tag:theconversation.com,2011:/uk/topics/health-costs-27038/articlesHealth costs – The Conversation2023-08-31T21:39:50Ztag:theconversation.com,2011:article/2114122023-08-31T21:39:50Z2023-08-31T21:39:50ZHere’s what new 60-day prescriptions mean for you and your hip pocket<figure><img src="https://images.theconversation.com/files/545417/original/file-20230829-19-mvx2g4.jpg?ixlib=rb-1.1.0&rect=1%2C0%2C997%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/customer-paying-bill-by-cell-phone-623126426">Shutterstock</a></span></figcaption></figure><p>From today, there are significant <a href="https://www.health.gov.au/our-work/60-day-prescriptions">changes</a> to how some common medicines are prescribed and dispensed in Australia. This means you could walk away from the pharmacy with 60-days’ worth of your usual medicine from a single prescription.</p>
<p>Until now, most long-term medicines were only available for 30 days at a time. So the price of these medicines for some patients may effectively halve. </p>
<p>You would also need fewer trips to the GP for a prescription and fewer visits to the pharmacy to have your medicine dispensed.</p>
<p>But not all medicines are yet eligible for 60-day scripts and not everyone is prescribed 60-days’ worth of medicine at a time. Here’s what the changes mean for you.</p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/last-year-half-a-million-australians-couldnt-afford-to-fill-a-script-heres-how-to-rein-in-rising-health-costs-178301">Last year, half a million Australians couldn't afford to fill a script. Here's how to rein in rising health costs</a>
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<h2>Can I get a 60-day script today?</h2>
<p>If you have a current prescription, you need to use this prescription first before you get a new one. To be eligible for a prescription that provides medicine for 60 days your medication needs to be on the <a href="https://www.pbs.gov.au/industry/listing/elements/pbac-meetings/pbac-outcomes/2022-12/Increased-Dispensing-Quantities-List-of-Medicines.pdf">approved list</a>.</p>
<p>Your doctor also needs to assess if you are stable on it. This is to avoid wastage. We know new treatments can result in frequent changes to medication regimens, which would result in wasted medicines if they don’t end up being used.</p>
<p>Your doctor may also give you “repeat” prescriptions for 60-days’ worth of medicines at a time. Under the new rules, this could mean up to <a href="https://www.health.gov.au/resources/publications/60-day-prescriptions-information-kit-for-prescribers?language=ha">12 months’ supply</a> of medicine (the initial script plus five “repeats”). You would have to pay for each of these repeat scripts when your medicine is dispensed every 60 days.</p>
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Read more:
<a href="https://theconversation.com/what-time-of-day-should-i-take-my-medicine-125809">What time of day should I take my medicine?</a>
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</em>
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<h2>Is my medicine on the list?</h2>
<p>The roll-out of 60-day scripts will be in three stages. The first stage, which begins today, <a href="https://www.health.gov.au/our-work/60-day-dispensing/pbs-medicines-current-item-codes">includes</a> medicines for cardiovascular disease (such as heart disease and stroke), heart failure, high cholesterol, gout, osteoporosis, and the gut conditions Crohn’s disease and ulcerative colitis.</p>
<p>This includes some of the most common medicines prescribed in Australia, such as atorvastatin for lowering cholesterol, and perindopril for lowering blood pressure.</p>
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<a href="https://images.theconversation.com/files/545419/original/file-20230829-21-3sh11g.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Person adding medications to pill organizer" src="https://images.theconversation.com/files/545419/original/file-20230829-21-3sh11g.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/545419/original/file-20230829-21-3sh11g.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/545419/original/file-20230829-21-3sh11g.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/545419/original/file-20230829-21-3sh11g.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/545419/original/file-20230829-21-3sh11g.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/545419/original/file-20230829-21-3sh11g.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/545419/original/file-20230829-21-3sh11g.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">Not all your medicines may be affected by the changes.</span>
<span class="attribution"><a class="source" href="https://unsplash.com/photos/1TL8AoEDj_c">Laurynas Mereckas/Unsplash</a></span>
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<p>The following stages, set to be rolled out over the coming 12 months, include medicines for diabetes, epilepsy, glaucoma, asthma and Parkinson’s disease. </p>
<p>When fully implemented, these changes will affect more than 300 prescription medicines available on the Pharmaceutical Benefits Scheme (PBS).</p>
<p>These medicines have been chosen because they are appropriate treatments for people living with stable, chronic health conditions, they meet clinical safety criteria, and are considered cost-effective.</p>
<p>Medicines not available for 60-day dispensing are those only for short-term use and medicines known to be at risk of overuse. These <a href="https://www.nps.org.au/australian-prescriber/articles/pharmaceutical-drug-misuse-in-australia#information-sources-for-prescribers">include</a> pain medicines and some medicines for mental health conditions.</p>
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<strong>
Read more:
<a href="https://theconversation.com/heres-why-pharmacists-are-angry-at-script-changes-and-why-the-government-is-making-them-anyway-204028">Here's why pharmacists are angry at script changes – and why the government is making them anyway</a>
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<h2>Will I save money?</h2>
<p>The government has brought in these changes mainly to try to make medicines more affordable. We know people do not seek medical care or fill prescriptions <a href="https://www.abs.gov.au/statistics/health/health-services/patient-experiences/latest-release">due to cost</a>. </p>
<p>The <a href="https://www.pbs.gov.au/info/healthpro/explanatory-notes/front/fee">maximum price you pay</a> at the pharmacy for a PBS script (known as the co-payment) is not changing. <a href="https://www.pbs.gov.au/info/about-the-pbs">It’s still</a> A$7.30 for concession card holders and $30 for non-concession card holders. But by having 60-day dispensing, you’ll only be charged this every two months instead of every month.</p>
<p>But not everyone will save money from a 60-day prescription because in some cases your pharmacy may already be discounting your medicine. If the price for 60-days’ supply would not take the price over $30, you may not be getting two scripts for the price of one. </p>
<p>For example, a commonly discounted medicine is atorvastatin. In Australia, a non-concession patient generally pays between $8 and $22 for 30-days’ supply. But it’s likely that a 60-day supply would cost between $15 and $30.</p>
<p>The amount you or your family need to pay to reach the <a href="https://www.pbs.gov.au/info/general/faq#WhatisthePBSSafetyNet">PBS safety net</a> is also not changing. This is the threshold you need to reach before medicines become free (for concession card holders) or discounted (non-concession card holders) for the rest of the calendar year. In some instances, 60-day dispensing may result in you or your family reaching the safety net threshold later, or not at all.</p>
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<a href="https://images.theconversation.com/files/545421/original/file-20230829-15-pcnddr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Older woman looking into purse, holding coin" src="https://images.theconversation.com/files/545421/original/file-20230829-15-pcnddr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/545421/original/file-20230829-15-pcnddr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=401&fit=crop&dpr=1 600w, https://images.theconversation.com/files/545421/original/file-20230829-15-pcnddr.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=401&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/545421/original/file-20230829-15-pcnddr.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=401&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/545421/original/file-20230829-15-pcnddr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=504&fit=crop&dpr=1 754w, https://images.theconversation.com/files/545421/original/file-20230829-15-pcnddr.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=504&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/545421/original/file-20230829-15-pcnddr.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=504&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">The changes are meant to make medicines more affordable.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/hands-old-person-senior-hold-wallet-1844510152">Shutterstock</a></span>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/what-is-the-pbs-safety-net-and-is-it-really-the-best-way-to-cut-the-cost-of-medicines-180315">What is the PBS safety net and is it really the best way to cut the cost of medicines?</a>
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<h2>How should I store my medicine?</h2>
<p>If you don’t store your medicines correctly at home they can become degraded and not work so well. With a 60-day supply, correct storage is even more important. </p>
<p>As a general rule of thumb, never store your medicines in hot rooms or your car (even in winter) and don’t store them in direct sunlight. If your medicine needs to be stored in the fridge, your pharmacist will let you know.</p>
<p>One example is <a href="https://media.healthdirect.org.au/medicines/GuildLink_Information/58775/CMI/ujcxalae10320.pdf">latanoprost</a>, which are drops for the eye condition glaucoma. You can keep the bottle you are using in the cupboard but you need to store the unopened, second bottle in the fridge.</p>
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<p>
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<strong>
Read more:
<a href="https://theconversation.com/health-check-what-should-you-do-with-your-unused-medicine-81406">Health Check: what should you do with your unused medicine?</a>
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<h2>In a nutshell</h2>
<p>Remember, 60-day dispensing is only available for new prescriptions. When you next see your doctor, if your condition is stable and your medicine is suitable, you will be provided a 60-day script. Your pharmacist will then dispense a 60-day supply.</p>
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<p><em>If you have any questions about the new rules, ask your local pharmacist. Information is also available from the <a href="https://www.health.gov.au/our-work/60-day-prescriptions">Commonwealth health department</a> and the <a href="https://www.60dayscripts.com.au/">Consumers Health Forum</a>.</em></p><img src="https://counter.theconversation.com/content/211412/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Andrew Bartlett is a member of the Pharmaceutical Society of Australia, a previous director of Blooms the Chemist management services and remains a shareholder.</span></em></p><p class="fine-print"><em><span>Associate Professor Nial Wheate in the past has received funding from the ACT Cancer Council, Tenovus Scotland, Medical Research Scotland, Scottish Crucible, and the Scottish Universities Life Sciences Alliance. He is a Fellow of the Royal Australian Chemical Institute, a member of the Australasian Pharmaceutical Science Association, and a member of the Australian Institute of Company Directors. Nial is the chief scientific officer of Vaihea Skincare LLC, a director of SetDose Pty Ltd a medical device company, and a Standards Australia panel member for sunscreen agents. Nial regularly consults to industry on issues to do with medicine risk assessments, manufacturing, design, and testing.</span></em></p>The price you pay at the pharmacy for your long-term medicines may effectively halve. But not all medicines or patients qualify.Andrew Bartlett, Associate Lecturer Pharmacy Practice, University of SydneyNial Wheate, Associate Professor of the Sydney Pharmacy School, University of SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2027112023-03-28T19:21:39Z2023-03-28T19:21:39ZPart-time work is valuable to people with disability – but full time is more likely to attract government support<figure><img src="https://images.theconversation.com/files/517821/original/file-20230328-21-jxmot8.jpg?ixlib=rb-1.1.0&rect=62%2C0%2C5928%2C3862&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/low-angle-view-happy-businesswoman-disability-2124023477">Shutterstock</a></span></figcaption></figure><p>Work isn’t just about getting paid. Employment can provide a <a href="https://pubmed.ncbi.nlm.nih.gov/29392591/">number of benefits</a> for people in terms of health, wellbeing, social, economic and financial inclusion. It can also reduce reliance on government income supports. Arguably, work is even more important for people with disability, who are more likely to be in <a href="https://jech.bmj.com/content/68/11/1064.short">lower socioeconomic groups</a> and <a href="https://www.sciencedirect.com/science/article/pii/S1936657420300960">socially isolated</a>.</p>
<p>Our <a href="https://www.unsw.adfa.edu.au/sites/default/files/documents/RFQ07019_MSPGH_CRE_DH_Wise_Employment_Report.pdf">new research</a> shows part-time work is valuable to people with disability and supports their wellbeing. It can also lead to reduced costs for health care. </p>
<p>But if more people with disability are to be supported into part-time and full-time work, we need changes to existing programs and services.</p>
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<em>
<strong>
Read more:
<a href="https://theconversation.com/australia-is-lagging-when-it-comes-to-employing-people-with-disability-quotas-for-disability-services-could-be-a-start-199405">Australia is lagging when it comes to employing people with disability – quotas for disability services could be a start</a>
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<h2>Employment and disability</h2>
<p>In Australia, <a href="https://www.aihw.gov.au/reports/disability/people-with-disability-in-australia/contents/employment">54%</a> of people with disability are employed, compared with 84% of the wider population. This gap is worsening. In the last ten years, employment of people with disability has <a href="https://www.theguardian.com/australia-news/2021/mar/31/australias-disability-employment-down-3-in-past-decade-as-service-scheme-criticised-for-poor-outcomes">decreased by 3%</a>, while the rest of the population is up 23%.</p>
<p>Australia’s federal and state governments invest significant resources in employment supports for people with disability. Notable is the A$800 million spent each year on <a href="https://www.dss.gov.au/our-responsibilities/disability-and-carers/programmes-services/disability-employment-services">Disability Employment Services</a>. There are also significant investments through the National Disability Insurance Scheme (NDIS) and other programs.</p>
<p>People with disability are <a href="https://www.abs.gov.au/statistics/health/disability/disability-ageing-and-carers-australia-summary-findings/latest-release">twice as likely</a> to work part time as people without disability. Yet, many of the government-funded programs for people with disability focus on getting people into <a href="https://disability.royalcommission.gov.au/publications/employment">full-time work</a>.</p>
<h2>The right fit</h2>
<p>For our research, funded by WISE Employment, we spoke to 25 current Disability Employment Services clients. They told us part-time work can have a positive impact on many areas of wellbeing by building confidence, helping people better engage with families and communities, increase social networks and improve financial stability. As one person explained, </p>
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<p>before becoming chronically ill I worked full time and had a lot of pride being independent. Being able to re-join the workforce has given me back that sense of self-sufficiency.</p>
</blockquote>
<p>For some people with disability, capacity limitations and having to balance family and medical appointments means that they may only be able to work part time. </p>
<blockquote>
<p>I’m recovering from cancer […] I’m hoping I’ll get my energy and stamina back. It’s hard after having time off work and then coming back. I’m just coping with part time, I wouldn’t cope with full time. </p>
</blockquote>
<p>Returning to work or entering the workforce for the first time can be a difficult transition. Part-time work can be a helpful springboard into full-time employment. </p>
<p>Care also needs to be taken to match people to the right job – one that uses their skills, with appropriate supports in place. When people go into unsupportive jobs that do not make appropriate accommodations for disability – or if the job or environment is not a good fit – it can have a detrimental impact on their mental health and wellbeing.</p>
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<a href="https://images.theconversation.com/files/517822/original/file-20230328-18-j3k4ik.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Woman and young man with disability working in large greenhouse" src="https://images.theconversation.com/files/517822/original/file-20230328-18-j3k4ik.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/517822/original/file-20230328-18-j3k4ik.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/517822/original/file-20230328-18-j3k4ik.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/517822/original/file-20230328-18-j3k4ik.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/517822/original/file-20230328-18-j3k4ik.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/517822/original/file-20230328-18-j3k4ik.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/517822/original/file-20230328-18-j3k4ik.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">Part-time work can make returning to work or first jobs easier.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/experienced-woman-florist-helping-young-employee-2174778477">Shutterstock</a></span>
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<em>
<strong>
Read more:
<a href="https://theconversation.com/the-number-one-barrier-has-probably-been-stigma-the-challenges-facing-disabled-workers-in-the-australian-screen-industry-200345">‘The number one barrier has probably been stigma’: the challenges facing disabled workers in the Australian screen industry</a>
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<h2>The numbers</h2>
<p>We also looked at client data from several sources (including service provider WISE Employment and Personal Wellbeing Index questionnaires completed by Department of Employment Services participants each year) for links between part-time work and wellbeing, mental health and health-care costs.</p>
<p>We found wellbeing scores are higher for those who are employed compared to those who are unemployed. There was no difference in wellbeing scores if individuals were employed full or part time. But we did find evidence those employed in casual jobs have slightly lower wellbeing.</p>
<p>We also drew on data from the <a href="https://melbourneinstitute.unimelb.edu.au/hilda">Household, Income and Labour Dynamics in Australia Survey</a>, which collects information annually on a broad range of topics, including demographic, social, economic and health characteristics of individuals. This data shows engagement with employment is associated with large mental health gains compared to being unemployed. And these effects are more pronounced for people with disability compared to those without disability.</p>
<p>As people work more hours, we see greater mental health benefits for people with disability. These effects seem to be greater for women engaged in part-time work, although the impact is the same for men and women with disability in full-time work.</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1640485023764602889"}"></div></p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/inclusion-means-everyone-5-disability-attitude-shifts-to-end-violence-abuse-and-neglect-199003">Inclusion means everyone: 5 disability attitude shifts to end violence, abuse and neglect</a>
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<h2>And it saves health dollars</h2>
<p>We also drew on integrated data from sources, including the census, social security payments, tax records, death records and Medicare records. This shows a gradual reduction in costs associated with overall health-care services, mental health services and mental health scripts as the number of hours worked increased. </p>
<p>Finally, we applied the results of our analysis to current Disability Employment Services participants and people with disability on <a href="https://www.dewr.gov.au/jobactive">jobactive</a> (now Workforce Australia). </p>
<p>We estimate that if if those who are not working were instead working part time (14–29 hours per week), it would save approximately $62.5 million per year in health-care services (including mental health services) and mental health prescriptions.</p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/low-staff-turnover-high-loyalty-and-productivity-gains-the-business-benefits-of-hiring-people-with-intellectual-disability-180587">Low staff turnover, high loyalty and productivity gains: the business benefits of hiring people with intellectual disability</a>
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<h2>The need for reform</h2>
<p>Our research suggests there is value in part-time work for improving the wellbeing of people with disability. This comes with reduced health-care costs. But if we are to increase the number of people with disability working full and part time we need to change existing programs and services. </p>
<p>There needs to be careful thought given to brokerage processes that engage people in part-time jobs and the kinds of incentives offered to employers. </p>
<p>Rather than the frequently “blunt” mechanisms used by Disability Employment Services and the NDIS that categorise people as “working” versus “not working”, there needs to be ways to recognise the potential of part-time work to improve wellbeing.</p><img src="https://counter.theconversation.com/content/202711/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Helen Dickinson receives funding from ARC, NHMRC, WISE and CYDA.</span></em></p><p class="fine-print"><em><span>Dennis Petrie receives funding from WISE, Department of Health and Aged Care, NHMRC, ARC and NDIA. </span></em></p><p class="fine-print"><em><span>Zoe Aitken receives funding from NHMRC and WISE.</span></em></p>Our analysis of part-time work and its impact on wellbeing shows getting more people with disability into employment could save millions in health-care costs.Helen Dickinson, Professor, Public Service Research, UNSW SydneyDennis Petrie, Professor of Health Economics, Monash UniversityZoe Aitken, Research Fellow, The University of MelbourneLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1815952022-04-28T20:02:15Z2022-04-28T20:02:15ZRising out-of-pocket health costs are a worry. But the major parties have barely mentioned it<figure><img src="https://images.theconversation.com/files/459931/original/file-20220427-18-i0jg5g.jpg?ixlib=rb-1.1.0&rect=2%2C1%2C995%2C664&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/sad-black-woman-near-window-reading-1314448082">Shutterstock</a></span></figcaption></figure><p>Rising out-of-pocket costs for health care is an important issue the major parties have not yet substantially addressed during the election campaign.</p>
<p>We heard just this week how health-care costs are rising <a href="https://theconversation.com/inflation-hits-an-extraordinary-5-1-how-long-until-mortgage-rates-climb-181832">faster than</a> other costs of living pressures.
<a href="https://www.abs.gov.au/statistics/economy/price-indexes-and-inflation/consumer-price-index-australia/latest-release#key-statistics">Health-care costs</a> are also rising faster than <a href="https://www.abs.gov.au/statistics/economy/price-indexes-and-inflation/wage-price-index-australia/dec-2021">wages</a>. The rising cost of specialists’ fees, in particular, are a concern. So, many Australian families are finding it increasingly difficult to keep up. </p>
<p>Earlier this year, a major consumer survey <a href="https://healthsystemsustainability.com.au/the-voice-of-australian-health-consumers/">found</a> 30% of people with chronic conditions were not confident they could afford needed health care if they became seriously ill; 14% could not pay for health care or medicine because of a shortage of money.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/inflation-hits-5-1-how-long-until-mortgage-rates-climb-181832">Inflation hits 5.1%. How long until mortgage rates climb?</a>
</strong>
</em>
</p>
<hr>
<h2>Out-of-pocket costs are rising</h2>
<p>Out-of-pocket health-care costs cover a range of expenses not covered by Medicare or private health insurance, such as doctors’ fees for consultations and surgery.</p>
<p>Only 35.1% of specialist consultations were <a href="https://www1.health.gov.au/internet/main/publishing.nsf/Content/Medicare%20Statistics-1">bulk billed in 2020-21</a> compared with 88.8% of GP services.</p>
<p>For private (multi-day) hospital care in 2019-20, <a href="https://www1.health.gov.au/internet/main/publishing.nsf/Content/health-casemix-data-collections-publications-HCPAnnualReports">43.7% of separations</a> (hospital admissions that include procedures and operations) had no hospital or medical out-of-pocket cost.</p>
<p>Out-of-pocket costs are rising, <a href="https://www1.health.gov.au/internet/main/publishing.nsf/Content/Medicare%20Statistics-1">Medicare statistics show</a>.</p>
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<p>There is ample <a href="https://link.springer.com/article/10.1007/s10198-013-0526-8">evidence</a> out-of-pocket costs reduce access to, and use of, health care. This more strongly affects people who need health care the most.</p>
<p>For instance, access to timely specialist care in Australia depends on your income and ability to pay.</p>
<p>Although richer people <a href="https://www.sciencedirect.com/science/article/pii/S0277953618302041">use more specialist care</a>, on average, it is less-affluent people who have higher need for <a href="https://www.sciencedirect.com/science/article/pii/S0168851020302244?casa_token=UO9uqqBMiDgAAAAA:esi0pxqJkXVpBeI2qB2HwxiCBgTcL7VRMlcMDyp_Y0TaQo81MNugRrPRkGpbtsSR5ubUA5Kx_TA">health care</a>. Yet it is less-affluent people who have to wait to see a specialist in a public hospital. </p>
<p>High doctors’ fees have other consequences. They may provide skewed incentives to doctors, leading to <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(16)30947-3/fulltext">overdiagnosis and overtreatment</a>. Doctors may also flock to high-earning specialties while we have a shortage of GPs (who are paid <a href="https://melbourneinstitute.unimelb.edu.au/__data/assets/pdf_file/0011/3809963/ANZ-Health-Sector-Report-2021.pdf">half as much</a> as specialists).</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/specialists-are-free-to-set-their-fees-but-there-are-ways-to-ensure-patients-dont-get-ripped-off-97372">Specialists are free to set their fees, but there are ways to ensure patients don't get ripped off</a>
</strong>
</em>
</p>
<hr>
<h2>What do the major parties promise?</h2>
<p>Health policies <a href="https://www.abc.net.au/news/2022-04-20/federal-election-liberal-labor-nationals-greens-policy-positions/100482298">announced</a> by the major parties ahead of the federal election do not necessarily translate into lower out-of-pocket health costs, or focus on the most pressing issue.</p>
<p>The Coalition has promised to <a href="https://theconversation.com/what-is-the-pbs-safety-net-and-is-it-really-the-best-way-to-cut-the-cost-of-medicines-180315">lower the safety net threshold</a> for the Pharmaceutical Benefits Scheme. This announcement, made in this year’s federal budget, would make medicines cheaper or free for people who need multiple scripts a year.</p>
<p>But this is an area where out-of-pocket costs have been falling for <a href="https://www.abs.gov.au/statistics/economy/price-indexes-and-inflation/consumer-price-index-australia/mar-2022/640105.xlsx">some time</a> compared with other areas of spending. So any announcement may have been better targeted at areas where out-of-pocket costs are growing more quickly.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/459940/original/file-20220427-18-rzq6w3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Person using EFTPOS machine in pharmacy or clinic" src="https://images.theconversation.com/files/459940/original/file-20220427-18-rzq6w3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/459940/original/file-20220427-18-rzq6w3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/459940/original/file-20220427-18-rzq6w3.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/459940/original/file-20220427-18-rzq6w3.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/459940/original/file-20220427-18-rzq6w3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/459940/original/file-20220427-18-rzq6w3.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/459940/original/file-20220427-18-rzq6w3.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">Election policies announced so far don’t always address the biggest out-of-pocket costs.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/paying-pharmacy-407956288">Shutterstock</a></span>
</figcaption>
</figure>
<p>In any election there is always a focus on access to GPs and bulk billing. This includes Labor’s proposal for new <a href="https://theconversation.com/labors-urgent-care-centres-are-a-step-in-the-right-direction-but-not-a-panacea-181237">urgent care centres</a>, which would provide bulk billed services to take the pressure off emergency departments.</p>
<p>However, neither of the major parties are doing anything about the continuing and much larger increases in specialists’ out-of-pocket costs. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/labors-urgent-care-centres-are-a-step-in-the-right-direction-but-not-a-panacea-181237">Labor’s urgent care centres are a step in the right direction – but not a panacea</a>
</strong>
</em>
</p>
<hr>
<h2>Can informed patients make a difference?</h2>
<p>The Coalition introduced a price transparency <a href="https://www.health.gov.au/resources/apps-and-tools/medical-costs-finder">website</a> <a href="https://www.abc.net.au/news/2019-12-30/government-health-website-out-of-pocket-hospital-costs/11832410">in 2019</a> that provides estimates of out-of-pocket costs for private hospital care, with plans for doctors to voluntarily upload their fees. Some <a href="https://www.medibank.com.au/health-support/hospital-assist/costs/">private health insurers</a> also have such websites.</p>
<p>However, these websites rely entirely on consumers doing the “leg work” by shopping around to reduce their out-of-pocket costs. The assumption is that by providing consumers with more information, they will make better choices. But this is too simplistic because information can difficult to get and understand, and these websites don’t include data on the quality of care.</p>
<p><a href="https://minerva-access.unimelb.edu.au/items/a0d05155-4781-59fa-bebd-5a5565c3012d">Our review</a> on price transparency websites in health care shows <a href="https://theconversation.com/we-need-more-than-a-website-to-stop-australians-paying-exorbitant-out-of-pocket-health-costs-108740">they may not work</a> for consumers. Not all consumers <a href="https://doi.org/10.1016/j.ijindorg.2021.102716">can or want</a> to use them. There’s also the risk doctors could use these websites to see what other doctors are charging and increase their fees.</p>
<p>It could be better if these websites were used by GPs when referring patients to specialists. Patients can also be encouraged to ask about the out-of-pocket cost when booking an appointment or during the visit. </p>
<p>But this does not help patients who are usually in a vulnerable position, who want care quickly, do not have the information or time to shop around, and might think the care they receive will be affected if they ask about cost. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/doctors-fees-shouldnt-just-be-transparent-they-should-be-fair-and-reasonable-100948">Doctors’ fees shouldn't just be transparent, they should be fair and reasonable</a>
</strong>
</em>
</p>
<hr>
<h2>Can doctors make a difference?</h2>
<p>Doctors set their own fees and many use the Australian Medical Association fee schedule as guidance. They decide what fee to charge, whether to bulk bill, or whether to use gap cover provided by private health insurers for private hospital care. </p>
<p>At the moment it would require a brave politician to directly control doctors’ fees given the constitutional protections they have and the way Medicare and private health insurance were designed to provide subsidies to patients, not to directly pay doctors.</p>
<p>However, something the major parties can address is “bill shock”. Patients don’t always know the doctor’s fee before they visit, and in some circumstances don’t know in advance how much a procedure will cost.</p>
<p>If care involves many tests, visits and procedures over time by different doctors, then there will be a bill for each. This shifts all the financial risk to patients, something private health insurance was designed to handle. </p>
<p>At a minimum, doctors’s fees and out-of-pocket costs need to be bundled together and published as an upfront quote or range for the expected course of care. This is something that could be addressed by one of the major parties. </p>
<h2>What next?</h2>
<p>Addressing rising out-of-pocket health costs is a complex area linked closely to broader reform of the health-care system, which neither major party has promised to do anything about.</p>
<p>Without such reforms we’ll see Australians prioritising spending on food, housing and petrol over health care, in the current climate.</p>
<p>But Australia cannot afford to allow this to happen. As we have witnessed during the pandemic, an unhealthy population is not only bad for individuals, it’s bad for us all.</p><img src="https://counter.theconversation.com/content/181595/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Anthony Scott receives funding from a research grant awarded by the Medibank Better Health Foundation on out of pocket costs and price transparency.</span></em></p>Health-care costs are continuing to rise faster than wages, so many Australian families are finding it increasingly difficult to keep up.Anthony Scott, Professor of health economics, The University of MelbourneLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1783012022-03-06T18:59:03Z2022-03-06T18:59:03ZLast year, half a million Australians couldn’t afford to fill a script. Here’s how to rein in rising health costs<figure><img src="https://images.theconversation.com/files/449730/original/file-20220303-17-1uwhfd3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/latin-woman-protective-face-masks-sitting-1794695587">Shutterstock</a></span></figcaption></figure><p>Nearly every Australian uses some part of the health system every year, whether it be going to the GP, getting a prescription filled, or seeing a specialist. </p>
<p>Despite having a universal health-care system, we often still pay for these services out of our own pockets.</p>
<p>Sadly, these out-of-pocket payments are unaffordable for many Australians – so they skip the trip to the doctor, or defer going to the chemist. </p>
<p>This is bad for those individuals, but also bad for taxpayers and the economy. It makes people sicker, widens inequities, and puts further strain on the health system down the track.</p>
<p>In the Grattan Institute’s <a href="https://grattan.edu.au/report/not-so-universal-how-to-reduce-out-of-pocket-healthcare-payments">latest report</a>, we identify what governments should do to make health care more affordable for more Australians.</p>
<h2>Who is missing health care because of cost?</h2>
<p>In 2020-21, <a href="https://www.abs.gov.au/statistics/health/health-services/patient-experiences-australia-summary-findings/latest-release">more than half a million people</a> deferred or did not fill a prescription because of cost. Nearly half a million decided not to see a specialist because of cost.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/we-need-more-than-a-website-to-stop-australians-paying-exorbitant-out-of-pocket-health-costs-108740">We need more than a website to stop Australians paying exorbitant out-of-pocket health costs</a>
</strong>
</em>
</p>
<hr>
<p>People with chronic conditions have much higher health-care costs, particularly if they have multiple chronic conditions; they spend between <a href="https://grattan.edu.au/report/not-so-universal-how-to-reduce-out-of-pocket-healthcare-payments">A$200-600 on average on health care each year</a>.</p>
<p>But they are also less likely to be able to afford their ongoing care because their chronic condition can make it more difficult to keep or get a job.</p>
<p>Many of these people who are forgoing health care due to cost are younger, particularly younger women:</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/450228/original/file-20220306-85660-16z4awf.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/450228/original/file-20220306-85660-16z4awf.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/450228/original/file-20220306-85660-16z4awf.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=784&fit=crop&dpr=1 600w, https://images.theconversation.com/files/450228/original/file-20220306-85660-16z4awf.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=784&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/450228/original/file-20220306-85660-16z4awf.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=784&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/450228/original/file-20220306-85660-16z4awf.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=985&fit=crop&dpr=1 754w, https://images.theconversation.com/files/450228/original/file-20220306-85660-16z4awf.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=985&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/450228/original/file-20220306-85660-16z4awf.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=985&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption"></span>
<span class="attribution"><span class="source">Grattan Institute</span>, <a class="license" href="http://creativecommons.org/licenses/by-nc-sa/4.0/">CC BY-NC-SA</a></span>
</figcaption>
</figure>
<p>Younger people tend to have fewer savings, and can therefore find it harder to afford care. And women are more likely to have chronic health conditions. About <a href="https://www.abs.gov.au/statistics/health/health-conditions-and-risks/national-health-survey-first-results/latest-release">55% of people with two chronic conditions are women</a>, and 60% of people with three or more chronic conditions are women.</p>
<p>Chronic conditions are becoming more common, so more and more Australians will be facing higher health-care costs and are at risk of missing needed care. </p>
<p>Over the past ten years, <a href="https://www1.health.gov.au/internet/main/publishing.nsf/Content/Medicare%20Statistics-1">average out-of-pocket payments rose by 50%</a>, and they will continue to rise unless governments act now.</p>
<figure class="align-center ">
<img alt="Pharmacist takes medicine from a cupboard." src="https://images.theconversation.com/files/449734/original/file-20220303-4451-q09y2b.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/449734/original/file-20220303-4451-q09y2b.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/449734/original/file-20220303-4451-q09y2b.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/449734/original/file-20220303-4451-q09y2b.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/449734/original/file-20220303-4451-q09y2b.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/449734/original/file-20220303-4451-q09y2b.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/449734/original/file-20220303-4451-q09y2b.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">Out of pocket costs are likely to rise without government action.</span>
<span class="attribution"><a class="source" href="https://unsplash.com/photos/cw2Zn2ZQ9YQ">Unsplash/National Cancer Institute</a></span>
</figcaption>
</figure>
<h2>What can be done?</h2>
<p>The federal government can do much more to reduce out-of-pocket payments and avoid unnecessary costs down the line.</p>
<p><strong>Cost of medicines</strong></p>
<p>While Australia has a world-renowned Pharmaceutical Benefits Scheme (PBS) that helps keep many medications affordable, Australians are still spending nearly A$3 billion on PBS-listed prescriptions each year, including <a href="https://www.pbs.gov.au/info/statistics/expenditure-prescriptions/pbs-expenditure-and-prescriptions-report-30-june-2021">A$1.5 billion on mandatory co-payments</a> and <a href="https://www.pbs.gov.au/info/statistics/under-co-payment/ucp-data-report">A$1.4 billion on PBS-listed prescriptions</a> which cost less than the co-payment.</p>
<p>The federal government should lower the cost of prescriptions for people taking five or more medications for chronic conditions, after their GP conducts a medication review triggered by a computer-generated alert. </p>
<p>We estimate this could reduce inappropriate medication use for about 300,000 patients. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/poor-and-elderly-australians-let-down-by-ailing-primary-health-system-100586">Poor and elderly Australians let down by ailing primary health system</a>
</strong>
</em>
</p>
<hr>
<p>The government should also extend the duration of prescriptions for some medications to reduce the number of Pharmaceutical Benefits Scheme co-payments people have to make to pharmacies.</p>
<p><strong>Tests and scans</strong></p>
<p>The government should abolish the out-of-pocket burden from diagnostic services, such as blood tests and scans. </p>
<p>Australians spend about <a href="https://www1.health.gov.au/internet/main/publishing.nsf/Content/Medicare%20Statistics-1">A$400 million on these services each year</a> – even though patients aren’t the real users of these tests, doctors are. </p>
<figure class="align-center ">
<img alt="Doctor types on laptop/" src="https://images.theconversation.com/files/449735/original/file-20220303-17-1jjr308.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/449735/original/file-20220303-17-1jjr308.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/449735/original/file-20220303-17-1jjr308.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/449735/original/file-20220303-17-1jjr308.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/449735/original/file-20220303-17-1jjr308.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/449735/original/file-20220303-17-1jjr308.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/449735/original/file-20220303-17-1jjr308.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">Doctors are the real users of tests and scans.</span>
<span class="attribution"><a class="source" href="https://unsplash.com/photos/NFvdKIhxYlU">Unsplash/National Cancer Institute</a></span>
</figcaption>
</figure>
<p>With these services now frequently provided by large corporations, the federal government should fund them directly through a commercial tender instead.</p>
<p><strong>Patient enrolment</strong></p>
<p>The government should expand the voluntary patient enrolment scheme to people with two or more chronic conditions. </p>
<p>Patient enrolment is where a patient can enrol in a GP practice and nominate a GP to be their “usual doctor”. It can help make care more affordable for people with chronic conditions by reducing their exposure to out-of-pocket payments. </p>
<p>Greater GP stewardship over a person’s care could reduce inefficiencies in areas such as routine repeat prescriptions and routine renewal of specialist referrals. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/why-it-costs-you-so-much-to-see-a-specialist-and-what-the-government-should-do-about-it-81998">Why it costs you so much to see a specialist – and what the government should do about it</a>
</strong>
</em>
</p>
<hr>
<p>The government has already committed to this reform for people older than 70. If it was expanded to younger people, we estimate an additional 1.7 million people would be eligible for the program.</p>
<p><strong>Bulk billing</strong></p>
<p>The vast majority of health services people receive outside hospital are “bulk-billed” – meaning the patient pays nothing out of pocket. But bulk-billing rates for specialists and allied health are still far too low – at about <a href="https://www1.health.gov.au/internet/main/publishing.nsf/Content/Medicare%20Statistics-1">46% for specialists and 56% for allied health</a>. </p>
<p>The federal and state governments should expand the number of health-care services provided free of charge, particularly in lower-income areas and areas where bulk-billing rates are especially low.</p>
<p>Our analysis shows that if state and federal governments invest an additional A$710 million a year on these reforms, they could save Australians about A$1 billion in out-of-pockets a year, and enable more people to get the care they need, when they need it. That’s a healthy return on investment.</p><img src="https://counter.theconversation.com/content/178301/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Stephen Duckett is chair of the board of directors of the Eastern Melbourne Primary Health Network. Grattan Institute began with contributions to its endowment of $15 million from each of the Federal and Victorian Governments, $4 million from BHP Billiton, and $1 million from NAB. In order to safeguard its independence, Grattan Institute’s board controls this endowment. The funds are invested and contribute to funding Grattan Institute's activities. Grattan Institute also receives funding from corporates, foundations, and individuals to support its general activities, as disclosed on its website.</span></em></p><p class="fine-print"><em><span>Linda Lin is currently on secondment to the Grattan Institute from the Victorian Department of Health.</span></em></p><p class="fine-print"><em><span>Anika Stobart does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>People who need the most health care – the poor and the chronically ill – miss out on care the most. But there are ways to reduce this inequity.Stephen Duckett, Director, Health and Aged Care Program, Grattan InstituteAnika Stobart, Associate, Grattan InstituteLinda Lin, Senior associate, Grattan InstituteLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1754802022-02-03T13:11:18Z2022-02-03T13:11:18ZRecord-breaking rapid DNA sequencing promises timely diagnosis for thousands of rare disease cases<figure><img src="https://images.theconversation.com/files/444145/original/file-20220202-23996-qrz7h1.jpg?ixlib=rb-1.1.0&rect=0%2C7%2C5184%2C3437&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">For patients, often children, with rare diseases, getting a diagnosis is difficult and time-consuming.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/pediatrician-meeting-with-mother-and-child-in-royalty-free-image/629600296">monkeybusinessimages/iStock via Getty Images</a></span></figcaption></figure><p>For children suffering from rare diseases, it usually <a href="https://www.globalrarediseasecommission.com/Report">takes years to receive a diagnosis</a>. This “<a href="https://www.raconteur.net/infographics/the-diagnostic-odyssey/">diagnostic odyssey</a>” is filled with multiple referrals and a barrage of tests, seeking to uncover the root cause behind mysterious and debilitating symptoms. </p>
<p>A new speed record in DNA sequencing may soon help families more quickly find answers to difficult and life-altering questions. </p>
<p>In just <a href="https://doi.org/10.1056/NEJMc2112090">7 hours, 18 minutes</a>, a team of researchers at Stanford Medicine went from collecting a blood sample to offering a disease diagnosis. This unprecedented turnaround time is the result of ultra-rapid DNA sequencing technology paired with massive cloud storage and computing. This improved method of diagnosing diseases allows researchers to discover previously undocumented sources of genetic diseases, shining new light on the <a href="https://www.genome.gov/human-genome-project/Completion-FAQ#:%7E:text=with%20a%20G.-,The%20human%20genome%20contains%20approximately%203%20billion%20of%20these%20base,nucleus%20of%20all%20our%20cells.">6 billion letters</a> in the human genome.</p>
<p>More than <a href="https://www.nichd.nih.gov/newsroom/resources/spotlight/020116-rare-disease-day">7,000 rare diseases</a> affect <a href="https://doi.org/10.1038/s41431-019-0508-0">300 million people worldwide</a>, 50% of whom are children. Of these diseases, <a href="https://doi.org/10.1016/S2213-8587(19)30006-3">80% have a genetic component</a>. The onset of some rare genetic diseases can be swift and debilitating. Spotting symptoms and identifying the root cause is a race against the clock for many families.</p>
<p>I’m a <a href="https://scholar.google.com/citations?user=F5ogte8AAAAJ&hl=en">biotechnology and policy scholar</a> who works on improving access to innovative health care technologies. Whether it’s simple and affordable tests or <a href="https://theconversation.com/new-gene-therapies-may-soon-treat-dozens-of-rare-diseases-but-million-dollar-price-tags-will-put-them-out-of-reach-for-many-164990">sophisticated and expensive gene therapies</a>, medical breakthroughs need to reach populations around the world. I believe that ultra-rapid DNA sequencing is key to casting a wider net and providing a faster turnaround for diagnosing rare diseases.</p>
<h2>A new Guinness World Record</h2>
<p>The <a href="https://www.genome.gov/human-genome-project">Human Genome Project</a>, the first successful attempt to sequence a complete or “whole” human genome, took 13 years, from 1990 to 2003, and cost $2.7 billion. In 2014, the field of whole genome sequencing passed another major milestone by hitting the <a href="https://www.forbes.com/sites/matthewherper/2014/01/14/the-1000-genome-arrives-for-real-this-time/?sh=476fbb015796">$1,000 price point</a>. Every year, the cost of sequencing continues to fall, driven by engineering and computational innovation.</p>
<p>In their quest for a world record, Stanford researchers reached for a DNA sequencing platform from the company <a href="https://nanoporetech.com/">Oxford Nanopore Technologies</a>, which developed a device that reads genomes by <a href="https://www.youtube.com/watch?v=E9-Rm5AoZGw">pulling large strands of DNA through pores</a> comparable in size and composition to the openings in biological cell membranes. As a DNA strand passes through the pore, the device reads subtle electrical changes unique to each DNA letter, thus detecting the DNA sequence.</p>
<p>Thousands of these pores are distributed across a device called a flow cell. The researchers sequenced a single patient’s genome across 48 flow cells simultaneously, allowing them to read the entire genome in a record time of 5 hours, 2 minutes.</p>
<p>The ultra-rapid DNA sequencing generated terabytes of data, which was moved to a <a href="https://blogs.nvidia.com/blog/2022/01/12/world-record-genome-sequencing-parabricks/">cloud-based storage system</a>. In the cloud, algorithms scanned the genome, looking for tiny variations – mutations – within the DNA sequence that could help explain the origin of a genetic disease.</p>
<h2>Rewriting the diagnostic odyssey</h2>
<p>If a disease’s origin is thought to reside in the genome, the standard medical way forward is to order a <a href="https://medlineplus.gov/genetics/understanding/testing/types/">gene panel</a>. This test sequences a list of predetermined genes for possible disease-causing mutations. Receiving test results usually takes <a href="https://www.massgeneral.org/cancer-center/treatments-and-services/cancer-genetics/genetic-testing-frequently-asked-questions">two to three weeks but can take up to eight weeks</a>, and can miss mutations in genes not on the list.</p>
<p>Shortening the sequencing and analysis process to seven hours and expanding the sequencing from a few genes to the entire genome could fundamentally alter the diagnostic odyssey. Ultra-rapid DNA sequencing has already made a difference in the lives of two children.</p>
<p>Matthew Junzman, a 13-year-old from Oregon, was rushed to Stanford Hospital and placed on life support. His heart was failing, and no one knew why. Doctors <a href="https://med.stanford.edu/news/all-news/2022/01/dna-sequencing-technique.html">narrowed down the cause to two options</a>: myocarditis, a reversible condition involving inflammation of the heart, or an untreatable genetic condition.</p>
<p>In the Stanford study, doctors performed an ultra-rapid DNA sequencing test, which quickly revealed that Matthew had a genetic condition. He was immediately placed on a transplant list and received a new heart three weeks later.</p>
<p>In the same study, a 3-month-old patient was <a href="https://med.stanford.edu/news/all-news/2022/01/dna-sequencing-technique.html">admitted to the pediatric hospital suffering from seizures</a>. Using the ultra-rapid DNA sequencing process, doctors quickly spotted a mutation in a gene that explained the seizures. Standard tests would have initially missed this diagnosis.</p>
<h2>Disease diagnosis is a global problem</h2>
<p>Advances in health care technology typically have a high price tag when they first become available. Corporate competition, cheaper materials and new generations of technology can help drive down costs. But infrastructure, political and regulatory hurdles all contribute to limiting global access.</p>
<p>While Oxford Nanopore’s technology is cheaper than several alternative sequencing devices, costs of equipment and materials are still prohibitively expensive for labs in many countries. Similarly, <a href="https://www.worldbank.org/en/publication/wdr2021">less than 20%</a> of low- and middle-income countries have modern data infrastructure. This removes the possibility of cloud computing in many places.</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/iHQQk2LUJVI?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">Researchers in Africa are working to ensure that African populations are represented in and benefit from advances in genomic research.</span></figcaption>
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<p>Bringing ultra-rapid DNA sequencing to these countries will involve investing in regional efforts to support genomic research. For example, the <a href="https://h3africa.org/">Human Heredity & Health in Africa</a> Initiative invests in scientific infrastructure and workforce development to study health and disease for African populations. Providing groups like these with the equipment and software needed for ultra-rapid DNA sequencing will ensure that rare diseases that are more common in African populations will not go unexplored. </p>
<p>There are no approved treatments for <a href="https://doi.org/10.1016/S2213-8587(19)30006-3">95% of rare diseases</a>. The limited number of individuals affected by a given rare disease makes it difficult to study symptoms and design clinical trials. <a href="https://www3.weforum.org/docs/WEF_Global_Data_Access_for_Solving_Rare_Disease_Report_2020.pdf">Creating data-sharing systems and crafting regulations</a> will be vital to allow people to safely share their personal information between countries. The <a href="https://www.ejprarediseases.org/">European Joint Programme on Rare Diseases</a> and the <a href="https://www.ga4gh.org/">Global Alliance for Genomics & Health</a> are making progress toward these goals, building bridges between rare disease communities around the world.</p>
<p>As ultra-rapid genome sequencing becomes a feature in hospitals across high-income countries, I believe it’s important to consider how the broader rare disease community will have access to these tools and benefit from the wave of new disease insight on the horizon.</p>
<p>[<em>Understand new developments in science, health and technology, each week.</em> <a href="https://memberservices.theconversation.com/newsletters/?nl=science&source=inline-science-understand">Subscribe to The Conversation’s science newsletter</a>.]</p><img src="https://counter.theconversation.com/content/175480/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Kevin Doxzen is affiliated with the World Economic Forum. </span></em></p>Record-breaking technology can sequence an entire human genome in a matter of hours. The work could be a lifeline for people suffering from the more than 5,000 known rare genetic diseases.Kevin Doxzen, Postdoctoral Fellow in Precision Medicine and Emerging Biotechnologies, Arizona State UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1660872021-09-07T12:48:49Z2021-09-07T12:48:49ZThe next attack on the Affordable Care Act may cost you free preventive health care<figure><img src="https://images.theconversation.com/files/419146/original/file-20210902-23-1rk6juj.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C1998%2C1488&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A provision of the Affordable Care Act makes it easier for patients to receive preventive care.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/doctor-listening-to-heartbeat-of-patient-royalty-free-image/633707477">Jose Luis Pelaez Inc/Digital Vision via Getty Images</a></span></figcaption></figure><p>Many Americans breathed a sigh of relief when the Supreme Court left the Affordable Care Act (ACA) in place following its <a href="https://www.supremecourt.gov/opinions/20pdf/19-840_6jfm.pdf">third major legal challenge</a> in June 2021. This decision left <a href="https://source.wustl.edu/2017/02/americans-divided-on-obamacare-repeal-poll-finds/">widely supported policies</a> in place, like ensuring coverage <a href="https://www.healthcare.gov/coverage/pre-existing-conditions/">regardless of preexisting conditions</a>, coverage for <a href="https://www.healthcare.gov/young-adults/children-under-26/">dependents up to age 26</a> on their parents’ plan and removal of <a href="https://www.healthcare.gov/health-care-law-protections/lifetime-and-yearly-limits/">annual and lifetime benefit limits</a>.</p>
<p>But the hits keep coming. One of the most popular benefits offered by the ACA, <a href="https://www.kff.org/health-reform/fact-sheet/preventive-services-covered-by-private-health-plans/">free preventive care</a> through many employer-based and marketplace insurance plans, is under attack by another legal domino, <a href="https://www.vox.com/2021/4/2/22360341/obamacare-lawsuit-supreme-court-little-sisters-kelley-becerra-reed-oconnor-nondelegation">Kelley v. Becerra</a>. As University of Michigan law professor Nicholas Bagley sees it, “[t]his time, the law’s opponents <a href="https://www.theatlantic.com/ideas/archive/2021/06/next-major-challenge-affordable-care-act/619159/">stand a good chance of succeeding</a>.”</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1405860623372754945"}"></div></p>
<p>We are <a href="https://scholar.google.com/citations?user=bDT820kAAAAJ&hl=en">public health</a> and <a href="https://scholar.google.com/citations?user=Ks-_ZlIAAAAJ&hl=en">economics</a> researchers at Boston University who have been studying how preventive care is covered by the ACA and what this means for patients. With this policy now in jeopardy, health care in the U.S. stands to take a big step backward. </p>
<h2>What did the ACA do for preventive health?</h2>
<p>The Affordable Care Act tried to achieve the twin ideals of <a href="https://www.healthcare.gov/glossary/affordable-care-act/">making health care more accessible while reducing health care spending</a>. It <a href="https://www.healthcare.gov/glossary/marketplace/">created marketplaces</a> for individuals to purchase health insurance and <a href="https://www.healthcare.gov/medicaid-chip/medicaid-expansion-and-you/">expanded Medicaid</a> to increase coverage for more low-income people.</p>
<p>One way it has tried to reach both goals is to prioritize <a href="https://www.kff.org/health-reform/report/preventive-services-tracker/">preventive services</a> that maximize patient health and minimize cost, like cancer screenings, vaccinations and access to contraception. Eliminating financial barriers to health screenings increases the likelihood that common but costly chronic conditions, such as heart disease, will be <a href="https://doi.org/10.1377/hlthaff.2008.0701">diagnosed early on</a>.</p>
<p><a href="https://www.law.cornell.edu/cfr/text/29/2590.715-2713">Section 2713</a> of the ACA requires insurers to offer <a href="https://www.healthcare.gov/coverage/preventive-care-benefits/">full coverage of preventive services</a> that are endorsed by three federal groups: the U.S. Preventive Services Task Force, the Advisory Committee on Immunization Practices and the Health Resources and Services Administration. This means that eligible preventive services ordered by your doctor won’t cost you anything out of pocket. For example, <a href="https://www.congress.gov/bill/116th-congress/house-bill/748/">the CARES Act</a> used this provision to ensure COVID-19 vaccines would be free for many Americans.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/418993/original/file-20210901-13-wnh1xo.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Healthcare provider examining child in exam room." src="https://images.theconversation.com/files/418993/original/file-20210901-13-wnh1xo.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/418993/original/file-20210901-13-wnh1xo.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/418993/original/file-20210901-13-wnh1xo.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/418993/original/file-20210901-13-wnh1xo.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/418993/original/file-20210901-13-wnh1xo.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/418993/original/file-20210901-13-wnh1xo.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/418993/original/file-20210901-13-wnh1xo.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">The Affordable Care Act significantly reduced the costs of well-child visits since it was instated.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/girl-having-checkup-in-doctors-office-royalty-free-image/153337724">John Fedele/The Image Bank via Getty Images</a></span>
</figcaption>
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<p>Removing the financial barrier has drastically reduced the average cost of a range of preventive services. Our study found that the costs of <a href="https://doi.org/10.1001/jamanetworkopen.2021.1248">well-child visits</a> and <a href="https://doi.org/10.1097/MLR.0000000000000610">mammograms</a> were reduced by 56% and 74%, respectively, from 2006 to 2018. We also found that the ACA reduced the share of children’s preventive checkups that included out-of-pocket costs <a href="https://doi.org/10.1001/jamanetworkopen.2021.1248">from over 50% in 2010 to under 15% in 2018</a>. </p>
<h2>Residual costs for preventive services remain</h2>
<p>Despite these reductions in costs, there are limitations to this benefit. For example, it <a href="https://www.carecredit.com/well-u/health-wellness/what-is-covered-in-preventive-care-what-isnt/">doesn’t cover follow-up tests or treatments</a>. This means that if a routine mammogram or colonoscopy reveals something that requires further care, patients may have to pay for the initial screening test, too. And some patients still <a href="https://www.washingtonpost.com/national/health-science/getting-charged-for-free-preventive-care/2014/01/17/98fbd1fa-7ec2-11e3-95c6-0a7aa80874bc_story.html">receive unexpected bills</a> for preventive care that should have been covered. This can happen, for example, when providers submit incorrect billing codes to insurers, which have <a href="https://www.consumerreports.org/health-insurance/what-to-do-when-your-insurer-wont-cover-free-preventive-care/">specific and often idiosyncratic preventive care guidelines</a>. </p>
<p>We also studied the <a href="https://doi.org/10.1016/j.ypmed.2021.106690">residual out-of-pocket costs</a> that privately insured Americans had after using eligible preventive services in 2018. We found that these patients paid between $75 million to $219 million per year combined for services that should have been free for them. Unexpected preventive care bills were most likely to hit patients living in rural areas or the South, as well as those seeking women’s services such as contraception and other reproductive health care. Among patients attempting to get a free wellness visit from their doctor, nearly 1 in 5 were later asked to pay for it.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/418998/original/file-20210901-17-1llknsw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Medical bills stacked on top of each other with a credit card nestled between forms." src="https://images.theconversation.com/files/418998/original/file-20210901-17-1llknsw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/418998/original/file-20210901-17-1llknsw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/418998/original/file-20210901-17-1llknsw.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/418998/original/file-20210901-17-1llknsw.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/418998/original/file-20210901-17-1llknsw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/418998/original/file-20210901-17-1llknsw.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/418998/original/file-20210901-17-1llknsw.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">Lack of standardized billing and policy compliance has led to unexpected bills.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/medical-bills-royalty-free-image/184284259">DNY59/E+ via Getty Images</a></span>
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<p>Nevertheless, the preventive health provision of the ACA has resulted in <a href="https://doi.org/10.1001/jamanetworkopen.2021.1248">significant reductions in patient costs</a> for many essential and popular services. And <a href="https://labblog.uofmhealth.org/industry-dx/what-happens-when-preventive-care-becomes-free-to-patients">removing financial barriers</a> is a key way to encourage patients to use preventive services intended to protect their health.</p>
<h2>The threat of Kelley v. Becerra</h2>
<p>The plaintiffs who brought the <a href="https://khn.org/news/article/lawsuit-targets-health-law-no-charge-coverage-of-preventive-exams-like-mammograms/">latest legal challenge</a> to the ACA, Kelley v. Becerra, object to covering contraception and preexposure prophylaxis (PrEP) for HIV on religious and moral grounds. The case is currently awaiting decision in a district court in Texas, but seems to be headed to the Supreme Court.</p>
<p>The case rests on <a href="https://www.theatlantic.com/ideas/archive/2021/06/next-major-challenge-affordable-care-act/619159/">two legal issues</a>: 1) violation of the nondelegation doctrine, and 2) the appointments clause of the Constitution. The <a href="https://ballotpedia.org/Nondelegation_doctrine">nondelegation doctrine</a> is a rarely used legal argument that requires Congress to specify how their powers should be used. It essentially argues that Congress was too vague by not specifying which preventive services would be included in Section 2713 up front. The <a href="https://constitution.congress.gov/browse/essay/artII_S2_C2_2_1_4/">appointments clause</a> specifies that the people using government powers must be “officers of the United States.” In this case, it is unclear whether those in the federal groups that determine eligible preventive care services qualify.</p>
<p>Texas District Judge Reed O’Connor has indicated so far that he <a href="https://www.latimes.com/business/story/2021-06-21/obamacare-legal-threat-remains">takes a kind view</a> toward the plaintiff’s case. He could rule that this provision of the ACA is unconstitutional and put the case on a path to the Supreme Court. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/419002/original/file-20210902-19-azgfs0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Demonstrator holds a sign saying " src="https://images.theconversation.com/files/419002/original/file-20210902-19-azgfs0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/419002/original/file-20210902-19-azgfs0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/419002/original/file-20210902-19-azgfs0.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/419002/original/file-20210902-19-azgfs0.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/419002/original/file-20210902-19-azgfs0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/419002/original/file-20210902-19-azgfs0.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/419002/original/file-20210902-19-azgfs0.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">The Affordable Care Act has faced many legal challenges over the years.</span>
<span class="attribution"><a class="source" href="https://newsroom.ap.org/detail/SupremeCourtHealthCare/af7a18ea1fc84b39af301fa84aec0672">AP Photo/Alex Brandon</a></span>
</figcaption>
</figure>
<h2>Patients stand to lose more than just money</h2>
<p>If Section 2713 were repealed, insurers would have the freedom to reimpose patient cost-sharing for preventive care. In the short run, this could increase the financial strain that patients face when seeking preventive care and discourage them from doing so. In the long run, this could result in increased rates of preventable and expensive-to-treat chronic conditions. And because Section 2713 is what allows free COVID-19 vaccines for those with private health insurance, some patients <a href="https://acasignups.net/21/06/20/updated-well-was-fun-while-it-lasted-next-big-aca-lawsuit-coming-down-pike">may have to pay</a> for their vaccines and future boosters if the provision is axed.</p>
<p>[<em>Over 100,000 readers rely on The Conversation’s newsletter to understand the world.</em> <a href="https://theconversation.com/us/newsletters/the-daily-3?utm_source=TCUS&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=100Ksignup">Sign up today</a>.]</p>
<p>The ACA has been instrumental in expanding access to preventive care for millions of Americans. While the ACA’s preventive health coverage provision isn’t perfect, a lot of progress that has been made toward lower-cost, higher-value care may be erased if Section 2713 is repealed.</p>
<p><a href="https://labblog.uofmhealth.org/industry-dx/what-happens-when-preventive-care-becomes-free-to-patients">Lower-income patients</a> will stand to lose the most. And it could make ending the COVID-19 pandemic that much harder.</p><img src="https://counter.theconversation.com/content/166087/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Paul Shafer has received funding in the past three years from the Commonwealth Fund, Kate B. Reynolds Charitable Trust, Robert Wood Johnson Foundation, Horowitz Foundation for Social Policy, Starbucks Coffee Company, and Renova Health.</span></em></p><p class="fine-print"><em><span>Alex Hoagland 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>The Affordable Care Act has allowed many preventive health services, including cancer screenings and vaccines, to be free of charge. But legal challenges may lead to costly repercussions for patients.Paul Shafer, Assistant Professor, Health Law, Policy, and Management, Boston UniversityAlex Hoagland, PhD Candidate in Health Economics, Boston UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1541772021-02-03T03:46:50Z2021-02-03T03:46:50ZShould GPs charge for bandages or dressings? Hunt says no to ‘band-aid tax’. So here are some other options<figure><img src="https://images.theconversation.com/files/382088/original/file-20210202-15-dafd7t.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C1000%2C667&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/medical-assistant-applying-gauze-bandage-onto-623834861">from www.shutterstock.com</a></span></figcaption></figure><p>Federal Health Minister Greg Hunt recently <a href="https://www.health.gov.au/ministers/the-hon-greg-hunt-mp/media/doorstop-interview-on-31-january-2021">ruled out</a> GP patients having to pay for bandages and dressings, despite a major Medicare review recommending it.</p>
<blockquote>
<p>We won’t be putting in place extra charges for patients. I am ruling that out.</p>
</blockquote>
<p>Hunt was commenting on a <a href="https://www.health.gov.au/resources/publications/report-from-the-wound-management-working-group">recommendation</a> from the Medicare Benefits Schedule Review Taskforce to charge bulk-billed patients for bandages and dressings. The idea was to save patients some money at the pharmacy, where such products can be expensive. The recommendation also addressed <a href="https://medicalrepublic.com.au/wound-dressings-may-soon-to-be-covered/25714">some GPs’ concerns</a> they were out of pocket by supplying these items. However, some people <a href="https://twitter.com/SwannyQLD/status/1355669803822850052">had called</a> the recommendation to charge patients a “<a href="https://twitter.com/australiandr/status/1356090593919729670">band-aid tax</a>”.</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1355780810067091456"}"></div></p>
<p>Rather than charging patients, Hunt said <a href="https://www.health.gov.au/ministers/the-hon-greg-hunt-mp/media/doorstop-interview-on-31-january-2021">he’d discuss</a> “alternative sources of government support” for general practices and doctors to supply these items. Here are some options and what they could mean for you.</p>
<h2>A thin end of the wedge?</h2>
<p>Since 2015, the taskforce has been <a href="https://www1.health.gov.au/internet/main/publishing.nsf/Content/MBSReviewTaskforce">reviewing about 5,700 items</a> on the Medicare Benefits Schedule to see which services you receive at your GP or specialist align with current evidence and practice, are safe and might benefit you.</p>
<p>Of its <a href="https://www.health.gov.au/resources/publications/medicare-benefits-schedule-review-taskforce-final-report">1,400 or more recommendations</a>, this one initially seems to be the thin end of the wedge. What would GPs charge you for next? Using equipment to take your blood pressure? The paper your bill is printed on? Luckily, separate charges for such items are <a href="https://www.croakey.org/fatal-wound-for-medicare-new-fees-for-dressings-herald-the-end-of-bulk-billing/">illegal</a>.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/medicare-review-must-deal-with-elephant-in-the-room-incentives-40819">Medicare review must deal with 'elephant in the room' incentives</a>
</strong>
</em>
</p>
<hr>
<p>GPs can already choose to charge any amount for a consultation. And you would presume all GPs’ costs — including rent for their premises, equipment, office chairs, as well as consumables such as bandages and dressings — are considered when they decide on the level of fee to charge, or whether to bulk-bill. If the costs of supplies are increasing, then GPs can simply increase the consultation fee.</p>
<p>The recommendation also seemed inconsistent with the objectives of the review. This included trying to simplify the Medicare Benefits Schedule (not making it <a href="https://www.croakey.org/fatal-wound-for-medicare-new-fees-for-dressings-herald-the-end-of-bulk-billing/">more complicated</a>). The recommendation also seemed inconsistent with strong recommendations aimed at reducing patients’ out-of-pocket costs and making health care more affordable.</p>
<h2>What was the taskforce thinking?</h2>
<p>The taskforce argued people with chronic wounds, such as <a href="https://www.betterhealth.vic.gov.au/health/ConditionsAndTreatments/leg-ulcers">venous leg ulcers</a>, often paid a lot for wound dressings they used at home.</p>
<p>Though GPs and practice nurses help dress wounds, patients still need to regularly manage and dress wounds themselves at home. So the taskforce was arguing these costs should be subsidised.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/curious-kids-how-do-wounds-heal-118603">Curious Kids: how do wounds heal?</a>
</strong>
</em>
</p>
<hr>
<p>The recommendation to allow GPs to charge patients was where the consultation was bulk-billed. This seemed to assume this would be cheaper for patients rather than them buying their own dressings from pharmacies and supermarkets. So the intention was to reduce out-of-pocket costs overall. </p>
<p>However, this recommendation relies on GPs charging patients less than what pharmacies or supermarkets may charge and GPs would not try to profit from selling dressings to patients. However, the taskforce presented no evidence or data to show this would be the case, even though its recommendations are supposed to be evidence-based.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/382095/original/file-20210202-17-14xbotj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Bandages and dressings on supermarket shelf" src="https://images.theconversation.com/files/382095/original/file-20210202-17-14xbotj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/382095/original/file-20210202-17-14xbotj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=338&fit=crop&dpr=1 600w, https://images.theconversation.com/files/382095/original/file-20210202-17-14xbotj.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=338&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/382095/original/file-20210202-17-14xbotj.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=338&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/382095/original/file-20210202-17-14xbotj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=425&fit=crop&dpr=1 754w, https://images.theconversation.com/files/382095/original/file-20210202-17-14xbotj.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=425&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/382095/original/file-20210202-17-14xbotj.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=425&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">The taskforce thought patients could save money by going to their GP for their dressings rather than buying them at the pharmacy or supermarket.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/shah-alam-malaysia-9-june-2019-1419324386">www.shutterstock.com</a></span>
</figcaption>
</figure>
<h2>Managing wounds well has both health and economic benefits</h2>
<p>Inadequate wound care can have debilitating effects and adversely influence people’s mobility and quality of life. Like any health-care treatment, keeping out-of-pocket costs low for patients can help improve access to health care and improve health outcomes. The issue is how to do this.</p>
<p>Treatment is also <a href="https://link.springer.com/article/10.1186/s12913-018-3234-3">highly cost-effective</a>. For instance, providing compression therapy products, such as compression bandages for leg ulcers, would cost the health system an additional A$270 million over five years. But it would save about $1.4 billion over the same period.</p>
<p>So it seems to make sense for new policies to try and reduce the costs GP practices and patients face for these supplies.</p>
<h2>How do we reduce the costs?</h2>
<p><strong>Centralise purchasing</strong></p>
<p>GP practices and pharmacies buy their supplies on the open market, and small GP practices may not be able to get good deals. </p>
<p>So the taskforce also recommended a Commonwealth-funded wound consumables scheme to centralise purchasing and price negotiation, as is done for medical devices and pharmaceuticals at the Commonwealth level. The idea is to keep prices low.</p>
<p><strong>Offer discounts</strong></p>
<p>Certain patients with chronic wounds could also be eligible for heavily discounted dressings from their pharmacy, though this may be difficult for less-mobile patients. GPs could “prescribe” which dressings are needed and for how long, and the pharmacies could “dispense” these for patients from the wound consumables scheme. </p>
<p><strong>Rethink dispensing</strong></p>
<p>GPs could also dispense these dressings themselves. For eligible patients who are not mobile and cannot easily visit pharmacies, GPs could provide and apply dressings for chronic wounds in the practice (or through practice nurses visiting patients at home). GPs could also provide dressings for patients to apply at home. Providing dressings at home or in the GP practice would require additional payments to general practices from Medicare.</p>
<p>This payment would need to provide incentives for GPs to manage the wounds more effectively and to buy high-quality, low-cost dressings, perhaps purchased via the wound consumables scheme.</p>
<h2>What needs to happen?</h2>
<p>For patients with chronic wounds that need long-term care (not just people wanting a band-aid), reducing the costs of bandages and dressings is likely to improve access and improve outcomes. </p>
<p>Examining the regulation of these markets could be a first step to ensure prices are as low as possible. This could include considering more centralised purchasing, followed by considering additional funding to subsidise these very cost-effective treatments.</p><img src="https://counter.theconversation.com/content/154177/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Anthony Scott receives funding for research grants from NHMRC, ARC, and Medibank Better Health Foundation.</span></em></p>Wound care might be costly, but it’s cost-effective, saving health dollars in the long run. The issue is, who pays?Anthony Scott, Professor, The University of MelbourneLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1477432020-10-25T19:04:06Z2020-10-25T19:04:06ZMould and damp health costs are about 3 times those of sugary drinks. We need a healthy housing agenda<figure><img src="https://images.theconversation.com/files/364623/original/file-20201021-23-10a2hib.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C4463%2C2977&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/girl-found-mold-corner-your-kitchen-1082148548">Burdun Iliya/Shutterstock</a></span></figcaption></figure><p>The World Health Organisation has always been interested in housing as one of the big “<a href="https://doi.org/10.1016/S0140-6736(17)32848-9">causes of the causes</a>”, of the social determinants, of health. The WHO launched evidence-based <a href="https://www.who.int/publications/i/item/9789241550376">guidelines</a> for healthy housing policies in 2019. </p>
<p>Australia is behind the eight ball on healthy housing. Other governments, including in the <a href="https://nchh.org/information-and-evidence/healthy-housing-policy/national/">United States</a>, <a href="https://www.gov.uk/government/collections/housing-for-health">United Kingdom</a> and <a href="https://www.health.govt.nz/our-work/preventative-health-wellness/healthy-homes-initiative">New Zealand</a>, acknowledge housing as an important contributor to the burden of disease. These countries have major policy initiatives focused on this agenda. </p>
<p>In Australia, however, we do housing and we do health, but they sit in different portfolios of government and aren’t together in the (policy) room often enough. Housing should be embedded in our <a href="https://www1.health.gov.au/internet/main/publishing.nsf/Content/national-preventive-health-strategy">National Preventive Health Strategy</a>.</p>
<p>The COVID-19 pandemic has forced us to rethink how we approach health and protect our populations. It has amplified social and economic vulnerability. The pandemic has almost certainly brought housing and health together in our minds.</p>
<p>Housing – its ability to provide shelter, its quality, location, warmth – has proven to be a key factor in the pandemic’s “syndemic” nature. That is, as well as shaping exposure to the virus itself, housing contributes to the social patterning of chronic diseases that increase COVID-19 risks. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/363116/original/file-20201013-15-ywklc6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Graphic showing interactions of COVID-19 with social determinants of health and non-communicable diseases" src="https://images.theconversation.com/files/363116/original/file-20201013-15-ywklc6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/363116/original/file-20201013-15-ywklc6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=600&fit=crop&dpr=1 600w, https://images.theconversation.com/files/363116/original/file-20201013-15-ywklc6.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=600&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/363116/original/file-20201013-15-ywklc6.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=600&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/363116/original/file-20201013-15-ywklc6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=754&fit=crop&dpr=1 754w, https://images.theconversation.com/files/363116/original/file-20201013-15-ywklc6.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=754&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/363116/original/file-20201013-15-ywklc6.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=754&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Interactions of COVID-19, non-communicable diseases (NCDs) and the social determinants of health.</span>
<span class="attribution"><a class="source" href="https://jech.bmj.com/content/74/11/964">Bambra et al, The COVID-19 pandemic and health inequalities (2020), Journal of Epidemiology & Community Health</a></span>
</figcaption>
</figure>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/overcrowding-and-affordability-stress-melbournes-covid-19-hotspots-are-also-housing-crisis-hotspots-141381">Overcrowding and affordability stress: Melbourne's COVID-19 hotspots are also housing crisis hotspots</a>
</strong>
</em>
</p>
<hr>
<h2>Housing and health are intertwined</h2>
<p>Housing affects health in many ways. At the broad scale, <a href="https://theconversation.com/poor-housing-leaves-its-mark-on-our-mental-health-for-years-to-come-120595">housing disadvantage</a>, <a href="https://theconversation.com/dangerous-to-human-health-thats-a-housing-problem-much-bigger-than-a-few-high-profile-apartment-blocks-120656">unaffordable housing</a> and housing of poor quality have been the focus of much recent Australian research. More specific housing drivers of health, such as household mould, injury, overcrowding, noise, cold and damp, have received <a href="https://www.who.int/publications/i/item/9789241550376">renewed global attention</a>. </p>
<p>However, capturing the combined health effect of housing is difficult. It’s hard to measure and has many components, and everyone has slightly different housing (and health). </p>
<p>But epidemiologists can provide us with a useful way of estimating the “burden” of various risk factors for population health. Housing risk factors have rarely been examined in Australia, but <a href="https://onlinelibrary.wiley.com/doi/abs/10.1111/1745-5871.12326">our estimates</a> flag that the <a href="https://theconversation.com/poor-housing-leaves-its-mark-on-our-mental-health-for-years-to-come-120595">increasing health burden of housing</a> demands attention. </p>
<p>For example, we estimate the health cost (measured in <a href="https://www.who.int/healthinfo/global_burden_disease/metrics_daly/en/">disability-adjusted life years</a>) due to respiratory and cardiovascular disease that can be attributed to mouldy or damp housing is about three times the cost attributable to sugary drinks in Australia. Damp, cold and mouldy housing generates a substantial health burden and could be an easy target for public health prevention strategies. These housing conditions stand alongside many of the classic risk factors such as diet, smoking and obesity. </p>
<p>This estimate of health burden does not even factor in the important role housing plays in mental health. Housing affordability, security, suitability, location and condition are all associated with good mental health. </p>
<p>With rates of eviction likely to increase once moratoriums are lifted across the country, the housing-related mental health burden will almost certainly increase too. </p>
<p>We have previously estimated more than <a href="https://doi-org.proxy.library.adelaide.edu.au/10.1111/1745-5871.12326">2.5 million Australians are living in unhealthy housing</a> — and that this number is rising. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/285245/original/file-20190723-91850-x1veo5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/285245/original/file-20190723-91850-x1veo5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/285245/original/file-20190723-91850-x1veo5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=298&fit=crop&dpr=1 600w, https://images.theconversation.com/files/285245/original/file-20190723-91850-x1veo5.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=298&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/285245/original/file-20190723-91850-x1veo5.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=298&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/285245/original/file-20190723-91850-x1veo5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=374&fit=crop&dpr=1 754w, https://images.theconversation.com/files/285245/original/file-20190723-91850-x1veo5.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=374&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/285245/original/file-20190723-91850-x1veo5.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=374&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">The Australian Index of Unhealthy Housing – a composite measure of housing affordability, security, quality, location and accessibility – shows increases in unhealthy housing from 2000 to 2016.</span>
<span class="attribution"><a class="source" href="https://onlinelibrary.wiley.com/doi/full/10.1111/1745-5871.12326">Adapted from Baker et al (2019), An Australian geography of unhealthy housing</a></span>
</figcaption>
</figure>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/covid-spurred-action-on-rough-sleepers-but-greater-homelessness-challenges-lie-ahead-147102">COVID spurred action on rough sleepers but greater homelessness challenges lie ahead</a>
</strong>
</em>
</p>
<hr>
<h2>What housing actions will improve health?</h2>
<p>Simple housing-focused interventions could reduce the sizeable health burden from housing-related problems. As the WHO advocates, this requires policy and research that have an eye on both health and housing. </p>
<p>In practical terms, a preventive health strategy would include:</p>
<ul>
<li><p>minimum rental housing standards to protect occupants’ health, which would target structural factors related to damp and mould, ventilation, heating and cooling, injury hazards, maintenance and repair</p></li>
<li><p>good-quality public housing that is easy to access as a foundation for healthy lives</p></li>
<li><p>help with fixing problems, such as mould removal and servicing of heaters, for people in poor-quality housing</p></li>
<li><p>insulation to maintain indoor temperature and increase energy efficiency. </p></li>
</ul>
<figure class="align-center ">
<img alt="Sick woman sitting on couch with a blanket over her" src="https://images.theconversation.com/files/364625/original/file-20201021-21-g0yykq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/364625/original/file-20201021-21-g0yykq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/364625/original/file-20201021-21-g0yykq.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/364625/original/file-20201021-21-g0yykq.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/364625/original/file-20201021-21-g0yykq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/364625/original/file-20201021-21-g0yykq.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/364625/original/file-20201021-21-g0yykq.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">Poorly insulated housing is a serious health issue in Australia.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/middleaged-50s-sick-frozen-woman-seated-1575687859">fizkes/Shutterstock</a></span>
</figcaption>
</figure>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/chilly-house-mouldy-rooms-heres-how-to-improve-low-income-renters-access-to-decent-housing-116749">Chilly house? Mouldy rooms? Here's how to improve low-income renters’ access to decent housing</a>
</strong>
</em>
</p>
<hr>
<h2>COVID adds urgency to rethinking our approach</h2>
<p>COVID has caused us to rapidly rethink public housing, nursing homes, share houses and small inner-city apartments. When choosing our current housing, few of us would have factored in the potential for isolation and loneliness, the need for separate working and study spaces, access to private green space, or the infection risk of shared lifts. </p>
<p>The experience of many Australians during the pandemic has almost certainly changed our view of the housing that we need, and what we consider to be healthy. It is time to harness this knowledge and learn from our COVID-19 experience. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/how-might-covid-19-change-what-australians-want-from-their-homes-145626">How might COVID-19 change what Australians want from their homes?</a>
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</p>
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<p>Many have <a href="https://theconversation.com/social-housing-was-one-hell-of-a-missed-budget-opportunity-but-theres-time-147665">lamented the missed opportunity</a> to create economic stimulus in our nation’s COVID recovery plan by building more social housing. But social housing is only a small part of the story. Australia needs to embrace a future where good population health goes hand in hand with good-quality, affordable and secure housing – where health is at the forefront of housing policy and public preventive health strategies harness housing. </p>
<h2>7 key questions for a healthy housing agenda</h2>
<p>The time is right for Australia to put housing and health in the same room and develop a national healthy housing agenda. Our <a href="https://www.healthyhousing-cre.org/">National Health and Medical Research Council-funded Centre for Research Excellence in Healthy Housing</a> aims to lead and shape this agenda. In doing so, we pose the following questions to our governments, research community and stakeholders:</p>
<ol>
<li><p>How can we respond in a nationally co-ordinated way to the emerging challenges that COVID-19 presents to healthy housing? </p></li>
<li><p>Who should be included in the conversation and in developing the agenda – and what is the role of the Commonwealth Department of Health? </p></li>
<li><p>Where does responsibility for providing healthy housing lie?</p></li>
<li><p>What is the “minimum standard” of housing that we want to provide to all Australians?</p></li>
<li><p>What are the healthy housing priorities? Warmth? Mould? Tenure security? <a href="https://academic.oup.com/aje/article/174/7/753/115870">Affordability</a>?</p></li>
<li><p>What groups in our society demand immediate attention? Children? Renters? People with disabilities? </p></li>
<li><p>How will an Australian healthy housing agenda fit within a national housing agenda (when one exists)? </p></li>
</ol>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/coronavirus-lays-bare-5-big-housing-system-flaws-to-be-fixed-137162">Coronavirus lays bare 5 big housing system flaws to be fixed</a>
</strong>
</em>
</p>
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<img src="https://counter.theconversation.com/content/147743/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Rebecca Bentley receives funding from the Australian Research Council and the National Health and Medical Research Council. </span></em></p><p class="fine-print"><em><span>Emma Baker receives funding from the Australian Research Council, the National Health and Medical Research Council and the Australian Housing and Urban Research Institute. She holds a board position with Habitat for Humanity SA.</span></em></p>In Australia, we do housing and we do health, but they sit in different portfolios of government and the policy dots aren’t joined often enough.Rebecca Bentley, Professor of Social Epidemiology, Principal Research Fellow in Social Epidemiology and Director of the Centre for Research Excellence in Healthy Housing in Melbourne School of Population and Global Health, The University of MelbourneEmma Baker, Professor of Housing Research and Deputy Director of the NHMRC Centre of Excellence for Healthy Housing, University of AdelaideLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1435402020-07-29T08:23:26Z2020-07-29T08:23:26ZNo, Australia should not follow Sweden’s approach to coronavirus<p>The COVID-19 pandemic has brought once-in-a-generation destruction to the lives and livelihoods of people around the world. </p>
<p>The costs of preventing the spread of COVID-19 must always be compared to the health, social and economic costs of viable alternatives. Countries across the globe have dealt with this balancing act differently. </p>
<p>One country in particular that has attracted attention for its lighter approach to lockdown is Sweden. Some people have <a href="https://www.abc.net.au/news/2020-07-28/gigi-foster-covid-qanda-sweden/12497940?nw=0">regarded</a> Sweden as an example for Australia to follow.</p>
<p>But Sweden shouldn’t be seen as a model for Australia when it comes to COVID-19. The virus has <a href="https://ourworldindata.org/coronavirus-data-explorer?zoomToSelection=true&casesMetric=true&dailyFreq=true&smoothing=7&country=SWE%7ENOR%7EFIN%7EDNK&pickerMetric=location&pickerSort=asc">spread rapidly</a>, they’ve had more deaths, and the <a href="https://www.riksbank.se/globalassets/media/rapporter/ppr/fordjupningar/engelska/2020/economic-development-according-to-two-alternative-scenarios-article-in-monetary-policy-report-july-2020.pdf">economy is suffering</a> just as badly as their neighbours with heavier lockdowns.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/6-countries-6-curves-how-nations-that-moved-fast-against-covid-19-avoided-disaster-137333">6 countries, 6 curves: how nations that moved fast against COVID-19 avoided disaster</a>
</strong>
</em>
</p>
<hr>
<h2>Sweden’s approach was softer, but it wasn’t unrestricted</h2>
<p>While some people called Sweden’s approach a “let it rip” policy, this was never the case. Swedes were not free to go about their lives as normal. </p>
<p>Sweden’s policymakers did introduce restrictions <a href="https://www.government.se/government-policy/the-governments-work-in-response-to-the-virus-responsible-for-covid-19/">to limit</a> the spread of COVID-19 infection, but they tried to do so in a way that minimised the effects on people and companies.</p>
<p>Bars and restaurants could remain open, but with capacity constraints and a requirement of table service. Schools were kept open to preschool and primary students, but were closed to senior students. Non-essential international arrivals were banned, but only from countries outside Europe.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/350101/original/file-20200729-23-eppoiz.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/350101/original/file-20200729-23-eppoiz.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=450&fit=crop&dpr=1 600w, https://images.theconversation.com/files/350101/original/file-20200729-23-eppoiz.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=450&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/350101/original/file-20200729-23-eppoiz.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=450&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/350101/original/file-20200729-23-eppoiz.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=566&fit=crop&dpr=1 754w, https://images.theconversation.com/files/350101/original/file-20200729-23-eppoiz.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=566&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/350101/original/file-20200729-23-eppoiz.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=566&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Sweden’s restrictions in March and April were light compared to its neighbours.</span>
<span class="attribution"><span class="source">Oxford</span></span>
</figcaption>
</figure>
<p>There were social distancing requirements and protections for vulnerable populations. Visits to aged care facilities were prohibited. People over the age of 70, pregnant women, and those with pre-existing health conditions were encouraged to “<a href="https://www.krisinformation.se/en/hazards-and-risks/disasters-and-incidents/2020/official-information-on-the-new-coronavirus/du-som-ar-over-70-ar">avoid social contacts</a>” and to ask others to do shopping and errands for them.</p>
<p>These <a href="https://www.krisinformation.se/en/hazards-and-risks/disasters-and-incidents/2020/official-information-on-the-new-coronavirus/restriktioner-och-forbud">restrictions</a> and recommendations remain in place.</p>
<h2>High case numbers and deaths</h2>
<p>As in Denmark and Norway, the number of new COVID-19 cases rose rapidly in Sweden from the start of March. But Denmark and Norway both implemented tighter restrictions, and their case numbers fell away from April. </p>
<p>Sweden maintained its rate of roughly <a href="https://ourworldindata.org/coronavirus-data-explorer?zoomToSelection=true&casesMetric=true&dailyFreq=true&smoothing=7&country=SWE%7ENOR%7EFIN%7EDNK&pickerMetric=location&pickerSort=asc">600 new cases</a> per day throughout April and May, and then the numbers started to rise again, reaching 1,300 per day at the start of July.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/350102/original/file-20200729-15-52r1bo.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/350102/original/file-20200729-15-52r1bo.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=450&fit=crop&dpr=1 600w, https://images.theconversation.com/files/350102/original/file-20200729-15-52r1bo.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=450&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/350102/original/file-20200729-15-52r1bo.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=450&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/350102/original/file-20200729-15-52r1bo.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=566&fit=crop&dpr=1 754w, https://images.theconversation.com/files/350102/original/file-20200729-15-52r1bo.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=566&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/350102/original/file-20200729-15-52r1bo.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=566&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Sweden continues to have more cases than comparable countries.</span>
<span class="attribution"><span class="source">Our World In Data</span></span>
</figcaption>
</figure>
<p>By the end of July, Sweden had the <a href="https://www.worldometers.info/coronavirus/">7th highest</a> per-capita death rate in the world, and about <a href="https://ourworldindata.org/coronavirus-data-explorer?zoomToSelection=true&casesMetric=true&dailyFreq=true&smoothing=7&country=SWE%7ENOR%7EFIN%7EDNK&pickerMetric=location&pickerSort=asc">ten times larger</a> than its Nordic neighbours. Outbreaks spread to <a href="https://www.bbc.com/news/world-europe-52704836">aged care facilities</a> and the vulnerable. </p>
<p>Sweden has to date had about 80,000 <a href="https://ourworldindata.org/coronavirus/country/sweden">confirmed cases</a> of COVID-19 — though this is likely to be an underestimate — and about 5,700 people have died. This would equate to about 15,000 lives lost in Australia.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/in-many-countries-the-coronavirus-pandemic-is-accelerating-not-slowing-141238">In many countries the coronavirus pandemic is accelerating, not slowing</a>
</strong>
</em>
</p>
<hr>
<h2>Sweden’s economic situation is still very serious</h2>
<p>Even with its lighter lockdowns, Sweden has suffered economic losses almost as severe as its Nordic counterparts.</p>
<p>The Swedish labour market has been <a href="https://www.government.se/press-releases/2020/06/some-signs-of-recovery-in-the-economy--but-situation-still-very-serious/">hit hard</a>. Unemployment is expected to peak at between 9-11%, cushioned by a fall in labour-force participation as Swedes leave the labour market entirely. </p>
<p>The country’s central bank estimates <a href="https://www.riksbank.se/globalassets/media/rapporter/ppr/fordjupningar/engelska/2020/economic-development-according-to-two-alternative-scenarios-article-in-monetary-policy-report-july-2020.pdf">GDP will fall by 4-6%</a>, depending on a second wave of infections.</p>
<p>In comparison, Australia’s treasury expects the unemployment rate here to peak <a href="https://budget.gov.au/2020-efu/downloads/JEFU2020.pdf">at 9.25%</a>, and for GDP to fall by 2.5%.</p>
<p>Like in Australia, the Swedish government has provided financial support to businesses to reduce the number of job losses, and given additional support to the “<a href="https://www.government.se/articles/2020/03/economic-measures-in-response-to-covid-19/">many people</a>” who will lose their jobs.</p>
<p>Economists from the University of Copenhagen have <a href="https://arxiv.org/pdf/2005.04630.pdf">compared Sweden and Denmark</a>. Both countries had similar exposure to COVID-19 at the beginning of the pandemic, and similar economic conditions before the crisis.</p>
<p>Denmark imposed stricter restrictions from early March, closing the border to all foreign nationals, limiting social gatherings to ten, shutting schools, universities, and non-essential work, and encouraging the entire population to stay home and minimise social contact.</p>
<p>The economists examined the spending of 860,000 people in the two countries. They found consumer spending dropped by 29% in Denmark, but it also fell by 25% in Sweden. People in both countries had changed their behaviour to reduce their risk of infection, regardless of government-mandated restrictions.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/350103/original/file-20200729-15-tjuxv5.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/350103/original/file-20200729-15-tjuxv5.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=450&fit=crop&dpr=1 600w, https://images.theconversation.com/files/350103/original/file-20200729-15-tjuxv5.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=450&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/350103/original/file-20200729-15-tjuxv5.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=450&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/350103/original/file-20200729-15-tjuxv5.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=566&fit=crop&dpr=1 754w, https://images.theconversation.com/files/350103/original/file-20200729-15-tjuxv5.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=566&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/350103/original/file-20200729-15-tjuxv5.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=566&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">COVID-19, rather than lockdowns, drove the economic decline.</span>
<span class="attribution"><span class="source">Figure A4, Andersen et al 2020, Pandemic, Shutdown and Consumer Spending: Lessons from Scandinavian Policy Responses to COVID-19, May 2020</span></span>
</figcaption>
</figure>
<h2>Where Sweden stands now</h2>
<p>Swedes’ confidence in the ability of their government and health authority to handle the crisis <a href="https://www.bbc.com/news/world-europe-53498133">decreased</a> between April and June. </p>
<p>Their neighbours seem to have limited confidence too. Norway, Denmark and Finland have created a “<a href="https://www.cnbc.com/2020/06/17/swedens-exclusion-from-nordic-travel-area-swedens-foreign-minister.html">travel bubble</a>”, but Sweden is excluded from it.</p>
<p>While new COVID-19 cases in Sweden have been decreasing from the peak at the beginning of July, they still sit at about 250 per day. Denmark and Norway have been below that level since mid-April.</p>
<p>Swedes have paid a heavy price to get to where they are — and they’re still quite some way from controlling the spread of COVID-19, as their neighbours have done.</p>
<p>We don’t have to lose the lives that Sweden has to learn from its experience. Loose restrictions make COVID-19 harder to control. When the virus is out of control it spreads rapidly, putting millions of vulnerable people at greater risk and reducing the economic activity of the population.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/social-distancing-may-be-worth-it-but-we-need-to-talk-about-economic-costs-133907">Social distancing may be worth it, but we need to talk about economic costs</a>
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</em>
</p>
<hr>
<img src="https://counter.theconversation.com/content/143540/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Grattan Institute began with contributions to its endowment of $15 million from each of the Federal and Victorian Governments, $4 million from BHP Billiton, and $1 million from NAB. In order to safeguard its independence, Grattan Institute’s board controls this endowment. The funds are invested and contribute to funding Grattan Institute's activities. Grattan Institute also receives funding from corporates, foundations, and individuals to support its general activities, as disclosed on its website</span></em></p><p class="fine-print"><em><span>Will Mackey 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>Despite a lighter lockdown, Sweden hasn’t avoided the damaging economic disruption experienced elsewhere.Stephen Duckett, Director, Health Program, Grattan InstituteWill Mackey, Senior Associate, Grattan InstituteLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1422832020-07-13T20:03:10Z2020-07-13T20:03:10ZIs aggressive hotel isolation worth the cost to fight COVID-19? The answer depends on family size<p>Australia has <a href="https://theconversation.com/cases-deaths-and-coronavirus-tests-how-australia-compares-to-the-rest-of-the-world-139753">fared better</a> than most countries in reducing its COVID-19 cases to very low numbers. However, on June 15, new <a href="https://www.theguardian.com/australia-news/2020/jul/09/coronavirus-victoria-melbourne-covid-19-cases-clusters-hotspot-suburbs-hard-lockdown-family-outbreak-towers-flemington-keilor-downs-albanvale-hallam-coburg-brimbank-wollert-ascot-vale-maribyrnong-fawkner-tullamarine-truganina">clusters of infection were identified</a> in Victoria. The numbers grew so rapidly that metropolitan <a href="https://www.abc.net.au/news/2020-07-07/metropolitan-melbourne-suburbs-back-in-coronavirus-lockdown/12431564">Melbourne is back in lockdown</a> and the <a href="https://theconversation.com/heres-how-the-victoria-nsw-border-closure-will-work-and-how-residents-might-be-affected-142045">border with New South Wales is closed</a>.</p>
<iframe src="https://e.infogram.com/_/BVyGKCraDEOpSkWDdO13?src=embed" title="Daily transmission sources in Victoria since March" width="100%" height="770" scrolling="no" frameborder="0" style="border:none;" allowfullscreen="allowfullscreen"></iframe>
<p>Lapses in quarantine for people with COVID-19 returning from overseas are <a href="https://www.theguardian.com/australia-news/2020/jul/09/coronavirus-victoria-melbourne-covid-19-cases-clusters-hotspot-suburbs-hard-lockdown-family-outbreak-towers-flemington-keilor-downs-albanvale-hallam-coburg-brimbank-wollert-ascot-vale-maribyrnong-fawkner-tullamarine-truganina">believed to have led to community transmission</a> in Victoria. Hotel isolation has been effective in other states. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/melbournes-lockdown-came-too-late-its-time-to-consider-moving-infected-people-outside-the-home-142162">Melbourne's lockdown came too late. It's time to consider moving infected people outside the home</a>
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<hr>
<p>However, while incoming travellers to Australia are forced to isolate for two weeks, any onshore patients are only asked to self-isolate at home. Community spread due to a patient failing to comply with the self-isolation rule (or more innocently as a member of a shared household) could easily create multiple new clusters as in Victoria. </p>
<p>So how do the costs and risks of aggressive hotel isolation compare with self-isolation at home? We ran the numbers. Although hotel isolation is more expensive than self-isolation at home, for families of more than five people we found the likely costs flowing from transmission to others would justify hotel isolation.</p>
<p>The recent outbreaks in Victoria, especially in <a href="https://theconversation.com/nine-melbourne-tower-blocks-put-into-hard-lockdown-what-does-it-mean-and-will-it-work-142033">higher-density public housing towers</a>, illustrate the high risk of disease spread within and across households. Ultimately, this transmission can place an intolerable burden on the health-care system, as we have seen overseas. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/288-new-coronavirus-cases-marks-victorias-worst-day-and-it-will-probably-get-worse-before-it-gets-better-142481">288 new coronavirus cases marks Victoria's worst day. And it will probably get worse before it gets better</a>
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</p>
<hr>
<h2>Weighing up the options</h2>
<p>We analysed the economic costs and benefits of forced isolation of onshore patients to help guide decisions on when patients should be forcibly isolated away from the family home. We first considered the cost of the two alternatives when a person is confirmed positive: </p>
<ol>
<li><p>home isolation: self-isolating at home where the person may live with other household members</p></li>
<li><p>hotel isolation: isolating the person in a hotel room to prevent interaction with other householders.</p></li>
</ol>
<p>In hotel isolation, the <a href="https://www.ato.gov.au/Business/PAYG-withholding/Payments-you-need-to-withhold-from/Payments-to-employees/Allowances-and-reimbursements/Travel-allowances/">estimated cost</a> is A$177 per night for accommodation plus A$113.70 per day for food and other essentials. Therefore, the total cost of isolating a confirmed case in a hotel room for a <a href="https://www1.health.gov.au/internet/main/publishing.nsf/Content/cdna-song-novel-coronavirus.htm">typical isolation period of 14 days</a> would be $4,069.80. </p>
<p>On the other hand, when a confirmed case is asked to self-isolate at home, we need to consider the cost of hospital care for other householders who might contract the virus. </p>
<p>The chance of spreading the virus to other household members, known as the <a href="https://www.cdc.gov/csels/dsepd/ss1978/lesson3/section2.html">household secondary attack rate</a> (HSAR), is typically <a href="https://www.who.int/docs/default-source/coronaviruse/who-china-joint-mission-on-covid-19-final-report.pdf">between 3% and 15%</a>. But it could be higher depending on the environment and how aggressive the virus is. We assume the rate to be 15% with a household size of 2.6, <a href="https://aifs.gov.au/facts-and-figures/population-and-households">the average for Australia</a>. </p>
<p>Based on current data, an estimated <a href="https://doi.org/10.33321/cdi.2020.44.35">20% of cases</a> will require hospitalisation, of which <a href="https://jamanetwork.com/journals/jama/fullarticle/2763188">about 25%</a> will be admitted to intensive care units. The average stay in hospital is reported as 16 days (with ten days in ICU) if the confirmed case needs critical care. Otherwise, the average is eight days on wards. The costs of one day in ICU and on wards in Australia are reported as <a href="https://www.mja.com.au/journal/2019/211/7/financial-cost-intensive-care-australia-multicentre-registry-study">A$5,000 and A$1,800</a> respectively. </p>
<p>On our calculations, the expected cost of self-isolating a confirmed case and exposing other household members would be $1,248. </p>
<p>This suggests the cost of isolating in a hotel room is significantly greater than for self-isolating at home in an average-sized household.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/melbournes-hotel-quarantine-bungle-is-disappointing-but-not-surprising-it-was-overseen-by-a-flawed-security-industry-142044">Melbourne's hotel quarantine bungle is disappointing but not surprising. It was overseen by a flawed security industry</a>
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</em>
</p>
<hr>
<h2>Household size matters</h2>
<p>The household secondary attack rate is highly dependent on factors such as types of activities, duration of event, household ventilation and <a href="https://theconversation.com/can-people-spread-the-coronavirus-if-they-dont-have-symptoms-5-questions-answered-about-asymptomatic-covid-19-140531">viral shedding</a>. The rate can be <a href="https://www.health.gov.au/resources/publications/coronavirus-covid-19-information-for-clinicians">as high as 100%</a>. In other words, the whole household is infected.</p>
<p>Further analysis of the relationship between household size and secondary attack rate shows the cost of home isolation increases greatly and exceeds the cost of hotel isolation when household size is five people or more. </p>
<p>So, the decision on where to isolate an infected person needs to be re-evaluated when five or more people are living in the home. <a href="https://profile.id.com.au/australia/household-size">More than 10% of households</a> in Australia have five or more members. </p>
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<em>
<strong>
Read more:
<a href="https://theconversation.com/kissing-can-be-dangerous-how-old-advice-for-tb-seems-strangely-familiar-today-140172">'Kissing can be dangerous': how old advice for TB seems strangely familiar today</a>
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<h2>What does this mean for stopping the spread?</h2>
<p>This analysis is particularly relevant to decisions on measures to contain outbreaks such as the isolation of whole buildings, as in Victoria. </p>
<iframe src="https://e.infogram.com/_/UMM38OXwG7MK4ZxIvWIW?src=embed" title="Progression of Victoria&'s largest (≥10) clusters and outbreaks" width="100%" height="1151" scrolling="no" frameborder="0" style="border:none;" allowfullscreen="allowfullscreen"></iframe>
<p>The lockdown of public housing towers may be considered a larger case of “home isolation” where density and dwelling sizes may greatly increase the likely household attack rate. The increased risk of infection for individuals within the building or groups of buildings suggests hotel isolation could be both a safer and more cost-effective measure. </p>
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<em>
<strong>
Read more:
<a href="https://theconversation.com/overcrowding-and-affordability-stress-melbournes-covid-19-hotspots-are-also-housing-crisis-hotspots-141381">Overcrowding and affordability stress: Melbourne's COVID-19 hotspots are also housing crisis hotspots</a>
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<p>Facing the <a href="https://theconversation.com/victoria-is-on-the-precipice-of-an-uncontrolled-coronavirus-outbreak-will-the-new-measures-work-141706">risks of a second wave of COVID-19 infections</a>, the government needs to consider multiple measures to control the spread of the virus. Although our findings show the cost of self-isolating a patient in his/her home is cheaper than a hotel room on average, this is not the case for all household sizes. Strategies such as <a href="https://theconversation.com/australias-coronavirus-testing-rates-are-some-of-the-best-in-the-world-compare-our-stats-using-this-interactive-142289">testing</a>, <a href="https://theconversation.com/melbournes-lockdown-came-too-late-its-time-to-consider-moving-infected-people-outside-the-home-142162">isolation</a> and <a href="https://theconversation.com/victorias-coronavirus-contact-tracers-are-already-under-the-pump-what-happens-next-141792">contact tracing</a>, including use of the COVIDSafe app, can play a crucial role in the broader control of COVID-19.</p><img src="https://counter.theconversation.com/content/142283/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Francesco Paolucci receives funding from the ARC, NHMRC, EU Commission (HORIZON 2020). He is Prof of Health Economics at the University of Newcastle and also at the University of Bologna. </span></em></p><p class="fine-print"><em><span>Adrian Melia, Doowon Lee, and Nader Mahmoudi 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>The spread of the virus through households creates costs higher than for isolation in hotels when families are large and living at close quarters as in Melbourne’s public housing towers.Francesco Paolucci, Professor of Health Economics, University of Bologna, University of NewcastleAdrian Melia, Senior Lecturer in Accounting and Finance, University of NewcastleDoowon Lee, Assistant Dean, International - Strategy and Programs Office PVC - Business and Law, University of NewcastleNader Mahmoudi, Graduate Researcher, University of NewcastleLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1221812019-09-05T18:49:19Z2019-09-05T18:49:19ZWorking the system: 3 ways planners can defy the odds to promote good health for all of us<figure><img src="https://images.theconversation.com/files/291031/original/file-20190905-175691-1sxurwl.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Urban planning that provides green space and cycling and walking infrastructure promotes better health for all.</span> <span class="attribution"><a class="source" href="https://commons.wikimedia.org/wiki/File:Capital_city_trail,_melbourne,_australia.jpg">Mat Connolley/Wikimedia</a>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span></figcaption></figure><p>Many of the chronic and costly diseases Australians face are related to how we live in cities. The speed of modern life clashes with poorly designed urban areas. As a result, health-promoting activities, such as regular physical activity, community interaction and the preparation of healthy food, become low priorities.</p>
<p>We know better urban planning can encourage healthier behaviours. Providing infrastructure for walking and cycling is a prime example. </p>
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<em>
<strong>
Read more:
<a href="https://theconversation.com/is-your-experience-diet-making-you-unwell-105370">Is your 'experience diet' making you unwell?</a>
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</em>
</p>
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<p>Yet there are other, often overlooked, ways that urban planners are on the front line when it comes to promoting the health of Australians. In particular, the way cities are planned can reduce inequities in both access to health services and health outcomes. This has important implications for the health of individuals and their communities.</p>
<p>Urban planners are well versed in the fundamentals of planning the equitable city. But planners must work within the constraints of our political systems and prevailing approaches to government. Our recent <a href="https://www.tandfonline.com/doi/abs/10.1080/08111146.2017.1299704?journalCode=cupr20">analysis</a> of health and urban planning in Australia identified a few key ways urban planners can “work the system” to promote health equity.</p>
<h2>Why is equity so important for health?</h2>
<p>Promoting equity is important for health because there is a social gradient to the differences between people’s health. In general, <a href="https://www.aihw.gov.au/getmedia/746ded57-183a-40e9-8bdb-828e21203175/aihw-aus-221-chapter-4-2.pdf.aspx">the higher a person’s socio-economic position, the healthier he or she is</a>. People from poorer social or economic circumstances have higher rates of illness and disability, and live shorter lives. </p>
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<em>
<strong>
Read more:
<a href="https://theconversation.com/designing-suburbs-to-cut-car-use-closes-gaps-in-health-and-wealth-83961">Designing suburbs to cut car use closes gaps in health and wealth</a>
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<p>Differences in life expectancies across the nation illustrate this. In 2016, a man born in remote New South Wales had a <a href="https://www.aihw.gov.au/reports/australias-health/australias-health-2018/contents/table-of-contents">life expectancy 13 years less</a> than a man born in the affluent suburb of Mosman in Sydney.</p>
<p>To promote equity, we need to define what we are seeking to equalise. In this case, it is the distribution of the social determinants of health. </p>
<p>These determinants are the conditions in which people are born, grow up, live, work and age. Factors such as income, education, employment, empowerment and social support can strengthen or undermine health and well-being.</p>
<p>Our planners have access to the data and the grounded knowledge required to expose gaps in services. For example, a local infrastructure planner can readily identify the communities that lack internet broadband access but need it. A transport planner working for Sydney’s City Rail knows all too well which train service is unreliable, and which train station is routinely missed during the peak because of overcrowding. </p>
<p>Planners also have the skills and insights to raise concerns about shortages of residential housing stock, before these trigger the kind of housing affordability crises we have seen recently in Australian cities.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/291027/original/file-20190905-175700-1gktnc2.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/291027/original/file-20190905-175700-1gktnc2.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/291027/original/file-20190905-175700-1gktnc2.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=226&fit=crop&dpr=1 600w, https://images.theconversation.com/files/291027/original/file-20190905-175700-1gktnc2.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=226&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/291027/original/file-20190905-175700-1gktnc2.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=226&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/291027/original/file-20190905-175700-1gktnc2.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=284&fit=crop&dpr=1 754w, https://images.theconversation.com/files/291027/original/file-20190905-175700-1gktnc2.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=284&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/291027/original/file-20190905-175700-1gktnc2.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=284&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Governments like the state government of New South Wales are starting to make explicit connections between urban planning and community health.</span>
<span class="attribution"><a class="source" href="https://future.transport.nsw.gov.au/designing-future/six-outcomes-for-nsw/successful-places">NSW Government/Transport for NSW 2019</a></span>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/with-health-assuming-its-rightful-place-in-planning-here-are-3-key-lessons-from-nsw-94171">With health assuming its rightful place in planning, here are 3 key lessons from NSW</a>
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<h2>Planners need to ‘work the system’</h2>
<p>The real challenge for planners promoting equity in Australia is the need to work within the constraints of the nation’s dominant political economy. In Australia today, we have a neoliberal system, epitomised by “the subjugation of the public to the private, the state to the market, the social to the economic”, as <a href="https://www.e-elgar.com/shop/analysing-social-policy">John Clarke put it</a>. The result of this has been a progressive withdrawal of government involvement in many areas since the latter half of the 20th century.</p>
<p>Our <a href="https://www.tandfonline.com/doi/abs/10.1080/08111146.2017.1299704?journalCode=cupr20">recent analysis</a> of health and urban planning in Australia provides several recommendations on how urban planners can work within this system to promote health equity.</p>
<h2>Play to emotions</h2>
<p>The first is to harness the power of human health’s emotive appeal. Relative to other planning concerns, such as environmental sustainability, health is an issue that appeals more directly to the individual. </p>
<p>By making clear the links between good planning principles and human health, planners can leverage this emotion to promote concepts that might otherwise be ignored in developer-driven agendas. The protection of green open spaces for physical activity and community connection is a good example. By pointing out how important these things are for human health, urban planners can make a compelling and robust case for preserving these spaces.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/higher-density-cities-need-greening-to-stay-healthy-and-liveable-75840">Higher-density cities need greening to stay healthy and liveable</a>
</strong>
</em>
</p>
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<h2>Speak the language of money</h2>
<p>A second way that planning for health can leverage space in a neoliberal system is to speak the language of the market. In 2016-17, Australia <a href="https://www.aihw.gov.au/reports/health-welfare-expenditure/health-expenditure-australia-2016-17/contents/table-of-contents">spent A$180.7 billion on health</a>. This spending increases from year to year, <a href="https://www.aihw.gov.au/getmedia/941d2d8b-68e0-4883-a0c0-138d43dba1b0/aihw-aus-221-chapter-2-2.pdf.aspx#targetText=Between%202006%E2%80%9307%20and%202015,50%25%20over%20the%20same%20period.">outpacing growth in inflation, population or the economy</a>. </p>
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<a href="https://images.theconversation.com/files/291028/original/file-20190905-175691-r11up4.PNG?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/291028/original/file-20190905-175691-r11up4.PNG?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/291028/original/file-20190905-175691-r11up4.PNG?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=297&fit=crop&dpr=1 600w, https://images.theconversation.com/files/291028/original/file-20190905-175691-r11up4.PNG?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=297&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/291028/original/file-20190905-175691-r11up4.PNG?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=297&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/291028/original/file-20190905-175691-r11up4.PNG?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=373&fit=crop&dpr=1 754w, https://images.theconversation.com/files/291028/original/file-20190905-175691-r11up4.PNG?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=373&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/291028/original/file-20190905-175691-r11up4.PNG?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=373&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Ever-increasing health expenditure (shown here, adjusted for inflation, from 2006-07 to 2015-16) presents an opportunity to show how good planning can produce cost savings.</span>
<span class="attribution"><a class="source" href="https://www.aihw.gov.au/getmedia/941d2d8b-68e0-4883-a0c0-138d43dba1b0/aihw-aus-221-chapter-2-2.pdf.aspx">AIHW health expenditure database; Table S2.2.1</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
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<p>Most of this funding is dedicated to treating people once they are sick, rather than preventing illness. But prevention would produce large cost-savings. These savings can be captured in decision-making tools such as cost-benefit analysis.</p>
<p>Planners are in a powerful position to work with public health professionals to develop a deeper understanding of the health cost savings to be made from better urban planning decisions.</p>
<h2>Enlist trusted figures</h2>
<p>Finally, health can be promoted by harnessing the power of the health fraternity. <a href="https://www.ncbi.nlm.nih.gov/pubmed/28973409">Australian research</a> shows the voice of a well-versed and respected individual can often make the difference when it comes to preserving a piece of open space, funding a cycleway or protecting the use of land for farmers’ markets.</p>
<p>Australians hold health professionals in high esteem. Polling company Roy Morgan conducts an <a href="http://www.roymorgan.com/findings/7244-roy-morgan-image-of-professions-may-2017-201706051543">Image of Professions Survey</a>, asking Australians to rank 30 professions by characteristics such as ethics and honesty. Medical professionals, such as nurses, doctors, pharmacists and dentists, have consistently featured in the top five. These trusted professionals could be influential voices for healthy built environment agendas.</p>
<p>Our cities can and should be places that promote good health for everyone who lives in them. Quite simply, this means the (re)prioritisation of well-being over economic growth. </p>
<p>This is a crucial barrier to planning healthy built environments in Australia. Yet it is not insurmountable. Indeed, the key to overcoming it may well be harnessing the power of health as a significant concern for all.</p>
<hr>
<p><em>The ideas in this article are taken from a new book, <a href="https://www.routledge.com/Planning-Australias-Healthy-Built-Environments-1st-Edition/Kent-Thompson/p/book/9781138696365">Planning Australia’s Healthy Built Environments</a>. Join Jennifer Kent at the <a href="http://www.festivalofurbanism.com/2019/2019/9/9/festival-launch-how-can-your-city-and-the-housing-you-live-in-impact-health">Festival of Urbanism</a> in Sydney on September 9 to explore these issues.</em></p><img src="https://counter.theconversation.com/content/122181/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jennifer L. Kent 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>Planners understand the key elements of urban communities that will improve residents’ health and well-being. They also need to be able to convince others to create such communities.Jennifer L. Kent, Research Fellow, Urban and Regional Planning, University of SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1066022018-11-13T19:03:22Z2018-11-13T19:03:22ZHospital discharges to ‘no fixed address’ – here’s a much better way<figure><img src="https://images.theconversation.com/files/245232/original/file-20181113-194519-q0a6ti.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Dr Jim O'Connell and therapy dog Maestro spend some time with a client at the medical respite centre in Boston.</span> <span class="attribution"><span class="source">Courtesy of Boston Health Care for the Homeless Program</span></span></figcaption></figure><blockquote>
<p>Why treat people and send them back to the conditions that made them sick? <strong>– <a href="https://www.bloomsbury.com/uk/the-health-gap-9781408857991/">Michael Marmot, The Health Gap, 2015</a></strong></p>
</blockquote>
<p>“Homelessness is one of the most intractable and complex problems facing cities around the globe,” says my colleague Dr Jim O’Connell from the Boston Health Care for the Homeless Program (<a href="https://www.bhchp.org/">BHCHP</a>). It is somewhat sobering to hear that Boston is now into its third “ten-year plan” to end homelessness. Despite the success of Boston’s <a href="https://www.mhsa.net/HHG">Housing First programs</a> in housing many people who have lived on the streets for years, it has proven difficult to “turn off the homelessness tap”.</p>
<p>The reasons include the lack of affordable housing options and a systemic failure to break the cycle of people leaving the corrections system without somewhere to live. O'Connell has just spent a week in Perth as a Raine Medical Foundation Visiting Fellow at UWA. He recounts that around half the people entering Boston homeless shelters indicate that “a jail” was where they slept the previous night. </p>
<p>These are cautionary warnings for Australia, where <a href="https://aaeh.org.au/">concerted efforts to end homelessness</a> are up against an affordable housing crisis and huge <a href="https://www.aihw.gov.au/reports/housing-assistance/housing-assistance-in-australia-2018/contents/housing-in-australia">public housing wait lists</a>. Alarming numbers of people are <a href="https://theconversation.com/how-we-can-put-a-stop-to-the-revolving-door-between-homelessness-and-imprisonment-91394">released from Australian prisons to homelessness</a> each year. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/a-community-fix-for-the-affordable-housing-crisis-102840">A community fix for the affordable housing crisis</a>
</strong>
</em>
</p>
<hr>
<p>So while ending homelessness in Australia is a vital aspiration, which <a href="https://www.homelessnessaustralia.org.au/sites/homelessnessaus/files/2017-10/HA%20Position%20Paper%20-%20FINAL_0.pdf">needs to be backed by a coordinated national strategy</a>, multisectoral action and greater dedicated funding, our cities also need to be better equipped to deal with the health impacts and other consequences of homelessness until it can be eradicated.</p>
<h2>Hospital and human costs are high</h2>
<p>One of the most costly consequences of homelessness for any city is the burden on the health system. Although mental and physical health issues can contribute to homelessness, being homeless also <a href="https://www.mja.com.au/journal/2018/209/5/homeless-health-care-meeting-challenges-providing-primary-care">increases the risk of many health problems</a>. These include psychiatric illness, substance use and chronic and infectious diseases. </p>
<p>Across Australia, people who are homeless are among the most frequent presenters to emergency departments. Their rate of unplanned hospital admissions is high. The average stay is longer too. </p>
<p>All of this strains the resources of our public hospitals, as shown in our <a href="http://homelesshealthcare.org.au/wp-content/uploads/2018/07/Royal-Perth-Hospital-Homeless-Team-FINAL-report-June-2018.pdf">recent analysis</a> of data for homeless patients seen at Royal Perth Hospital.</p>
<p>Globally and within Australia, pressure is mounting on hospitals to shorten stays in costly hospital beds. However, post-discharge care via less costly “hospital in the home” programs is not an option for patients with “no fixed address”. </p>
<p>As a result homeless patients face either longer inpatient admissions or are discharged when too unwell for the challenges of living on the street. And that in turn results in deteriorating health and many unplanned readmissions.</p>
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<a href="https://images.theconversation.com/files/245204/original/file-20181113-194513-29h4l1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/245204/original/file-20181113-194513-29h4l1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/245204/original/file-20181113-194513-29h4l1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=358&fit=crop&dpr=1 600w, https://images.theconversation.com/files/245204/original/file-20181113-194513-29h4l1.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=358&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/245204/original/file-20181113-194513-29h4l1.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=358&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/245204/original/file-20181113-194513-29h4l1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=450&fit=crop&dpr=1 754w, https://images.theconversation.com/files/245204/original/file-20181113-194513-29h4l1.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=450&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/245204/original/file-20181113-194513-29h4l1.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=450&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Life on the street is no place for a person to recover after being discharged from hospital.</span>
<span class="attribution"><span class="source">Courtesy of BHCHP</span>, <span class="license">Author provided</span></span>
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<h2>Respite centres offer a solution</h2>
<p>An innovative solution to these problems is the <a href="https://www.bhchp.org/medical-respite-care">medical respite model</a> for homeless people. This originated in the United States in the mid-1980s. </p>
<p>A respite centre enables people who are homeless to recuperate after hospital in a more home-like environment. Here they can receive follow-up care, social support and be linked to community services and accommodation providers.</p>
<p>A more homely non-hospital environment is a critical ingredient, as hospitals can be traumatising for homeless people. Many of them have suffered violence, sexual abuse, neglect, incarceration or other forms of trauma, further compounded by the trauma of living on the streets. From the Boston experience, therapy dogs, social connection, recreational activities, art therapy and patient support groups are among the healing benefits that can be provided outside a hospital environment.</p>
<p>One of our reasons for bringing Jim O’Connell to Australia this month has been to draw on his experience as a founder of the first medical respite centre for homeless people in the US. It began as a 25-bed facility in Boston in 1985 and now has 124 beds. Sadly, the demand keeps growing – for every bed that becomes available, there are 20 calls from hospitals wanting a bed for homeless patients. </p>
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<figcaption><span class="caption">Video production: Isaac Wood.</span></figcaption>
</figure>
<h2>What facilities does Australia have?</h2>
<p>The respite centre model has flourished in North America, with over 70 in cities across the US and a growing number in Canada. Australia at present has two small examples, in Melbourne and Sydney.</p>
<p>In Melbourne, <a href="https://www.svhm.org.au/health-professionals/aged-and-community-care/health-independence-program/hospital-admission-risk-program-harp/the-cottage">The Cottage</a> is literally a cottage next to St Vincent’s Hospital in Melbourne. It has six patient beds, with an average stay of nine days. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/245201/original/file-20181113-194485-1pl3a5z.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/245201/original/file-20181113-194485-1pl3a5z.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/245201/original/file-20181113-194485-1pl3a5z.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/245201/original/file-20181113-194485-1pl3a5z.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/245201/original/file-20181113-194485-1pl3a5z.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/245201/original/file-20181113-194485-1pl3a5z.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/245201/original/file-20181113-194485-1pl3a5z.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/245201/original/file-20181113-194485-1pl3a5z.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">The Cottage in Melbourne improves the well-being of people who are homeless and saves on healthcare costs, but has high demand for its six beds.</span>
<span class="attribution"><span class="source">Image: Befekir Kebede, courtesy of St Vincent's Hospital Melbourne</span>, <span class="license">Author provided</span></span>
</figcaption>
</figure>
<p>Our <a href="https://www.emeraldinsight.com/doi/full/10.1108/HCS-08-2018-0020">evaluation of The Cottage</a>, published just last week, shows it provides a valuable step-down alternative and period of stability for homeless people. This enables staff to build trusting relationships and increase patient capacity to manage their own health. </p>
<p><a href="https://www.svhs.org.au/our-services/list-of-services/homeless-health-service">Tierney House</a> is a 12-bed short-stay respite unit run by St Vincent’s Hospital Sydney. <a href="https://www.abc.net.au/7.30/breaking-the-hospital-homeless-cycle/8333772">Support and care is provided</a> for around $400 a day. This is far cheaper than the average Australian <a href="https://www.ihpa.gov.au/publications/national-hospital-cost-data-collection-public-hospitals-cost-report-round-20-0">hospital bed cost of $2,003 a day</a> in 2015-16.</p>
<p>Perth is seeking to establish Australia’s first 20-bed medical recovery centre for people who are homeless. It’s based on the US respite care model, but with a sharpened focus on connecting people to housing and long-term health and other support to remain housed. Linking people to a general practitioner through <a href="https://homelesshealthcare.org.au">Homeless Healthcare</a> will be a critical part of the model, as its GPs and nurses can provide primary care and follow-up in the community to avert future hospital admissions.</p>
<p>As Dr Andrew Davies, of Homeless Healthcare, and I <a href="https://www.mja.com.au/journal/2018/209/5/homeless-health-care-meeting-challenges-providing-primary-care">stressed recently in the MJA</a>, the absence of safe and secure housing lies at the core of the health disparities seen among people who are homeless. This is particularly apparent when they are discharged from hospital before they are well enough to return to the streets. </p>
<p>Just imagine trying to recover from a hospital admission without a safe place to rest and sleep, nowhere to wash, no secure storage for medications, not to mention poor access to nutritious food and difficulty maintaining hygienic wound care.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/245200/original/file-20181113-194509-1y6cy2n.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/245200/original/file-20181113-194509-1y6cy2n.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/245200/original/file-20181113-194509-1y6cy2n.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=539&fit=crop&dpr=1 600w, https://images.theconversation.com/files/245200/original/file-20181113-194509-1y6cy2n.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=539&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/245200/original/file-20181113-194509-1y6cy2n.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=539&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/245200/original/file-20181113-194509-1y6cy2n.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=678&fit=crop&dpr=1 754w, https://images.theconversation.com/files/245200/original/file-20181113-194509-1y6cy2n.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=678&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/245200/original/file-20181113-194509-1y6cy2n.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=678&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption"></span>
<span class="attribution"><a class="source" href="https://www.emeraldinsight.com/doi/full/10.1108/HCS-08-2018-0020">Adapted from Homeless Healthcare evaluation report</a>, <span class="license">Author provided</span></span>
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<h2>The need is growing</h2>
<p>Australia is facing escalating and unsustainable health care costs, exacerbated by an ageing population and the rising burden of chronic disease. A medical recovery centre presents a cost-effective solution for government given the high rates of emergency department presentations and hospital re-admissions when people remain homeless. </p>
<p><a href="https://jamanetwork.com/journals/jama/fullarticle/183842">Published evaluations</a> of US respite centres show 24-36% reductions in emergency department presentations. Reductions in inpatient days were between 29% and 58%. The reduced health care use equates to millions of dollars in <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1483848/">cost savings</a>. </p>
<p>We need to do more than lament the revolving door between hospital and the street faced by people who are homeless across Australian cities. As Andrew Davies poignantly observes:</p>
<blockquote>
<p>Acute hospitals treat acute medical problems. If we fail to address the underlying chronic disease and social determinants of the health of homeless people, we will continue to watch people slowly die on the streets.</p>
</blockquote>
<p>The medical recovery centre model provides a critical and cost-effective circuit-breaker. By enabling “hospital in the home” care for people without a home, it reduces hospital readmissions. </p>
<p>Chronic rough sleepers are one of the most marginalised groups in our society. A medical recovery centre offers a safe period of respite where they can be connected to housing and other supports to break the cycle of homelessness. </p>
<hr>
<p><em>Jim O'Connell is guest speaker at the <a href="https://www.eventbrite.com.au/e/aaeh-national-health-homelessness-and-the-vulnerably-housed-roundtable-tickets-51240102526">National Health, Homelessness and the Vulnerably Housed Roundtable</a> in Brisbane tomorrow, November 15, organised by the Australian Alliance to End Homelessness.</em></p><img src="https://counter.theconversation.com/content/106602/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Lisa Wood and Homeless Healthcare received a Raine Medical Foundation Visiting Fellow grant to bring Dr Jim O'Connell to Perth. </span></em></p>Life on the street is no place to recover from a stay in hospital, but that’s what happens to many people who are homeless. But there’s a proven model to provide care that also cuts healthcare costs.Lisa Wood, Associate Professor, School of Population and Global Health, The University of Western AustraliaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/839582017-09-17T19:41:51Z2017-09-17T19:41:51ZMost private patients are wasting money on costly rehab after major knee surgery<figure><img src="https://images.theconversation.com/files/186134/original/file-20170915-16328-1i7l3b6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Going home after a total knee replacement and having regular physiotherapy means you recover just as fast as if you'd chosen to stay in hospital for your rehab. And it's cheaper.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/download/success?src=iUfn6Ao_58FYDTdOJO61ZQ-1-40">from www.shutterstock.com</a></span></figcaption></figure><p>Most private patients who have had knee replacement surgery recover just as well with a cheaper form of rehabilitation than many are currently offered, research published today in the <a href="http://www.mja.com.au">Medical Journal of Australia</a> shows.</p>
<p>We found people who have had uncomplicated <a href="https://www.betterhealth.vic.gov.au/health/conditionsandtreatments/knee-replacement-surgery">total knee arthroplasty</a> recover just as fast and with similar outcomes after out-patient rehab – which involves people leaving hospital and having regular visits to a physiotherapist – rather than the costly in-patient option, where patients stay in hospital for their rehab.</p>
<p>Not only could most private patients avoid up to two weeks in hospital, they could save themselves or their insurers several thousands of dollars.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/confused-about-your-private-health-insurance-coverage-youre-not-alone-49493">Confused about your private health insurance coverage? You're not alone</a>
</strong>
</em>
</p>
<hr>
<h2>What is knee arthroplasty?</h2>
<p><a href="https://www.betterhealth.vic.gov.au/health/conditionsandtreatments/knee-replacement-surgery">Knee arthroplasty</a> is major surgery, involving complex anaesthesia, removing the diseased knee joint and inserting artificial joint parts. Patients take a long time to recover; knee pain and swelling, and even muscle weakness, last for many months afterwards.</p>
<p>It’s a very common procedure. There’s a <a href="http://www.oarsijournal.com/article/S1063-4584(16)30400-9/abstract">one in five chance</a> of women having the procedure at some point in their lives; for men, that’s one in seven. The main reasons people have the surgery include severe knee pain or an unstable knee, mostly due to age-related osteoarthritis.</p>
<p><a href="https://aoanjrr.sahmri.com/knees">Over 50,000 knee arthroplasty surgeries</a> are performed in Australia each year, with <a href="https://aoanjrr.sahmri.com/documents/10180/275103/Analysis%20of%20State%20and%20Territory%20Health%20Data%20-%20All%20Arthroplasty">over two-thirds</a> in the private sector.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/surgery-isnt-always-the-best-option-and-the-decision-shouldnt-just-lie-with-the-doctor-64228">Surgery isn't always the best option, and the decision shouldn't just lie with the doctor</a>
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</p>
<hr>
<p>The <a href="http://www.racgp.org.au/afp/2013/november/osteoarthritis/">number of procedures is rising</a> because more people have age-related osteoarthritis, partly because we are living longer and partly because we are becoming more overweight, which puts more pressure on the knees.</p>
<p>The surgery also seems to be safer than it used to be, <a href="http://jamanetwork.com/journals/jamainternalmedicine/fullarticle/414360">including for elderly people</a>. So, anecdotally, people are opting to have the surgery now where before they may have thought it too risky.</p>
<h2>What rehab options are there?</h2>
<p>Rehab options after knee surgery can vary depending on whether you’re a public or private patient.</p>
<p><a href="http://www.acornregistry.org/images/2016%20ANNUAL%20REPORT%20SUPPLEMENTARY%20TABLE.pdf">In the public system</a>, in-patient rehab is generally reserved for patients who are too frail to go home, who have no support at home, or have had complications after surgery. Most public patients attend rehab as an out-patient.</p>
<p>But in-patient rehab is more common for <a href="https://www.surgeons.org/media/25492528/surgical-variance-reports-2017-orthopaedic-surgery.pdf">private patients</a>, whose surgeon may offer it as an option.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/186127/original/file-20170915-27823-1ja058g.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/186127/original/file-20170915-27823-1ja058g.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/186127/original/file-20170915-27823-1ja058g.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/186127/original/file-20170915-27823-1ja058g.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/186127/original/file-20170915-27823-1ja058g.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/186127/original/file-20170915-27823-1ja058g.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/186127/original/file-20170915-27823-1ja058g.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/186127/original/file-20170915-27823-1ja058g.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">Physiotherapy is the main form of rehab after knee replacement surgery.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/515526961?src=WDzphwE-vZZmbZF5utNGsg-1-44&size=medium_jpg">from www.shutterstock.com</a></span>
</figcaption>
</figure>
<p>While physiotherapy is the mainstay of formal rehab for both public and private patients, those who attend as an in-patient can also see other health professionals like rehab physicians, occupational therapists and nurses.</p>
<p>Private patients who choose in-patient rehab after knee surgery typically stay in hospital for 7-14 days. This adds another <a href="https://www.surgeons.org/media/25492528/surgical-variance-reports-2017-orthopaedic-surgery.pdf">A$9,500 or so to the median A$22,000 bill</a> for the surgery itself. By comparison, we found rehab as an out-patient costs just a median A$374.</p>
<h2>Which is better value for money?</h2>
<p>To find out which option gave private patients the best outcomes, we conducted a national study involving privately insured people who had undergone uncomplicated total knee arthroplasty. We then compared the outcomes between people who had in-patient therapy with those who went straight home.</p>
<p>People with significant complications following surgery, who progressed slowly in the early days after surgery, and people with limited help at home, were excluded from our study.</p>
<p>To ensure we compared apples with apples, we matched people who went to in-patient rehab with those who did not on many characteristics including age, gender, body-mass index (a measure of obesity), and the severity of disease before surgery.</p>
<p>We phoned people 35, 90 and 365 days after surgery and asked for details about their recovery and the types of rehabilitation they had.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/infographic-a-snapshot-of-private-health-insurance-in-australia-39237">INFOGRAPHIC: A snapshot of private health insurance in Australia</a>
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</em>
</p>
<hr>
<p>People who received in-patient therapy reported similar knee-joint pain, and similar function and quality of life. Patients and their carers also took the same time off work regardless of the rehab option.</p>
<p>Median rehab costs for those who had in-patient therapy (A$9,978) were also much higher than costs for those who did not (A$374). The higher costs were due to the in-patient component, but, interestingly, also slightly more community-based therapy.</p>
<p>The main implication of our study is, given the cost difference between rehabilitation options, community-based (non-inpatient) alternatives seem to be better value.</p>
<h2>What do we make of all this?</h2>
<p>Our findings support our earlier trial <a href="http://jamanetwork.com/journals/jama/fullarticle/2610335">published this year</a>, as well as one by a Canadian team <a href="https://www.ncbi.nlm.nih.gov/pubmed/18676897">published</a> almost ten years ago.</p>
<p>Together, these studies suggest community-based rehab is better value for patients without complications, regardless of whether they are public or private patients.</p>
<p>We acknowledge that patients who receive in-patient rehab are <a href="https://bmchealthservres.biomedcentral.com/articles/10.1186/s12913-017-2379-9">generally very satisfied with it</a>; they enjoy the convenience of the “one stop shop” and it may provide respite for carers. </p>
<p>However, we also know patients who go home <a href="https://bmchealthservres.biomedcentral.com/articles/10.1186/s12913-017-2379-9">are also</a> <a href="http://jamanetwork.com/journals/jama/fullarticle/2610335">satisfied</a>; many surgeons and physiotherapists also rate community-based therapy <a href="https://bmchealthservres.biomedcentral.com/articles/10.1186/s12913-017-2379-9">very highly</a>.</p>
<p>The challenge for researchers, health-care providers, governments, patients and
policymakers is to encourage the uptake of community-based therapies where appropriate so that in-patient rehab is reserved for those most in need. </p>
<p>If private sector rehab costs are kept in check, there is less pressure on health insurance premiums to rise. Hopefully, this in turn, encourages people to stay insured.</p>
<h2>How do I choose what’s best for me?</h2>
<p>To choose the best rehab option for you, here are three questions to ask your surgeon before your operation:</p>
<p>1) How do I know if I need in-patient rehab?</p>
<p>2) If I choose in-patient rehab, will I recover more quickly or better?</p>
<p>3) What are my rehab options other than as an in-patient?</p><img src="https://counter.theconversation.com/content/83958/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Justine Naylor has received funding from government (NHMRC, MAA) and non-government (HCF Research Foundation, Medibank) sources to conduct research studies. In the case of the non-government grants, the funder has not influenced the research question, study design or analysis.</span></em></p>Private patients who stay in hospital for costly rehab after major knee surgery recover just as fast as people who go home and have physiotherapy. So, why pay more?Justine Naylor, Associate Professor, South Western Sydney Clinical School, UNSW SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/777762017-06-02T02:54:00Z2017-06-02T02:54:00ZAs patients turn to medical crowdfunding, concerns emerge about privacy<figure><img src="https://images.theconversation.com/files/171701/original/file-20170531-25684-1wskylm.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Many people are crowdfunding to be able to meet the high costs of health care. </span> <span class="attribution"><a class="source" href="https://www.flickr.com/photos/59937401@N07/6127243966/in/photolist-akrJam-8vGnwi-bmm7zF-eSmRdt-4wgEuR-sdgEgj-8yofaw-61Wwyv-nQ23bo-JiSSTg-7Jcr9c-bmm8h6-4EjNgb-s6cDYe-phbmfo-qXewsX-64qbTH-e7sR4B-qStV6b-fPxGqz-eWpxhk-nhj29q-mw8S3M-iNpH9k-9UKpqH-e3ne6z-aFbuaF-rMfHPS-oYnMVT-9NEtYQ-9NGKrb-svVHnc-dAtRx5-f4ozF8-9M2DUT-T4tu4i-9NJybd-akrHc3-pMrvbd-nEJeRn-61Ww6B-dAon8i-uY5czy-AUUHn-7bneJx-5Axiq4-JDEwi1-UcQg9b-bTwp2k-fAHZYN">Images Money</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span></figcaption></figure><p>Facebook recently <a href="http://www.marketwatch.com/story/facebook-crowdfunding-launch-could-boost-its-only-declining-business-2017-03-31">announced</a> that it is getting more involved in the personal crowdfunding business. Individual users will have the option of placing a “donate” button on their posts to raise funds for six categories of causes that include personal emergencies and health-related expenses. </p>
<p>Given the enormous user base of Facebook, this practice will most likely benefit many people. But, as a <a href="https://www.sfu.ca/fhs/people/profiles/jeremy-snyder.html">bioethicist</a> researching <a href="https://scholar.google.ca/citations?user=KfFTxmwAAAAJ&hl=en">issues related to medical crowdfunding</a> for the past two years, I am concerned about this development, particularly with regard to privacy.</p>
<h2>Growing popularity of medical crowdfunding</h2>
<p>The crowdfunding platform YouCaring reported that medical campaigns were its fastest-growing fundraising category in 2015. <a href="https://finance.yahoo.com/news/more-people-are-turning-to-crowdfunding-sites-to-pay-for-medical-bills-180951544.html">Since 2012</a> YouCaring has raised US$240 million for these campaigns. Similarly, another crowdfunding site, GoFundMe, has raised <a href="https://www.nerdwallet.com/blog/loans/medical-debt-crowdfunding-bankruptcy/">$930 million</a> for medical crowdfunding campaigns. </p>
<p>Crowdfunding for medical expenses began with the development of personal crowdfunding platforms such as YouCaring and IndieGoGo in the U.S. a <a href="http://www.cmaj.ca/content/184/2/E123.full.pdf">decade ago</a>. Campaigners request funds for direct medical expenses such as paying hospital bills for cancer treatment or dental care. Help paying indirect medical expenses is also commonly sought, such as support for time off work and funding for travel to hospitals for treatment.</p>
<p>On the face of it, expanded access to funds through medical crowdfunding on Facebook and other platforms is a <a href="http://onlinelibrary.wiley.com/doi/10.1002/hast.645/full">good thing</a>. Americans with medical needs and who have limited or no health insurance face either having to forego necessary medical care or having their <a href="https://www.buzzfeed.com/annehelenpetersen/real-peril-of-crowdfunding-healthcare">savings wiped out</a>. </p>
<p>Even in countries with universal medical coverage like Canada, medical crowdfunding is <a href="http://jme.bmj.com/content/early/2017/01/30/medethics-2016-103933">often</a> used for what is considered nonessential care (for example, dental care or fertility treatments) or other health-related expenses such as travel to access medical care.</p>
<p>Thus, medical crowdfunding can literally be a lifesaver.</p>
<h2>Issues around privacy</h2>
<p>However, there is a downside. As my research shows, medical crowdfunding has the potential to seriously <a href="http://onlinelibrary.wiley.com/doi/10.1002/hast.645/full">undermine the medical privacy of users</a>. </p>
<p>Typically, medical crowdfunding platforms (including but not limited to Facebook) urge their users to be as open as possible about the recipient’s medical condition. They also ask users to give regular updates about the progress of their medical care. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/171705/original/file-20170531-25673-1bzgrny.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/171705/original/file-20170531-25673-1bzgrny.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=461&fit=crop&dpr=1 600w, https://images.theconversation.com/files/171705/original/file-20170531-25673-1bzgrny.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=461&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/171705/original/file-20170531-25673-1bzgrny.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=461&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/171705/original/file-20170531-25673-1bzgrny.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=579&fit=crop&dpr=1 754w, https://images.theconversation.com/files/171705/original/file-20170531-25673-1bzgrny.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=579&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/171705/original/file-20170531-25673-1bzgrny.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=579&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Medical crowdfunding could undermine patients’ privacy.</span>
<span class="attribution"><a class="source" href="https://www.flickr.com/photos/pennstatelive/32682639501/in/photolist-RN455v-8mdk2y-TmMTKE-edLMjC-aBgCzw-TCGvGp-jz8szx-edXdav-jCjVEd-Uk61pi-7x6Sq6-HDueJU-qMo5n-uwQfvJ-UzBYDd-6Eenjf-UrKPDM-dvnP9P-rkGHu3-75ZwUi-8JCfon-2K4xwW-56PAfA-2JZcJX-72Wx-7gfuAU-4mKc8-hHPh5F-i2kD-fMxTgV-4wDP9s-fdx4t4-hMEwbd-hMA9f5-72VQ-4bAoK4-4xWcCE-72VF-or4ECh-oiusRh-dvu3My-6F96jW-72VX-72Xn-2JZcVi-72Zx-nvbWUG-S9YQhN-isnXuh-7W2esz">Penn State</a>, <a class="license" href="http://creativecommons.org/licenses/by-nc-nd/4.0/">CC BY-NC-ND</a></span>
</figcaption>
</figure>
<p>These posts <a href="http://www.sciencedirect.com/science/article/pii/S0277953616305317">regularly include</a> pictures and videos of the recipient and also images from doctors’ offices and hospital beds. This sharing of information amounts to a <a href="https://doi.org/10.1177/1461444816667723">vast loss of privacy</a>. </p>
<p>Medical emergencies and medical need are situations of great vulnerability, and often highly bodily invasive. Many patients might prefer to keep these details private or at the least limited to a select group of <a href="https://doi.org/10.1177/1461444816667723">friends and family</a>. However, these images are on display at any time on medical crowdfunding platforms. </p>
<p>For example, one of the campaigns <a href="https://www.youcaring.com/olesy-kuznetsov-609177">featured</a> at YouCaring leads off with an image of an emaciated woman in a hospital bed, surrounded by tubes and wires. In this campaign’s description, the woman reports severe symptoms including her teeth “falling apart” and her extreme financial distress. </p>
<h2>Who decides?</h2>
<p>Such images also raise questions about <a href="http://onlinelibrary.wiley.com/doi/10.1002/hast.645/full">consent</a>. While one might argue that campaigners are choosing to share this information with their friends, those in severe financial need may feel they have <a href="http://www.sciencedirect.com/science/article/pii/S0277953616305317">no other alternative</a>. </p>
<p>Moreover, medical crowdfunding campaigns are often run by friends and families of the recipient. While their intentions are likely good, it is not always clear whether they have permission to share the patient’s private medical details online. The individual might be partially or fully incapacitated, or not be involved in the campaign due to the stigma associated with asking others for financial assistance. </p>
<p>Consent might also be an issue when these campaigns are managed on behalf of young children who are then burdened with a permanent, public record of their medical history.</p>
<h2>Protecting medical data</h2>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/171704/original/file-20170531-25664-1awztif.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/171704/original/file-20170531-25664-1awztif.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/171704/original/file-20170531-25664-1awztif.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/171704/original/file-20170531-25664-1awztif.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/171704/original/file-20170531-25664-1awztif.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/171704/original/file-20170531-25664-1awztif.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/171704/original/file-20170531-25664-1awztif.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">Why medical crowdfunding platforms need to take steps to protect privacy.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/443233411?src=s54Q9VlDzHsKRpIOdpf8Aw-1-14&size=huge_jpg">Keyboard image via www.shutterstock.com</a></span>
</figcaption>
</figure>
<p>None of this is to say that medical crowdfunding is, overall, a bad thing. Rather, it creates a threat to medical privacy that ought to be carefully thought through.</p>
<p>I argue that Facebook, in particular, should be especially sensitive to these concerns. Facebook collects a huge amount of personal data from users – considerably more than is the case for other crowdfunding platforms. In the past, Facebook also has faced sustained criticism in the <a href="https://www.cnet.com/news/facebook-faces-criticism-over-its-privacy-policy/">U.S.</a> and <a href="https://www.theguardian.com/technology/2017/may/16/facebook-facing-privacy-actions-across-europe-as-france-fines-firm-150k">Europe</a> about failing to protect users’ privacy. </p>
<p>Given this, in my view, all medical crowdfunding platforms should take steps to clarify how medical data posted online can be protected from misuse, and ensure that users are aware of these problems. </p>
<p>As it stands, users are in competition with one another to present the most compelling case for donation. This pressure to share private medical information can be relieved only by a clear response from crowdfunding platforms to limit this practice.</p><img src="https://counter.theconversation.com/content/77776/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jeremy Snyder receives funding from the Canadian Institutes of Health Research. </span></em></p>Many Americans unable to afford health expenses are raising funds through medical crowdfunding. What are the risks?Jeremy Snyder, Associate Professor, Faculty of Health Sciences, Simon Fraser UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/727972017-02-10T06:18:57Z2017-02-10T06:18:57ZIncreased private health insurance premiums don’t mean increased value<p>A topic of discussion at many barbecues this summer will inevitably be private health insurance. Is it worth it? Do we need it? Every year it gets more expensive. The <a href="http://www.abc.net.au/news/2017-02-10/health-insurance-premiums-set-to-rise-by-nearly-5-percent/8258014">average 4.8% increase in premiums</a> just announced will have more Australians raising these questions, and debating with their friends how much they value choice of doctor, reduced waiting times for elective surgery, and having a private room when in hospital.</p>
<p>Private health insurance is mostly a private industry, but governments play a key role in ensuring private health insurance companies remain profitable and viable. Government policies encourage us all to have private health insurance by providing incentives for people to take out health insurance and imposing tax penalties for those on high incomes who do not have private health insurance. </p>
<p>Government makes decisions about pricing and funds the 30% rebate for many consumers with private health insurance. This is costing tax payers an estimated <a href="http://www.smh.com.au/national/health/time-to-review-the-6-billion-private-health-insurance-subsidy-academic-says-20160708-gq1t2z.html">A$6 billion each year</a>; <a href="http://past.electionwatch.edu.au/australia-2013/analysis/economic-case-slashing-health-rebates">money many economists argue</a> is not justified and would be better spent in the public system. </p>
<h2>Should the government have allowed this premium rise?</h2>
<p>Each year private health insurance funds lobby the government to increase premiums. They claim increases are warranted because of an ageing population, increasing costs of health services and technologies, and decreasing government subsidies to consumers. </p>
<p>New federal health minister Greg Hunt has approved an average increase in premiums of 4.8%, with actual price hikes <a href="https://www.finder.com.au/full-roundup-health-insurance-premiums-to-rise-by-4-84">ranging from 2.9% up to 8.5%</a>. This will mean families <a href="http://www.smh.com.au/federal-politics/political-news/private-health-insurance-premiums-to-rise-by-nearly-5-per-cent-20170209-gu9p8t.html">will pay up to $200 more per year</a>, and singles up to $100 more each year. </p>
<p>The <a href="http://www.smh.com.au/federal-politics/political-news/private-health-insurance-premiums-to-rise-by-nearly-5-per-cent-20170209-gu9p8t.html">government argues</a> this is the lowest premium increase in a decade. But this ignores the <a href="http://www.smh.com.au/business/consumer-affairs/economists-say-health-insurance-premium-hikes-well-above-cpi-are-unwarranted-20170207-gu766d.html">cumulative increase of 28%</a> since 2012. </p>
<p>A premium that was $2000 in 2010 <a href="http://www.smh.com.au/business/consumer-affairs/economists-say-health-insurance-premium-hikes-well-above-cpi-are-unwarranted-20170207-gu766d.html">now costs about $3000</a>. <a href="http://www.smh.com.au/business/consumer-affairs/economists-say-health-insurance-premium-hikes-well-above-cpi-are-unwarranted-20170207-gu766d.html">Many economists believe</a> current premium increases, which are well over inflation rates, can’t be justified. </p>
<p>At a time when <a href="https://chf.org.au/media-releases/health-fund-profits-while-their-members-lose-out-time-change">health insurance funds have increased profits</a>, people are wondering about the value for money they get when they sign up for private health insurance. </p>
<p>Dissatisfaction on the issue was clearly on the political agenda in 2016, when previous health minister Sussan Ley announced a public consultation on private health insurance. <a href="https://theconversation.com/is-the-investment-in-private-health-insurance-worthwhile-68980">This consultation made clear</a> the concerns people have about poor value for money, high out of pocket costs, and complex regulations. </p>
<p>These issues have all been raised <a href="http://sydney.edu.au/health-sciences/research/healthcare-choice/index.shtml">in our own research with consumers</a>, and have been repeatedly raised by consumer organisations such as the <a href="https://chf.org.au/media-releases/mycover-reform-give-consumers-fair-go-health-insurance">Consumer Health Forum</a>. Despite this consultation, it appears little has changed. </p>
<p>It is claimed Australians are <a href="http://www.smh.com.au/federal-politics/political-news/private-health-insurance-premiums-to-rise-by-nearly-5-per-cent-20170209-gu9p8t.html">paying more than ever</a> for their private health insurance <a href="http://www.smh.com.au/business/consumer-affairs/private-health-funds-enjoy-big-profits-but-give-less-to-members-apra-data-shows-20160818-gqvo2d.html">but are getting less and less</a>. <a href="https://theconversation.com/is-the-investment-in-private-health-insurance-worthwhile-68980">There are concerns</a> about lack of transparency about what is covered, waiting periods and exclusions, and unexpected out-of-pocket costs.</p>
<h2>Shifting responsibility to consumers</h2>
<p>Each year when we discuss the premium price hikes, the concern is focused on how consumers, not industry, will react. The onus is often on consumers to be more aware, more active, and lobby for their needs. There are <a href="https://www.doineedhealthinsurance.com.au/result.html">a range of sites</a> dedicated to helping consumers make the best choice. </p>
<p>There is alarm that some people will drop their cover completely. But given the fear people have about needing private health insurance, there seems to be more consensus that people will reduce their level of cover rather than dropping it. </p>
<p>However, the risks of doing so are often not explored. Exposure to large and unexpected out of pocket costs, and as found in <a href="http://sydney.edu.au/health-sciences/research/healthcare-choice/index.shtml">our research</a>, the realisation (too late) that some procedures are not covered. When people do use their private health insurance they are likely to pay a gap, but these expenses are not clearly defined.</p>
<p>While there is a focus on people questioning the value of private health insurance, and whether these increased premiums are justified, there is very little questioning of how we might maximise the value of the public health care system. </p>
<p>For example, the outrage is not extended to the need to lobby government about strengthening the public health system, which is where most people, especially those who are poor and with complex health needs, end up.</p>
<p>Lots of arguments are made that the private health sector is important for a strong public system. In our research, it was evident some people view having private health insurance as helping out the health care system, and making space in the public system for people who cannot afford health insurance.</p>
<p>We know many Australians take out health insurance simply to avoid paying more tax through the Medicare levy surcharge. Some question whether they would rather be putting their money into Medicare than an industry they may choose never to use.</p>
<p>The federal government needs to implement greater protections for those who purchase private health insurance and ensure better value for the substantial funds taxpayers invest in private health insurance, directly and indirectly, through the private health insurance rebate, premiums, Medicare reimbursements and out-of-pocket costs.</p><img src="https://counter.theconversation.com/content/72797/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Karen Willis received funding from the Australian Research Council (2013-2015) to investigate choice and health care.</span></em></p><p class="fine-print"><em><span>Sophie Lewis 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>Each year private health insurance funds lobby the government to increase private health insurance premiums. They claim increases are warranted because of increasing costs.Karen Willis, Associate Dean (Learning and Teaching), Faculty of Health Sciences, Australian Catholic UniversitySophie Lewis, Lecturer, University of SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/722782017-02-09T19:11:54Z2017-02-09T19:11:54ZFactCheck: are bulk-billing rates falling, or at record levels?<blockquote>
<p>Falling bulk-billing rates … – <strong>Labor leader Bill Shorten, <a href="http://www.billshorten.com.au/address_to_the_national_press_club_canberra_tuesday_31_january_2017">address</a> to the National Press Club, Canberra, January 31, 2017.</strong></p>
<p>Bulk-billing is at record levels … – <strong>Prime Minister Malcolm Turnbull, <a href="http://malcolmturnbull.com.au/media/address-at-the-national-press-club-and-qa-canberra">address</a> to the National Press Club, Canberra, February 1, 2017.</strong> </p>
</blockquote>
<p>In speeches delivered 24 hours apart, Labor leader Bill Shorten and Prime Minister Malcolm Turnbull made conflicting claims about the state of bulk-billing rates in Australia. </p>
<p>A bulk-billed consultation occurs when the fee charged by the doctor or medical provider is equal to the benefit paid by Medicare - leaving zero out-of-pocket cost to the patient. The percentage of Medicare-funded consultations that are bulk-billed is referred to as the <em>bulk-billing rates</em>. These rates are widely seen as a proxy indicator of the accessibility of Medicare-funded health care. </p>
<p>Shorten said that bulk-billing rates are falling. The next day, Turnbull stood at the same lectern and said bulk-billing rates are at record levels.</p>
<p>Who was right? </p>
<h2>Checking the sources</h2>
<p>When asked for sources to support his statement, a spokesperson for Bill Shorten said:</p>
<blockquote>
<p>The government’s figures <a href="http://www.health.gov.au/internet/main/publishing.nsf/Content/1A9DB6D72BD5879ACA257BF0001AFE28/$File/MBS%20Statistics%2020163%20SepQtr%2020161006.pdf">show</a> that from June to September 2016 the bulk-billing rate for non-referred attendances fell from 84.6% to 84.1%.</p>
</blockquote>
<p>The spokesperson added:</p>
<blockquote>
<p>Through an information request through the Parliamentary Budget Office, we know that for item 23 – a standard GP consultation – we also know the bulk-billing rate is falling: from 82.81% in April 2016 to 82.38% in May 2016 to 81.97% in June 2016. This trend continues as is reflected in the rate falling for all non-referred attendances from June to September.</p>
</blockquote>
<p>The Conversation has independently verified those figures, which are not publicly available.</p>
<p>A spokesperson for Malcolm Turnbull told The Conversation that:</p>
<blockquote>
<p>The headline <a href="http://www.health.gov.au/internet/main/publishing.nsf/Content/Medicare+Statistics-1">bulk-billing rate</a> of 85.1% for GP services is the official bulk-billing figure for 2015-16. This is the highest bulk-billing rate for GP services since 1984-85 (when Medicare started) – ie: record levels.</p>
<p>The headline bulk-billing rate of 78.2% for all Medicare services is the official bulk-billing figure for 2015-16. This is the highest bulk-billing rate for Total Medicare services since 1984-85 (when Medicare started) ie: again, record levels … the bulk-billing rate has been reported on a consistent basis under all governments since 1984-85.</p>
</blockquote>
<p>You can read the full responses from Shorten and Turnbull <a href="http://theconversation.com/full-responses-from-malcolm-turnbull-and-bill-shorten-72407">here</a>.</p>
<h2>Same source, different statistics</h2>
<p>Both Shorten and Turnbull’s statements are supported by the Department of Health’s Medicare Statistics – but Shorten has quoted <a href="http://health.gov.au/internet/main/publishing.nsf/Content/Quarterly-Medicare-Statistics">quarterly statistics</a> while Turnbull has quoted <a href="http://www.health.gov.au/internet/main/publishing.nsf/Content/Annual-Medicare-Statistics">annual figures</a>. </p>
<p>They are also both looking at slightly different categories within the Medicare bulk-billing data collected by the Department of Health. </p>
<p>Overall, however, neither politicians’ sound bite provide a complete picture on what’s happening with bulk-billing in Australia. </p>
<h2>Yearly data on bulk-billing rates show record highs</h2>
<p>The chart below shows the annual bulk-billing statistics for the financial years from 1984-85 to 2015-16. It shows the bulk-billing rate for all Medicare claims combined and selected services – not just GP visits. </p>
<iframe src="https://datawrapper.dwcdn.net/UbmwH/2/" frameborder="0" allowtransparency="true" allowfullscreen="allowfullscreen" webkitallowfullscreen="webkitallowfullscreen" mozallowfullscreen="mozallowfullscreen" oallowfullscreen="oallowfullscreen" msallowfullscreen="msallowfullscreen" width="100%" height="520"></iframe>
<p>For overall Medicare claims (the red line), the bulk-billing rate in 2015-16 reached 78.2%. As correctly stated by Turnbull, this is an all-time high within the annual statistics. </p>
<p>Annual bulk-billing levels were also at record highs last financial year for non-referred GP attendances (which, by and large, means going to see your GP), pathology services and diagnostic imaging. </p>
<p>However, the bulk-billing rate for specialist services (the black line) in 2015-16 was at 30.2%, still below the record level set in 1995-96 of 32.5%. </p>
<p>So, technically, Turnbull is right to say bulk-billing rates are at record highs – as long as you use annual statistics and ignore the most recent data for the July to September 2016 quarter. </p>
<h2>But quarterly data show bulk-billing rates fell in the third quarter of 2016</h2>
<p><a href="http://health.gov.au/internet/main/publishing.nsf/Content/Quarterly-Medicare-Statistics">Quarterly statistics</a> on bulk-billing rates are shown in the chart below. </p>
<iframe src="https://datawrapper.dwcdn.net/3I9Lr/2/" frameborder="0" allowtransparency="true" allowfullscreen="allowfullscreen" webkitallowfullscreen="webkitallowfullscreen" mozallowfullscreen="mozallowfullscreen" oallowfullscreen="oallowfullscreen" msallowfullscreen="msallowfullscreen" width="100%" height="520"></iframe>
<p>As you can see, drilling down to the quarterly data reveals that bulk-billing rates fell in the third quarter of 2016.</p>
<p>For total Medicare claims (the red line), bulk-billing rates fell by 1.1% in between the June and September 2016 quarters. But it is worth noting that it fell from the highest bulk-billing rates on record (78.7%). </p>
<p>The fall between June and September 2016 is the 11th biggest quarterly decrease (in percentage terms) since Medicare’s inception. But while it was a relatively large drop in bulk-billing, it is still within the range of quarterly variability that we’ve seen historically. </p>
<p>For non-referred GP attendances (the blue line), the September quarter data shows a 0.6% fall in bulk-billing rates compared to June 2016. For pathology services (the orange line), the bulk-billing rate fell by 1.7% in the September quarter which is in addition to a 0.23% fall in the June quarter. </p>
<p>So, technically, Shorten is correct to say that the latest data show a fall in the bulk-billing rate – but he has zeroed in on a very recent fall that is within the range of normal variability. This recent drop doesn’t tell us much about the overall trend. </p>
<p>There is considerable variation in the quarterly bulk-billing rate. This makes it difficult, at this stage, to say anything certain about whether bulk-billing rates will continue to fall as part of a downward trend, or whether the latest quarterly decline is just an anomaly.</p>
<h2>Longer-term trends trump quarterly data</h2>
<p>The Department of Health is set to release the December quarter data later this month. This much anticipated release will give further insights into whether a downward trend in bulk-billing rates is emerging or whether the last quarter was a blip. </p>
<p>The figures for the last quarter of 2016 are likely to attract considerable attention as policymakers will be eager to learn whether the Medicare indexation freeze is having an effect on bulk-billing rates. </p>
<p>The freeze has been in place since 2014 and is set to continue until 2020. In effect, that means that the Medicare contribution to each health care service has not changed for the last three years. </p>
<p>Others have <a href="https://theconversation.com/confused-about-the-medicare-rebate-freeze-heres-what-you-need-to-know-59661">argued</a> that this will put pressure on doctor’s ability to bulk-bill. </p>
<p>Note that there was substantial negative bulk-billing growth in the period after the last Medicare indexation freeze and this did impact the annual level of bulk-billing.</p>
<h2>What bulk-billing rates don’t tell us</h2>
<p>One of the fundamental aims of Medicare is to improve access to care. Bulk-billing rates serve as an important proxy on how Medicare is performing with respect to allowing people of all income groups to access health care.</p>
<p>However, there are significant limitations. Bulk-billing rates cannot tell you, for example, whether bulk-billing services are fairly distributed across income groups or people in high health care need.</p>
<p>And headline bulk-billing rates do not reveal out-of-pocket costs for those patients who are not bulk-billed. </p>
<p>For example, for people who were not bulk-billed (almost 70% of specialist consultations) the average patient co-payment for a specialist consultation was $72 (<a href="http://health.gov.au/internet/main/publishing.nsf/Content/Quarterly-Medicare-Statistics">as shown in Table 1.5a in the quarterly Department of Health statistics</a>). </p>
<p>So any discussion of health care access needs to go beyond one simple headline measure.</p>
<h2>Verdict</h2>
<p>Technically, Shorten and Turnbull were both right – but their quotes don’t tell the whole story.</p>
<p>Shorten’s statement that we are seeing “falling bulk-billing rates” is correct if you look at the most recent quarterly statistics for total Medicare bulk-billing claims. But that fall was within the range of variation that we observe every quarter. Furthermore, one quarter of data is not enough to be making such generalised statements on total Medicare bulk-billing rates. </p>
<p>As Shorten’s <a href="http://theconversation.com/full-responses-from-malcolm-turnbull-and-bill-shorten-72407">full response</a> notes, there has also been a fall for three consecutive quarters in bulk-billing for GP visits lasting less than 20 minutes. However, this data is not publicly available so we can’t say for sure that there’s a trend in this particular item.</p>
<p>Turnbull’s statement that “bulk-billing is at record levels” is correct if you look at the yearly statistics, though it doesn’t factor in the decrease in bulk-billing in the third quarter of last year.</p>
<p>It is too early to say whether the recent quarterly fall in total Medicare bulk-billing rates was an anomaly or perhaps signals a broader trend. Data due for release within the next week will tell us more about the true state of bulk-billing in Australia. <strong>– Thomas Longden and Kees Van Gool</strong></p>
<hr>
<h1>Review</h1>
<p>This FactCheck is accurate and fair. It presents the statistical information most relevant to the problem and clearly contrasts the data that each politician drew from in making their statements. A couple of further points:</p>
<p>First, the <a href="http://theconversation.com/full-responses-from-malcolm-turnbull-and-bill-shorten-72407">full response</a> provided by Bill Shorten’s office mentions that bulk-billing rates specifically for item 23 (a standard level B GP consultation lasting less than 20 minutes) decreased in the three consecutive quarters to June 2016. Compared to the bulk-billing rates for the broader Medicare Benefit Schedule categories, this may suggest a slightly more convincing pattern of decline – but only for this particular item.</p>
<p>Second, bulk-billing rates vary considerably across states. Some states experienced a larger drop in bulk-billing rates in the September 2016 quarter than others. For example, Tasmania’s bulk-billing rate for non-referred GP services declined by more than 2% whilst the Northern Territory’s rate showed no decline. Likewise, the annual statistics show that Tasmania’s bulk-billing rate for non-referred GP services fell between 2014-15 and 2015-16 even as the country’s bulk-billing rate rose to record levels. </p>
<p>These variations in state trends can be obscured when we focus solely on data for Australia as a whole. <strong>– Rosemary Elkins and Stefanie Schurer</strong></p>
<hr>
<p><div class="callout"> Have you ever seen a “fact” worth checking? The Conversation’s FactCheck asks academic experts to test claims and see how true they are. We then ask a second academic to review an anonymous copy of the article. You can request a check at checkit@theconversation.edu.au. Please include the statement you would like us to check, the date it was made, and a link if possible.</div></p><img src="https://counter.theconversation.com/content/72278/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Thomas Longden receives funding from the Department of Health.
</span></em></p><p class="fine-print"><em><span>Kees Van Gool receives funding from the Australian Research Council and the Department of Health.</span></em></p><p class="fine-print"><em><span>Stefanie Schurer receives funding from the ARC and the NHMRC.</span></em></p><p class="fine-print"><em><span>Rosemary Elkins 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>In twin speeches to the National Press Club, Labor leader Bill Shorten said bulk-billing rates are falling, while Prime Minister Malcolm Turnbull said bulk-billing is at record levels. Who was right?Thomas Longden, Senior Research Fellow, University of Technology SydneyKees Van Gool, Health economist, University of Technology SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/662782016-10-19T04:35:27Z2016-10-19T04:35:27ZFactCheck: Have average out-of-pocket costs for GP visits risen almost 20% under the Coalition?<blockquote>
<p>These statistics ignore the fact that under this government, average out-of-pocket costs for GP visits are up by almost 20%. <strong>– Shadow minister for health and Medicare Catherine King, <a href="http://www.theaustralian.com.au/national-affairs/health/bulkbilling-rates-stay-high-for-poor-increasing-for-wealthy/news-story/b29d5bc3c91b3bc2aa5a68e527e9cff4">quoted in The Australian</a>, September 27, 2016.</strong></p>
</blockquote>
<p>In 2013, Labor introduced a <a href="https://theconversation.com/confused-about-the-medicare-rebate-freeze-heres-what-you-need-to-know-59661">fee freeze on Medicare rebates</a> in an effort to rein in the cost of government health spending. After winning the 2013 election, the Coalition government extended that fee freeze twice. Labor has now said it would lift the Medicare rebate freeze if elected.</p>
<p>In that context, the Australian Medical Association is <a href="https://ama.com.au/ausmed/health-costs-rise-rebate-freeze-bites">recommending</a> GPs raise their fees for a standard appointment of less than 20 minutes to A$78 from November 2016.</p>
<p>A news <a href="http://www.theaustralian.com.au/national-affairs/health/bulkbilling-rates-stay-high-for-poor-increasing-for-wealthy/news-story/b29d5bc3c91b3bc2aa5a68e527e9cff4">report</a> in The Australian quoted shadow minister for health and Medicare, Labor MP Catherine King, saying that average out-of-pocket costs for GP visits are up by almost 20% under the current government.</p>
<p>Is that right?</p>
<h2>Checking the source</h2>
<p>There are two components to pricing for medical services in Australia: bulk-billing rates, and rates for services that aren’t bulk-billed. </p>
<p>For services that aren’t bulk-billed, patients pay an “out-of-pocket cost”, which is the difference between the Medicare rebate and the fee the doctor charges. </p>
<p>When asked for sources to support the statement, a spokesperson for Catherine King said:</p>
<blockquote>
<p>The figure was taken from the <a href="http://www.health.gov.au/internet/main/publishing.nsf/Content/Quarterly-Medicare-Statistics">Medicare quarterly statistics to June 2016 (Tab 1.5b)</a>.</p>
<p>The average patient contribution for a patient billed GP service was $29.11 in September 2013, and is now $34.61 – a 18.9% increase. Accordingly, when we say “this Government” we are referring to the Abbott/Turnbull Liberal Government.</p>
<p>An additional source which might also be of use – the <a href="http://www.racgp.org.au/home">Royal Australian College of General Practitioners</a> (RACGP) <a href="http://www.racgp.org.au/yourracgp/news/media-releases/medicare-rebate-freeze-new-evidence-showing-patient-out-of-pocket-costs-increasing/">note</a> that in the last 12 months, out of pocket costs have risen by 6%.</p>
</blockquote>
<p>So King’s figure of “almost 20%” comes from a reliable source. </p>
<h2>Have average out-of-pocket costs for GP visits gone up by almost 20% since 2013?</h2>
<p>Yes. According to Medicare <a href="http://www.health.gov.au/internet/main/publishing.nsf/Content/Quarterly-Medicare-Statistics">data</a>, out-of-pocket costs for GP visits have increased by nearly 20% since the Coalition won government in 2013, as the chart shows.</p>
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<p>It’s not entirely clear why the cost consistently dips slightly in the December quarter, creating the step-shaped formation in the chart above. It may be because of the way the Department of Health processes Medicare claims around this time of year. Nevertheless, the trend is clearly upward over time.</p>
<p>And it’s not just out-of-pocket costs for GP visits that have been rising. The <a href="http://www.health.gov.au/internet/main/publishing.nsf/Content/Quarterly-Medicare-Statistics">Medicare quarterly statistics to June 2016</a> show out-of-pocket costs for all Medicare services have increased by 25.1% since September 2013. Over the same period, out-of-pocket costs for specialist appointments are up by 29.7%.</p>
<h2>Costs were also climbing under Labor</h2>
<p>However, that rise in out-of-pocket costs started well before the Coalition took power in 2013.</p>
<p>In fact, as the chart above also shows, under the previous Labor government out-of-pocket costs for GP services grew from around $18.31 in December 2007 (when Labor’s Kevin Rudd was sworn in as prime minister) to $29.11 when Rudd lost power in September 2013.</p>
<p>(As a side note, the rate of growth in out-of-pocket costs for specialist services has continued to rise faster than that for GPs.)</p>
<h2>While out-of-pocket costs rose, bulk-billing rates have too</h2>
<p>Interestingly, Medicare data also show bulk-billing rates continue to climb, even after the fee-freeze was introduced by Labor in 2013 and after the Coalition government decided to extend the freeze:</p>
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<p>This may be because the best way to get many patients to return (and so maintain doctor earnings) is not to charge them at all – <a href="http://onlinelibrary.wiley.com/doi/10.1111/joie.12098/full">competition</a> is at play and is keeping bulk-billing rates high. </p>
<p><a href="http://onlinelibrary.wiley.com/doi/10.1111/joie.12098/full">Research</a> has shown that GPs in affluent areas are less likely to offer bulk-billing, and more likely to charge higher prices.</p>
<h2>Verdict</h2>
<p>Catherine King was correct to say that “under this government, average out-of-pocket costs for GP visits are up by almost 20%.” However, that’s not the whole story.</p>
<p>Average out-of-pocket costs for visiting a GP have been rising for some time and rose under Labor too. <strong>– Anthony Scott</strong></p>
<hr>
<h2>Review</h2>
<p>I agree that the statement by Catherine King is factually accurate, out-of-pocket costs for GP visits have increased by almost 20% since September 2013, but there is more to the story than that.</p>
<p>Out-of-pocket costs for going to see a GP also rose during the Rudd/Gillard period. In fact, using the same data that Catherine King refers to and shown in the article above, I have calculated that out-of-pocket costs rose <em>faster</em> under the last Labor government (in terms of percentage change) than the current Coalition government.</p>
<p>To compare how fast GP out-of-pocket fees grew under Labor (between 2007 and 2013) and the Coalition (between 2013 and 2016), I looked at the percentage change over four quarters. This is a way of using the quarterly data to see how things are changing every 12 months. </p>
<p>Using this method, the average yearly percentage change in out-of-pocket costs under Labor was around 8%. The average yearly percentage change under the Coalition to date (between 2013 and 2016) was 5.4%. (These figures only cover patients who were not bulk billed.)</p>
<p>An important point noted in the article is that bulk-billed patients, who are not represented in this figure, do not pay any out-of-pocket costs. Bulk-billing rates have increased over the same period, to record levels around 80%. </p>
<p>So the proportion of patients paying any out-of-pocket costs has actually been falling. Competition fostered by an increase in supply of GPs in recent years is likely keeping bulk-billing rates high and slowing the growth in out-of-pocket costs. <strong>– Peter Sivey</strong></p>
<hr>
<p><div class="callout"> Have you ever seen a “fact” worth checking? The Conversation’s FactCheck asks academic experts to test claims and see how true they are. We then ask a second academic to review an anonymous copy of the article. You can request a check at checkit@theconversation.edu.au. Please include the statement you would like us to check, the date it was made, and a link if possible.</div></p><img src="https://counter.theconversation.com/content/66278/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Anthony Scott's current research is funded from the National Health and Medical Research Council, Australian Research Council, Medibank Private Ltd, and the World Bank. He is a member of the Patient Identification Working Group of the Health Care Homes Implementation Advisory Group of the Australian Government Department of Health.
</span></em></p><p class="fine-print"><em><span>Peter Sivey receives funding from the Australian Research Council and has previously has previously been funded by Health Workforce Australia and the National Health and Medical Research Council.</span></em></p>Shadow minister for health and medicare Catherine King said under this government, average out-of-pocket costs for GP visits are up by almost 20%. Is that true?Anthony Scott, Professor, The University of MelbourneLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/671312016-10-19T03:38:57Z2016-10-19T03:38:57ZThe slow climb from innovation to cure: treating anaemia with gene editing<figure><img src="https://images.theconversation.com/files/142099/original/image-20161018-12440-153fy3h.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Gene editing technology may soon prevent the formation of sickle-shaped red blood cells in a common and deadly form of anaemia. </span> <span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-404084629/stock-photo-sickle-cell-anemia-3d-illustration-showing-blood-vessel-with-normal-and-deformated-red-blood-cells.html?src=h15EzG6U1E3CTHGS_nEB4w-1-3">Shutterstock/Uber Images</a></span></figcaption></figure><p>The ability to precisely edit DNA via <a href="https://theconversation.com/explainer-what-is-genome-editing-25072">CRISPR</a> technology has emerged as one of the most powerful advances in biology. A <a href="http://stm.sciencemag.org/content/8/360/360ra134">new paper</a> showing repair of a genetic mutation in human blood cells represents an important step towards treating the common, debilitating and expensive-to-treat blood disease known as <a href="http://www.who.int/mediacentre/factsheets/fs308/en/">sickle cell anaemia</a>. </p>
<p>Gene therapy has been a long time coming. </p>
<p>Other breakthroughs – such as vitamins, antibiotics, and vaccines – were translated into medical remedies very quickly. Advances in diagnosis and the combination of different therapies have gradually improved cancer <a href="http://www.aihw.gov.au/media-release-detail/?id=10737422964">survival rates</a>, and <a href="https://www.eurekalert.org/pub_releases/2015-06/idso-tyo060215.php">HIV</a> can often be controlled with combination therapy.</p>
<p>But inherited genetic mutations that lead to unrelenting and life-long disease have stumped us. It has proved much harder than expected to put replacement genes into cells. Too often our genome seems to recognise the new DNA as foreign and shuts it down. </p>
<p>But <a href="https://theconversation.com/explainer-what-is-genome-editing-25072">CRISPR</a> technology offers a completely new approach. We can now repair a gene, whereas in the past gene therapy involved adding a replacement gene.</p>
<h2>A common, debilitating and expensive disease</h2>
<p><a href="http://www.who.int/mediacentre/factsheets/fs308/en/">Sickle cell anaemia</a> results from a mutation in a gene that encodes haemoglobin – the protein in red blood cells that carries oxygen around our bodies. The mutation not only impairs the function of the protein, but also causes it to aggregate and distort cell shape. This leads to clumps of cells that block blood vessels, with devastating effects. Vital organs are damaged, strokes and episodes of great pain occur, and life span is reduced by around 30 years.</p>
<p>Blood transfusions can help but ultimately excess iron – a key component of haemoglobin – accumulates and tissues are further damaged. Life-long treatments are estimated to cost a <a href="http://science.sciencemag.org/content/352/6289/1059.full.pdf+html">million</a> dollars per patient.</p>
<p>Sadly, this disease is common. Mutations in globin genes are the most prevalent of all single gene disorders. In the US there are around <a href="http://science.sciencemag.org/content/352/6289/1059.full.pdf+html">70,000</a> patients at any given time, and across the world about <a href="http://perspectivesinmedicine.cshlp.org/content/2/9/a011692.full">200,000</a> children with sickle cell anaemia are born each year. The total costs in terms of human suffering and the ultimately ineffective spending on health care is colossal.</p>
<h2>Targeting the mutation</h2>
<p>Researchers led by <a href="http://stemcellcenter.berkeley.edu/JacobCorn.html">Jacob Corn</a> at Berkeley – the home of <a href="http://mcb.berkeley.edu/faculty/all/doudnaj">Jennifer Doudna</a>, a CRISPR pioneer – have introduced several innovations to bring CRISPR therapy for sickle cell anaemia closer to the clinic.</p>
<p>As described in their <a href="http://stm.sciencemag.org/content/8/360/360ra134">newest paper</a>, their basic strategy was to purify immature blood cells (before they lose their nucleus, a normal part of red <a href="https://en.wikipedia.org/wiki/Haematopoiesis">blood cell development</a>), correct the mutation using a CRISPR system, and then graft the cells back into a recipient – in this case a laboratory mouse.</p>
<p>The team developed a number of innovations. They first synthesised all the components of the CRISPR machinery in the lab, then assembled them and delivered the parcel into cells using an electric shock process termed “electroporation”. The parcel contained bespoke molecular tools to find, cut and replace the target mutation in the haemoglobin gene.</p>
<p>The authors targeted the gene-editing parcel to blood cells that subsequently divide and give rise to many generations of blood cells. This feature is essential for long-term treatment, since red blood cells quickly wear out as they are being pumped around our bodies.</p>
<p>Using their technique, the team was able to successfully correct the target gene mutation in about 10% of cells. This might not sound much, but should be enough to have very real clinical benefits for patients.</p>
<h2>How far off is use in the clinic?</h2>
<p>While this work most certainly advances the use of CRISPR for editing human cells, a number of factors limit immediate applicability. </p>
<p>First, this paper concerned the correction of human blood cells that were grafted into laboratory mice. Although the same cells could be re-introduced into human patients, a lot more cells would be required to treat a human, since humans are much bigger than mice. </p>
<p>Also, the choice of “blood progenitor cells” to target is interesting. <a href="https://en.wikipedia.org/wiki/Haematopoiesis">Blood progenitor cells</a> are cells that have begun to develop down the pathway that forms blood. They aren’t self-renewing in the same way immortal <a href="https://theconversation.com/explainer-what-are-stem-cells-14391">stem cells</a> are, so the supply of corrected blood will eventually run out.</p>
<p>It would have been better to use actual blood stem cells and sustain the cell renewal for longer, but those cells are much rarer and are difficult to recover in large numbers from patients. Also, some researchers have struggled to achieve gene correction in blood stem cells, and they wonder if these cells have all the required repair pathways.</p>
<p>Nevertheless, even corrected progenitor blood cells could be effective over reasonable periods, so this could represent a new treatment if not a cure.</p>
<h2>Ethical and political factors</h2>
<p>When considering this work it is worth noting that we are talking about correcting blood cells. This is quite different from <a href="http://link.springer.com/article/10.1007/s13238-015-0153-5">earlier work</a> by a separate team that used donated, non-viable human embryos for their research. </p>
<p>Previous CRISPR experiments focused on the use of gene editing to change the genome of the entire body, which would be included in the eggs or sperm of any offspring if it came to fruition. Such gene therapy remains <a href="https://ghr.nlm.nih.gov/primer/therapy/ethics">highly controversial</a> and is considered unethical by many – partly because it could affect future generations who cannot consent to the treatment. </p>
<p>The work on blood progenitor cells is called “somatic” gene therapy, because only somatic or body cells are altered, and this is widely accepted as appropriate. </p>
<p>Beyond the important ethical considerations, will expensive treatments like this actually enter the clinic? </p>
<p>In America, yes they may. With strong investment in medical companies and health care insurance processes it could be <a href="http://science.sciencemag.org/content/352/6289/1059.full.pdf+html">cost effective</a> in the USA. </p>
<p>In other developing countries it could be much harder. Consequently, a great many laboratories – including <a href="http://www.crossleylab.unsw.edu.au/">my own</a> – continue to work on understanding the fundamental biology of the haemoglobin gene. The goal is to find affordable drugs that could treat the disease and could be made available throughout the world.</p><img src="https://counter.theconversation.com/content/67131/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Merlin Crossley for the University of New South Wales (UNSW) and receives funding from the National Health and Medical Research Council for work related to Sickle Cell Disease, and also receives funding from the Australian Research Council. He is a Trust Member of the Australian Museum, Board Member of the Sydney Institute of Marine Science, the Australian Science Media Centre (AusSMC) and on the Editorial Board of The Conversation in Australia.</span></em></p>A new study has advanced the use of a technique known as ‘CRISPR’ to treat a common inherited form of anaemia.Merlin Crossley, Deputy Vice-Chancellor Education and Professor of Molecular Biology, UNSW SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/516612016-07-12T05:51:55Z2016-07-12T05:51:55ZA snapshot of the challenges facing the new Turnbull government<p><em>With a federal election outcome, it’s time to take stock of how Australia is doing, where it’s going, and what governments can do about it. In partnership with the Grattan Institute, we explore the pressing policy challenges facing Australia in terms of economic growth, budgets, cities, transport, energy, health, school education, and higher education.</em></p>
<p><em>The infographic below sets out these challenges at a glance.</em></p>
<hr>
<p><iframe id="tc-infographic-209" class="tc-infographic" height="400px" src="https://cdn.theconversation.com/infographics/209/bd9332da5bfa19f626eb93bc5d8b5a8b05f7e514/site/index.html" width="100%" style="border: none" frameborder="0"></iframe></p><img src="https://counter.theconversation.com/content/51661/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>In the late 1990s, Andrew Norton was a policy adviser to a Liberal education minister. He was also appointed by a Liberal minister in 2013 as co-reviewer of the demand driven funding system for higher education.</span></em></p><p class="fine-print"><em><span>Through his superannuation fund, Tony Wood owns shares in several energy and resources companies that would have an interest in the topic covered by this article.</span></em></p><p class="fine-print"><em><span>Jim Minifie, John Daley, Marion Terrill, Peter Goss, and Stephen Duckett 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>What are the key policy challenges facing the new Turnbull government in terms of economic growth and budgets, cities, transport, energy, school education, higher education and health?John Daley, Chief Executive Officer, Grattan InstituteAndrew Norton, Program Director, Higher Education, Grattan InstituteJim Minifie, Productivity Growth Program Director, Grattan InstituteMarion Terrill, Transport Program Director, Grattan InstitutePeter Goss, School Education Program Director, Grattan InstituteStephen Duckett, Director, Health Program, Grattan InstituteTony Wood, Program Director, Energy, Grattan InstituteLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/572902016-04-28T04:48:02Z2016-04-28T04:48:02ZNew homelessness report shows the cost of waiting for early intervention<figure><img src="https://images.theconversation.com/files/120266/original/image-20160427-1352-1hlfb3c.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Homeless young people have a significantly higher prevalence of adverse health issues and greater levels of contact with the justice system.</span> <span class="attribution"><span class="source">AAP/Mick Tsikas</span></span></figcaption></figure><p>New findings from the <a href="http://www.csi.edu.au/media/uploads/CYHA_FINAL_REPORT_18April2016_v0dqGpT.pdf">Cost of Youth Homelessness in Australia</a> research project, released on Thursday, show the rising costs of health and justice services associated with homelessness. </p>
<p>The homeless young people in the study reported significantly higher prevalence of adverse health issues than the general population, or even compared to other unemployed, job-seeking youth. This created an average additional cost, compared to the unemployed group, of A$6,744 per person per year. </p>
<p>Homelessness also means considerably greater contact with and involvement in the justice system. This was an average cost of $8,242 higher than for the unemployed group. The total cost offsets for young people becoming homeless is therefore an average of $14,986 per person per year. </p>
<p>On the basis of the 41,780 young people between aged 15 and 24 who were clients of <a href="http://www.housing.nsw.gov.au/help-with-housing/homelessness/specialist-homelessness-services">Specialist Homelessness Services</a> in 2014-15 and presented alone rather than in a family group, the total annual cost to the Australian economy of additional health and justice services is an estimated $747 million – or $626 million annually more than for unemployed youth. </p>
<p>This $747 million exceeds the total cost – approximately $619 million – of providing Specialist Homelessness Services to the 256,000 people (young and old) assisted by the system over the same period.</p>
<h2>Has ‘early intervention’ influenced policy?</h2>
<p>Early intervention to arrest the onset of youth homelessness is not a new idea.</p>
<p>Debate about early intervention started in the 1990s following several research projects that proffered evidence that it was possible:</p>
<ul>
<li><p>it was advocated in a <a href="http://catalogue.nla.gov.au/Record/2232072">parliamentary report</a> on youth homelessness in 1995;</p></li>
<li><p>it was examined by a <a href="https://pmtranscripts.dpmc.gov.au/release/transcript-9988">government taskforce</a> in 1996-97; and </p></li>
<li><p>after a pilot program, the first early intervention program for at-risk and homeless young people, <a href="https://www.dss.gov.au/families-and-children/programmes-services/reconnect">Reconnect</a>, was launched.</p></li>
</ul>
<p>But apart from Reconnect, little has been done to develop Australia’s early intervention capacity. This is despite “youth homelessness” having had a visible profile in the media and in public debate. This is undoubtedly in large part due to the 1989 Human Rights and Equal Opportunity Commission <a href="https://www.humanrights.gov.au/sites/default/files/Contents.pdf">inquiry into youth homelessness</a>.</p>
<p>Twenty-five years later, an independent National Youth Commission Inquiry into Youth Homelessness revisited the same issue in much the same way. <a href="http://www.theoasismovie.com.au/pdfs/Homeless_report.pdf">It found</a> the problem had not been substantially redressed.</p>
<p>In December 2008, a federal government <a href="http://www.homelesshub.ca/resource/road-home-national-approach-reducing-homelessness-australia">white paper</a> placed “early intervention” on the policy agenda as a means of “turning off the tap”. But little was done in six years of Labor governments. </p>
<p>And, despite a roundtable on prevention and early intervention convened in 2014 by then-social services minister Kevin Andrews, the Abbott and Turnbull governments have done nothing to give effect to the framework so positively received.</p>
<p>Specialist Homelessness Services <a href="http://www.aihw.gov.au/publication-detail/?id=60129550000">assisted</a> 250,000 men, women and children in 2013-14. Nearly one-third (30%) were single individuals. Another one-third were sole parents with children (33%). Just less than one-third were other families (29%). The balance consisted of “other groups” of non-related persons (7%).</p>
<p>In 2013-14, of the 76,200 individuals who were alone when they presented to services, 44,414 were young people aged 15-24 years – or nearly six out of every ten single clients.</p>
<h2>Widening the debate</h2>
<p>The debate about responding to homelessness has too often been confined to claims about increasing homelessness services or reforming homelessness services. The overall costs and benefits are not considered. The huge demand-driven costs associated with young people becoming homeless are not factored in. </p>
<p>Policies that respond to homelessness in ways that avoid these costs have to be more seriously considered. Our report’s findings provide a strong economic rationale for investing in early intervention to stem the flow of young people into homelessness. </p>
<p>And for those young people who become homeless despite early intervention – or who were already living independently prior to homelessness – the policy imperative is to support them to exit homelessness as quickly as possible. </p>
<p>For these young people, this involves setting them up in safe, secure and appropriate housing quickly – or rapid rehousing. </p>
<p>A rapid and agile response has proved difficult to deliver because it requires quick access to some form of appropriate youth housing. The most important issue is wrap-around integrated support for young people to remain in education, training or employment as a way of replicating – as well as can be achieved – the all-inclusive support that families provide.</p>
<p>Waiting for early intervention and an adequate response to youth homelessness feels like “waiting for Godot”, as the two homeless men did in Samuel Beckett’s <a href="https://en.wikipedia.org/wiki/Waiting_for_Godot">famous absurdist play</a>. But, as the findings of our research show, the Australian community and economy are paying the substantial cost of the status quo.</p><img src="https://counter.theconversation.com/content/57290/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The Cost of Youth Homelessness in Australia study was undertaken by principal researchers Associate Professor David MacKenzie of Swinburne University of Technology, Professor Paul Flatau of The University of Western Australia and Professor Adam Steen of Charles Sturt University, and associate researcher, Dr Monica Thielking, Swinburne. The project was funded by the Australian Research Council in partnership with The Salvation Army, Mission Australia and Anglicare NSW South, NSW West & ACT.</span></em></p>A new report’s findings provide a strong economic rationale for investing in early intervention to stem the flow of young people into homelessness.Adam Steen, Professor in Finance, Charles Sturt UniversityLicensed as Creative Commons – attribution, no derivatives.