We had bad debts, because some people couldn’t afford to pay their hospital bills and I was allowed by policy to recommend that some be written off. But for others I had to seek court authorisation to seize their wages to pay off their hospital debt. </p>
<p>Medibank changed that. Now all Australians can get public hospital care without any financial barrier.</p>
<figure class="align-center ">
<img alt="Doctor draws blood from patient" src="https://images.theconversation.com/files/571350/original/file-20240125-19-xmbtth.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/571350/original/file-20240125-19-xmbtth.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/571350/original/file-20240125-19-xmbtth.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/571350/original/file-20240125-19-xmbtth.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/571350/original/file-20240125-19-xmbtth.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/571350/original/file-20240125-19-xmbtth.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/571350/original/file-20240125-19-xmbtth.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">Before Medicare and Medibank, patients often faced hospital care debts.</span>
<span class="attribution"><a class="source" href="https://unsplash.com/photos/a-woman-laying-in-a-hospital-bed-next-to-a-man-dkZQfm1LLQE">National Cancer Institute/Unsplash</a></span>
</figcaption>
</figure>
<p>But the financial barriers to seeing a GP or a private specialist (out of hospital) have remained. Doctors continue to charge what they like, with Medicare often only covering a portion of their fees. This has left many patients facing significant out-of-pocket payments.</p>
<p>When Medicare was designed, medical care was provided mostly by solo medical practitioners working in practices they owned. It was a one-to-one professional relationship, with the patient paying the practitioner for each service. </p>
<p>Over time, general practice evolved into group practices organised as partnerships. Next, they <a href="https://onlinelibrary.wiley.com/doi/10.5694/mja2.51038">consolidated and corporatised</a>. A handful of corporates now provide all <a href="https://www.accc.gov.au/system/files/public-registers/documents/ACL%20Healius%20%20-%20Statement%20of%20Issues.pdf">private pathology</a> (which tests blood and other tissues) and <a href="https://www.jacr.org/article/S1546-1440(07)00614-X/fulltext">radiology</a> (which provides imaging services) and a large proportion of GP care. </p>
<p>Corporates have not made the same inroads into most other specialties. But since the 1980s, states have reduced public hospital outpatient services. So patients are now more reliant on private medical specialists for care referred by their GP.</p>
<h2>Much has changed, but cost of living pressures remain</h2>
<p>Health-care needs have changed. As we live longer, we live with more diseases, many of which are chronic. The care required increasingly involves many different health providers and includes non-medical specialties such as podiatry, physiotherapy and psychology. </p>
<p>When Medicare was introduced, university education was offered for only a few of these professions. But their training has evolved and so too what they can do. This is particularly the case for nursing. It has evolved from an apprenticeship model to a profession with its own specialties. A subset – nurse practitioners – have the authority to diagnose and prescribe medication.</p>
<p>Broader technology trends have also had an impact on health care, as with all other sectors. Virtual care and telehealth <a href="https://theconversation.com/what-can-you-use-a-telehealth-consult-for-and-when-should-you-physically-visit-your-gp-135046">proved their worth</a> during the early years of the COVID pandemic, just as generative AI is beginning to show its promise now.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/ai-can-help-detect-breast-cancer-but-we-dont-yet-know-if-it-can-improve-survival-rates-210800">AI can help detect breast cancer. But we don't yet know if it can improve survival rates</a>
</strong>
</em>
</p>
<hr>
<p>Medicare was first and foremost about efficiently removing financial barriers to access. It was introduced as part of an <a href="https://www.jstor.org/stable/20635272">agreement with the Labor movement</a> about reducing costs of living and, in particular, ensuring people could attend a doctor without having to worry about how they would pay for the visit.</p>
<p>However, <a href="https://www.abs.gov.au/statistics/health/health-services/patient-experiences/2022-23#data-downloads">about 1.2 million Australians</a> deferred or missed out on seeing a GP because of cost in the 2022-23 financial year. Lower-income Australians have higher rates of missing out on care. </p>
<p>Medical fees aren’t regulated and so consumers face a lottery – not knowing whether a fee will be charged and having no control over that decision. Only about 52% of all Australians were <a href="https://www.health.gov.au/sites/default/files/2023-08/medicare-statistics-per-patient-bulk-billing-dashboard-2022-23.pdf">always bulk-billed</a> in 2022-23, down from 66% a year earlier. </p>
<p>So how can we get Medicare back on track towards its goal of universal health care for all Australians? Here are three radical reforms we should prioritise. </p>
<h2>1. Make GP care affordable for all</h2>
<p>Rebates are currently subject to political whim. The Liberal government (in office from 2013 to 2022) froze rebates, leading to increases in average out-of-pocket payments and reduced bulk-billing.</p>
<p>The first step in reducing costs as a barrier to GP care should be introduction of independent fee-setting. </p>
<p>Canadian Medicare – which was the model for Australia’s system – mostly has <a href="https://journals.sagepub.com/doi/full/10.1177/0840470421994304">no out-of-pocket payments</a>. Fees are set by negotiations, not politicians’ whims, and this is <a href="https://laws-lois.justice.gc.ca/eng/acts/C-6/page-1.html#h-151558">enshrined in legislation</a>. </p>
<p>With independent fee-setting in place, a new scheme of “participating providers” should be introduced. Under such a scheme, practices would bulk-bill everyone, and participate in agreed quality-improvement programs.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/what-if-medicare-was-restricted-to-gps-who-bulk-billed-this-kind-of-reform-is-possible-203543">What if Medicare was restricted to GPs who bulk billed? This kind of reform is possible</a>
</strong>
</em>
</p>
<hr>
<p>If fees are set independently and fairly, extra billing over and above the fee is unjustifiable. Non-participating practices would not be eligible for Medicare benefits. </p>
<p>It’s anticipated the vast majority of practices would agree to participate. In Canada, the participation rate is roughly 100%, and bulk billing in Australia is <a href="https://www.health.gov.au/resources/publications/medicare-quarterly-statistics-bulk-billing-by-primary-health-network-september-quarter-2023-24">still over 75%</a>.</p>
<p>Participating practices should also be eligible for additional grants to employ other health professionals to provide a more comprehensive range of services – such as physiotherapists and psychologists – to meet the contemporary needs of a population with increasing chronic illness. </p>
<p>If successful, these changes would mean all Australians can access a GP and other primary care services without any out-of-pocket costs.</p>
<h2>2. Deal with diagnostics</h2>
<figure class="align-center ">
<img alt="Blood vials" src="https://images.theconversation.com/files/571360/original/file-20240125-25-3sefgm.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/571360/original/file-20240125-25-3sefgm.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/571360/original/file-20240125-25-3sefgm.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/571360/original/file-20240125-25-3sefgm.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/571360/original/file-20240125-25-3sefgm.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/571360/original/file-20240125-25-3sefgm.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/571360/original/file-20240125-25-3sefgm.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 cost of processing tests varies.</span>
<span class="attribution"><a class="source" href="https://unsplash.com/photos/green-pink-and-purple-plastic-bottles-0jE8ynV4mis">Testalize.me/Unsplash</a></span>
</figcaption>
</figure>
<p>Despite the evolution of ownership and market structures, pathology and radiology services are still reimbursed by fees for each service (with complex rules about rebates when multiple tests are performed simultaneously). </p>
<p>But while both industries are expensive to set up and buy or lease equipment, the cost of processing an additional test or image is low and sometimes close to zero. This means Medicare pays pathology and radiology providers much more than the tests or images cost.</p>
<p>Both industries are also ripe for further technological change, with the quality of generative AI rapidly improving, and costs likely to further reduce.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/blood-money-pathology-cuts-can-reduce-spending-without-compromising-health-54834">Blood money: pathology cuts can reduce spending without compromising health</a>
</strong>
</em>
</p>
<hr>
<p>The uncapped fee-for-service model for pathology and radiology needs to be replaced by one in which the benefits of technological change are shared between shareholders and taxpayers, rather than all accruing to the former. </p>
<p>This could be done by replacing fee-for-service payments with a payment model used in the corporate world. Private and public providers could be <a href="https://grattan.edu.au/report/blood-money-paying-for-pathology-services/">invited to tender</a> to provide these services in certain areas, with conditions around geographic access, quality and no out-of-pocket payments for consumers. </p>
<p>The same model could also apply to other technology-intensive types of health care, such as radiotherapy for cancer.</p>
<p>These changes might be cost-neutral for government, and save consumers the $24 they currently pay out of pocket on every pathology test that is not currently bulk-billed and $122 on each non-bulk-billed diagnostic imaging test.</p>
<h2>3. Cover dental care too</h2>
<figure class="align-center ">
<img alt="Boy undergoes dental treatment" src="https://images.theconversation.com/files/571358/original/file-20240125-19-wcmr9t.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/571358/original/file-20240125-19-wcmr9t.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=338&fit=crop&dpr=1 600w, https://images.theconversation.com/files/571358/original/file-20240125-19-wcmr9t.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=338&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/571358/original/file-20240125-19-wcmr9t.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=338&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/571358/original/file-20240125-19-wcmr9t.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=424&fit=crop&dpr=1 754w, https://images.theconversation.com/files/571358/original/file-20240125-19-wcmr9t.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=424&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/571358/original/file-20240125-19-wcmr9t.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=424&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Dental care is largely unaffordable.</span>
<span class="attribution"><a class="source" href="https://unsplash.com/photos/boy-in-blue-long-sleeve-shirt-drinking-from-a-feeding-bottle-loBRFqXm1QA">Lafayett Zapata Montero/Unsplash</a></span>
</figcaption>
</figure>
<p>A major omission from Medicare from the start, and a source of continuing inequity, is oral health care. More than two million Australians <a href="https://www.abs.gov.au/statistics/health/health-services/patient-experiences/2022-23#data-downloads">missed out</a> on oral health care because of cost in 2022-23.</p>
<p>A new scheme to <a href="https://grattan.edu.au/report/filling-the-gap/">slowly expand universal protection</a> against the costs of oral health care should be phased in over the next decade. This would eventually mean all preventive and basic dental care would be available for everyone, with no out-of-pocket payments. </p>
<p>This would require a parallel expansion of the oral health workforce (dentists and <a href="https://www.dentalboard.gov.au/Registration/Oral-Health-Therapist.aspx">oral health therapists</a>) and development of new payment models based on a participating practice model rather than simply introducing another unregulated schedule of oral health fees paid via Medicare.</p>
<p>Innovation <a href="https://www.health.gov.au/sites/default/files/2023-12/nhra-mid-term-review-final-report-october-2023.pdf">needs to be built into the Australian health system</a>. However, the foundations for innovation must be based on Medicare’s founding principles of addressing financial barriers to provide universal and equitable health care to all Australians. </p>
<hr>
<p>
<em>
<strong>
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>
</strong>
</em>
</p>
<hr>
<img src="https://counter.theconversation.com/content/217264/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Stephen Duckett, like all Australians, benefits from Medicare.</span></em></p>The health care world has changed a lot in 40 years, but Medicare hasn’t. Here are three areas for radical forms to the system that will achieve its aims of universal health care for all Australians.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/2174952024-01-10T23:10:59Z2024-01-10T23:10:59ZBreaking the curve: A call for comprehensive scoliosis awareness and care<figure><img src="https://images.theconversation.com/files/568748/original/file-20240110-29-9agwvv.jpg?ixlib=rb-1.1.0&rect=1417%2C0%2C7257%2C5787&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Scoliosis is a prevalent and underappreciated condition across Canada.</span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><iframe style="width: 100%; height: 100px; border: none; position: relative; z-index: 1;" allowtransparency="" allow="clipboard-read; clipboard-write" src="https://narrations.ad-auris.com/widget/the-conversation-canada/breaking-the-curve-a-call-for-comprehensive-scoliosis-awareness-and-care" width="100%" height="400"></iframe>
<p><a href="https://www.cbc.ca/news/canada/wait-times-marketplace-1.6620306">Cael</a> was a typical 15-year-old — until the discovery of an already advanced abnormal curvature of his spine. </p>
<p>“I felt like the Hunchback of Notre Dame,” Cael told CBC News, recalling the emotionally draining and gruesome two-year wait for spinal surgery during which his curve progressed to a whopping 108 degrees.</p>
<p><a href="https://doi.org/10.1016/s0140-6736(08)60658-3">Scoliosis is an abnormal twisting and curving of the spine that can develop at any age, but mostly occurs during rapid growth spurts in children</a>, and as part of spine aging in adults over the age of 60. </p>
<p>Of all types of scoliosis in children, adolescent idiopathic scoliosis is the most prevalent, <a href="https://doi.org/10.1016/j.semarthrit.2016.07.013">accounting for as many as nine in 10 cases and impacting up to one in 20 adolescents globally</a>. On the other end of the age spectrum, a staggering <a href="https://doi.org/10.1097/01.brs.0000160842.43482.cd">two-thirds of older adults are also affected</a>.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/explainer-everything-you-need-to-know-about-scoliosis-28409">Explainer: everything you need to know about scoliosis</a>
</strong>
</em>
</p>
<hr>
<p>In clinical care, research and education related to scoliosis, disparities persist worldwide. Despite its widespread prevalence, scoliosis often goes undiagnosed, or has delayed diagnosis as in Cael’s case. It also receives limited attention in clinical and public health education, leading to significant gaps in health care.</p>
<p>This general lack of awareness has serious implications for thousands of people like Cael.</p>
<h2>Gaps in effective care</h2>
<p>In the United States, fewer than half of states legislate <a href="https://doi.org/10.1186/1748-7161-8-17">school-based scoliosis screening in children</a>. Even worse, Canada discontinued screening back in <a href="https://canadiantaskforce.ca/wp-content/uploads/2016/09/1994-red-brick-en.pdf">1979</a> because it was not considered cost-effective. </p>
<p>Pediatricians’ <a href="https://cps.ca/en/documents/position/greig-health-record-technical-report">screening</a> practices vary, and some cases of scoliosis in children are only discovered when an unrelated chest X-ray reveals a curved spine. With about <a href="https://doi.org/10.1007/s00586-011-2074-1">30 per cent of cases being hereditary</a>, parents may not recognize the signs early on.</p>
<p>The <a href="https://www.srs.org/Files/Patient-Brochures/Patient.Adolescent_Idiopathic_Scoliosis_Handbook_for_Patients.pdf">recommended care</a> in North America involves bracing for mild to moderate curves (25° to 45°) and surgery for curves exceeding 45°. Shockingly, <a href="https://doi.org/10.1097/brs.0b013e318059b5f7">32 per cent of Canadian children</a>, like Cael, face delayed referrals, discovering significant curves when they finally see specialists.</p>
<figure class="align-center ">
<img alt="X-ray images of two human torsos showing signs of scoliosis" src="https://images.theconversation.com/files/568729/original/file-20240110-27-7zzgup.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/568729/original/file-20240110-27-7zzgup.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=530&fit=crop&dpr=1 600w, https://images.theconversation.com/files/568729/original/file-20240110-27-7zzgup.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=530&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/568729/original/file-20240110-27-7zzgup.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=530&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/568729/original/file-20240110-27-7zzgup.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=666&fit=crop&dpr=1 754w, https://images.theconversation.com/files/568729/original/file-20240110-27-7zzgup.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=666&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/568729/original/file-20240110-27-7zzgup.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=666&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Radiologic comparison of adult idiopathic scoliosis (A) and adult degenerative scoliosis (B).</span>
<span class="attribution"><span class="source">(Cho KJ, Kim YT, Shin SH, Suk SI)</span>, <a class="license" href="http://creativecommons.org/licenses/by-nc/4.0/">CC BY-NC</a></span>
</figcaption>
</figure>
<p>Despite documented success in managing scoliosis through early <a href="https://doi.org/10.1016/j.spinee.2015.01.019">screening</a>, <a href="https://doi.org/10.1016/j.physio.2023.07.005">exercise rehabilitation</a> and <a href="https://doi.org/10.1056/nejmoa1307337">brace</a> treatment, global health-care education often neglects this condition. </p>
<p>The general lack of global awareness leaves physicians, nurses and other practitioners unaware of effective treatments and referral processes, contributing to the misunderstanding and under-treatment of patients. Consequently, when children with scoliosis eventually reach specialists for care, they may encounter challenges navigating the health-care system as they transition into adulthood.</p>
<h2>Sex disparities</h2>
<p>It is unclear why adolescent idiopathic <a href="https://doi.org/10.1016/j.semarthrit.2016.07.013">scoliosis affects mainly girls</a>. The more severe the curve, the more likely the patient is female. Due to their specific biology, <a href="https://doi.org/10.1016/j.semarthrit.2016.07.013">females</a> also face a five-fold higher risk of progressive deformities and are 10 times more likely, compared to males, to require surgery.</p>
<p>Despite generally uncomplicated <a href="https://doi.org/10.1097/00007632-200107010-00015">pregnancies and deliveries</a>, women with scoliosis often face <a href="https://doi.org/10.1097/bpo.0000000000002499">difficulties receiving pain control</a> during labour, with higher epidural failure rates. Moreover, they often suffer pregnancy-related back pain, and their spine <a href="https://doi.org/10.7759/cureus.46782">curvature may worsen after pregnancy</a>.</p>
<h2>Health-care access barriers</h2>
<p>Health-care access in the U.S. is influenced by a range of factors including race, income and health insurance coverage. </p>
<p>Patients with <a href="https://doi.org/10.1097/bpo.0000000000002551">better insurance</a> plans tend to seek pediatric orthopedic care at a younger age. Those with public insurance tend to have worse spine curvatures by the time they reach a scoliosis specialist; this is particularly striking among Black patients with public insurance, who are <a href="https://doi.org/10.1097/bpo.0000000000002213">67 per cent less likely</a> to be diagnosed at a stage early enough for effective brace treatment compared to Black patients with private insurance.</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/iMmQZ6J6WrE?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">A brief overview on recognizing idiopathic scoliosis produced by Veritas Health.</span></figcaption>
</figure>
<p>While Canada’s health-care system covers spinal fusion for severe scoliosis, the lack of a national insurance program in the U.S. leads to varying out-of-pocket expenses for patients. </p>
<p>Those without insurance often cannot afford surgery at all. </p>
<p>But even with Canada’s universal coverage, patients typically wait <a href="http://waittimes.alberta.ca/WaitTimeTrends.jsp?rcatID=56&rhaID=All_34_&doSearch=true&urgencyCode=9&facilityID=-9_&checkedRegionNo=0&oldCheckedRegionNo=0&oldCheckedFacilityNo=0&ifDisplayFacility=false&ifDisplayPhysician=false&command=goToAccessGoals&chartType=access_goal&subChartType=90_75_50_25_AVERAGE_&disabledChartType=trend&status=processAjax&ifHavingFPTMeasurement=true#WaitTimeInfo">an entire year</a> for surgery due to a shortage of providers. Because of regional variability in resources such as access to spinal surgeons, funding and specialized facilities, some kids, like Cael, wait even longer, experiencing physical, emotional and psychological burdens, while their curves get progressively worse. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/how-healthy-is-the-canadian-health-care-system-82674">How healthy is the Canadian health-care system?</a>
</strong>
</em>
</p>
<hr>
<p>Delayed surgery in Canada cost the health-care system <a href="https://www.childrenshealthcarecanada.ca/en/child-health-advocacy/no-child-elects-wait_october2023.pdf">$44.6 million</a> due to more complex surgeries, extended hospital stays, readmission and re-operation rates.</p>
<h2>Workforce and research disparities</h2>
<p>Ongoing gender disparities in the health-care workforce and lack of research funding for this female-predominant condition continue to hamper effective action.</p>
<p><a href="https://doi.org/10.1016/j.wneu.2018.09.152">Fewer than five per cent of spinal surgeons</a> identify as women. <a href="https://journals.lww.com/annalsofsurgery/toc/2011/04000">Glass-ceiling</a> effects surround women surgeons in this male-dominated culture, perpetuating gendered training environments, being held to higher standards and earning lower wages. The dearth of senior women role models and mentors is a further barrier for career advancement and retention.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/canadas-health-care-crisis-is-gendered-how-the-burden-of-care-falls-to-women-215751">Canada’s health-care crisis is gendered: How the burden of care falls to women</a>
</strong>
</em>
</p>
<hr>
<p>Furthermore, <a href="https://doi.org/10.1038/d41586-023-01472-5">research funding</a> for diseases, such as scoliosis, that mainly affect females has historically lagged far behind funding for male-predominant diseases. <a href="https://doi.org/10.1002/9781119374855.ch26">Improving workforce diversity</a> is an important facet of addressing health disparities and shaping research agendas.</p>
<p>Inequities abound in scoliosis care and research. The impact of lack of awareness and delayed care extends beyond physical challenges. The patient and their family suffer emotionally, incurring significant financial burden while fearing the future. </p>
<p>The message is clear, we must do better for this underserved population.</p><img src="https://counter.theconversation.com/content/217495/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>Scoliosis is a treatable condition, but only if detected early. Greater awareness of the condition and its dynamics will greatly aid in patient care moving forward.Sanja Schreiber, Adjunct Professor, Faculty of Rehabilitation Medicine - Physical Therapy, University of AlbertaEmily Somers, Professor of Internal Medicine, Environmental Health Sciences, and Obstetrics & Gynecology, University of MichiganLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2198782023-12-19T23:42:53Z2023-12-19T23:42:53ZOral health is health: Better access to dental care may have potential benefits beyond Canadians’ mouths<figure><img src="https://images.theconversation.com/files/566686/original/file-20231219-15-3hv10x.jpg?ixlib=rb-1.1.0&rect=688%2C22%2C4303%2C2964&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Because oral health is linked to overall health, dental care needs to be viewed as an integral part of health care. </span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><iframe style="width: 100%; height: 100px; border: none; position: relative; z-index: 1;" allowtransparency="" allow="clipboard-read; clipboard-write" src="https://narrations.ad-auris.com/widget/the-conversation-canada/oral-health-is-health-better-access-to-dental-care-may-have-potential-benefits-beyond-canadians-mouths" width="100%" height="400"></iframe>
<p>Oral diseases, particularly dental decay and periodontal (gum) diseases, are largely preventable, yet are some of the <a href="https://www.who.int/data/gho/data/themes/oral-health-data-portal">most common non-communicable diseases around the world</a>. Pain due to untreated dental decay impacts eating and sleep quality, among other essential functions. Indeed, the agonizing nature of dental pain earned it the title of “<a href="https://doi.org/10.1038/sj.bdj.4809302">the hell of all diseases</a>” more than 200 years ago.</p>
<p>But pain is only the most obvious of the many ways oral health is linked to overall health.</p>
<h2>Access to dental care</h2>
<p>The federal government recently launched the long-anticipated <a href="https://www.canada.ca/en/services/benefits/dental/dental-care-plan.html">Canada Dental Care Plan</a> (CDCP) to improve access to dental care for the almost <a href="https://www.canada.ca/en/health-canada/news/2023/12/the-canadian-dental-care-plan.html">nine million Canadians</a> who lack dental insurance.</p>
<p>The program comes in light of the increasing barriers to dental care with the most recent data from Statistics Canada showing that <a href="https://www150.statcan.gc.ca/n1/daily-quotidien/231106/dq231106a-eng.htm">one in four Canadians avoid seeing a dental professional due to costs</a>. While this burden affects mostly low-income families, seniors and people living with disabilities, it also places a huge toll on the population as a whole.</p>
<p>On top of the time lost from school or work due to dental problems, many without the means to access dental care end up seeking care in hospital emergency departments, unnecessarily costing the health-care system billions of dollars.</p>
<p>The CDCP is an important milestone that could eventually get many Canadians the dental care they need and deserve. Meanwhile, this investment in oral health is a reminder of the importance of a healthy mouth, what makes it fundamental to overall health, and notably, how the potential impact of improving access to dental care for those who need it most may extend beyond the mouth.</p>
<h2>Oral health is integral for overall health</h2>
<p>The <a href="https://www.who.int/health-topics/oral-health#tab=tab_1">World Health Organization</a> (WHO) defines oral health as “the state of the mouth, teeth and orofacial structures that enables individuals to perform essential functions such as eating, breathing and speaking, and encompassing psychosocial dimensions such as self-confidence, well-being, and the ability to socialize and work without pain, discomfort and embarrassment.”</p>
<p>A healthy, disease-free mouth is key to quality of life and well-being. Being fundamental to various essential functions, the lack of oral health connects it to a number of chronic diseases in several ways.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/filling-the-gaps-why-canada-still-needs-a-public-dental-health-plan-despite-decades-of-medicare-181306">Filling the gaps: Why Canada still needs a public dental health plan despite decades of medicare</a>
</strong>
</em>
</p>
<hr>
<p>The most <a href="https://iris.who.int/bitstream/handle/10665/373542/9789240070820-eng.pdf?sequence=1">recent WHO report</a> shows that dental decay and gum diseases affect almost 25 per cent of Canadian adults — a higher figure than that observed in the United States. Importantly, both conditions are among the most common causes of tooth loss in adults globally, thereby impacting the ability to eat, the quality of nutrition and, in seniors, <a href="https://doi.org/10.1111/jgs.16377">contributing to frailty</a> and <a href="https://doi.org/10.1111/jgs.13190">declining cognitive health</a>.</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/uMVgyZcH1ig?wmode=transparent&start=49" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">Prime Minister Justin Trudeau making an announcement about applying for the federal dental benefit, at one of Western University’s dental clinics in December 2022.</span></figcaption>
</figure>
<p>Severe gum disease in particular is an inflammatory condition that is linked to several other chronic conditions through <a href="https://doi.org/10.1038/s41577-020-00488-6">exacerbating inflammatory reactions</a> in other organs and body systems and that may arguably contribute to some <a href="https://doi.org/10.1016/j.amjcard.2016.05.036">heart</a> and <a href="https://doi.org/10.1111/nep.13225">kidney diseases</a>, among others.</p>
<p>Importantly, there is <a href="https://doi.org/10.1038/sj.bdj.2017.544">a bidirectional relationship between gum diseases and diabetes</a>, where severe inflammation of the gums and supporting bone can aggravate the risk and complications of diabetes, and vice versa.</p>
<p>The consequences of an unhealthy mouth also extend to an individual’s social interactions. For example, those experiencing poor esthetics due to crooked, broken or stained teeth are more likely to be <a href="https://doi.org/10.1016/j.ssmph.2015.11.001">stigmatized and blamed for their dental appearance</a>. In severe cases, they may potentially have <a href="https://www.thestar.com/news/why-is-he-out-of-work/article_711c362f-333c-5580-97ae-7f4646eb092d.html">fewer opportunities for employment</a>.</p>
<p>Observations such as these bring to mind the 19th century’s French naturalist and father of paleontology, Georges Cuvier who famously said, “<a href="https://wellcomecollection.org/articles/W3LpDykAACgAEVFi">Show me your teeth and I will tell you who you are</a>.” </p>
<p>Cuvier’s statement at the time intended to describe how teeth where distinctive of populations according to diets and environmental impacts. Nevertheless, it is not hard to see its relevance to the appearance and health of the mouth and teeth and their impact on how one is perceived in today’s society.</p>
<h2>Children’s health and dental care</h2>
<figure class="align-center ">
<img alt="A boy being examined. by a dental care worker out of shot" src="https://images.theconversation.com/files/566687/original/file-20231219-23-k1u7se.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/566687/original/file-20231219-23-k1u7se.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/566687/original/file-20231219-23-k1u7se.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/566687/original/file-20231219-23-k1u7se.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/566687/original/file-20231219-23-k1u7se.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/566687/original/file-20231219-23-k1u7se.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/566687/original/file-20231219-23-k1u7se.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">Canadian kindergarteners in need of dental treatment are found to score lower on physical, cognitive, social and emotional development scales than those without dental problems.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<p>Certainly, oral diseases affect all age groups and children are no exception. Recent reports show that almost <a href="https://iris.who.int/bitstream/handle/10665/373542/9789240070820-eng.pdf?sequence=1">39 per cent of Canadian children</a> under nine years old have dental decay. Just like in adults, the impact of dental decay on children extends to poor nutrition, and affects sleep and development.</p>
<p>For example, Canadian kindergarteners in need of dental treatment were found to <a href="https://doi.org/10.1186/s12887-019-1868-x">score lower on physical, cognitive, social and emotional development scales</a> than those without dental problems. On top of this, researchers found the treatment of severely decayed teeth to be by far <a href="https://publications.gc.ca/collections/collection_2014/icis-cihi/H118-94-2013-eng.pdf">the most common reason for children aged one to five years old to receive general anesthesia to undergo surgery</a>.</p>
<h2>Dental care and chronic conditions</h2>
<p>The connection between oral health and overall health is evident in myriad ways, and so is the need to improve oral health and access to dental care in Canada. It also raises the question of whether dental care can help alleviate chronic conditions beyond the mouth. </p>
<p>The <a href="https://doi.org/10.1038/s41467-022-35337-8">scientific evidence on that varies</a>, and largely depends on the chronic condition in question. For example, patients with diabetes are among those who can benefit the most from having better access to dental care. Treating gum diseases can help subside body inflammation and <a href="https://doi.org/10.1002%2F14651858.CD004714.pub4">reduce the risk and complications of diabetes by helping the body regulate blood glucose levels</a>. </p>
<p>Notably, Canada ranks <a href="https://iris.who.int/bitstream/handle/10665/373542/9789240070820-eng.pdf">fourth out of 29 countries</a> in the Region of the Americas in its rate of lip and oral cavity cancer. Many dentists are trained to spot the signs of oral cancer and can help in its early detection, which can be lifesaving.</p>
<p>As we learn more on the impact of dental treatment on chronic disease management, we know that facilitating access to dental care can have promising results on several fronts. In addition to saving costs for individuals and our health-care system, it would enhance the population’s oral health and potentially help in the management of some chronic diseases, such as diabetes. </p>
<p>Importantly, it can reduce the pervasive and inequitable burden of oral diseases. </p>
<p>Indeed, investing in better access to dental care may bring us closer to a healthy smile and beyond, for every Canadian.</p><img src="https://counter.theconversation.com/content/219878/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Noha Aziz-Ezzat Gomaa receives or has received funding from the Canadian Institutes of Health Research, the Schulich School of Medicine & Dentistry at Western University, and the Children's Health Foundation. She is affiliated with various national and provincial dental professional associations.</span></em></p>In addition to saving costs for individuals and our health-care system, facilitating access to dental care would enhance the population’s oral health and potentially help in managing chronic diseases.Noha A. Gomaa, Assistant Professor, Dental Public Health and Oral Medicine, Schulich School of Medicine & Dentistry, Western UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2178032023-12-18T23:18:02Z2023-12-18T23:18:02ZWomen want to see the same health provider during pregnancy, birth and beyond<figure><img src="https://images.theconversation.com/files/566233/original/file-20231218-17-b7lsjp.jpg?ixlib=rb-1.1.0&rect=8%2C146%2C5742%2C3578&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/mid-adult-female-nurse-comforting-tensed-228783766">Tyler Olson/Shutterstock</a></span></figcaption></figure><p>In theory, pregnant women in Australia <a href="https://theconversation.com/explainer-what-are-womens-options-for-giving-birth-55133">can choose</a> the type of health provider they see during pregnancy, labour and after they give birth. But this is often dependent on where you live and how much you can afford in out-of-pocket costs. </p>
<p>While standard public hospital care is the <a href="https://www.aihw.gov.au/reports/mothers-babies/maternity-models-of-care/contents/about">most common</a> in Australia, accounting for 40.9% of births, the other main options are: </p>
<ul>
<li>GP shared care, where the woman sees her GP for some appointments (15% of births)</li>
<li>midwifery continuity of care in the public system, often called <a href="https://theconversation.com/call-the-midwife-playing-catch-up-with-australias-maternity-care-22544">midwifery group practice</a> or caseload care, where the woman sees the same midwife of team of midwives (14%)</li>
<li>private obstetrician care (10.6%)</li>
<li>private midwifery care (1.9%). </li>
</ul>
<p>Given the choice, which model would women prefer?</p>
<p>Our <a href="https://bmcpregnancychildbirth.biomedcentral.com/articles/10.1186/s12884-023-06130-2">new research</a>, published BMC Pregnancy and Childbirth, found women favoured seeing the same health provider throughout pregnancy, in labour and after they have their baby – whether that’s via midwifery group practice, a private midwife or a private obstetrician. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/more-than-6-000-women-told-us-what-they-wanted-for-their-next-pregnancy-and-birth-heres-what-they-said-211435">More than 6,000 women told us what they wanted for their next pregnancy and birth. Here's what they said</a>
</strong>
</em>
</p>
<hr>
<h2>Assessing strengths and limitations</h2>
<p>We surveyed 8,804 Australian women for the Birth Experience Study (BESt) and 2,909 provided additional comments about their model of maternity care. The respondents were representative of state and territory population breakdowns, however fewer respondents were First Nations or from culturally or linguistically diverse backgrounds.</p>
<p>We analysed these comments in six categories – standard maternity care, high-risk maternity care, GP shared care, midwifery group practice, private obstetric care and private midwifery care – based on the perceived strengths and limitations for each model of care.</p>
<p>Overall, we found models of care that were fragmented and didn’t provide continuity through the pregnancy, birth and postnatal period (standard care, high risk care and GP shared care) were more likely to be described negatively, with more comments about limitations than strengths. </p>
<h2>What women thought of standard maternity care in hospitals</h2>
<p>Women who experienced standard maternity care, where they saw many different health care providers, were disappointed about having to retell their story at every appointment and said they would have preferred continuity of midwifery care. </p>
<p>Positive comments about this model of care were often about a midwife or doctor who went above and beyond and gave extra care within the constraints of a fragmented system. </p>
<figure class="align-center ">
<img alt="Baby being cleaned after birth" src="https://images.theconversation.com/files/566239/original/file-20231218-29-ls16h5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/566239/original/file-20231218-29-ls16h5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=397&fit=crop&dpr=1 600w, https://images.theconversation.com/files/566239/original/file-20231218-29-ls16h5.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=397&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/566239/original/file-20231218-29-ls16h5.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=397&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/566239/original/file-20231218-29-ls16h5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=499&fit=crop&dpr=1 754w, https://images.theconversation.com/files/566239/original/file-20231218-29-ls16h5.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=499&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/566239/original/file-20231218-29-ls16h5.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=499&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Sometimes midwives and doctors in the public system exceeded expectations.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/baby-being-cleaned-assessed-by-paediatrician-1118249573">Inez Carter/Shutterstock</a></span>
</figcaption>
</figure>
<p>The model of care with the highest number of comments about limitations was high-risk maternity care. For women with pregnancy complications who have their baby in the public system, this means seeing different doctors on different days. </p>
<p>Some respondents received conflicting advice from different doctors, and said the focus was on their complications instead of their pregnancy journey. One woman in high-risk care noted:</p>
<blockquote>
<p>The experience was very impersonal, their focus was my cervix, not preparing me for birth.</p>
</blockquote>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/1-in-10-women-report-disrespectful-or-abusive-care-in-childbirth-186827">1 in 10 women report disrespectful or abusive care in childbirth</a>
</strong>
</em>
</p>
<hr>
<h2>Why women favoured continuity of care</h2>
<p>Overall, there were more positive comments about models of care that provided continuity of care: private midwifery care, private obstetric care and midwifery group practice in public hospitals. </p>
<p>Women recognised the benefits of continuity and how this included informed decision-making and supported their choices.</p>
<p>The model of care with the highest number of positive comments was care from a privately practising midwife. Women felt they received the “gold standard of maternity care” when they had this model. One woman described her care as:</p>
<blockquote>
<p>Extremely personable! Home visits were like having tea with a friend but very professional. Her knowledge and empathy made me feel safe and protected. She respected all of my decisions. She reminded me often that I didn’t need her help when it came to birthing my child, but she was there if I wanted it (or did need it).</p>
</blockquote>
<p>However, this is a private model of care and women need to pay for it. So there are barriers in accessing this model of care due to the <a href="https://doi.org/10.1016/j.wombi.2020.06.001">cost</a> and the small numbers working in Australia, particularly in <a href="https://www.ruralhealth.org.au/sites/default/files/publications/fact-sheet-midwives.pdf">regional, rural and remote areas</a>, among other barriers.</p>
<p>Women who had private obstetricians were also positive about their care, especially among women with medical or pregnancy complications – this type of care had the second-highest number of positive comments. </p>
<p>This was followed by women who had continuity of care from midwives in the public system, which was described as respectful and supportive. </p>
<p><iframe id="iRWBu" class="tc-infographic-datawrapper" src="https://datawrapper.dwcdn.net/iRWBu/2/" height="400px" width="100%" style="border: none" frameborder="0"></iframe></p>
<p>However, one of the limitations about continuity models of care is when the woman doesn’t feel connected to her midwife or doctor. Some women who experienced this wished they had the opportunity to choose a different midwife or doctor. </p>
<h2>What about shared care with a GP?</h2>
<p>While shared care between the <a href="https://raisingchildren.net.au/pregnancy/health-wellbeing/tests-appointments/gps-shared-care-pregnancy">GP</a> and hospital model of care is widely promoted in the public maternity care system as providing continuity, it had a similar number of negative comments to those who had fragmented standard hospital care. </p>
<p>Considering there is strong evidence about the <a href="https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD004667.pub5/full">benefits of midwifery continuity of care</a>, and this model of care appears to be most acceptable to women, it’s time to expand access so all Australian women can access continuity of care, regardless of their location or ability to pay. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/birthing-on-country-services-centre-first-nations-cultures-and-empower-women-in-pregnancy-and-childbirth-170641">Birthing on Country services centre First Nations cultures and empower women in pregnancy and childbirth</a>
</strong>
</em>
</p>
<hr>
<img src="https://counter.theconversation.com/content/217803/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Hazel Keedle is affiliated with the Australian College of Midwives. Funding for this study was from a School of Nursing and Midwifery Partnership Grant through Western Sydney University, The Qiara Vincent Thiang Memorial Award and Maridulu Budyari Gumal SPHERE Maternal, Newborn and Women’s Clinical Academic Group funding.</span></em></p><p class="fine-print"><em><span>Hannah Dahlen has received funding from the National Health and Medical Research Commission, the Australian Research Council, the Medical Research Future Fund (funding and for this study and funding from a School of Nursing and Midwifery Partnership Grant through Western Sydney University), The Qiara Vincent Thiang Memorial Award and Maridulu Budyari Gumal SPHERE Maternal, Newborn and Women’s Clinical Academic Group funding.</span></em></p>Women favour seeing the same health provider throughout pregnancy, in labour and after they have their baby – whether that’s via midwifery group practice, a private midwife or a private obstetrician.Hazel Keedle, Senior Lecturer of Midwifery, Western Sydney UniversityHannah Dahlen, Professor of Midwifery, Associate Dean Research and HDR, Midwifery Discipline Leader, Western Sydney UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2173742023-11-30T01:09:07Z2023-11-30T01:09:07ZArtificial intelligence is already in our hospitals. 5 questions people want answered<figure><img src="https://images.theconversation.com/files/560122/original/file-20231117-23-mms70g.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C1000%2C666&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/female-face-matrix-digital-numbers-artifical-2268966863">Shutterstock</a></span></figcaption></figure><p>Artificial intelligence (AI) is already being used in health care. AI can look for patterns in <a href="https://journal.achsm.org.au/index.php/achsm/article/view/861">medical images</a> to help diagnose disease. It can help predict who in a hospital ward might <a href="https://www.jmir.org/2021/9/e28209">deteriorate</a>. It can <a href="https://elicit.com/">rapidly summarise</a> medical research papers to help doctors stay up-to-date with the latest evidence.</p>
<p>These are examples of AI making <a href="https://theconversation.com/artificial-intelligence-wont-replace-a-doctor-any-time-soon-but-it-can-help-with-diagnosis-83353">or shaping</a> decisions health professionals previously made. More applications are being developed.</p>
<p>But what do consumers think of using AI in health care? And how should their answers shape how it’s used in the future?</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/ai-is-already-being-used-in-healthcare-but-not-all-of-it-is-medical-grade-207912">AI is already being used in healthcare. But not all of it is 'medical grade'</a>
</strong>
</em>
</p>
<hr>
<h2>What do consumers think?</h2>
<p>AI systems are trained to look for patterns in large amounts of data. Based on these patterns, AI systems can make recommendations, suggest diagnoses, or initiate actions. They can potentially continually learn, becoming better at tasks over time.</p>
<p>If we draw together <a href="https://www.sciencedirect.com/science/article/pii/S0277953623007141#appsec1">international</a> evidence, including <a href="https://www.uow.edu.au/the-arts-social-sciences-humanities/research/acheev/artificial-intelligence-in-health/">our own</a> <a href="https://journal.achsm.org.au/index.php/achsm/article/view/861">and that</a> <a href="https://humanfactors.jmir.org/2022/3/e34514/authors">of others</a>, it seems most consumers accept the potential value of AI in health care. </p>
<p>This value could include, for example, increasing the <a href="https://www.jmir.org/2022/8/e37611/">accuracy of diagnoses</a> or improving <a href="https://mental.jmir.org/2019/11/e12942/">access to care</a>. At present, these are largely potential, rather than proven, benefits. </p>
<p>But consumers say their acceptance is conditional. They still have serious concerns.</p>
<p><strong>1. Does the AI work?</strong></p>
<p>A baseline expectation is AI tools should work well. Often, consumers say AI should be at least as good as a <a href="https://journal.achsm.org.au/index.php/achsm/article/view/861">human doctor</a> at the tasks it performs. They say we should not use AI if it will lead to more incorrect diagnoses or medical errors.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/ai-chatbots-are-still-far-from-replacing-human-therapists-201084">AI chatbots are still far from replacing human therapists</a>
</strong>
</em>
</p>
<hr>
<p><strong>2. Who’s responsible if AI gets it wrong?</strong></p>
<p>Consumers also worry that if AI systems generate decisions – such as diagnoses or treatment plans – without human input, it may be unclear who is responsible for errors. So people often want clinicians to remain responsible for the final decisions, and for <a href="https://www.nature.com/articles/s41746-021-00509-1">protecting patients</a> from harms.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/who-will-write-the-rules-for-ai-how-nations-are-racing-to-regulate-artificial-intelligence-216900">Who will write the rules for AI? How nations are racing to regulate artificial intelligence</a>
</strong>
</em>
</p>
<hr>
<p><strong>3. Will AI make health care less fair?</strong></p>
<p>If health services are <a href="https://theconversation.com/ms-dhu-coronial-findings-show-importance-of-teaching-doctors-and-nurses-about-unconscious-bias-60319">already discriminatory</a>, AI systems can learn these patterns from data and <a href="https://www.science.org/doi/10.1126/science.aax2342">repeat or worsen</a> the discrimination. So AI used in health care can make health inequities worse. In our studies consumers said this <a href="https://journals.sagepub.com/doi/pdf/10.1177/20552076231191057">is not OK</a>.</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1655077669610962944"}"></div></p>
<p><strong>4. Will AI dehumanise health care?</strong></p>
<p>Consumers are concerned AI will take the “human” elements out of health care, consistently saying AI tools should <a href="https://journals.sagepub.com/doi/full/10.1177/20552076221116772">support rather than replace</a> doctors. Often, this is because AI is perceived to lack important human traits, <a href="https://journals.sagepub.com/doi/full/10.1177/2055207619871808">such as empathy</a>. Consumers say the communication skills, care and touch of a health professional are especially important when feeling vulnerable.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/chatbots-for-medical-advice-three-ways-to-avoid-misleading-information-213266">Chatbots for medical advice: three ways to avoid misleading information</a>
</strong>
</em>
</p>
<hr>
<p><strong>5. Will AI de-skill our health workers?</strong></p>
<p>Consumers value human clinicians and their expertise. In our <a href="https://journals.sagepub.com/doi/full/10.1177/20552076231191057">research with women</a> about AI in breast screening, women were concerned about the potential effect on radiologists’ skills and expertise. Women saw this expertise as a precious shared resource: too much dependence on AI tools, and this resource might be lost.</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"926426239119716352"}"></div></p>
<h2>Consumers and communities need a say</h2>
<p>The Australian health-care system cannot focus only on the technical elements of AI tools. Social and ethical considerations, including high-quality engagement with consumers and communities, are essential to shape AI use in health care.</p>
<p>Communities need opportunities to develop <a href="https://theconversation.com/chatbots-for-medical-advice-three-ways-to-avoid-misleading-information-213266">digital health literacy</a>: <a href="https://www.goodthingsfoundation.org.au/the-digital-divide/digital-health/">digital skills</a> to access reliable, trustworthy health information, services and resources. </p>
<p>Respectful engagement with Aboriginal and Torres Strait Islander communities must be central. This includes upholding Indigenous data sovereignty, which the Australian Institute of Aboriginal and Torres Strait Islander Studies <a href="https://aiatsis.gov.au/publication/116530">describes as</a>:</p>
<blockquote>
<p>the right of Indigenous peoples to govern the collection, ownership and application of data about Indigenous communities, peoples, lands, and resources.</p>
</blockquote>
<p>This includes any use of data to create AI. </p>
<p>This critically important consumer and community engagement needs to take place before managers design (more) AI into health systems, before <a href="https://theconversation.com/who-will-write-the-rules-for-ai-how-nations-are-racing-to-regulate-artificial-intelligence-216900">regulators</a> create guidance for how AI should and shouldn’t be used, and before clinicians consider buying a new AI tool for their practice.</p>
<p>We’re making some progress. Earlier this year, we ran a <a href="https://www.uow.edu.au/the-arts-social-sciences-humanities/research/acheev/artificial-intelligence-in-health/">citizens’ jury on AI in health care</a>. We supported 30 diverse Australians, from every state and territory, to spend three weeks learning about AI in health care, and developing recommendations for policymakers.</p>
<p>Their recommendations, which will be published in an upcoming issue of the Medical Journal of Australia, have informed a recently released <a href="https://aihealthalliance.org/">national roadmap</a> for using AI in health care.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/worried-about-ai-you-might-have-ai-nxiety-heres-how-to-cope-205874">Worried about AI? You might have AI-nxiety – here's how to cope</a>
</strong>
</em>
</p>
<hr>
<h2>That’s not all</h2>
<p>Health professionals also need to be upskilled and supported to use AI in health care. They need to learn to be critical users of digital health tools, including understanding their pros and cons.</p>
<p>Our <a href="https://pubmed.ncbi.nlm.nih.gov/37071804/">analysis</a> of safety events reported to the Food and Drug Administration shows the most serious harms reported to the US regulator came not from a faulty device, but from the way consumers and clinicians used the device.</p>
<p>We also need to consider when health professionals should tell patients an AI tool is being used in their care, and when health workers should seek informed consent for that use.</p>
<p>Lastly, people involved in every stage of developing and using AI need to get accustomed to asking themselves: do consumers and communities agree this is a justified use of AI? </p>
<p>Only then will we have the AI-enabled health-care system consumers actually want.</p><img src="https://counter.theconversation.com/content/217374/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Stacy Carter receives funding from National Health and Medical Research Council, National Breast Cancer Foundation, Medical Research Futures Fund. </span></em></p><p class="fine-print"><em><span>Emma Frost receives funding from the Australian Government Research Training Program and the National Health and Medical Research Council.</span></em></p><p class="fine-print"><em><span>Farah Magrabi receives funding from the National Health and Medical Research Council, the Digital Health CRC and Macquarie University. She is Co-Chair of the Australian Alliance for AI in Healthcare's Safety, Quality and Ethics Working Group. </span></em></p><p class="fine-print"><em><span>Yves Saint James Aquino receives funding from the National Health and Medical Research Council (CRE 2006-545 - WiserHealthcare). He is affiliated with Bellberry Limited, a not-for-profit organisation providing scientific and ethical review of human research projects.</span></em></p>Before AI becomes widespread in health care, we need to ask what matters to consumers.Stacy Carter, Professor and Director, Australian Centre for Health Engagement, Evidence and Values, University of WollongongEmma Frost, PhD candidate, Australian Centre for Health Engagement, Evidence and Values, University of WollongongFarah Magrabi, Professor of Biomedical and Health Informatics at the Australian Institute of Health Innovation, Macquarie UniversityYves Saint James Aquino, Research Fellow, Australian Centre for Health Engagement, Evidence and Values, University of WollongongLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2101752023-11-28T13:39:50Z2023-11-28T13:39:50ZA researcher’s prescription for better health care: A dose of humility for doctors, nurses and clinicians<figure><img src="https://images.theconversation.com/files/559428/original/file-20231114-23-30bea5.jpg?ixlib=rb-1.1.0&rect=0%2C33%2C7348%2C4869&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Humility among health care providers can help prevent burnout.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/synchronizing-their-tasks-before-shift-royalty-free-image/543353618?phrase=doctors+conferring+with+patients&searchscope=image%2Cfilm&adppopup=true">Cecilie Arcurs/E+ via Getty Images</a></span></figcaption></figure><p>Better health care for patients begins with humility – a term not often associated with medicine.</p>
<p>I witnessed displays of humility firsthand eight years ago, the night my son was born, in the way the doctor and doula worked together to deliver our baby.</p>
<p>Neither tried to assert dominance over the other. Instead, they openly communicated with each other, respected each other’s roles, trusted each other and worked as a team. And what was most meaningful to us – they included my wife on that team by actively listening to her and putting her needs at the forefront.</p>
<p>Together, the team’s professional humility helped create the most unforgettable moment of our lives: the birth of a healthy baby boy.</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/3boKz0Exros?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">A talk on the concept of “teaming.”</span></figcaption>
</figure>
<h2>The patient as part of the team</h2>
<p>Our experience with them made a significant impression on me because <a href="https://scholar.google.com/citations?user=ZIS0zKMAAAAJ&hl=en&oi=ao">I’m a social scientist</a> who studies how clinicians collaborate. Specifically, I explore how doctors, nurses and the entire health care team can better show professional humility to ensure better outcomes for patients and for health care workers as well.</p>
<p>Put simply, professional humility in the health care setting is when doctors, nurses, physician assistants, pharmacists, physical therapists, support staff – basically every health care provider – see each other as playing on the same team. </p>
<p>That means team members share the same goals, understand the limitations of their own profession, see the strengths offered by others and include the patient and their caregivers in decision-making. </p>
<p>That willingness to make the patient part of the team is key to professional humility. Instead of talking about the patient among themselves, the providers address the patient directly and <a href="https://doi.org/10.1186/s12912-021-00684-2">actively listen</a>. They openly admit when they don’t know the answer or if they were incorrect. And rather than talking down to the patient, they explain things calmly, <a href="https://theconversation.com/confused-by-what-your-doctor-tells-you-a-new-study-discovers-how-communication-gaps-between-doctors-and-patients-can-be-cured-173805">using everyday language</a> and avoiding arcane medical jargon. </p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/zc33PlyWLPI?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">What we have here is a failure to communicate.</span></figcaption>
</figure>
<h2>The power of humility</h2>
<p>A growing body of research demonstrates that clinicians’ humility positively affects patient <a href="https://doi.org/10.1016/j.pec.2019.07.022">satisfaction, health outcomes</a> and <a href="https://doi.org/10.1016/j.pec.2016.01.012">overall care</a>. Additionally, emerging evidence indicates that having humility is good for health care providers as well – serving as a <a href="https://doi.org/10.1007/s12144-022-03324-3">protective factor against burnout</a> and even <a href="https://theconversation.com/medical-guidelines-that-embrace-the-humility-of-uncertainty-could-help-doctors-choose-treatments-with-more-research-evidence-behind-them-183328">clinical uncertainty</a>.</p>
<p>But if humility is so beneficial, why isn’t there <a href="https://doi.org/10.1097/XCS.0000000000000640">more of it in health care</a>? And why is it not formally taught in medical, nursing and other health profession schools? </p>
<p>Most people have likely experienced or witnessed scenarios where clinicians <a href="https://doi.org/10.1177/15248399211027540">exhibit the opposite of humility</a>, such as when providers show open disrespect for each other or engage in power struggles, or when a patient feels ignored, rushed, dismissed or spoken to rudely. These are common examples of a lack of humility in health care. </p>
<p>But humility can be difficult to achieve in professional settings. In my experience, there are still assumptions by health care providers that displaying intellectual humility <a href="https://doi.org/10.1007/978-981-19-1512-3_24">suggests a lack of knowledge and confidence</a>, the opposite of what the health professions want to instill in their students.</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/7zk_AJBO60Y?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">Better communication between doctors and patients develops trusting relationships.</span></figcaption>
</figure>
<h2>Money concerns and turf battles</h2>
<p>The lack of emphasis on humility in health care could also be due to pervasive, systemic issues nested deep within the industry itself. The very culture of today’s health care industry is heavily influenced by <a href="https://doi.org/10.1007/s10198-015-0736-3">competition for patients and resources</a>, <a href="https://doi.org/10.1186/s13047-015-0061-1">battles over money and turf</a> and <a href="https://doi.org/10.1177/1062860613518963">infighting between and within departments</a>. Even the years of professional training are riddled with competition for the best test scores, opportunities and recognition. These are hardly the kinds of backstories that lead people to suddenly embrace the relatively unexplored concept of practicing humility. </p>
<p>In fact, research shows that humility is not a sign of weakness or self-doubt. Instead, it reflects <a href="https://doi.org/10.1016/j.mayocp.2023.01.020">exceptional security and confidence</a>. These are essential attributes for a patient-centered, team-oriented health care workforce.</p>
<p>Here’s another example of professional humility that I experienced when my son was about 6. He was spinning around in my office chair while I was close by in a meeting. He slipped off and hit his head on the corner of my desk, causing quite a gash. </p>
<p>Luckily, my meeting was with a group of doctors, nurses and physician assistants. I had a team of clinicians right there to assess my son for any need of stitches. Gently talking to him, disregarding professional “rank” by collectively assessing the wound, openly seeking their colleagues’ opinions and engaging me directly about possible next steps – all while jokingly noting the serendipity of the situation – clearly reflected professional humility. </p>
<p>Researchers are just starting to scratch the surface of understanding precisely how professional humility leads to teamwork and more effective care. But the early research suggests that it’s an essential ingredient. </p>
<p>If you do find yourself or a loved one in the hospital, you may be confronted with hard decisions and frightening uncertainties about the future. When that happens, you will no doubt want a health care team that is harmonious, communicative and connected. That sense of calm in the chaos provides patients and family with reassurance, hope and healing.</p><img src="https://counter.theconversation.com/content/210175/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Barret Michalec receives funding from the Robert Wood Johnson Foundation, and has received funding from the Josiah Macy Jr. Foundation and the Arnold P. Gold Foundation.
(potential) Relevant Affiliations: Associate Clinical Professor, Medical Humanities, Creighton University School of Medicine.
This article was produced with support from UC Berkeley's Greater Good Science Center and the John Templeton Foundation as part of the GGSC's initiative on Expanding Awareness of the Science of Intellectual Humility.</span></em></p>Research shows that when health care professionals work in a collaborative manner, patient satisfaction and outcomes improve.Barret Michalec, Research Associate Professor of Nursing and Health Innovation, Arizona State UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2163992023-11-19T13:00:25Z2023-11-19T13:00:25ZFood insecurity in Canada is the worst it’s ever been — here’s how we can solve it<p>According to the latest Statistics Canada data, household food insecurity in the 10 provinces has reached a record high. Drawing on data from StatCan’s Canadian Income Survey, our <a href="https://proof.utoronto.ca/resource/household-food-insecurity-in-canada-2022/">new report</a> has found that the percentage of households with inadequate or insecure access to food due to financial constraints rose to 17.8 per cent in 2022 from 15.9 per cent in 2021.</p>
<p>That amounts to 6.9 million Canadians — 1.1 million more than in 2021 — living in households with experiences that range from worrying about running out of food before there’s enough money to buy more to not eating at all for entire days because of a lack of income.</p>
<p>One-quarter of food-insecure households were severely food insecure, meaning 1.5 million Canadians had to cut or skip meals over the past 12 months.</p>
<p>These estimates don’t include people living in First Nations or the territories – the Northwest Territories, Yukon and Nunavut – <a href="https://proof.utoronto.ca/resources/indigenous-food-insecurity/">where rates of food insecurity are typically even higher</a>.</p>
<p>The rate of household food insecurity differs dramatically across the provinces, ranging from 13.8 per cent in Québec to 22.9 per cent in Newfoundland and Labrador in 2022. Every province experienced an increase from the previous year.</p>
<h2>Health-care system impact</h2>
<p>These numbers are important because they tell us about more than just household food situations. By the time someone reports being unable to afford the food they need, they’re likely compromising spending on other necessities, like housing and <a href="https://doi.org/10.9778/cmajo.20190075">prescription medications</a>.</p>
<p>Living in these circumstances is <a href="https://proof.utoronto.ca/food-insecurity/what-are-the-implications-of-food-insecurity-for-health-and-health-care/">very harmful to people’s health and well-being</a>. The health implications extend beyond poor nutrition and diet-related diseases to a sweeping array of adverse health outcomes, including physical and mental health conditions and <a href="https://doi.org/10.1503/cmaj.190385">premature death</a>.</p>
<p>When we look at the health administration records of Canadians living in food-insecure households, the extraordinary toll food insecurity is taking on individuals and on our health-care system is obvious.</p>
<p>Because their health is worse, people living in these households require more health care. Both <a href="https://doi.org/10.17269/s41997-023-00812-2">the children</a> and <a href="https://doi.org/10.1503/cmaj.150234">the adults</a> in food-insecure households are more likely to use outpatient services and to be hospitalized. Once admitted, <a href="https://doi.org/10.1377/hlthaff.2019.01637">they stay in acute care for longer and are more likely to require readmission</a>. </p>
<p>The increased use of the health-care system translates to greater health-care costs and an additional burden on our public system that simply isn’t necessary.</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/ulxb-XOd064?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
</figure>
<h2>Evidence-based policy interventions</h2>
<p>Reducing food insecurity requires concerted efforts by federal and provincial governments to address the root cause — the inadequacy of household incomes to meet basic needs. </p>
<p>Providing better income support gives households a fighting chance of managing sudden losses of income or increases in expenses without having to compromise necessities.</p>
<p>Studies have shown food insecurity decreases when low-income households receive more money via <a href="https://doi.org/10.1016/j.amepre.2023.01.027">child benefits</a> or <a href="https://doi.org/10.3138/cpp.2014-080">social assistance programs</a>. That’s also the case when households transition to a more adequate and stable source of income — namely, when low-income adults become <a href="https://doi.org/10.3138/cpp.2015-069">eligible for public pensions programs</a>, Old Age Security and Guaranteed Income Supplement. </p>
<p>However, the way these programs are currently designed means our social safety net is anything but.</p>
<h2>Public income supports</h2>
<p>Households with limited or no employment income and reliant on provincial social assistance or Employment Insurance are very likely to be food insecure. Relying on social assistance almost guarantees food insecurity; seven in 10 households on social assistance were food insecure in 2022.</p>
<p>In most jurisdictions, social assistance benefits aren’t indexed to inflation, so the poorest people in our communities become even poorer as prices rise. Provinces should look to raise and index benefit amounts, asset limits and earning exemptions so that recipients have enough for basic needs while in these programs of last resort.</p>
<p>Households reliant on employment income fare better, but simply having a job isn’t enough to prevent food insecurity. In fact, the main source of income for 60 per cent of food-insecure households in the 10 provinces is salaries and wages. The policies meant to support workers in need, like the Canada Worker Benefit and similar provincial benefits, are clearly insufficient.</p>
<p>There’s also a need to expand job opportunities and improve the quality and stability of employment through policies like higher employment standards, support for collective bargaining and increased minimum wage, which several provinces are embracing.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/levelling-the-playing-field-the-case-for-a-federal-anti-scab-law-217341">Levelling the playing field: The case for a federal ‘anti-scab’ law</a>
</strong>
</em>
</p>
<hr>
<h2>Children in food-insecure households</h2>
<p>The Canada Child Benefit has been widely credited for reducing child poverty, but this benefit goes to <a href="https://www.ourcommons.ca/DocumentViewer/en/42-1/HUMA/meeting-149/evidence#Int-10639051">90 per cent of families in Canada</a>. In stretching itself so thin, the benefit isn’t providing enough support to the families that really need it. </p>
<p>Just having a child in the household means a higher risk of food insecurity in Canada. In 2022, 1.8 million children — or one in four — under the age of 18 lived in a food-insecure household. Households with children also made up the majority of the increase in food insecurity from 2021 to 2022. The Canada Child Benefit needs to be restructured to insulate lower-income families from food insecurity more effectively.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/canadas-welfare-system-is-failing-mothers-with-infants-204716">Canada's welfare system is failing mothers with infants</a>
</strong>
</em>
</p>
<hr>
<p>Governments have failed to implement enduring changes to income policies informed by research on food insecurity. Instead, we’ve almost exclusively seen small, limited-time benefits, like the federal Grocery Rebate, and <a href="https://theconversation.com/canadas-national-food-policy-is-at-risk-of-enshrining-a-two-tiered-food-system-205741">continued funding for community food programs</a> as the response to the hardships Canadians are facing. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/federal-budget-2023-grocery-rebate-is-the-right-direction-on-food-insecurity-but-theres-a-long-road-ahead-201926">Federal budget 2023: Grocery rebate is the right direction on food insecurity, but there's a long road ahead</a>
</strong>
</em>
</p>
<hr>
<p>The noteworthy exception is the <a href="https://www.gov.nl.ca/releases/2023/exec/1108n01/">newly announced Poverty Reduction Plan in Newfoundland and Labrador</a>. The existing research suggests that it will help reduce food insecurity in that province.</p>
<h2>Food insecurity festers</h2>
<p>The prevalence and severity of food insecurity in Canada has likely already worsened since 2022, given continued high inflation — particularly the <a href="https://www.ctvnews.ca/canada/canadian-housing-costs-have-hit-30-year-high-statcan-data-shows-1.6568256">record-setting increases in the cost of food, rent and mortgage interest</a> — and a lack of major policy action to offset the added burden on households.</p>
<p>The persistence of food insecurity in Canada is a policy choice. By not doing more to improve the adequacy and stability of household resources, our federal and provincial governments are choosing to let food insecurity fester. </p>
<p>In doing so, they are allowing the health of millions of Canadians to be eroded as we unnecessarily tax our already over-burdened health-care system.</p><img src="https://counter.theconversation.com/content/216399/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Valerie Tarasuk receives funding from the Canadian Institutes of Health Research. She has previously received research funds from the Joannah and Brian Lawson Centre for Child Nutrition and a consulting fee from the Office of the Auditor General of Canada.</span></em></p><p class="fine-print"><em><span>Tim Li 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 persistence of food insecurity in Canada is a policy choice. By not doing more to improve the adequacy and stability of household income, governments are choosing to let food insecurity fester.Valerie Tarasuk, Professor of Nutritional Sciences, University of TorontoTim Li, Research Program Coordinator, Food Insecurity, University of TorontoLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2170502023-11-12T14:02:41Z2023-11-12T14:02:41ZRegina hospital allegations point to an epidemic of bullying and discrimination in health care<figure><img src="https://images.theconversation.com/files/558148/original/file-20231107-15-3o7m1j.jpg?ixlib=rb-1.1.0&rect=0%2C34%2C1920%2C1043&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Complaints of racial discrimination at the Regina General Hospital highlight how bullying and harassment are damaging workplaces across Canada. </span> <span class="attribution"><a class="source" href="https://momsandkidssask.saskhealthauthority.ca/hospitals-facilities/hospitals-health-centres/regina-general-hospital">(Moms & Kids Health Saskatchewan)</a></span></figcaption></figure><iframe style="width: 100%; height: 100px; border: none; position: relative; z-index: 1;" allowtransparency="" allow="clipboard-read; clipboard-write" src="https://narrations.ad-auris.com/widget/the-conversation-canada/regina-hospital-allegations-point-to-an-epidemic-of-bullying-and-discrimination-in-health-care" width="100%" height="400"></iframe>
<p>Foreign-trained physicians at Regina General Hospital have <a href="https://www.ctvnews.ca/health/the-most-toxic-place-foreign-trained-doctors-file-human-rights-complaint-alleging-discrimination-1.6627237">alleged that discriminatory practices</a> by the hospital’s “racist, and discriminatory leadership” have led to them being targeted and sidelined. </p>
<p>Ten physicians trained in Africa and Asia filed a complaint with the Saskatchewan Human Rights Commission alleging they have faced bullying, harassment and racial discrimination. They claim that since a new director for the division of internal medicine was hired, <a href="https://www.cbc.ca/news/canada/saskatchewan/human-rights-complaint-internal-medicine-regina-general-hospital-1.7021106">white physicians have been given more favoured shifts</a>.</p>
<p>When the physicians brought their concerns to hospital administrators, they said their complaints were dismissed. <a href="https://www.ctvnews.ca/health/the-most-toxic-place-foreign-trained-doctors-file-human-rights-complaint-alleging-discrimination-1.6627237">A Saskatchewan Health Authority (SHA) spokesperson said</a> the health authority was committed to having a representative workforce and would not comment on legal matters. Saskatchewan’s health minister <a href="https://regina.ctvnews.ca/sask-health-minister-says-alleged-racism-at-regina-hospital-under-third-party-review-1.6633523">said the SHA has launched a third-party investigation into the circumstances</a>.</p>
<h2>Physicians in distress</h2>
<p>Workplace violence in the form of bullying, harassment, sexual abuse and discrimination is not new to health care. The industry operates within a framework of entrenched hierarchical structures that create fertile ground for senior professionals to exhibit negative behavior towards their less experienced and trained counterparts. In fact, <a href="https://www.cma.ca/physician-wellness-hub/content/bullying-workplace">a 2018 survey by Resident Doctors of Canada</a> noted that more than three-quarters of medical residents said they had experienced workplace bullying, harassment and intimidation.</p>
<p>While bullying can manifest in any workplace, a more significant and enduring issue emerges when a toxic work environment not only tolerates but also enables such behavior. <a href="https://doi.org/10.36834%2Fcmej.57019">A systematic review</a> of 52 studies into workplace bullying in medicine found that it was prevalent and led to a range of negative outcomes that impact patient care and physician burnout.</p>
<p>In addition to causing distress to those directly impacted, widespread abuse in hospitals has far-reaching negative consequences. The rupture of trust and a breakdown in support invariably leads to a greater <a href="https://doi.org/10.1186/s12960-019-0433-x">likelihood of medical errors and misjudgments</a>.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/558151/original/file-20231107-19-7023v6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="A stressed Black doctor in scrubs sits with her head resting on her hands." src="https://images.theconversation.com/files/558151/original/file-20231107-19-7023v6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/558151/original/file-20231107-19-7023v6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/558151/original/file-20231107-19-7023v6.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/558151/original/file-20231107-19-7023v6.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/558151/original/file-20231107-19-7023v6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/558151/original/file-20231107-19-7023v6.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/558151/original/file-20231107-19-7023v6.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Workplace bullying in hospitals can have far-reaching negative impacts on health-care workers and patients.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<p>Racialized physicians in particular are more likely to encounter racism at work, and when this happens, they usually feel abandoned by their employers. This is re-enforced when complaints go unaddressed or if they are unfairly dismissed through policies designed by the organization. </p>
<p>In British Columbia, <a href="https://engage.gov.bc.ca/app/uploads/sites/613/2021/02/In-Plain-Sight-Data-Report_Dec2020.pdf1_.pdf">a 2020 report</a> described widespread systemic racism against Indigenous Peoples in the provincial health-care system. Almost 60 per cent of Indigenous people described witnessing racism and discrimination.</p>
<p>Hospital reputations are also adversely affected, which undermines patient confidence and draws unfavourable scrutiny. Bullying at work also has an <a href="https://www.routledge.com/Bullying-and-Harassment-in-the-Workplace-Theory-Research-and-Practice/Einarsen-Hoel-Zapf-Cooper/p/book/9781138615991">impact on the organization as a whole</a>. The negative impact on a person’s self-worth can significantly affect their performance at work. Frequent employee turnovers, diminished staff retention and a <a href="https://doi.org/10.1007/978-981-13-0935-9_8">general decline in employee morale</a> can result in significant financial consequences. An environment that is unsafe and antagonistic compromises the standard of care provided to patients and jeopardizes the fundamental <a href="https://www.britannica.com/topic/Hippocratic-oath">principles of professional ethics</a>.</p>
<p>Like other health issues, workplace bullying has severe consequences and can lead to <a href="http://dx.doi.org/10.28933/ijprr-2020-01-1205">long-term psychological stress</a>. Bullying is also linked to <a href="https://academic.oup.com/eurheartj/article/40/14/1124/5180493?login=false">cardiovascular illness</a>, musculoskeletal disorders, <a href="https://doi.org/10.1111/j.1467-9450.2011.00932.x">sleep problems</a>, and <a href="https://doi.org/10.5964/ejop.v15i4.1733">generalized pain</a>. For those who are already struggling with mental health issues and suicidal thoughts, workplace bullying can increase the <a href="https://www.suicideinfo.ca/local_resource/workplace-suicide-prevention/">risk of suicide</a>.</p>
<h2>Independent oversight needed</h2>
<p>It’s time to understand workplace violence as a <a href="https://theconversation.com/workplace-bullying-should-be-treated-as-a-public-health-issue-190330">public health issue</a>. Substantial change may finally be achieved by allocating the proper financial and legal resources required for assessing, substantiating and intervening in to workplace bullying under the framework of the <a href="https://lois-laws.justice.gc.ca/eng/acts/P-29.5/">Public Health Act</a>. There is <a href="https://doi.org/10.22454/FamMed.2020.384384">no independent oversight of complaints in Canada</a>, and it’s time to acknowledge that internal <a href="https://hrdailyadvisor.blr.com/2020/07/07/the-dangers-of-mishandling-harassment-complaints/">human resource departments are ill equipped</a> to deal with this issue.</p>
<p>A bold step forward would be the appointment of a national commissioner for workplace violence with the authority to probe allegations and impose heavy penalties. Such a dedicated entity would send a clear message: workplace harassment and discrimination will not be tolerated.</p>
<p>Workplace bullying could be significantly reduced by a public health mandate that includes a <a href="https://www.cdc.gov/eis/field-epi-manual/chapters/Interventions.html">universal prevention focus</a>, intensive intervention and ongoing public health surveillance. </p>
<p>Through a national public health mandate, the commissioner could prevent and address workplace bullying, harassment and sexual abuse through mandatory, sector-specific training for workers and employers. </p>
<p>They could also oversee a confidential and standardized reporting system for complaints. This would remove the risk of retaliation by employers or supervisors and circumvent internal investigations that can be riddled with conflicts of interest.</p>
<p>A public health framework also allows experts to improve strategies to prevent bullying. Legal mechanisms with financial and criminal penalties would create an accountability framework for organizations that promotes safe and respectful workplaces. These strategies, along with a regulatory authority that can intervene, will improve workplaces across Canada.</p><img src="https://counter.theconversation.com/content/217050/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jason Walker 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>Internal reviews are insufficient to investigate discrimination by hospital administrators and external frameworks are needed to protect employees who face bullying and harassment.Jason Walker, Program Director & Associate Professor, Industrial-Organizational and Applied Psychology, Adler UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2135542023-11-06T05:40:20Z2023-11-06T05:40:20ZA 4-day week might not work in health care. But adapting this model could reduce burnout among staff<figure><img src="https://images.theconversation.com/files/557212/original/file-20231102-15-bi7e32.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C2995%2C1576&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/nurse-stress-depression-man-on-hospital-2265615149">PeopleImages.com - Yuri A/Shutterstock</a></span></figcaption></figure><p>The COVID pandemic saw a <a href="https://www.sbs.com.au/news/article/burnt-out-australias-hospital-system-struggling-to-cope-amid-covid-19-wave-healthcare-workers-warn/lru94oiaj">mass exodus</a> of health-care workers across developed countries, exacerbating an existing <a href="https://www.afr.com/politics/no-answers-to-huge-problem-of-healthcare-worker-exodus-20230307-p5cq5o">health-care staffing crisis</a>. </p>
<p>In Australia, turnover rates among hospital staff <a href="https://www.oracle.com/au/human-capital-management/cost-employee-turnover-healthcare/#:%7E:text=In%202022%2C%20turnover%20rates%20for,to%2094%25%20at%20nursing%20homes.">reached nearly 20%</a> in 2022. Hospital waiting lists in Victoria alone ballooned to <a href="https://www.theage.com.au/national/victoria/cash-alone-won-t-fix-hospital-staffing-woes-20230414-p5d0fa.html">80,000 in 2023</a>.</p>
<p>The <a href="https://www.nsinursingsolutions.com/Documents/Library/NSI_National_Health_Care_Retention_Report.pdf">United States</a> and the <a href="https://www.theguardian.com/society/2023/mar/26/nhs-england-staff-shortages-could-exceed-570000-by-2036-study-finds">United Kingdom</a> have faced similar staffing issues.</p>
<p>Efforts are underway globally to <a href="https://www.education.gov.au/higher-education-funding/commonwealth-grant-scheme-cgs/20000-additional-commonwealth-supported-places">educate new health professionals</a> and boost the <a href="https://www.health.gov.au/ministers/the-hon-mark-butler-mp/media/government-cuts-red-tape-for-overseas-trained-doctors">skilled migration of doctors</a>.</p>
<p>However, retaining existing staff is a paramount strategy. </p>
<p>The pandemic accelerated the exploration of more flexible work arrangements, while the idea of a four-day work week is continually gaining traction. Could this be a solution to improve the retention of burnt out staff in the health-care sector?</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/health-worker-burnout-and-compassion-fatigue-put-patients-at-risk-how-can-we-help-them-help-us-191429">Health worker burnout and 'compassion fatigue' put patients at risk. How can we help them help us?</a>
</strong>
</em>
</p>
<hr>
<h2>Burnout</h2>
<p>Health-care professionals have historically experienced <a href="https://www.mayoclinicproceedings.org/article/S0025-6196(18)30938-8/fulltext">high levels of burnout</a>. </p>
<p>The strain of balancing demanding work schedules, including long hours and shift work, with family responsibilities, can lead to work-family conflicts. Also, the nature of the profession means staff are often exposed to traumatic situations such as patient deaths, further elevating stress levels. COVID has intensified the issue of <a href="https://www.frontiersin.org/articles/10.3389/fpubh.2021.750529/full?hidemenu=true">burnout in health care</a>. </p>
<p>Burnout commonly leads <a href="https://www.forbes.com/sites/debgordon/2022/05/17/amid-healthcares-great-resignation-burned-out-workers-are-pursuing-flexibility-and-passion/?sh=5c4314507fda">health-care workers to resign</a>, and also contributes to <a href="https://www.emerald.com/insight/content/doi/10.1108/01437721011050594/full/html?casa_token=nr9ADuU_NwcAAAAA:GpDmtyeG9mgabwrsADWwebyIQhYePpc4ZgM2Cu9VfPOsP7VQUEo5cyJhPriWp7yqA2B3HBYW-WAOPRfNF-zdlywoomCPN5Z_6FPFYc2F9hZx3-UIrPwm">early retirement</a>. </p>
<p>For those who remain in the profession, burnout <a href="https://www.sciencedirect.com/science/article/abs/pii/S0025619616001014">negatively affects productivity</a>, including increasing the likelihood of perceived <a href="https://jamanetwork.com/journals/jama/article-abstract/203249">medical errors</a>. </p>
<figure class="align-center ">
<img alt="A nurse attends to a patient's IV drip." src="https://images.theconversation.com/files/557213/original/file-20231102-25-oc7b5i.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/557213/original/file-20231102-25-oc7b5i.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=338&fit=crop&dpr=1 600w, https://images.theconversation.com/files/557213/original/file-20231102-25-oc7b5i.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=338&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/557213/original/file-20231102-25-oc7b5i.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=338&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/557213/original/file-20231102-25-oc7b5i.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=424&fit=crop&dpr=1 754w, https://images.theconversation.com/files/557213/original/file-20231102-25-oc7b5i.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=424&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/557213/original/file-20231102-25-oc7b5i.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=424&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Staff shortages are a big issue in the health-care sector.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/hospital-ward-professional-black-head-nurse-1985507474">Gorodenkoff/Shutterstock</a></span>
</figcaption>
</figure>
<h2>Rise of the four-day week</h2>
<p>A four-day work week is based on the so-called 100-80-100 arrangement, where 100% of productivity is achieved in 80% of the time with 100% of pay. So that might mean working Monday to Thursday, but getting paid a full wage, and with an expectation that you’ll produce as much in four days as you did in five.</p>
<p>In a pilot study by Cambridge University and <a href="https://www.4dayweek.com">4 Day Week Global</a>, <a href="https://www.cam.ac.uk/stories/fourdayweek">71% of participants reported</a> feeling less burnt out, while there was a 57% fall in staff resignations. These outcomes <a href="https://sloanreview.mit.edu/article/how-far-reaching-could-the-four-day-workweek-become/">are similar to results</a> from trials in Belgium, Spain, Japan, Australia, and New Zealand. </p>
<p>But the execution of a four-day work week in health care comes with unique challenges. The model has primarily been trialled in office and corporate environments, where a five-day work week, totalling 35-40 hours, is conventional. </p>
<p>For many health-care workers, especially nurses, longer hours and shift work are the norm. Nurses are often expected to work on public holidays, and may have to work for <a href="https://www.healthstaffrecruitment.com.au/news/nurse-working-hours-in-australia/">six or seven consecutive days</a> before having a few days off, instead of the standard five days on, two days off. </p>
<p>Also, many health-care services, such as hospitals and aged care facilities, require staffing seven days a week. It’s imperative any restructured work arrangements are designed to ensure continuous, adequate staffing.</p>
<p>Consequently, a direct transition from a five-day to a four-day work week might not be immediately logical or applicable.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/4-day-work-week-trials-have-been-labelled-a-resounding-success-but-4-big-questions-need-answers-201476">4-day work week trials have been labelled a ‘resounding success’. But 4 big questions need answers</a>
</strong>
</em>
</p>
<hr>
<p>Instead, this model should be conceptualised more broadly for health care, focusing on reducing and optimising working hours, and addressing the specifics of rostering and workforce planning in the industry. </p>
<h2>Applying this model to health care</h2>
<p>The focus should be on achieving greater productivity through reducing stress and burnout. Although shifting to a four-day work week won’t necessarily be practical, there should be an emphasis on shorter hours, guided by the 100-80-100 model.</p>
<p>The application of this model within health care would vary. For example, specialist physicians work <a href="https://labourmarketinsights.gov.au/occupation-profile/specialist-physicians?occupationCode=2533#:%7E:text=Around%2079%25%20of%20people%20employed,(44%20hours%20per%20week).">50 hours a week on average</a>, so applying the model would reduce their work week to 40 hours.</p>
<p>Shift design, particularly <a href="https://link.springer.com/article/10.1007/s10729-022-09613-4">for nurses</a>, should focus on ways to reduce fatigue and in turn burnout. This might include scheduling shifts at a consistent time of day for individual staff members, implementing shorter shifts, and rostering reasonable consecutive working days (instead of seven or more days in a row before getting a day off).</p>
<figure class="align-center ">
<img alt="Four people working around a table in an office." src="https://images.theconversation.com/files/557214/original/file-20231102-21-q9g8oq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/557214/original/file-20231102-21-q9g8oq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=379&fit=crop&dpr=1 600w, https://images.theconversation.com/files/557214/original/file-20231102-21-q9g8oq.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=379&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/557214/original/file-20231102-21-q9g8oq.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=379&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/557214/original/file-20231102-21-q9g8oq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=476&fit=crop&dpr=1 754w, https://images.theconversation.com/files/557214/original/file-20231102-21-q9g8oq.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=476&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/557214/original/file-20231102-21-q9g8oq.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=476&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Trials of a four-day work week have shown positive results in corporate settings.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/office-colleagues-having-casual-discussion-during-1791564398">Jacob Lund/Shutterstock</a></span>
</figcaption>
</figure>
<h2>The benefits</h2>
<p>Reducing the hours worked and optimising shift rostering could help to alleviate stress, burnout and work-family conflict for health-care workers. All this is likely to improve staff retention.</p>
<p>Any reduction in staff turnaround would save on direct costs associated with hiring new staff. The cost to replace a highly specialised health-care professional can reach up to <a href="https://www.oracle.com/au/human-capital-management/cost-employee-turnover-healthcare/">200% of their annual salary</a>. </p>
<p>Also, implementing shorter shifts – for example shifts lasting four or eight hours instead of 12 – may <a href="https://upaged.com/blog/healthcare-organisations-workplace-flexibility/">increase the uptake of</a> shift times that are usually hard to fill. Measures like shorter shifts could also appeal to part-time workers or those who have retired.</p>
<p>Finally, reducing burnout and absenteeism will improve productivity among staff. This will indirectly lower costs and benefit public health.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/a-burnt-out-health-workforce-impacts-patient-care-180021">A burnt-out health workforce impacts patient care</a>
</strong>
</em>
</p>
<hr>
<h2>Some challenges</h2>
<p>As it can take a <a href="https://ipractice.nl/en/symptoms/burnout/treatment-and-recovery/#:%7E:text=How%20Long%20Does%20Burnout%20Last,or%20periods%20of%20stagnant%20recovery.">few months</a> to a <a href="https://www.wellics.com/blog/how-long-to-recover-from-burnout">few years</a> to recover from burnout, once any changes are implemented, the benefits would take time to be seen. </p>
<p>And reducing working hours as well as other changes to rostering will initially be difficult given current staff shortages in the sector. </p>
<p>Hopefully, measures such as migration incentives and subsidised training for health-care professionals will bolster the workforce and make bridging this gap a little easier.</p>
<p>Although the implementation is not straightforward, changes to working arrangements in the health-care sector could have an even greater positive impact than in other industries.</p><img src="https://counter.theconversation.com/content/213554/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Nataliya Ilyushina receives funding from the ARC Centre of Excellence.</span></em></p>The COVID pandemic has exacerbated staff shortages in health care. We need to think about how we can better retain staff in this sector.Nataliya Ilyushina, Research Fellow, Blockchain Innovation Hub, RMIT UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2155102023-11-02T09:59:22Z2023-11-02T09:59:22ZThe future of medicine: 50-year forecast offers hope for HIV and cancer patients and predicts climate change to increasingly set agenda<p>The Covid-19 pandemic has changed the way we think about health and revealed significant flaws within our health care systems. It has also raised questions about the role of technology, as well as ethical concerns about the distribution of wealth and its impact on global health. How will this collective awakening that we have experienced influence the coming years and decades? This was the subject of our <a href="https://www.sciencedirect.com/science/article/pii/S0016328723000010">research on the future of medicine</a>.</p>
<p>We utilised the Delphi method in a three-round study involving 22 experts from seven European countries. Participants included physicians, academics, and industry professionals. Despite a slight reduction in panel size in later rounds, study validity remained intact. Data were collected through audio or video responses and analysed using <a href="https://en.wikipedia.org/wiki/NVivo">NVivo</a> 12. The research focused on updating current medical trends, identifying key drivers for future development, and making health care foresights. Data were coded independently to minimise bias and formed the basis for questions in subsequent rounds.</p>
<h2>1 to 2 years: beta and data</h2>
<p>While we remain in “eternal beta” – a state in which products or drugs are tested through active use by a wide audience – sales of portable smart electronic devices will continue to grow thanks to advances in sensors, artificial intelligence (AI) and the proliferation of 5G technology. Data generated by personal devices will also increasingly be transferred to professional devices. This will enable doctors to treat their patients more holistically and better inform their prescriptions.</p>
<h2>2 to 5 years: the private sector strikes back, climate-related tensions</h2>
<p>Rising strains on public health care are likely to bolster the role of private entities. Innovations in this sector will likely hinge on smart sensors, the blockchain, and digital health records. Over the same period, climate change will exacerbate health issues such as malnutrition and water scarcity, especially in vulnerable regions, necessitating a broader health care response.</p>
<h2>5 to 10 years: innovations leading to inequalities</h2>
<p>Advancements in genomics are accelerating personalised medicine, enabling better prediction and treatment of genetic diseases. Technologies like drug-gene interaction studies allow for optimised drug dosing, while nanotechnology permits targeted micro-dosing, reducing complications. However, the high cost of these innovations will exacerbate health care disparities, potentially fuelling social conflict, especially as climate change imposes additional health burdens.</p>
<h2>10 to 30 years: climate change takes centre stage</h2>
<p>Global warming, which according to the World Health Organisation could claim the lives of around 250,000 people a year by 2030, risks exacerbating inequalities in access to health care. Various disasters (floods, heat waves, etc.) disproportionately affect disadvantaged populations who do not have the resources to cope. This could put a strain on existing health care infrastructures, leading to disparities in access to care.</p>
<p>In addition, global warming could lead to forced migrations, placing an additional burden on health care systems in regions receiving climate migrants and creating difficulties in accessing health care due to social, economic, and linguistic barriers.</p>
<p>Experts predict that, within 10 to 15 years, technological advances could be less effective in meeting the needs of racial- and ethnic-minority patient groups. Indeed, the lack of diversity in clinical trials, a widely debated topic in medical research today, could contribute to the reduced effectiveness of drugs on a broad population.</p>
<p>However, experts anticipate that this trend will gradually fade over the next 20 to 30 years. They believe that health care companies will gradually adapt their treatments for people from lower socio-economic backgrounds and minority ethnic groups.</p>
<h2>30 to 50: a quantum leap</h2>
<p>Finally, looking ahead half a century, experts predict the emergence of highly effective treatments and even cures for diseases such as HIV and hepatitis C. There is no doubt that considerable progress has been made in the prevention, diagnosis, and treatment of diseases, particularly cancer.</p>
<p>The experts in our study predict a significant leap forward in these areas. They do not necessarily envisage a complete cure for all types of cancer or the eradication of major diseases, but do foresee progress in diagnostic and therapeutic methods that will enable a higher percentage of patients to be successfully treated at an early stage.</p>
<p>Against this backdrop of progress, they nevertheless stress that antibiotic resistance remains a real challenge. It is true that the development of new antibiotic molecules is still relatively slow. Our experts draw our attention to certain initiatives that focus on modifying existing antibiotics to overcome resistance, while others are exploring the use of bacteriophages, or studying entirely new classes of antibiotics.</p>
<p>Technological advances and a faster pace of life will continue to take their toll on our mental health, perhaps even increasingly so, with mood disorders becoming widespread. We could also see an increase in depression and certain personality disorders. This would force patients and doctors to resort to preventive medication, or even a “magic pill”, to cure mental disorders.</p>
<p>In addition, the problem of chronic metabolic diseases such as cardiovascular disease, diabetes and obesity is set to worsen. Contributing factors include the increasing prevalence of sedentary lifestyles, unhealthy diets, and an ageing population.</p>
<p>The incidence of pancreatic cancer, for example, has risen sharply in recent years. Researchers attribute this not only to lifestyle factors such as smoking, obesity and poor diet, but also to long-term exposure to certain environmental pollutants. Understanding and addressing these links between health and the environment is therefore becoming crucial to the future of health care.</p>
<h2>The ageing challenge</h2>
<p>Finally, the ageing of the population represents another major challenge that will have a considerable impact on health care systems, and not just on Western systems. The prevalence of age-related diseases such as neurodegenerative disorders, osteoporosis and certain types of cancer is set to increase.</p>
<p>This trend will not only place a considerable burden on health services, but will also require major changes in the way health care is delivered. Emphasis will need to be placed on preventive measures, early detection and management of chronic diseases, as well as health care environments and services adapted to the elderly.</p>
<p>In short, as we move forward in time, we imagine progress in the use of technology. While some of us will be offered the means to extend our longevity and improve our quality of life, others may suffer significant health disadvantages, particularly as a result of climate change.</p>
<p>General practitioners will have a cross-sectional view of a patient’s overall state of health, while specialists will be able to provide more targeted treatments. Personal care will become an even hotter topic, as lifestyle choices will reflect a person’s financial resources and social status. This will allow a commercial industry to thrive on the challenges of modern life.</p><img src="https://counter.theconversation.com/content/215510/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Les auteurs ne travaillent pas, ne conseillent pas, ne possèdent pas de parts, ne reçoivent pas de fonds d'une organisation qui pourrait tirer profit de cet article, et n'ont déclaré aucune autre affiliation que leur organisme de recherche.</span></em></p>Climate change, inequality, the evolution of knowledge… Experts have been surveyed, and a consensus is emerging on what to expect from the effects of these factors in the medical field.René Rohrbeck, Professor of Strategy, Director EDHEC Chair for Foresight, Innovation and Transformation, EDHEC Business SchoolAhmed Khwaja, Professor of Marketing, Business & Public Enterprise, Head of the Marketing Subject Group, Cambridge Judge Business SchoolHeikki Karjaluoto, Professor of Marketing, University of JyväskyläIgnat Kulkov, Postdoctoral researcher, EDHEC Business SchoolJoel Mero, Associate professor of marketing, University of JyväskyläJulia Kulkova, Adjunct professor, University of TurkuShasha Lu, Associate Professor in Marketing, Cambridge Judge Business SchoolLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2150562023-10-22T19:00:51Z2023-10-22T19:00:51ZFrom diagnosis to services and support: how Australia’s long COVID response is falling short<figure><img src="https://images.theconversation.com/files/554641/original/file-20231019-21-fu2amx.jpg?ixlib=rb-1.1.0&rect=82%2C0%2C9216%2C6111&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/caucasian-terrified-woman-lying-on-sofa-2229905047">gpointstudio/Shutterstock</a></span></figcaption></figure><p>Around <a href="https://www.aihw.gov.au/reports/covid-19/long-covid-in-australia-a-review-of-the-literature/summary">5-10% of people</a> in Australia experience symptoms for more than three months after a COVID infection, termed long COVID.</p>
<p>So far, more than <a href="https://www.who.int/europe/news-room/fact-sheets/item/post-covid-19-condition">200 different symptoms</a> have been recorded, ranging from shortness of breath to fatigue and brain fog. The effects are far-reaching for those with the condition, often affecting their capacity to work and their quality of life for many months or even years.</p>
<p>With this in mind, we set out to examine Australia’s long COVID guidelines, services and public health information. </p>
<p>Our <a href="https://www.ssph-journal.org/articles/10.3389/phrs.2023.1606084/full">research</a> found that compared to international standards, Australia is generally slow to recognise and investigate possible cases of long COVID. We also found the availability of multidisciplinary long COVID services was lacking in Australia, as was accessibility of trustworthy public health information.</p>
<h2>From COVID to long COVID</h2>
<p>Even with all the advancements in medical science, there’s not yet any simple blood test or scan that can definitively tell you if you have long COVID. A diagnosis is based on how long you’ve been dealing with symptoms. But the point at which you’ll receive that diagnosis can vary depending on where you live.</p>
<p>In our <a href="https://www.ssph-journal.org/articles/10.3389/phrs.2023.1606084/full">review</a>, we examined international guidelines from the <a href="https://app.magicapp.org/#/guideline/j1WBYn">World Health Organization</a> as well as national guidelines in the <a href="https://www.cdc.gov/coronavirus/2019-ncov/hcp/clinical-care/post-covid-conditions.html">United States</a>, the <a href="https://www.nice.org.uk/guidance/ng188/resources/covid19-rapid-guideline-managing-the-longterm-effects-of-covid19-pdf-51035515742">United Kingdom</a>, <a href="https://www.health.govt.nz/system/files/documents/publications/clinical_rehabilitation_guideline_for_people_with_long_covid_13_dec.pdf">New Zealand</a> and <a href="https://www.racgp.org.au/clinical-resources/covid-19-resources/clinical-care/caring-for-patients-with-post-covid-19-conditions/introduction">Australia</a>. </p>
<p>Most countries, including Australia, wait 12 weeks after the initial infection to officially diagnose long COVID. The US, however, determines a person has long COVID after just four weeks of continued symptoms. This discrepancy can have significant implications for how much support the person will get from the health system. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/what-do-we-know-about-long-covid-in-kids-and-what-do-i-do-if-i-think-my-child-has-it-205027">What do we know about long COVID in kids? And what do I do if I think my child has it?</a>
</strong>
</em>
</p>
<hr>
<p>Guidelines in Australia, the UK and the US do advocate for further investigation if symptoms persist for four weeks after contracting COVID. But we discovered this approach of early investigation is not consistently implemented in Australia.</p>
<p>On reviewing the eligibility criteria for long COVID services in Australia, we found that most of these services require a person to have had symptoms for 12 weeks or more to qualify for care. </p>
<h2>Get help early</h2>
<p>If your <a href="https://www.cdc.gov/coronavirus/2019-ncov/hcp/clinical-care/post-covid-conditions.html">symptoms continue</a> for four weeks or more after catching COVID, it’s important to act early by contacting your GP. They can investigate further and help you manage your symptoms.</p>
<p>Unfortunately not all GPs and health-care professionals are up to speed on long COVID. The Royal Australian College of General Practitioners has called for <a href="https://www1.racgp.org.au/newsgp/clinical/long-covid-education-should-be-part-of-cpd-report">better education for GPs</a>. </p>
<p>All health-care professionals, especially those working in the community, should be educated about how to spot long COVID early. This will enable them to refer patients for specialised care when required.</p>
<figure class="align-center ">
<img alt="A man seeing a doctor." src="https://images.theconversation.com/files/554643/original/file-20231019-17-5xld23.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/554643/original/file-20231019-17-5xld23.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=365&fit=crop&dpr=1 600w, https://images.theconversation.com/files/554643/original/file-20231019-17-5xld23.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=365&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/554643/original/file-20231019-17-5xld23.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=365&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/554643/original/file-20231019-17-5xld23.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=459&fit=crop&dpr=1 754w, https://images.theconversation.com/files/554643/original/file-20231019-17-5xld23.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=459&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/554643/original/file-20231019-17-5xld23.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=459&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">If you’ve been having symptoms for more than four weeks, see your GP.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/mature-male-patient-consultation-doctor-office-1393901459">Monkey Business Images/Shutterstock</a></span>
</figcaption>
</figure>
<h2>Australian long COVID services cannot meet demand</h2>
<p>Long COVID is a complicated health issue that can affect <a href="https://www.nature.com/articles/s41579-022-00846-2">multiple parts</a> of the body, and right now there are <a href="https://www.aihw.gov.au/reports/covid-19/long-covid-in-australia-a-review-of-the-literature/summary">no specific treatments</a> for the condition as a whole.</p>
<p>However, a mix of supports and services can help. This might include care from a cardiologist, neurologist and physiotherapist for different symptoms. Research has shown that a personalised, <a href="https://pubmed.ncbi.nlm.nih.gov/37052043/">multidisciplinary rehabilitation program</a> can have long-term benefits for people with long COVID. Long COVID clinics offer these sorts of programs.</p>
<p>When we conducted our research, we identified just 16 specialised long COVID clinics in Australia.</p>
<p>The vast majority of the Australian population has had COVID at least once. The current best estimate is <a href="https://www1.racgp.org.au/newsgp/clinical/vast-majority-of-australian-population-has-had-cov">80-85%</a>. If we do a conservative calculation and say out of 80% of Australians who have had COVID, 5% ended up with long COVID, that’s at least one million people.</p>
<p>Each long COVID clinic is then essentially tasked with serving more than 60,000 people. Even if we assume <a href="https://www.ijidonline.com/article/S1201-9712(23)00558-1/fulltext#%20">many have recovered</a> and don’t need these services, it’s still an impossible task.</p>
<p>So it’s not surprising reports suggest people have had to wait <a href="https://www.theguardian.com/australia-news/2022/aug/14/long-covid-clinic-wait-times-blow-out-as-health-experts-call-for-national-approach-to-condition">several months</a> to access these services.</p>
<p>Further, all of the 16 clinics were in big cities, and none in rural areas. There were also no long COVID clinics catering specifically to the unique needs of children, elderly people in aged care, or those with a disability.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/how-physios-and-occupational-therapists-are-helping-long-covid-sufferers-195354">How physios and occupational therapists are helping long COVID sufferers</a>
</strong>
</em>
</p>
<hr>
<p>Another gap we identified is that trustworthy public health information on long COVID, such as online resources, is either not readily available or not advertised. Where these resources exist, they are primarily in English, disadvantaging people with low health literacy or from non-English-speaking backgrounds.</p>
<p>Integrating advice in multiple languages on diet, movement, energy conservation and mental health with clinical support will be of great value to many people who are on the wait list for long COVID clinics.</p>
<figure class="align-center ">
<img alt="A woman sits at a laptop." src="https://images.theconversation.com/files/554648/original/file-20231019-17-ag8lw2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/554648/original/file-20231019-17-ag8lw2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/554648/original/file-20231019-17-ag8lw2.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/554648/original/file-20231019-17-ag8lw2.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/554648/original/file-20231019-17-ag8lw2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/554648/original/file-20231019-17-ag8lw2.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/554648/original/file-20231019-17-ag8lw2.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">We found public health information on long COVID in Australia was lacking.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/senior-asian-woman-stressed-does-not-1853210284">tairome/Shutterstock</a></span>
</figcaption>
</figure>
<p>If your COVID symptoms last more than four weeks, or if new symptoms appear during that first month, affecting your life or work, you might be in for the long haul. Our key message is act early. Book yourself in with your GP or a GP-led specialist clinic.</p>
<p>With COVID cases <a href="https://www.health.gov.au/health-alerts/covid-19/weekly-reporting">continuing to accumulate</a>, more and more people will find themselves with long COVID. As a society, we need to fast-track better services and work towards a deeper understanding of the condition.</p><img src="https://counter.theconversation.com/content/215056/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Zhen Zheng is a member of Australian Acupuncture and Chinese Medicine Association
Zhen Zheng co-leads a research program "Eat, Move, Heal for Long COVID" at RMIT University, aiming to improve education of the public and healthcare professionals about long COVID. </span></em></p><p class="fine-print"><em><span>Catherine Itsiopoulos has received funding from NHMRC for other research. She is a member of professional bodies including Dietitians Australia and The Australasian Society of Lifestyle Medicine.</span></em></p><p class="fine-print"><em><span>Member of RMIT University 'Eat, Move Heal Network' researching to develop tools to support patients with long COVID19 at home. Director of Biomedical and Health Innovation Enabling Impact Platform supporting multidisciplinary research within RMIT University. Unrelated research into ovarian cancer, one of our cancer human clinical trials receives partly support from Astrazeneca and ANZGOG.</span></em></p><p class="fine-print"><em><span>Rose (Shiqi) Luo 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>A recent study set out to investigate Australia’s long COVID guidelines, services and public health information.Zhen Zheng, Associate Professor, STEM | Health and Biomedical Sciences, RMIT UniversityCatherine Itsiopoulos, Professor and Dean, School of Health and Biomedical Sciences, RMIT UniversityMagdalena Plebanski, Professor of Immunology, RMIT UniversityRose (Shiqi) Luo, Early career researcher, RMIT UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2149372023-10-18T19:34:26Z2023-10-18T19:34:26ZThe impact of not having a family doctor: Patients are worse off, and so is the health system<figure><img src="https://images.theconversation.com/files/554202/original/file-20231017-27-bh0m9p.jpg?ixlib=rb-1.1.0&rect=1023%2C335%2C4423%2C2998&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Fixing the family doctor shortage can save lives and money at the same time.</span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><iframe style="width: 100%; height: 100px; border: none; position: relative; z-index: 1;" allowtransparency="" allow="clipboard-read; clipboard-write" src="https://narrations.ad-auris.com/widget/the-conversation-canada/the-impact-of-not-having-a-family-doctor-patients-are-worse-off-and-so-is-the-health-system" width="100%" height="400"></iframe>
<p><a href="https://doi.org/10.1503/cmaj.1096049">About 6.5 million Canadians</a> — roughly one in six — do not have access to primary medical care.</p>
<p>It’s a problem that puts their health at greater risk and renders the <a href="http://dx.doi.org/10.1136/fmch-2023-002236">entire public health-care system</a> less efficient than it could be, both economically and in terms of the quality of care for everyone.</p>
<p>In other words, if we can fix the shortage of family physicians, we can save lives and money at the same time.</p>
<h2>Shortage of family physicians</h2>
<p>Many factors are contributing to our current shortage.</p>
<p>For one, Canada’s health system needs not only more family doctors, but also more nurses and other health-care professionals. However, it <a href="https://www.cma.ca/our-focus/workforce-planning">lacks the capacity to collect and analyze data that’s required for integrated and proactive health human-resource planning</a>.</p>
<figure class="align-center ">
<img alt="A woman with gray hair in a white coat and stethoscope listening to a person with their back to the camera" src="https://images.theconversation.com/files/554203/original/file-20231017-18-qqvxjh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/554203/original/file-20231017-18-qqvxjh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=457&fit=crop&dpr=1 600w, https://images.theconversation.com/files/554203/original/file-20231017-18-qqvxjh.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=457&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/554203/original/file-20231017-18-qqvxjh.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=457&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/554203/original/file-20231017-18-qqvxjh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=574&fit=crop&dpr=1 754w, https://images.theconversation.com/files/554203/original/file-20231017-18-qqvxjh.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=574&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/554203/original/file-20231017-18-qqvxjh.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=574&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">The family medicine workforce is aging: Nearly one in six family doctors in Canada is 65 or older and nearing retirement.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<p>The increasing complexity and responsibility of family medicine, including a much greater <a href="https://www.cma.ca/news/addressing-physicians-administrative-burden-invisible-crisis-family-medicine">administrative burden</a>, has also made careers in family medicine less attractive. In 2015, 38 per cent of graduating medical students chose a career in family medicine. By 2022, <a href="https://www.cbc.ca/news/canada/ottawa/fewer-medical-students-are-pursuing-family-practices-and-these-doctors-are-worried-1.6516261">that number had dropped to 30 per cent</a>.</p>
<p>We are also losing practising family physicians. The rate of retirement <a href="https://www.cbc.ca/news/canada/toronto/ont-family-physicians-1.6596653">increased through the pandemic</a>. (Many doctors lost income during shutdowns but were still responsible for lease and staff costs.) The current family medicine workforce is also aging: <a href="https://www.theglobeandmail.com/canada/article-family-doctors-retiring/">Nearly one in six family doctors in Canada is 65 or older and nearing retirement</a>.</p>
<h2>Family doctors and health care</h2>
<p><a href="https://www.cfp.ca/content/69/4/269.long#ref-27">Research has shown</a> that patients who have a regular general-practitioner relationship for more than 15 years need about 30 per cent less after-hours care or hospital admissions and experience approximately 25 per cent less mortality compared to those who had a regular general practitioner for just one year.</p>
<p>Having access to family medicine provides four ingredients essential to good care: continuity, access, comprehensiveness and co-ordination.</p>
<p>While other specializations concentrate on narrower aspects of medicine, family physicians specialize in comprehensive medicine, and engage with patients directly over time. Family doctors know how to manage a huge range of symptoms and conditions across the span of a lifetime. </p>
<p>In fact, <a href="https://doi.org/10.1016/j.hjdsi.2015.02.002">a recent study</a> in the United States rated family medicine as the most complex of all medical specialties, requiring the highest degree of judgement and integrated knowledge.</p>
<figure class="align-center ">
<img alt="A doctor seen from behind with a woman and a child" src="https://images.theconversation.com/files/553750/original/file-20231013-23-5y4omv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/553750/original/file-20231013-23-5y4omv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=338&fit=crop&dpr=1 600w, https://images.theconversation.com/files/553750/original/file-20231013-23-5y4omv.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=338&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/553750/original/file-20231013-23-5y4omv.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=338&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/553750/original/file-20231013-23-5y4omv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=424&fit=crop&dpr=1 754w, https://images.theconversation.com/files/553750/original/file-20231013-23-5y4omv.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=424&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/553750/original/file-20231013-23-5y4omv.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=424&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Having access to family medicine provides four ingredients essential to good care: continuity, access, comprehensiveness and co-ordination.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<p>The work, while challenging, is valuable and <a href="https://doi.org/10.1503/cmaj.180186">makes the rest of the health-care system more efficient</a>.</p>
<p>Having a person or a team get to know your story over time is incredibly powerful. When I see patients I’ve known for a long time, we can get a lot done quickly. They tell me what’s worrying them, and together we can decide quickly if a familiar issue calls simply for assurance and encouragement, or whether something has changed and needs addressing.</p>
<p>We make these decisions based on symptoms and past medical history — factoring in elements such as stress, family situations, grief and expectations for health. Because patients know and trust me, I can tell them, “I think XYZ is going on, but if you see these symptoms or changes in the next four weeks, I want to hear about it.”</p>
<p>That trust provides the opportunity to reassure and the chance to separate something benign from something worrisome, which in turn offers incredible efficiency back to the system. Family physicians aren’t sending folks for long lists of <a href="https://doi.org/10.3122/jabfm.2011.03.100170">unnecessary investigations</a>, because we know our patients’ stories.</p>
<h2>Benefits for patients and the health system</h2>
<p>There is a belief in some circles that if we only shared one <a href="https://doi.org/10.1503/cmaj.181647">common medical record</a>, every patient’s story would become available to all, resolving the issue of providing continuity.</p>
<p>But having one person or team look after a patient’s primary care and keeping a good history is not the same as having many people looking after that patient and adding to that record in many settings and situations.</p>
<p>Patients without a family doctor must try to access the health-care system by going to an ER or walk-in clinic. That often means <a href="https://www.cihi.ca/en/nacrs-emergency-department-visits-and-lengths-of-stay">a long wait</a>, only being able to address one issue at a time and possibly that the treatment they will be offered will resolve the immediate concern, but <a href="https://doi.org/10.1002/hpm.2632">won’t necessarily address the root of the issue</a>.</p>
<p>Further, those patients likely miss the chance to tell a chapter of their health story to someone who will remember if a similar issue comes up in the future.</p>
<p>Family doctors are also experts in prevention. They know how to look for things that could become problematic down the line. Lack of access to family medicine puts people at greater risk of having diseases such as cancer <a href="https://doi.org/10.1038/nrclinonc.2013.212">go much longer without being diagnosed or treated</a>. </p>
<p>Finally, as anyone with a loved one dependent on help for the essential activities of daily life can tell you, <a href="https://www.hqontario.ca/Portals/0/documents/system-performance/connecting-the-dots-report-en.pdf">co-ordinating care</a> is a critical and effective function of family medicine.</p>
<p>Whether it’s referring patients to resources or specialized help or orchestrating something as personal and impactful as the choice to die at home, family doctors are experts in translating your health story into plans to assemble and oversee your broader health-care team.</p>
<p>The return on investment in a strong primary care foundation is an <a href="https://doi.org/10.1503/cmaj.109-5729">increase in the average lifespan</a>, a greater sense of health overall and a <a href="https://doi.org/10.1111/j.1468-0009.2005.00409.x">reduction in costs</a> in all other parts of the system.</p>
<p>The lack of family physicians is a problem worth solving.</p><img src="https://counter.theconversation.com/content/214937/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Cathy Risdon 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 shortage of family doctors affects not only patients, but the entire health-care system. A strong primary care foundation increases average lifespan, improves overall health and reduces costs.Cathy Risdon, Professor and Chair, Family Medicine, McMaster, McMaster UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2146892023-10-10T20:17:14Z2023-10-10T20:17:14ZMaking preventive care fair: New approaches like self-testing at home can save lives and promote health equity<figure><img src="https://images.theconversation.com/files/553014/original/file-20231010-19-axrszd.jpg?ixlib=rb-1.1.0&rect=6%2C121%2C4217%2C3262&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Justice in access to life-saving preventive care requires reaching out to those who need the most support.</span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><iframe style="width: 100%; height: 100px; border: none; position: relative; z-index: 1;" allowtransparency="" allow="clipboard-read; clipboard-write" src="https://narrations.ad-auris.com/widget/the-conversation-canada/making-preventive-care-fair-new-approaches-like-self-testing-at-home-can-save-lives-and-promote-health-equity" width="100%" height="400"></iframe>
<p>A fresh approach to preventive care is overdue to make health outcomes more fair. <a href="https://www.canada.ca/en/public-health/services/publications/science-research-data/key-health-inequalities-canada-national-portrait-executive-summary.html">Inequities based on racialization, income and gender mean that we need to urgently change the way care is provided</a>. Lives hang in the balance, especially for those who face barriers to care.</p>
<p>We worked with a national panel of colleagues and patients, all knowledgeable about health equity and many with lived experience of disadvantages, <a href="https://doi.org/10.1503/cmaj.230237">to develop guidance</a> on how to ensure everyone gets the preventive care they need, like cancer screening. It’s easy to bemoan inequities and idly suggest things should be different — our focus was on the specific actions that need to be taken.</p>
<h2>Home testing</h2>
<p>Outdated ways of providing care — like expecting patients to attend a clinic for a pelvic exam that is, at best, uncomfortable, and at worst, traumatizing, for cervical cancer screening — can lead to poor outcomes. In the case of cervical cancer screening, those outcomes can include delayed diagnosis of cervical cancer.</p>
<p><a href="https://doi.org/10.1001/jama.2018.10400">Self-testing for the virus that causes cervical cancer is at least as accurate</a> as the traditional approach of Pap tests that require a pelvic exam. Some patients avoid pelvic exams due to the inconvenience and discomfort, and survivors of sexual abuse might opt out of screening to avoid being re-traumatized. </p>
<p>The technology needed for self-testing has been <a href="https://www.cfp.ca/content/63/8/597?ijkey=fe09b8f3b9cb538fd1811755f762ff68d022894c&keytype2=tf_ipsecsha">around for years</a>. Studies have shown that it <a href="https://doi.org/10.1186/s12905-023-02174-w">helps connect people with care</a> in addition to being cost-effective. While the main benefit of self-testing is better access to screening for patients, avoiding visits also frees up physician time. </p>
<figure class="align-center ">
<img alt="A clinic waiting room with two women sitting in chairs and a person in scrubs approaching" src="https://images.theconversation.com/files/553015/original/file-20231010-15-278id.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/553015/original/file-20231010-15-278id.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=338&fit=crop&dpr=1 600w, https://images.theconversation.com/files/553015/original/file-20231010-15-278id.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=338&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/553015/original/file-20231010-15-278id.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=338&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/553015/original/file-20231010-15-278id.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=424&fit=crop&dpr=1 754w, https://images.theconversation.com/files/553015/original/file-20231010-15-278id.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=424&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/553015/original/file-20231010-15-278id.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=424&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">More equitable approaches, such as self-testing, can replace some outdated procedures that require clinic visits.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<p>Skin testing for tuberculosis exposure — which requires an initial visit to implant the test in the forearm, and a return visit two or three days later to read the test — is another example of an old practice that can take a back seat to a more efficient approach. </p>
<p>Many people who have made two trips for a skin test might be surprised to learn there is a <a href="https://doi.org/10.1080/24745332.2022.2036503">blood test that is likely more accurate, especially for those who have been vaccinated</a>. The test is not expensive or new. It can be done today. But, like self-testing for cervical cancer, it needs to be publicly funded for everyone. </p>
<p>Self-testing for HIV can also remove the need for patients to attend an appointment and wait to receive a result. The answer can be <a href="https://maphealth.ca/hiv-oral-self-test/">available in minutes and with tests that are available from vending machines as part of a pilot program</a>. </p>
<p>With self-testing, there is also no need for patients to worry about being asked leading questions or being judged by a doctor when they request a test. Self-testing for HIV is an example of an innovation that can help both individuals and the population by reducing the spread of HIV. </p>
<h2>Better access to screening</h2>
<p><a href="https://canadiantaskforce.ca/guidelines/published-guidelines/depression/">Current guidelines</a> in Canada assume that people will receive periodic assessments of their mental health. But we know that many people <a href="https://doi.org/10.1503/cmaj.1096049">do not receive routine primary care</a>. We also know that income, as well as other social factors such as <a href="https://www.canada.ca/en/public-health/services/publications/science-research-data/key-health-inequalities-canada-national-portrait-executive-summary.html">racialization and gender identity, can determine access to care</a>, in part because some face discrimination within the health-care system. </p>
<p>For these reasons, we recommend routine screening for depression for people experiencing disadvantages.</p>
<figure class="align-center ">
<img alt="A woman in a white coat taking an older man's blood pressure" src="https://images.theconversation.com/files/553016/original/file-20231010-24-upls4u.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/553016/original/file-20231010-24-upls4u.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/553016/original/file-20231010-24-upls4u.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/553016/original/file-20231010-24-upls4u.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/553016/original/file-20231010-24-upls4u.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/553016/original/file-20231010-24-upls4u.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/553016/original/file-20231010-24-upls4u.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 pressure checks every three to five years — together with a comprehensive assessment of cardiovascular risk — can help ensure people have appropriate access to life-saving medicines that have helped to extend life expectancy.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<p>Likewise, we suggest that people experiencing disadvantages be screened for colorectal cancer starting at age 45 years, while the <a href="https://canadiantaskforce.ca/guidelines/published-guidelines/colorectal-cancer/">recommendation for the general population is to start at age 50</a>. </p>
<p>Our recommendation for an earlier start is based on the fact that earlier screening <a href="https://doi.org/10.1001/jama.2021.6238">prevents deaths</a>, there are <a href="https://pubmed.ncbi.nlm.nih.gov/34128915/">disparities in cancer outcomes based on social factors</a>, and screening does not always start when patients are first notified. </p>
<p>High blood pressure is sometimes referred to as a “silent killer” because it usually causes no symptoms but it <a href="https://www.canada.ca/en/public-health/services/diseases/heart-health/high-blood-pressure.html">can result in a heart attack or a stroke</a>. We recommend blood pressure checks every three to five years — together with a comprehensive assessment of cardiovascular risk — to ensure people have appropriate access to life-saving medicines that have helped to extend life expectancy.</p>
<h2>Justice in access to care</h2>
<p>In an ideal world, guidance that prioritizes the health of those facing discrimination and disadvantages would not be needed. Life would be fair, care would be equitable and health outcomes would be level. But our world is not ideal. </p>
<p>We can actually achieve something better than “equal” treatment; we can achieve justice when it comes to access to life-saving preventive care by reaching out to those who need the most support.</p>
<p>One part of that is empowering patients and members of the public by informing them about the care they should be offered. You can visit <a href="https://www.screening.ca/">screening.ca</a> to be provided with a custom list of recommended interventions based on your age and answers to some yes-or-no questions.</p>
<p>Focusing on the needs of those who are treated unfairly could ultimately lead to improvements for everyone. Once the capacity of HPV testing is increased, self-testing will likely become a <a href="https://doi.org/10.1503/cmaj.211568">standard approach to cervical cancer screening, as it already has in Australia</a>. We could start with preventive care in redesigning health care for those who need it the most.</p>
<p>We also need to reflect on why the unfair status quo has persisted for so long. <a href="https://www.canada.ca/content/dam/phac-aspc/documents/services/publications/science-research/key-health-inequalities-canada-national-portrait-executive-summary/hir-full-report-eng.pdf">Governments</a> and large <a href="https://www.canada.ca/en/public-health/services/health-promotion/healthy-living/creating-a-healthier-canada-making-prevention-a-priority.html">health-care institutions</a> have all made grand statements about the need to tackle sexism, racism, ableism and other forms of discrimination. It is long past time for those institutions to fund and support specific actions to help those who have been disadvantaged by previous inaction.</p><img src="https://counter.theconversation.com/content/214689/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Nav Persaud receives funding from the Canadian Institutes of Health Research, the Canada Research Chairs program and the Ontario SPOR Support Unit. </span></em></p><p class="fine-print"><em><span>Aisha Lofters receives funding from the Canadian Institutes of Health Research, the Canadian Cancer Society, the Peter Gilgan Centre for Women's Cancers at Women's College Hospital, and Pfizer/ReThink Breast Cancer. </span></em></p>Cancer screening and other routine primary care can help address inequities if we choose to leave the unfair status quo behind.Nav Persaud, Canada Research Chair in Health Justice, University of TorontoAisha Lofters, Associate professor, Department of Family & Community Medicine, University of TorontoLicensed 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>
<hr>
<p>
<em>
<strong>
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>
</strong>
</em>
</p>
<hr>
<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>
<figure class="align-center ">
<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">
<figcaption>
<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>
</figcaption>
</figure>
<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>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/private-health-insurance-is-set-for-a-shake-up-but-asking-people-to-pay-more-for-policies-they-dont-want-isnt-the-answer-210981">Private health insurance is set for a shake-up. But asking people to pay more for policies they don't want isn't the answer</a>
</strong>
</em>
</p>
<hr>
<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>
<hr>
<p>
<em>
<strong>
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>
</strong>
</em>
</p>
<hr>
<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/2130572023-10-01T15:12:23Z2023-10-01T15:12:23ZFamily doctor shortage: Medical education reform can help address critical gaps, starting with a specialized program<figure><img src="https://images.theconversation.com/files/551040/original/file-20230928-25-8o9ec7.jpg?ixlib=rb-1.1.0&rect=0%2C8%2C5689%2C3386&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A program offers training and education specifically on family medicine from the start of medical school, while bypassing administrative hurdles to residency.</span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><iframe style="width: 100%; height: 100px; border: none; position: relative; z-index: 1;" allowtransparency="" allow="clipboard-read; clipboard-write" src="https://narrations.ad-auris.com/widget/the-conversation-canada/family-doctor-shortage-medical-education-reform-can-help-address-critical-gaps-starting-with-a-specialized-program" width="100%" height="400"></iframe>
<p>Recent reports indicate that <a href="https://doi.org/10.25318/1310048401-eng">over six million Canadians are without a family doctor</a>. This not only has a massive impact for those individuals, <a href="https://doi.org/10.1136%2Ffmch-2023-002236">but also for the entire health-care system</a>. Given current caseloads, about 4,000 family doctors would be required to address the current shortfall.</p>
<p>Education reform is part of the solution to this crisis. A new family medicine program in Ontario is designed to ensure that candidates who are the most qualified and motivated to pursue a community-based family practice get appropriate and comprehensive training. </p>
<p>The <a href="https://meds.queensu.ca/academics/queens-lakeridge-health-md-family-medicine-program">Queen’s-Lakeridge Health MD Family Medicine Program</a> focuses training and education on family medicine from the start of medical school, then advancing directly to residency. We were both involved in the conception and development of the program, Anthony Sanfilippo as senior advisor for educational expansion and innovation, and Jane Philpott as dean.</p>
<h2>Current medical education</h2>
<p>Under the existing system, medical schools across <a href="https://doi.org/10.12927%2Fhcpol.2021.26429">Canada welcomed about 3,100 young people</a> in September. They are eager, academically accomplished and committed. They have succeeded (some would say survived) a gruelling and competitive process that left the other 80 per cent of their similarly accomplished and committed co-applicants disappointed.</p>
<p>Given the <a href="https://doi.org/10.1503/cmaj.109-5704">minuscule attrition rate</a> after medical school admission and availability of postgraduate training positions, they are essentially assured of a career in medicine. That career, in today’s expanded world of specialization and sub-specialization, could be in any of well over 100 distinct areas of medical practice. Some of those fields are in desperate need of new recruits, particularly family medicine. </p>
<figure class="align-center ">
<img alt="A group of people in white coats listening to a colleague" src="https://images.theconversation.com/files/551041/original/file-20230928-19-4jgzhn.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/551041/original/file-20230928-19-4jgzhn.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/551041/original/file-20230928-19-4jgzhn.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/551041/original/file-20230928-19-4jgzhn.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/551041/original/file-20230928-19-4jgzhn.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/551041/original/file-20230928-19-4jgzhn.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/551041/original/file-20230928-19-4jgzhn.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 program is designed deliberately to prepare them for a career in community-based family medicine, and will include early clinical learning in family practice settings.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<p>Despite these pressing needs, students enter medical school with no commitment to any particular area of practice. Given <a href="https://www.carms.ca/pdfs/carms-forum-2023.pdf">current patterns of career selection</a>, it may be as few as 700 medical graduates per year who will be taking up the <a href="https://www.cfpc.ca/CFPC/media/Resources/Research/FM-Longitudinal-Survey-T1-entry-2021-Aggregate-Report.pdf">comprehensive, continuing family practices</a> that would address the needs of those patients.</p>
<p>In fact, much of their next three or (usually) four years in medical school will involve exploring various career options and engaging in yet <a href="https://doi.org/10.1503%2Fcmaj.170791">another highly competitive and arduous process</a> at the end of medical school to obtain a postgraduate training position. </p>
<p>In order to accomplish all this, their curricula will provide, in addition to scientific and professional skills common to all physicians, a broad sampling of specialties. This sampling will include learning, performance and clinical engagement in many areas of practice that they will never actually undertake or, if they do, will need to relearn and refine in their postgraduate training program.</p>
<p>What’s clear is that, without significant reform, modest expansion and even opening new schools will not come close to addressing our needs within the current training paradigm. </p>
<h2>A program specific to family medicine</h2>
<p>This year, for the first time, things will be different for the 20 students entering the new Queen’s-Lakeridge Health MD Family Medicine Program. Their admission was based not only on exemplary academic and personal credentials, but also on their commitment to a career in family medicine.</p>
<p>The program they are about to undertake is designed deliberately to prepare them for those careers, will include early clinical learning in family practice settings and will be taught predominantly by family physicians who are in active clinical practice providing the comprehensive, continuing, community-based care so desperately needed in our country.</p>
<figure class="align-center ">
<img alt="A doctor in an examining room with a woman and child" src="https://images.theconversation.com/files/551038/original/file-20230928-29-z7n11g.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/551038/original/file-20230928-29-z7n11g.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/551038/original/file-20230928-29-z7n11g.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/551038/original/file-20230928-29-z7n11g.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/551038/original/file-20230928-29-z7n11g.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/551038/original/file-20230928-29-z7n11g.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/551038/original/file-20230928-29-z7n11g.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 program will be taught predominantly by physicians who are in active clinical practice as family physicians providing comprehensive, continuing, community-based care.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<p>It began as a partnership between <a href="https://meds.queensu.ca/">Queen’s University School of Medicine</a> and <a href="https://www.lakeridgehealth.on.ca/">Lakeridge Health</a>, an integrated organization of five hospitals and over 20 community health locations providing care to the residents of Durham region. It was based on a shared recognition that medical schools have a role in addressing the critical shortage of family physicians impacting so many Canadians, and that this shortage can, in part, be addressed by providing specialized admission opportunities and more purpose-driven education to motivated applicants. </p>
<p>It also seeks to develop models of medical education that address the real needs of contemporary society, evolving in response to the expansion and diversification of medical practice. Medical problems that were previously treated exclusively in hospital or required only palliative management are now very effectively managed chronically with medication and regular followup in the community.</p>
<p>Durham Region provides an ideal location for this program given its increasing and highly diversified population. It’s also home to multiple, well developed medical practice settings (including acute care hospitals, chronic care and mental health facilities, ambulatory clinics, and both group and individual practices) as well as committed medical and administrative communities who have longstanding associations with Queen’s. </p>
<figure class="align-center ">
<img alt="A group of health professionals, some wearing scrubs and white coats" src="https://images.theconversation.com/files/551037/original/file-20230928-27-x3a3l6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/551037/original/file-20230928-27-x3a3l6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=375&fit=crop&dpr=1 600w, https://images.theconversation.com/files/551037/original/file-20230928-27-x3a3l6.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=375&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/551037/original/file-20230928-27-x3a3l6.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=375&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/551037/original/file-20230928-27-x3a3l6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=471&fit=crop&dpr=1 754w, https://images.theconversation.com/files/551037/original/file-20230928-27-x3a3l6.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=471&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/551037/original/file-20230928-27-x3a3l6.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=471&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Family doctors often practise in primary care teams along with multidisciplinary health-care workers such as nurse practitioners, dietitians and social workers.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<p>Queen’s School of Medicine and Lakeridge Health jointly proposed, and were supported by the Ontario Ministry of Health, in the development of this continuous six-year program that would prepare students to become qualified family physicians focused on providing comprehensive, continuing, community-based care.</p>
<h2>Themes specific to family medicine</h2>
<p>A joint Queen’s-Lakeridge Health Working Group was established to explore and implement the program based on four key themes:</p>
<p><strong>Admissions</strong> – After identifying attributes appropriate to a successful career in family practice, a novel admission process was developed that assesses academic aptitude for medicine as well as personal qualities and commitment that will promote both practice satisfaction and retention within communities.</p>
<p><strong>Curriculum</strong> – A novel curriculum was developed focused on fundamental and clinical training relevant to family medicine, with early and continuing placements in community practice settings. The curriculum incorporates key components of the undergraduate MD program and postgraduate family medicine program into an integrated program without the necessity for a secondary application process. The concept is that students will learn how to provide care to patients of all ages, in the types of settings in which they will eventually practise.</p>
<p><strong>Faculty Engagement</strong> – The faculty team blends Queen’s instructors based in Kingston with newly recruited faculty members in the Durham Region medical community. New faculty are welcomed into the Queen’s teaching community with an orientation and instruction process. Students will be learning from doctors who are actively involved in the type of practice in which they are training.</p>
<p><strong>Community Engagement</strong> – The new program is located in Durham Region. Together with Lakeridge Health administration and medical staff, facilities for teaching, housing and community placements have been established. In addition, student support and counselling have been developed locally, with strong support and integration with Kingston-based services.</p>
<h2>Addressing a critical gap</h2>
<p>These students will be able to undertake studies and training that will prepare them for their intended career, in the sort of settings in which they will eventually practise, and with guidance and mentorship of practising faculty. Their learning will be focused on family medicine. They will not be required to undertake any secondary application process, and will have considerable flexibility to tailor their training to the requirements of their eventual practice destination. </p>
<p>The aim is for them to emerge from the program prepared to qualify and practise as family physicians. </p>
<p>Importantly, this approach, although designed at this point for family medicine, could serve as a model for other medical specialties to address current and future medical workforce requirements.</p><img src="https://counter.theconversation.com/content/213057/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>Education has a role to play in addressing the shortage of family doctors. A new program is designed specifically for comprehensive, community-based family practice.Anthony Sanfilippo, Professor of Medicine (Cardiology), Queen's University, OntarioJane Philpott, Dean, Queen's Health Sciences, Queen's University, OntarioLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2126112023-09-17T20:00:35Z2023-09-17T20:00:35ZWho really benefits from private health insurance rebates? Not people who need cover the most<figure><img src="https://images.theconversation.com/files/547124/original/file-20230908-19-g6utdm.jpg?ixlib=rb-1.1.0&rect=0%2C2%2C1000%2C663&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/busy-nurses-station-modern-hospital-352316315">Shutterstock</a></span></figcaption></figure><p>The Australian government spends <a href="https://www.health.gov.au/ministers/the-hon-greg-hunt-mp/media/delivering-australias-lowest-private-health-insurance-premium-change-in-21-years">A$6.7 billion a year</a> on private health insurance rebates. These <a href="https://www.ato.gov.au/Individuals/Medicare-and-private-health-insurance/Private-health-insurance-rebate/">rebates</a> are the government’s contribution towards the costs of individuals’ premiums. </p>
<p>But our <a href="https://doi.org/10.1002/hec.4751">analysis</a> shows higher rebates for people aged 65 and older are not doing much to encourage them to sign up for private hospital cover, the very group who may benefit the most from it.</p>
<p>This and <a href="https://doi.org/10.1080/13504851.2017.1299094">other research</a> point to these rebates largely going to people on higher incomes, ones who’d be more likely to buy private health insurance anyway.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/the-private-health-insurance-rebate-has-cost-taxpayers-100-billion-and-only-benefits-some-should-we-scrap-it-181264">The private health insurance rebate has cost taxpayers $100 billion and only benefits some. Should we scrap it?</a>
</strong>
</em>
</p>
<hr>
<h2>Remind me, what are these rebates?</h2>
<p>In <a href="https://www.abs.gov.au/ausstats/abs@.nsf/2f762f95845417aeca25706c00834efa/0aaf3311ebcd3646ca2570ec000c46e4!OpenDocument#:%7E:text=The%20Federal%20Government%2030%25%20Rebate,the%20means%2Dtested%20PHIIS%20rebate.">1999</a>, the Australian government introduced the private health insurance rebate. Initially, the rebate meant the government paid 30% of the cost of private health insurance for everyone, regardless of income or age. Then in 2005, the Howard government increased the rebate rate to 35% for those aged 65-69 and to 40% for those aged 70 and older, regardless of how much they earned.</p>
<p>Over time, the rebate rates have decreased slightly and now depend on both income and age. However, the higher discount for older people has always remained.</p>
<p>We wanted to understand whether the higher rebates for older people actually encourage them to buy private health insurance. </p>
<p>So we looked at data from more than 300,000 people who filed tax returns over more than a decade (2001-2012). We then compared the trends in insurance coverage of people younger than 65 and older than 65, before and after the 2005 rebate policy change.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/private-health-insurance-is-set-for-a-shake-up-but-asking-people-to-pay-more-for-policies-they-dont-want-isnt-the-answer-210981">Private health insurance is set for a shake-up. But asking people to pay more for policies they don't want isn't the answer</a>
</strong>
</em>
</p>
<hr>
<h2>What we found</h2>
<p>We found higher rebates led to a modest and short-term increase in private health insurance take-up. We estimated that lowering premium prices by 10% through higher rebates would only result in 1-2% more people aged 65 and older buying private health insurance in the next two years.</p>
<p>This means higher rebates for older people are a very expensive way to get them to insure. </p>
<p>People aged 65-74 with income in the bottom 25% of earners were the most likely to buy insurance in response to higher rebates that reduced premium prices. That’s an income under $21,848 in today’s money (income increased to 2023 dollar amount, in line with the <a href="https://www.ato.gov.au/rates/consumer-price-index">consumer price index</a>).</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1690861390397833217"}"></div></p>
<h2>What do we propose?</h2>
<p>Our findings suggest a more targeted subsidy program would be a more effective way to increase private health insurance. To achieve this, we recommend lowering income thresholds for rebates to target people of all ages on genuinely low incomes.</p>
<p>Currently, people earning as much as $144,000 (singles) or $288,000 (families) can receive rebates.</p>
<p>Other evidence to back our proposal comes from <a href="https://melbourneinstitute.unimelb.edu.au/publications/working-papers/search/result?paper=4682822">research</a> released earlier this year. This suggests higher income earners are likely to buy private insurance regardless of rebates.</p>
<p>A recent <a href="https://consultations.health.gov.au/medical-benefits-division/consultation-on-phi-studies">consultation report</a> commissioned by the federal health department reviewed a range of health insurance incentives. </p>
<p>The <a href="https://consultations.health.gov.au/medical-benefits-division/consultation-on-phi-studies/supporting_documents/Finity%20Consulting%20MLS%20and%20PHI%20Rebate%20Final%20Report.pdf">report</a> recommends removing rebates for those with income higher than $108,000 for singles and $216,000 for families (we recommend removing them at $93,000 for singles and $186,000 for families). The report also recommends increasing rebates for those older than 65 (we believe income, rather than age, is a better marker of someone’s means).</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/547129/original/file-20230908-27-7xrh0v.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Elderly woman with empty purse in lap" src="https://images.theconversation.com/files/547129/original/file-20230908-27-7xrh0v.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/547129/original/file-20230908-27-7xrh0v.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/547129/original/file-20230908-27-7xrh0v.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/547129/original/file-20230908-27-7xrh0v.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/547129/original/file-20230908-27-7xrh0v.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/547129/original/file-20230908-27-7xrh0v.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/547129/original/file-20230908-27-7xrh0v.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">People on low incomes should be targeted instead.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/elderly-man-holding-old-coin-purse-727162720">Shutterstock</a></span>
</figcaption>
</figure>
<h2>Are rebates good value for money?</h2>
<p>We also need to look at whether rebates provide value for money more broadly, and across all ages. </p>
<p><a href="https://grattan.edu.au/wp-content/uploads/2019/12/926-Saving-Health-2.pdf">Existing evidence</a> shows a 10% decrease in premiums due to rebates only leads to a 3.5-5% increase in private health insurance take-up among all Australians. We show this is only <a href="https://doi.org/10.1002/hec.4751">1-2%</a> for people over 65.</p>
<p>So rebates are likely to <a href="https://doi.org/10.1016/j.jhealeco.2013.11.007">cost taxpayers more</a> than they generate in savings, and are largely windfalls to those who would privately insure anyway, often those who are financially better off.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/do-you-really-need-private-health-insurance-heres-what-you-need-to-know-before-deciding-93661">Do you really need private health insurance? Here's what you need to know before deciding</a>
</strong>
</em>
</p>
<hr>
<h2>What happens if we scrapped the rebates?</h2>
<p>It is uncertain how many people would drop private cover if the rebate was removed. </p>
<p>But based on research from when the rebate was introduced, the rebate might account for a maximum <a href="https://escholarship.org/content/qt6j47s8kq/qt6j47s8kq_noSplash_be059196ed2d70b94486039f64452494.pdf">10-15 percentage points</a> of the overall take-up rate. Other research suggests it might be much less than this, closer to <a href="https://www.sciencedirect.com/science/article/pii/S016762961300163X?casa_token=C-SdG98Jc2UAAAAA:KJLHBZ2BJhq9wRQQKUbEWPiqoeza1DEi3mZ9Y6O2GereVX1L1x0cJumVgrqBeMGa1ygDjFrPG7T5">2 percentage points</a>.</p>
<p>In other words, the rebate only appears to influence a small percentage of people to buy private health insurance. So scrapping it would likely have a similarly small effect.</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1695919937649250725"}"></div></p>
<p>Then there’s the impact of scrapping the rebate, people dropping their cover and putting more pressure on the public system. Earlier this year, we found private health insurance had <a href="https://theconversation.com/does-private-health-insurance-cut-public-hospital-waiting-lists-we-found-it-barely-makes-a-dent-211680">minimal impact</a> on reducing waiting times for surgery in Victorian public hospitals. So scrapping the rebate might have minimal impact on waiting lists.</p>
<p>Taken together, the billions of dollars a year the government spends to subsidise private health insurance via rebates might be better directed to public hospitals and other high-value care, including primary care and preventive care.</p><img src="https://counter.theconversation.com/content/212611/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Yuting Zhang has received funding from the Australian Research Council (future fellowship project ID FT200100630), Department of Veterans' Affairs, the Victorian Department of Health, and National Health and Medical Research Council. In the past, Professor Zhang has received funding from several US institutes including the US National Institutes of Health, Commonwealth fund, Agency for Healthcare Research and Quality, and Robert Wood Johnson Foundation. She has not received funding from for-profit industry including the private health insurance industry.</span></em></p><p class="fine-print"><em><span>Judith Liu received funding from Richard Ivan Downing Fellowship Fund (University of Melbourne) during the conduct of the study.</span></em></p><p class="fine-print"><em><span>Nathan Kettlewell 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>We found rebates don’t do much to encourage older people to sign up for private health insurance.Yuting Zhang, Professor of Health Economics, The University of MelbourneJudith Liu, Assistant Professor of Economics, University of OklahomaNathan Kettlewell, Chancellor's Research Fellow, Economics Discipline Group, University of Technology SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2104252023-09-13T18:40:20Z2023-09-13T18:40:20ZSolving Canada’s shortage of health professionals means training more of them, and patients have a key role in their education<figure><img src="https://images.theconversation.com/files/547848/original/file-20230912-7671-ly0s9f.jpg?ixlib=rb-1.1.0&rect=131%2C186%2C5013%2C3523&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A fundamental component for training health-care professionals is interacting with patients and families.</span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><iframe style="width: 100%; height: 100px; border: none; position: relative; z-index: 1;" allowtransparency="" allow="clipboard-read; clipboard-write" src="https://narrations.ad-auris.com/widget/the-conversation-canada/solving-canadas-shortage-of-health-professionals-means-training-more-of-them-and-patients-have-a-key-role-in-their-education" width="100%" height="400"></iframe>
<p><a href="https://www.ctvnews.ca/health/canadians-worried-about-the-state-of-provincial-health-systems-poll-1.6248713">Eighty-six per cent of Canadians</a> are worried about their health-care systems. Health-care professional organizations like the <a href="https://www.cma.ca/about-us/what-we-do/press-room/health-care-groups-call-premiers-make-canadas-collapsing-health-system-their-top-priority#:%7E:text=%22Canada%27s%20health%20care%20system%20is%20in%20crisis.%20While,only%20added%20fuel%20to%20an%20already%20raging%20fire.">Canadian Medical Association</a> and the <a href="https://www.casn.ca/2022/11/casn-releases-nurses-education-in-canada-statistics-report-2020-2021/">Canadian Association of Schools of Nursing</a> are sounding the alarm about the severe shortage of health-care providers. This shortage is contributing to Canada’s health-care crisis. </p>
<p>Canada urgently needs more trained health-care professionals. While they may not know it, everyone in Canada can play a key role in educating future health-care providers. </p>
<p>Each encounter that health-care students have with patients, families and communities helps them develop real-world understanding of the various needs of the diverse Canadian population.</p>
<h2>Canada’s shortage of health-care workers</h2>
<p>The House of Commons Standing Committee on Health’s March 2023 report titled <a href="https://www.ourcommons.ca/Content/Committee/441/HESA/Reports/RP12260300/hesarp10/hesarp10-e.pdf">Addressing Canada’s Health Workforce Crisis</a> explored and substantiated this shortage of health-care professionals. This report primarily focused on physicians and nurses. Canada anticipates a shortfall of <a href="https://www.canada.ca/en/employment-social-development/news/2023/06/canada-is-addressing-current-and-emerging-labour-demands-in-health-care.html">78,000 physicians</a> by 2031, and <a href="https://www.canadian-nurse.com/blogs/cn-content/2023/04/17/solutions-to-tackle-nursing-shortage#:%7E:text=A%202019%20analysis%20predicted%20a,care%20(OECD%2C%202022).">117,600 nurses</a> by 2030. </p>
<p>Other professions are also sounding the alarm of practitioner shortages, including <a href="https://www.ourcommons.ca/Content/Committee/441/HESA/Reports/RP12260300/hesarp10/hesarp10-e.pdf">dental professionals, medical laboratory specialists, occupational therapists</a> and <a href="https://www.longwoods.com/audio-video/longwoods-breakfast-series/Youtube/9588">pharmacists</a>. </p>
<p>In addition to these predictions, there are significant concerns about keeping the care providers we currently have. A 2022 report from the <a href="https://nursesunions.ca/wp-content/uploads/2022/11/CHWN-CFNU-Report_-Sustaining-Nursing-in-Canada2022_web.pdf">Canadian Federation of Nurses Unions</a> found that 94 per cent of nurse respondents showed signs of burnout, and over half wanted to leave their current job. Other health professions have raised similar concerns. </p>
<h2>Addressing the shortage</h2>
<p>There is no quick fix to these complex problems, and Canada is responding in a variety of ways. This includes recruiting <a href="https://www.canada.ca/en/employment-social-development/news/2022/12/government-of-canada-launches-call-for-proposals-to-help-internationally-educated-professionals-work-in-canadian-healthcare.html">internationally trained</a> practitioners, funding strategies to improve <a href="https://www.canada.ca/en/health-canada/news/2023/04/government-of-canada-announces-support-to-help-address-workforce-challenges-and-retention-in-nursing-field.html">retention</a> and increasing <a href="https://www.universityaffairs.ca/news/news-article/provincial-budget-round-up-2023-highlights-for-the-university-sector/">educational seats</a> to train more future health-care providers. </p>
<figure class="align-center ">
<img alt="A woman in scrubs shakes hands with a man using a wheelchair in front of two other people in scrubs" src="https://images.theconversation.com/files/547868/original/file-20230912-5779-i19k0y.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/547868/original/file-20230912-5779-i19k0y.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/547868/original/file-20230912-5779-i19k0y.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/547868/original/file-20230912-5779-i19k0y.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/547868/original/file-20230912-5779-i19k0y.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/547868/original/file-20230912-5779-i19k0y.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/547868/original/file-20230912-5779-i19k0y.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">Each encounter that health-care students have with patients, families and communities helps them develop real-world understanding of the various needs of the diverse Canadian population.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<p>These responses are being created from <a href="https://www.canada.ca/en/health-canada/news/2022/11/health-canada-announces-coalition-for-action-for-health-workers.html">federal</a>, provincial (such as <a href="https://novascotia.ca/news/release/?id=20221114001">Nova Scotia</a>) and local levels. However, these strategies are not quick fixes and efforts may not be successful. </p>
<p><a href="https://www.cbc.ca/news/health/financial-perks-doctor-recruitment-1.6548194">Retention efforts</a> have not been as effective as anticipated, as financial incentives do not appear to have the same influence they might have had in the past. International recruitment is fraught with <a href="https://theconversation.com/the-ethics-of-recruiting-international-health-care-workers-canadas-gains-could-mean-another-countrys-pain-208542">ethical concerns</a> and complex processes applicants need to work through in order to become licensed to practice.</p>
<h2>Education investments</h2>
<p>Significant provincial investments are being announced to create more seats in education programs for health-care professional students. The <a href="https://edmontonjournal.com/news/politics/alberta-to-expand-seats-in-health-care-education-with-200-million-over-three-years">Alberta government</a> is investing $72 million for 3,400 new seats in a variety of health-related training programs and $20 million for the creation of 120 new physician seats. </p>
<p><a href="https://globalnews.ca/news/9448757/additional-seats-saskatchewan-health-care-training-programs/">Saskatchewan</a> is adding 550 health-care provider education seats. <a href="https://news.umanitoba.ca/manitoba-government-announces-80-physician-training-seats-to-be-added/">Manitoba</a> announced an investment of $200 million for 2,000 health-care professionals, including 80 new physician seats and four <a href="https://news.gov.mb.ca/news/index.html?item=56297">respiratory therapy</a> students. </p>
<p><a href="https://www.universityaffairs.ca/news/news-article/provincial-budget-round-up-2023-highlights-for-the-university-sector/">Other provinces</a> are also investing in a variety of ways such as educational program grants to expand enrolment in Ontario, and student financial support in Prince Edward Island.</p>
<p>While increased training opportunities can increase the future workforce, having more students also requires additional resources and learning opportunities. Education for health-care professionals varies by the type of provider, and can range from certificate programs to graduate degrees. </p>
<h2>How Canadians can help</h2>
<p>We are a team of interdisciplinary researchers who teach health-care professionals in their foundational training. We know that despite significant differences in health-care education programs, one fundamental component for all learners is interacting with patients and families. </p>
<p>That means all Canadians play an essential part in educating future health-care providers. With more students enrolling, Canadians will have even more engagement with students in health-care settings.</p>
<p>Most health-care education programs include public interaction. Some public members purposefully engage. For example, some become guest speakers in classes, and share personal experiences with illness and health care. But more commonly, people engage with health-care professional students while looking after their health needs. </p>
<p>Canadians can anticipate interacting with students in common health-care spaces such as pharmacies, physiotherapy clinics, dental clinics, public health clinics, doctor’s offices, hospitals or outpatient clinics. But students may also be found in less expected places such as food banks, non-profit community organizations, schools and community settings. </p>
<p>Members of the public may feel less inclined to interact with students. This can be due to the perceived increased time it takes, worries about students’ knowledge or abilities, or because they might feel that they <a href="https://doi.org/10.1016/j.ijnurstu.2018.04.010">don’t have anything to contribute</a>. However, it is important for Canadians to know about the benefits of these interactions for both students and patients.</p>
<h2>What Canadians can teach health-care professional students</h2>
<p>Research has identified that student encounters with public patients and family members contributed to the development of their <a href="https://doi.org/10.1007/s10459-022-10137-3">communication</a>, <a href="https://doi.org/10.1080/0142159X.2019.1652731">compassion and empathy skills</a>. It also helped decrease stigma towards traditionally stigmatized groups and conditions, such as those with <a href="https://doi.org/10.1111/1440-1630.12205">mental illness</a>. </p>
<p>Interacting with the Canadian public also increased students’ ability to <a href="https://doi.org/10.1111/j.1365-2850.2011.01858.x">use appropriate language</a> and <a href="https://doi.org/10.1111/j.1365-2850.2012.01955.x">work with patients</a>. It enhanced their <a href="http://dx.doi.org/10.1136/bmjopen-2020-037217">self-confidence</a> and their motivation in caring for the public.</p>
<h2>How does this impact Canadians?</h2>
<p>While these interactions benefit student learning and will help contribute to a larger health workforce, they have also been found to benefit the public. </p>
<p>Research has found that student encounters can increase a patient’s <a href="https://doi.org/10.1111/inm.12021">sense of empowerment</a> to participate in their own health with shared decision-making. Additionally, there is a potential for the improvement of overall <a href="https://doi.org/10.1007/s10459-022-10137-3">health outcomes</a> of patients. One study found patients were more knowledgeable and better able to <a href="https://doi.org/10.1016/j.japh.2021.08.014">manage their own medications</a> after engaging with student practitioners.</p>
<p>The shortage of health professionals in Canada, and globally, is of sincere concern. To address this, it is essential that we increase the number of professionals being trained. This requires the Canadian public’s assistance as they encounter more health-care professional students. </p>
<p>Investing your time in interacting with students has benefits for the students and for you. Canadians can all play a part in building the future health workforce we desperately need. As health-care professionals, we thank you for the important role you play in educating and shaping our students and future health workforce. </p>
<p><em>Bryn Keogh co-authored this article. She is an undergraduate student at the University of Calgary in communication and media studies and received an Alberta Innovates Summer Research Studentship.</em></p><img src="https://counter.theconversation.com/content/210425/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>Each encounter that health-care students have with patients and families helps them understand real-world patient needs. That means all Canadians have a role in educating future health-care providers.Lisa McKendrick Calder, Associate Professor, Nursing, MacEwan UniversityEleftheria Laios, Educational Developer, Queen's University, OntarioKerry Wilbur, Associate Professor and Executive Director, Entry-to-Practice Education, Faculty of Pharmaceutical Sciences, University of British ColumbiaLorelli Nowell, Associate Professor and Assistant Dean of Graduate Programs, Faculty of Nursing, University of CalgaryWhitney Lucas Molitor, Associate Professor and Program Director, Occupational Therapy Department, University of South DakotaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2125022023-09-06T12:27:15Z2023-09-06T12:27:15ZTraditional medicine provides health care to many around the globe – the WHO is trying to make it safer and more standardized<figure><img src="https://images.theconversation.com/files/546464/original/file-20230905-503-nlkg3v.jpg?ixlib=rb-1.1.0&rect=3%2C9%2C2114%2C1400&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Ayurveda is one form of traditional medicine that can integrate aromatherapy. It's popular in South Asia. </span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/ayurveda-aromatherapy-with-essential-oil-diffuser-royalty-free-image/1333713382?phrase=ayurveda&adppopup=true">Microgen Images/Science Photo Library</a></span></figcaption></figure><p>For approximately <a href="https://www.who.int/news/item/25-03-2022-who-establishes-the-global-centre-for-traditional-medicine-in-india">80% of the world’s population</a>, the first stop after catching a cold or breaking a bone isn’t the hospital — maybe because there isn’t one nearby, or they can’t afford it. Instead, the first step is consulting traditional medicine, which cultures around the world have been using for thousands of years.</p>
<p><a href="https://www.who.int/health-topics/traditional-complementary-and-integrative-medicine#tab=tab_1">Traditional medicine</a> encompasses the healing knowledge, skills and practices used by a variety of cultures and groups. </p>
<p>Examples of traditional medicine include <a href="https://www.hopkinsmedicine.org/health/wellness-and-prevention/herbal-medicine">herbal medicine</a>; <a href="https://www.mayoclinic.org/tests-procedures/acupuncture/about/pac-20392763">acupuncture</a>; <a href="https://www.sciencedirect.com/topics/medicine-and-dentistry/tui-na">Tui Na</a> – which is a type of massage originating in China; <a href="https://www.nccih.nih.gov/health/ayurvedic-medicine-in-depth">Ayurveda</a> – which is an ancient system of promoting health through diet, exercise and lifestyle from India; <a href="https://www.britannica.com/science/Unani-medicine">and Unani</a> – which is another ancient system of health from South Asia, balancing key aspects of the mind, body and spirit. </p>
<p>In recognizing that traditional medicine and other alternative forms of healing are critical sources of health care for many people worldwide, the World Health Organization and the government of India co-hosted their first-ever <a href="https://www.who.int/news-room/events/detail/2023/08/17/default-calendar/the-first-who-traditional-medicine-global-summit">Traditional Medicine Summit</a>. The summit took place in August 2023 in Gandhinagar, Gujarat, India. </p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/jW-B8BpLQJE?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">August 2023 marked the WHO’s first global summit on traditional medicine.</span></figcaption>
</figure>
<p>The summit brought together health care policymakers, traditional medicine workers and users, international organizations, academics and private sector stakeholders from 88 <a href="https://www.who.int/countries">WHO member states</a>. Leaders at the summit aimed to share best practices and scientific evidence and data around traditional medicine. </p>
<p>As researchers interested in how to provide patients both in the U.S. and around the globe with the best <a href="http://gsm.utmck.edu/internalmed/faculty/terry.cfm">possible medical care</a>, <a href="https://scholar.google.com/citations?user=Wng1Wh0AAAAJ&hl=en">we were interested</a> in the summit’s findings. Understanding traditional medicine can help health care professionals create sustainable, personalized and culturally respectful practices.</p>
<h2>Critical health care for many</h2>
<p>In many countries, traditional medicine costs less and is <a href="https://doi.org/10.1093%2Fheapol%2Fczw022">more accessible</a> than conventional health care. And many conventional medicines come from the same source as compounds used in traditional medicine – <a href="https://doi.org/10.1021/acs.jnatprod.9b01285">up to 50% of drugs</a> have a <a href="https://theconversation.com/nature-is-the-worlds-original-pharmacy-returning-to-medicines-roots-could-help-fill-drug-discovery-gaps-176963">natural product root</a>, <a href="https://doi.org/10.1016/j.vph.2018.10.008">like aspirin</a>. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/546451/original/file-20230905-17-3flfzw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="An elderly man wearing a gray button-down shirt sorts bundles of dried herbs into eight piles, behind him is a wall of wooden drawers." src="https://images.theconversation.com/files/546451/original/file-20230905-17-3flfzw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/546451/original/file-20230905-17-3flfzw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=399&fit=crop&dpr=1 600w, https://images.theconversation.com/files/546451/original/file-20230905-17-3flfzw.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=399&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/546451/original/file-20230905-17-3flfzw.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=399&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/546451/original/file-20230905-17-3flfzw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=502&fit=crop&dpr=1 754w, https://images.theconversation.com/files/546451/original/file-20230905-17-3flfzw.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=502&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/546451/original/file-20230905-17-3flfzw.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"></a>
<figcaption>
<span class="caption">An herbalist sorts herbs at the Great China Herb Company in Chinatown in San Francisco. Herbal medicine is one form of traditional medicine.</span>
<span class="attribution"><a class="source" href="https://newsroom.ap.org/detail/TravelTripSanFranciscoChinatown/c09c3fae7725457ca4e548ceda2a2f34/photo?Query=traditional%20medicine&mediaType=photo&sortBy=&dateRange=Anytime&totalCount=377&currentItemNo=1&vs=true">AP Photo/Eric Risberg</a></span>
</figcaption>
</figure>
<p><a href="https://doi.org/10.2147/PPA.S398644">Many factors</a> may influence whether someone chooses traditional medicine, such as age and gender, religion, education and income level, and <a href="https://doi.org/10.1155/2021/9962892">distance to travel for treatment</a>. Cultural factors may also influence people’s use of traditional medicine. </p>
<p>In China, for example, as more people have embraced Western culture, fewer have <a href="https://doi.org/10.2105/AJPH.93.7.1082">chosen traditional medicine</a>. In contrast, many African migrants to Australia continue to use traditional medicine to express their cultural identity and maintain <a href="https://doi.org/10.1186/s12906-021-03424-w">a cohesive ethnic community</a>. A patient’s preference for traditional medicine often has significant personal, environmental and cultural relevance.</p>
<h2>A framework for traditional medicine</h2>
<p>Countries have been pushing the WHO to study and track data on traditional medicine for years. In the past, WHO has developed a “<a href="https://www.who.int/publications/i/item/9789241506096">traditional medicine strategy</a>” to help member states research, integrate and regulate traditional medicine in their national health systems. </p>
<p>The WHO also <a href="https://www.who.int/teams/integrated-health-services/traditional-complementary-and-integrative-medicine">created international terminology standards</a> for practicing various forms of traditional medicine.</p>
<p>The practice of traditional medicine varies greatly between countries, depending on how accessible it is and <a href="https://www.who.int/publications/i/item/978924151536">how culturally important it is</a> in each country. To make traditional medicine safer and more accessible on a broader scale, it’s important for policymakers and public health experts to develop standards and share best practices. The WHO summit was one step toward that goal.</p>
<p>The WHO also aims to collect data that could inform these standards and best practices. It is conducting the <a href="https://www.who.int/news-room/events/detail/2023/08/17/default-calendar/the-first-who-traditional-medicine-global-summit">Global Survey on Traditional Medicine</a> in 2023. As of August, approximately 55 member states out of the total 194 have completed and submitted their data.</p>
<h2>Acupuncture – a case study in safety and efficacy</h2>
<p>Some traditional medicine practices <a href="https://doi.org/10.7453/gahmj.2014.042">such as acupuncture</a> have shown consistent and credible benefits, and have even started to make it <a href="https://time.com/6171247/acupuncture-health-benefits-research/">into mainstream medicine</a> in the U.S. But leaders at the summit emphasized a need for more research on the efficacy and safety of traditional medicine. </p>
<p>Although traditional medicine can <a href="https://www.who.int/news-room/feature-stories/detail/traditional-medicine-has-a-long-history-of-contributing-to-conventional-medicine-and-continues-to-hold-promise">have a range of benefits</a>, some treatments come with health risks. </p>
<p>For example, acupuncture is <a href="https://www.nccih.nih.gov/health/acupuncture-what-you-need-to-know#">a traditional healing practice</a> that entails inserting needles at specific points on the body to relieve pain. But acupuncture can <a href="https://www.nccih.nih.gov/health/acupuncture-what-you-need-to-know">cause infections and injuries</a> if the practitioner doesn’t use sterile needles or if needles are inserted incorrectly.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/546455/original/file-20230905-17-dzwxii.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Two hands insert a needle into a patient's back, which is partially covered with a towel and which already has seven needles stuck in two lines." src="https://images.theconversation.com/files/546455/original/file-20230905-17-dzwxii.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/546455/original/file-20230905-17-dzwxii.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=372&fit=crop&dpr=1 600w, https://images.theconversation.com/files/546455/original/file-20230905-17-dzwxii.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=372&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/546455/original/file-20230905-17-dzwxii.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=372&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/546455/original/file-20230905-17-dzwxii.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=467&fit=crop&dpr=1 754w, https://images.theconversation.com/files/546455/original/file-20230905-17-dzwxii.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=467&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/546455/original/file-20230905-17-dzwxii.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=467&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Acupuncture is an example of a form of traditional healing that’s been implemented on a wide scale in the U.S. It has a variety of benefits, including no risk of addiction.</span>
<span class="attribution"><a class="source" href="https://newsroom.ap.org/detail/AcupuncturePainRelief/0b79ca38552c4b86a845bf4645755106/photo?Query=acupuncture&mediaType=photo&sortBy=&dateRange=Anytime&totalCount=246&currentItemNo=1&vs=true">AP Photo/M. Spencer Green</a></span>
</figcaption>
</figure>
<p>Still, acupuncture is the most commonly used traditional medicine practice across countries, with <a href="https://www.who.int/publications/i/item/978-92-4-001688-0">113 WHO member states</a> acknowledging their citizens practiced acupuncture in 2019.</p>
<p>Interestingly, <a href="https://news.va.gov/94087/battlefield-acupuncture-an-emerging-and-promising-alternative-to-risky-pain-medications/">battlefield acupuncture</a> has successfully treated many U.S. military members, for example, for pain reduction. It is simple to use, transportable and has no risk of addiction.</p>
<p>There’s also some evidence supporting the use of traditional medicine, including <a href="https://www.va.gov/WHOLEHEALTH/professional-resources/Acupuncture.asp">acupuncture</a>, <a href="https://www.va.gov/WHOLEHEALTH/professional-resources/Meditation.asp">meditation</a> and <a href="https://www.va.gov/WHOLEHEALTH/professional-resources/Yoga.asp">yoga</a> to treat post-traumatic stress disorder. </p>
<p>However, acupuncture practitioners aren’t trained in a uniform way across countries. To provide guidelines for best practice, the WHO developed standardized <a href="https://www.who.int/publications/i/item/978-92-4-001688-0">benchmarks for practicing acupuncture</a> in 2021. The WHO aims to develop similar standards for other forms of traditional medicine as well. </p>
<p>Interest in traditional medicine is growing among those who have mainly used conventional medicine in the past. More research and collaborative efforts to develop safety standards can make traditional medicine accessible to all who seek it.</p><img src="https://counter.theconversation.com/content/212502/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Dr. Ling Zhao received her medical training in China and PhD in the US. Her research focuses on novel interventions for chronic diseases. She has received research funding from NIH, including NCCIH. </span></em></p><p class="fine-print"><em><span>Paul D. Terry does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>More people are seeking out traditional forms of medicine, from acupuncture to herbal medicines. The WHO is working to develop standards to make these healing practices implementable on a wide scale.Ling Zhao, Professor of Nutrition, University of TennesseePaul D. Terry, Professor of Epidemiology, University of TennesseeLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2125852023-09-06T12:26:55Z2023-09-06T12:26:55ZThe US committed to meet the UN’s Sustainable Development Goals, but like other countries, it’s struggling to make progress<figure><img src="https://images.theconversation.com/files/546246/original/file-20230904-15-tjmfsz.jpg?ixlib=rb-1.1.0&rect=229%2C467%2C3173%2C2207&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Many colonias along the Texas-Mexico border still lack basic infrastructure, including running water.</span> <span class="attribution"><a class="source" href="https://newsroom.ap.org/detail/TexasBorderColonias/47c19c2a66e340d49a1d534f3b6df91e/photo">AP Photo/Eric Gay</a></span></figcaption></figure><p>In a Zen parable, a man sees a horse and rider galloping by. The man asks the rider where he’s going, and the rider responds, “I don’t know. Ask the horse!”</p>
<p>It is easy to feel out of control and helpless in the face of the many problems Americans are now experiencing – <a href="https://www.kff.org/health-costs/issue-brief/americans-challenges-with-health-care-costs/">unaffordable health care</a>, <a href="https://www.census.gov/newsroom/stories/poverty-awareness-month.html">poverty</a> and <a href="https://theconversation.com/ipcc-report-climate-solutions-exist-but-humanity-has-to-break-from-the-status-quo-and-embrace-innovation-202134">climate change</a>, to name a few. These problems are made harder by the ways in which people, including elected representatives, often talk past each other.</p>
<p>Most <a href="https://www.pewresearch.org/politics/2023/06/21/inflation-health-costs-partisan-cooperation-among-the-nations-top-problems/">people want</a> a strong economy, social well-being and a healthy environment. These goals are interdependent: A strong economy isn’t possible without a society peaceful enough to support investment and well-functioning markets, or without water and air clean enough to support life and productivity. This understanding – that economic, social and environmental well-being are intertwined – is the premise of sustainable development. </p>
<p>In 2015, the United Nations General Assembly <a href="https://press.un.org/en/2015/ga11688.doc.htm">unanimously adopted</a> 17 <a href="https://www.un.org/sustainabledevelopment/blog/2015/12/sustainable-development-goals-kick-off-with-start-of-new-year">Sustainable Development Goals</a>, known as the SDGs, with 169 measurable targets to be achieved by 2030. Though not legally binding, all nations, including the U.S., agreed to pursue this agenda.</p>
<p>The world is now halfway to that 2030 deadline. Countries have made some progress, such as reducing extreme poverty and child mortality, though the COVID-19 pandemic <a href="https://www.un.org/en/desa/it%E2%80%99s-now-or-never-achieving-sdgs-hinges-effective-crises-response">set back progress</a> on many targets.</p>
<p>On Sept. 18-19, 2023, countries are reviewing global progress toward those goals during a meeting at the United Nations. It’s a good opportunity for Americans to review their own progress because, as we see it, sustainable development is fundamentally American.</p>
<h2>Environment, economy and health intertwined</h2>
<p>Though not widely recognized, sustainable development has been a core American policy since President Richard Nixon signed the <a href="https://www.energy.gov/nepa/downloads/national-environmental-policy-act-1969">National Environmental Policy Act </a> into law in 1970. The law says that Americans should “use all practicable means and measures … to create and maintain conditions under which man [sic] and nature can exist in productive harmony and fulfill the social, economic, and other requirements of present and future generations of Americans.”</p>
<p>While it is tempting in today’s sour political climate to dismiss this as wishful thinking, the U.S. has made some progress reconciling economic development with environmental protection. </p>
<p>Gross domestic product, for example, grew 196% between 1980 and 2022, while total emissions of the six most common non-greenhouse air pollutants, including lead and sulfur dioxide, fell 73%, <a href="https://www.epa.gov/air-trends/air-quality-national-summary">according to the Environmental Protection Agency</a>. </p>
<p>The 2022 Inflation Reduction Act, a major sustainable development law, is designed to further accelerate the use of renewable energy and reduce greenhouse gas emissions through tax credits and other incentives. <a href="https://www.goldmansachs.com/intelligence/pages/the-us-is-poised-for-an-energy-revolution.html">Goldman Sachs</a> estimated the law would spur about US$3 trillion in renewable energy investment. The law has <a href="https://www.reuters.com/business/energy/one-year-biden-still-needs-explain-his-signature-clean-energy-legislation-2023-08-16/">already been credited with creating</a> 170,000 new jobs and leading to more than 270 new or expanded clean energy projects. That impact further demonstrates that environmental goals can align with economic growth.</p>
<p>The 2015 Sustainable Development Goals cover a broader range of environmental, social and economic issues, and there are indicators for assessing progress on each.</p>
<h2>How is America doing?</h2>
<p><a href="https://dashboards.sdgindex.org/rankings">The U.S. ranked 39th</a> out of 166 countries in a 2023 review of national efforts to implement the Sustainable Development Goals. </p>
<p>The <a href="https://www.unsdsn.org/about-us">Sustainable Development Solutions Network</a>, which operates under the auspices of the U.N. Secretary-General, finds that America is lagging behind the targets set <a href="https://sdgs.un.org/goals">for many of the Sustainable Development Goals</a> that are critical to the nation’s defense, competitiveness and health, such as reducing obesity, increasing life expectancy at birth, protecting labor rights, reducing maternal mortality, decreasing inequality and protecting biodiversity.</p>
<p>To understand where the U.S. is falling short, we asked <a href="https://www.eli.org/sites/default/files/files-pdf/GoverningforSustainability-TOC.pdf">26 experts working on various areas of sustainable development</a> to review the nation’s progress and make recommendations for future action. The resulting 2023 book, <a href="https://www.eli.org/eli-press-books/governing-sustainability">Governing for Sustainability</a>, provides some 500 U.S.-specific recommendations for achieving the Sustainable Development Goals.</p>
<figure class="align-center ">
<img alt="A young child, looking bored, sits on a woman's lap as a nurse tests her blood pressure." src="https://images.theconversation.com/files/546248/original/file-20230904-27-721s7p.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/546248/original/file-20230904-27-721s7p.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/546248/original/file-20230904-27-721s7p.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/546248/original/file-20230904-27-721s7p.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/546248/original/file-20230904-27-721s7p.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/546248/original/file-20230904-27-721s7p.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/546248/original/file-20230904-27-721s7p.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">Residents waited in long lines for a free annual health clinic in Wise, Va., in 2017. A nonprofit operated the annual pop-up clinic for two decades until the state expanded Medicaid eligibility in 2019, which helped more residents afford local health care.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/ruby-partin-and-her-adoptive-son-timothy-huff-visit-a-free-news-photo/820902146">John Moore/Getty Images</a></span>
</figcaption>
</figure>
<p>Health and access to quality health care loom large in many of the goals. The authors in several chapters explain why the nation cannot eliminate poverty or hunger, or have a vibrant economy, gender equality or education gains, without widely available, affordable health care. Yet, the U.S. has some of the <a href="https://www.pgpf.org/blog/2023/07/why-are-americans-paying-more-for-healthcare">highest health care costs in the world</a>. Several states have <a href="https://abcnews.go.com/Health/wireStory/georgia-medicaid-program-work-requirement-off-slow-start-102389380">rejected efforts to expand eligibility</a> for federal Medicaid health insurance for low-income residents, leaving many people without care.</p>
<p>Similarly, the authors show that human health, ecological health, clean water and economic vitality <a href="https://www.eli.org/eli-press-books/governing-sustainability">all require sound climate policy</a>. A quickly warming world <a href="https://theconversation.com/8-billion-people-four-ways-climate-change-and-population-growth-combine-to-threaten-public-health-with-global-consequences-193077">poses new health risks</a>, decimates ecosystems, strains potable water supplies and reduces global economic productivity.</p>
<p>Clean and abundant water is critical to a functioning economy and a stable, diverse ecosystem, and yet some areas of the United States <a href="https://theconversation.com/supreme-court-rules-the-us-is-not-required-to-ensure-access-to-water-for-the-navajo-nation-202588">still lack clean water</a> or <a href="https://theconversation.com/youth-living-in-settlements-at-us-border-suffer-poverty-and-lack-of-health-care-103416">indoor plumbing</a>. This often occurs in communities of color and low income, and it can impede economic prosperity and development in these areas.</p>
<p>Ready access to nutritious food is also a bedrock need to support many of the Sustainable Development Goals, from poverty alleviation to education, yet far too many American children <a href="https://doi.org/10.1001%2Fjamanetworkopen.2021.5262">rely on school lunches</a> for <a href="https://www.ppic.org/blog/feeding-children-when-schools-are-closed-for-covid-19/">basic sustenance</a>.</p>
<figure class="align-center ">
<img alt="A man squints into the sun as he holds a large hose that pours water into a tank in the back of a pickup truck." src="https://images.theconversation.com/files/546249/original/file-20230904-27-t1qoyk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/546249/original/file-20230904-27-t1qoyk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=399&fit=crop&dpr=1 600w, https://images.theconversation.com/files/546249/original/file-20230904-27-t1qoyk.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=399&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/546249/original/file-20230904-27-t1qoyk.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=399&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/546249/original/file-20230904-27-t1qoyk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=502&fit=crop&dpr=1 754w, https://images.theconversation.com/files/546249/original/file-20230904-27-t1qoyk.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=502&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/546249/original/file-20230904-27-t1qoyk.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">A U.S. Army veteran fills a tank in the back of his pickup with water in Laredo, Texas, to provide water for his mother’s home. Rural residents in parts of the Southwest have to truck in clean water.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/carlos-salas-u-s-army-veteran-fills-his-water-tank-that-is-news-photo/916823510">Salwan Georges/The Washington Post via Getty Images</a></span>
</figcaption>
</figure>
<p>The goals covering <a href="https://sdgs.un.org/goals/goal16">peace, justice, strong institutions</a> and <a href="https://sdgs.un.org/goals/goal17">partnerships</a> are necessary to achieve all of the goals. A society at war with itself and without rule of law cannot support a vibrant, diverse economy and lasting democracy. This has been shown repeatedly as some developing nations <a href="https://carnegieendowment.org/2022/10/20/understanding-and-responding-to-global-democratic-backsliding-pub-88173">backslide from democratic progress</a> and prosperity to civil war and poverty. <a href="https://www.eli.org/eli-press-books/governing-sustainability">Developed nations</a> are subject to the same forces.</p>
<h2>Taking the reins</h2>
<p>Sustainable development is emphatically not about government alone solving the nation’s problems. Businesses, universities and other organizations, as well as individuals, are essential to help the country realize its environmental, health and climate goals, fair practices and living wages. </p>
<p>The right place to “take the reins” is where you are, and with the problems or tasks in front of you – at work and at home. Figure out more sustainable ways to use water and energy, for example. Look at what our book recommends and what others are already doing to meet the Sustainable Development Goals. Seize opportunities such as saving money, and reduce risks by, for example, cutting greenhouse gas emissions. Every individual can contribute to a better future.</p><img src="https://counter.theconversation.com/content/212585/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 organization that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Halfway to the SDGs’ 2030 deadline, countries have made progress, but most are struggling to meet all 17 goals. The US is no exception.Scott Schang, Director of Environmental Law and Policy Clinic; Professor of Practice, Wake Forest UniversityJohn Dernbach, Professor of Law Emeritus, Widener UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2116952023-08-24T11:20:57Z2023-08-24T11:20:57ZSlower ageing, slower growth: the Intergenerational Report in 7 charts<figure><img src="https://images.theconversation.com/files/544483/original/file-20230824-21-yoknbr.png?ixlib=rb-1.1.0&rect=699%2C195%2C2869%2C1666&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://treasury.gov.au/publication/2023-intergenerational-report">Commonwealth Treasury</a></span></figcaption></figure><p>The Australian government has just released the latest iteration of its Intergenerational Report, the <a href="https://treasury.gov.au/intergenerational-report">sixth</a> since the first was published in 2002.</p>
<p>Each provides a snapshot of the sort of Australia in which future generations will find themselves in 40 years’ time, should current government policies continue. </p>
<p>Previous reports have dealt mainly with the impact of an older age profile on government budgets and our way of life. This one also made space for the impact of climate change.</p>
<h2>1. Increasing optimism about ageing</h2>
<p>The good news for future budgets in this report is that, although Australia’s population will still age rapidly, it is expected to age more slowly than previously thought. </p>
<p>The chart below shows the projections in each of the six reports for the proportion of the population aged 65 and over. </p>
<p>In 2002, the first intergenerational report predicted that by 2023 the share of the population aged 65 and over would have climbed from 12.5% to nearly 19%, and then would rise to 24.5% by 2042.</p>
<p>Yet, in the intervening years, Australia saw an unanticipated migration boom, which slowed that rate of ageing so that today only 17.3% of the population is aged 65 and over, and the projection for 2063 is 23.4%, less than the 24.5% originally expected for 2042.</p>
<hr>
<p><iframe id="863UC" class="tc-infographic-datawrapper" src="https://datawrapper.dwcdn.net/863UC/5/" height="400px" width="100%" style="border: none" frameborder="0"></iframe></p>
<hr>
<p>These updated projections suggest that by 2063 Australia’s population will be younger than that of Italy now, or Japan a decade ago.</p>
<p>And ageing will slow further if net migration climbs higher than the 235,000 per year assumed in the latest report. A more reasonable migration assumption might be that it will in fact increase alongside increases in the total population.</p>
<h2>2. Increased optimism about willing workers</h2>
<p>The projections for labour force participation (the proportion of the adult population who are either working or making themselves available for work) have become more optimistic with each intergenerational report.</p>
<p>While participation is still expected to drop, the latest projection is for more of a glide than a dive, leaving participation higher in 2063 than it was in 2002.</p>
<p>As the report puts it, participation is projected to decline from a record high of 66.6% in 2023 to 63.8% by 2063.</p>
<p>The gentle slope of the decline reflects offsetting forces. More of us will be older and less able to work, but within most age groups, more of us will be in work. </p>
<hr>
<p><iframe id="c09Ld" class="tc-infographic-datawrapper" src="https://datawrapper.dwcdn.net/c09Ld/4/" height="400px" width="100%" style="border: none" frameborder="0"></iframe></p>
<hr>
<h2>3. Increased optimism about the cost of the pension</h2>
<p>More optimistic demographic projections and sensible policy choices have resulted in less extreme increases in age-related spending.</p>
<p>Spending on pensions is projected to fall rather than climb as a share of the economy, falling from 2.3% to 2% of GDP. This is by design. </p>
<p>While in other countries pensions are more generous and increase with earnings, in Australia the age pension is more modest and reduces with means. </p>
<p>By pairing the age pension with superannuation, which increases people’s means in retirement, pension spending falls. </p>
<p>By the 2060s, pension spending in Australia will be less than half the rate of the next lowest-spending OECD country (though admittedly that comparison ignores tax expenditures on super). </p>
<hr>
<p><iframe id="Y6G17" class="tc-infographic-datawrapper" src="https://datawrapper.dwcdn.net/Y6G17/3/" height="400px" width="100%" style="border: none" frameborder="0"></iframe></p>
<hr>
<h2>4. Increased optimism about spending on health</h2>
<p>Government spending on health as a proportion of GDP is still projected to increase, from 4.6% now to 6.2% in 2063, but is expected to remain well short of the first intergenerational report’s projection of more than 8% by 2042. </p>
<p>Only 40% of this projected increase in health spending is due to ageing, which ought not to be the least bit surprising. </p>
<p>As people and societies grow richer and satisfy more of their basic needs, they naturally want to spend more of what they have on extending their lives and improving their health, demanding more and better healthcare from government. </p>
<hr>
<p><iframe id="X0nbl" class="tc-infographic-datawrapper" src="https://datawrapper.dwcdn.net/X0nbl/1/" height="400px" width="100%" style="border: none" frameborder="0"></iframe></p>
<hr>
<h2>5. Increased pessimism about the cost of aged care</h2>
<p>Spending on aged care is set to grow more than many other types of spending, albeit from a low base. </p>
<p>The Intergenerational Report has it doubling from 1.1% of GDP in to 2.5% in 2063.</p>
<p>The projection may well be an underestimate. Governments are yet to fully respond to demands for greater quality of care set out in the report of the <a href="https://agedcare.royalcommission.gov.au/">royal commission into aged care quality and safety</a>.</p>
<hr>
<p><iframe id="RKuD3" class="tc-infographic-datawrapper" src="https://datawrapper.dwcdn.net/RKuD3/1/" height="400px" width="100%" style="border: none" frameborder="0"></iframe></p>
<hr>
<h2>6. Increased pessimism about living standards</h2>
<p>When it comes to resources for meeting the needs we need to meet, the Nobel prizewinning economist Paul Krugman famously noted in 1994 that productivity wasn’t everything, but in the long run it was “<a href="https://www.oecd-ilibrary.org/economics/the-future-of-productivity/editorial_9789264248533-2-en">almost everything</a>”.</p>
<p>Productivity growth, and assumptions about future productivity growth, have continued to decline with almost every intergenerational report.</p>
<p>The assumption for long-term productivity growth in this report is 1.2%, down from 1.75% in the 2002 intergenerational report.</p>
<p>The difference this makes is enormous. The 2002 intergenerational report had living standards (GDP per person) climbing 90% in 40 years. This latest intergenerational report has them climbing only 57% in the next 40 years.</p>
<hr>
<p><iframe id="55j8Y" class="tc-infographic-datawrapper" src="https://datawrapper.dwcdn.net/55j8Y/1/" height="400px" width="100%" style="border: none" frameborder="0"></iframe></p>
<hr>
<h2>7. A deteriorating Commonwealth budget</h2>
<p>While slower ageing means this report predicts the government’s future budget deficits will be lower than those projected in all previous reports bar one, the budget is expected to be in a deepening deficit for much of the next 40 years.</p>
<p>Naturally, this can be fixed with more tax, but the projected lower rate of productivity growth means there will be relatively less to tax than was expected in the first intergenerational report in 2002.</p>
<hr>
<p><iframe id="sbn1y" class="tc-infographic-datawrapper" src="https://datawrapper.dwcdn.net/sbn1y/2/" height="400px" width="100%" style="border: none" frameborder="0"></iframe></p>
<hr>
<p>Launching the report at the National Press Club, Treasurer Jim Chalmers talked about the need for action now on multiple fronts, saying there would “never be a quiet time to think about the future”. </p>
<p>But on raising more tax he was silent, suggesting it was a question for the future.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/the-intergenerational-report-sets-the-scene-for-2063-but-what-is-it-211694">The intergenerational report sets the scene for 2063 – but what is it?</a>
</strong>
</em>
</p>
<hr>
<img src="https://counter.theconversation.com/content/211695/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Rafal Chomik works for the ARC Centre of Excellence in Population Ageing Research which receives funding from the ARC.</span></em></p>The latest Intergenerational Report shows Australia less old than it was going to be, but poorer. And eventually needing to pay more tax.Rafal Chomik, Senior Research Fellow, ARC Centre of Excellence in Population Ageing Research (CEPAR), UNSW SydneyLicensed as Creative Commons – attribution, no derivatives.